Atlantoaxial Subluxation Research Articles

Is the atlas size associated with the pathophysiology of symptomatic spinal canal stenosis at the C1 level?

Narrow cervical spinal canal is an important risk factor for the development of cervical myelopathy. Patients with this disease often present with congenital narrowness of the cervical spinal canal. While there are studies on patients with subaxial spinal canal stenosis (SAS), few examined the coexistence of congenital narrow spinal canal in patients with cervical myelopathy at the C1 level. We investigated the characteristics of patients with C1 stenosis (C1S) with special reference to the size of the atlas. Thirteen patients (8 men, 5 women, mean age 76 years) with C1S were retrospectively analyzed and their clinical characteristics and radiological findings were compared with 27 SAS patients and with 26 age-, sex-, and body habitus-matched asymptomatic individuals. Of the 13 C1S patients, 6 presented with a retro-odontoid pseudotumor, 5 with atlantoaxial subluxation, and 2 with ossification or calcification of the transverse ligament; they were significantly older and shorter, and their body weight was significantly lower than in SAS patients (p < 0.001). Their average C1 anteroposterior- and spinal canal diameter was 26.9 ± 2.4 mm and 12.8 ± 4.1 mm, respectively and significantly smaller than in patients with subaxial stenosis (p = 0.004). These measurements were also statistically smaller than in the controls, even after matching for age, gender, height, and body weight (p < 0.05). In patients with C1S, the atlas size was significantly smaller than in SAS patients and asymptomatic controls, indicating an association between a small atlas size and symptomatic spinal canal stenosis at the C1 level.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P110. The impact of chronic steroid and dmard therapy on atlanto-axial fusion rates in patients with rheumatoid arthritis: a multicenter review

BACKGROUND CONTEXT Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of the immune system primarily affecting the synovial joints leading to progressive joint destruction with a 1%–2% worldwide prevalence. The cervical spine is commonly affected in patients with RA leading to atlantoaxial subluxation (AAS), basilar invagination (BI), and subaxial subluxation. These patients commonly require stabilization of their AAS requiring either Occipitocervical or C1–C2 arthrodesis. RA has historically been treated with steroid therapy and although this has been falling out of favor with the advent of disease modifying anti-rheumatic drugs (DMARDs); however, some patients are unable to wean from steroids. Although DMARDs have become increasingly popular for treatment of RA there is a growing concern that the cytotoxicity of these agents may compromise wound healing and arthrodesis. Currently there is little information available regarding surgical outcomes in patients on DMARDs. This study aims to identify patients with RA and AAS that underwent surgical intervention. We hypothesize that DMARDS and low dose steroids do not adversely affect patient outcome. PURPOSE To identify the sigficance of impact that chronic steroid and/or DMARD therapy has on RA patients underdoing posterior arthrodesis for atlanto-axial instability. STUDY DESIGN/SETTING Multicenter retrospective review. PATIENT SAMPLE Patients with the diagnosis of RA requiring surgery for atlanto-axial pathology. Patients undergoing occipital–cervical and atlanto-axial arthrodesis were included. OUTCOME MEASURES Primary outcome measure was return to the OR. METHODS This study was a multicentered retrospective review from seven hospitals. All patients with the diagnosis of RA that underwent cervical spine surgery were identified and reviewed. All patients that underwent C1–C2 or occipital–cervical fusion for treatment of AAS dating back to January 2008 were identified and included in the review. Perioperative medications were reviewed for use of steroids, DMARDs, bisphosphonates and hormone therapy. Patients were stratified among 2 groups, those that had their steroids or DMARDs held perioperatively and those that did not. End point measurement was return to the operating room (OR) for wound failure, pseudoarthrosis, infection, or other reasons. RESULTS A total of 40 patients were idenitifed for inclusion in the review. There were two patients in the cohort that required return to the OR, one for pseudoarthrosis and one for wound failure. The patient with pseudoarthrosis maintained their anti-RA medications in the perioperative period while the patient with wound failure had their anti-RA medications held in the perioperative period. There was note however of patients experiencing RA flare-ups when the anti-RA medications were held. CONCLUSIONS Our cohort demonstrated a 5% return to OR rate in RA patients undergoing surgery for atanto-axial instability. There was no demonstrable affect on outcome with respect to holding or continuing anti-RA medications in the peri-operative period in our cohort. The overall affect these medications in this patient population may be benign. However, more studies are warranted to further investigate the impact these medications have in the perioperative period and overall outcome.

The Outcomes of Posterior Arthrodesis for Atlantoaxial Subluxation in Down Syndrome Patients: A Meta-Analysis.

This is a meta-analysis. To establish rates of (1) neurological complications, (2) bony-related complications, (3) complications delaying recovery, (4) reoperation, and (5) fatalities following posterior cervical arthrodesis in Down syndrome (DS) patients with atlantoaxial subluxation. To determine if presenting symptoms had any relationship to postoperative complications. Posterior arthrodesis is commonly utilized to correct cervical instability secondary to atlantoaxial instability in DS patients. However, there has never been a global evaluation of postoperative complications associated with posterior cervical spinal arthrodesis in DS patients. A comprehensive search of Medline/PubMed, EMBASE, and Ovid databases between January 1980 and July 2017 was utilized to identify DS patients with atlantoaxial subluxation who underwent posterior cervical arthrodesis. Data were sorted by neurological complications, complications delaying recovery, bony-related complications, reoperations, and fatalities. Patients were sorted into 2 groups based on presentation with or without neurological deficits. Twelve studies met inclusion criteria, including 128 DS patients. Mean age was 13.8 years (range: 6.7-32.7 y; 47.8% male). Mean follow-up was 31.7 months (range: 14.9-77 mo). All patients underwent primary posterior cervical arthrodesis with an average of 2.5 vertebrae fused. A total of 39.6% of patients had bony-related complications [95% confidence interval (CI), 31.4%-48.5%], 23.3% had neurological deficits (95% CI, 16.6%-31.6%), and 26.4% experienced complications delaying recovery (95% CI, 19.4%-34.9%). The reoperation rate was 34.9% (95% CI, 25.5%-45.6%). The mortality rate was 3.9% (95% CI, 1.5%-9.7%). Neurological complications were 4-fold (P<0.05) and reoperation was 5.5-fold (P<0.05) more likely in patients presenting with neurological deficits compared with those without. This study detailed global complication rates of posterior arthrodesis for DS patients, identifying bony-related complications and reoperations among the most common. Patients presenting with neurological symptoms and cervical instability have increased postoperative rates of neurological complications and reoperations than patients with instability alone. Further investigation into how postoperative complications effect patient independence is warranted.

Intraoperative ultrasound providing dynamic, real-time evaluation of the spinal cord can be useful in cases of intraoperative neuromonitoring (IONM) signal changes

Introduction: Intraoperative ultrasound is often used in neurosurgery for evaluation of tumors and Chiari malformations. It has been described as a “poor man’s MRI”, but has the advantage of being able to evaluate the spinal cord in real time with correction of spinal deformity. Case Report: Case 1: 14 y.o. male with Trisomy 21 and symptomatic atlantoaxial subluxation with spinal cord compression. C1/C2 subluxation did not reduce with positioning. Decompression was performed of …

Clinical significance of imaging findings for atlantoaxial rotatory subluxation in children

Background/aim: This study evaluated the usefulness of measuring the atlantodental interval (ADI) and lateral atlantodental spaces (LADSs) by retrospectively analyzing the imaging data of children of various ages with and without atlantoaxial rotatory subluxation (AARS). Materials and methods: The data of 495 children who underwent cranial computed tomography were collected. Among these children, 255 children were clinically diagnosed with AARS while 240 children were not. ADI and LADS values were measured. Results: The difference in mean ADI between children with and without AARS in all age groups was statistically significant (t-test, all P < 0.05). In children without AARS, the 95% reference range for ADI was <3.2 mm. The difference in the variance of bilateral lateral atlantodental spaces (VBLADSs) between children with and without AARS in all age groups was statistically significant (rank-sum test, all P < 0.05), with a 95% reference range of 0–2.20 mm (D-test). Conclusion: The ADI is a well-known and frequently used parameter and is not new, but there is little research about this in China and here we confirm its application in Chinese children. The LADS is not a frequently used parameter, but it does not significantly differ. The VBLADS parameter is new and significant in this manuscript. We concluded that VBLADSs of >2.2 mm are useful indicators for the diagnosis of AARS in patients ≤14 years old. Finally, it can be concluded that ADI of ≥3.2 mm and VBLADS of >2.2 mm are useful indicators for the diagnosis of AARS in patients ≤14 years old. Widened LADSs would not be helpful in the diagnosis of AARS in children.

Value of neurophysiologic monitoring in confirming indirect decompression of severe pediatric non-traumatic C1–C2 subluxation. A case report

Abstract Spinal cord compression from severe C1–C2 subluxation is a complex and challenging neurosurgical problem. A combination of surgical approaches may be required to decompress the spinal cord, including anterior transoral odontoidectomy, posterior cervical laminectomy, or indirect decompression by subluxation reduction. After decompression, an instrumented posterior fusion is then required to stabilize the spine. We report a case of a 13-year-old-girl who presented with spastic quadriparesis secondary to severe atlantoaxial subluxation, where intraoperative neurophysiologic monitoring (IOM) guided surgical decision making. The patient had congenital osseous abnormalities, including incomplete segmentation of C2 on C3, predisposing her to atlantoaxial dislocation. She underwent open surgical reduction of the C1–C2 subluxation with multi-modal intraoperative neurophysiologic guidance. Translaminar C2 screws and C1 lateral mass screws were placed bilaterally. Using a previously described distraction technique, we performed ventral translation of C2 relative to C1, thereby reducing the subluxation. Intraoperative radiographic images and neurophysiologic monitoring revealed significant improvements, confirming that adequate indirect decompression had been achieved. After subluxation reduction with intraoperative monitoring (IOM) improvements, we decided to proceed with a C1–C2 posterior fusion and avoid a cervical laminectomy and more extensive occipital cervical fusion procedure. After one year, the girl made a complete neurologic recovery and remains symptom-free 3 years post-surgery. Fusion to the occiput would have potentially caused greater morbidity in this patient. The neurophysiologic monitoring confirmed indirect decompression and served as a critical tool for the prediction of favorable neurologic outcome.

Post-operative regression of retro-odontoid pseudotumors treated with and without fusion.

Retro-odontoid pseudotumor is common in elderly people and is a cause of cervical myelopathy. The goal of the study was to investigate surgical procedures, outcomes, and post-operative spontaneous regression of posterior cervical retro-odontoid pseudotumors. The subjects were 29 patients who underwent surgery for myelopathy due to a retro-odontoid pseudotumor around the craniocervical region at 9 facilities and were followed-up for an average of 54months (range 12-96months). Data were collected in a multicenter review of a retrospective database. Comparisons were performed between cases treated with and without fusion. The JOA recovery rate at final follow-up did not differ significantly between the fusion (n = 17, including all 15 patients with atlantoaxial subluxation) and non-fusion (n = 12) groups. However, pseudotumor regression was significantly more frequent in the fusion group (100% vs. 42%, p < 0.01). In all patients, regression cases had significantly higher rates of contrast enhancement of the pseudotumor on pre-operative T1 gadolinium-enhanced MRI (68% vs. 14%, p = 0.013) and of JOA recovery (50% vs. 30%, p < 0.01). Regression of pseudotumor occurred in all cases treated with fusion surgery. There was a significant difference in pseudotumor regression with or without fusion, and regression was significantly related to gadolinium enhancement on MRI. Therefore, it is preferable to use fusion surgery for a retro-odontoid pseudotumor that shows contrast enhancement, even if there is no apparent instability pre-operatively. These slides can be retrieved under Electronic Supplementary Material.

O-3-14. Treatment of ulnar neuropathy after total elbow arthroplasty (TEA) and nerve conduction test

Ulnar neuropathy is one of complications of TEA (total elbow arthroplasty, incidence; 5 to 10%), yet there are not many evaluations and clinical course reports. Out of 117 patients with rheumatoid arthritis (RA) who underwent TEA, 8 patients showed numbness and muscle weakness of the ulnar nerve region after surgery, and received electromyography (EMG). EMG examinations revealed ulnar neuropathy at the elbow in 6 subjects, 5 of whom performed neurolysis. Two patients were diagnosed with cervical spondylosis. A 50-year-old female developed RA in 1998. She underwent left TEA (JACE) in June 2014. As numbness appeared, we performed EMG to her in October 2014. Delay of sensory nerve conduction velocity (SCV) was observed at cubital tunnel. In April 2015 left ulnar nerve neurolysis was performed. After that, both EMG finding and symptoms were improved. However, EMG in June 2016 again confirmed a delay in SCV and we performed a second ulnar nerve neurolysis in September 2016. Evaluations of ulnar neuropathy are important because RA also causes cervical spinal lesions such as atlantoaxial subluxation. Adhesion and scars are recognized at the elbow joint in the five patients who underwent neurolysis. Thus, it is necessary to follow up with electromyogram examination, for diagnosis of neuropathy and postoperative evaluation.

Traumatic injury of the transverse atlantal ligament

Introduction. In some cases C2 may suffer only rotational dislocation around its own axis (dens), causing no increase in the atlantodental interval (ADI), making it difficult to diagnose the instability in static radiographies. Objective. To report a case of atlanto-axial traumatic subluxation, without bony injury or displacement, in which the diagnosis cannot be achieved through conventional radiology and computed tomography, and discuss the types of transverse ligament injuries, its diagnosis, the instability and their treatment. Methods.A 61-year-old man, victim of head (occipital), complaining neck. Static radiographies and CT scan of cervical spine were performed, demonstrating no abnormalities. Flexion and extension cervical radiography revealed an increase of ADI in flexion, indicating instability and damage to the transverse atlantal ligament (TAL). The MRI of the cervical spine demonstrated the discontinuity of the TAL, configuring an injury to the structure of the ligament. The patient underwent to early surgery with C1-C2 fixation using the Goel-Harms’technique. Results. The diagnosis could be revealed only in dynamic radiographs or MRI study. The patient presented complete improvement of symptoms. Conclusions. The use of cervical dynamic radiography and / or magnetic resonance imaging allowed the diagnosis of instability and visualization of the TAL injury, avoiding the lack of diagnosis with its consequences. The MRI allows a direct view of the ligament injury, their classification and the prognostic evaluation of the injury, guiding the therapy, surgical or conservative.

Infectious process and torticollis, is there something to worry about?

Atlantoaxial rotatory subluxation in association with head and neck infectious process (Grisel’s syndrome) is a rare disease and poorly reported. The syndrome`s pathogenesis is unclear and several theories have been proposed to explain it. This paper report a 7 year old child with Grisel’s syndrome and the literature on this subject is briefly reviewed.

Anomaly-Related Pathologic Atlantoaxial Displacement in Pediatric Patients.

To analyze clinical and radiologic features of pathologic atlantoaxial displacement (PAAD) in pediatric patients and to compose a treatment algorithm for anomaly-related PAAD. Criteria of different types of PAAD and treatment algorithms have been widely reported in the literature but are difficult to apply to patients with odontoid abnormalities, C2-C3 block, spina bifida C1, and children. We evaluated results of treatment of 29 pediatric patients with PAAD caused by congenital anomalies of the craniovertebral junction (CVJ), treated in Ilizarov Center in 2009-2017, including 20 patients with atlantoaxial displacement (AAD) and 9 patients with atlantoaxial rotatory fixation. There were 14 males (48.3%) and 15 females (51.7%). We singled out 3 groups of patients: nonsyndromic (6 patients, 20.7%), Klippel-Feil syndrome (13 patients, 44.8%), and syndromic (10 patients, 34.5%). Odontoid abnormalities and C1 dysplasia were widely represented in the syndromic group. Local symptoms predominated in the nonsyndromic and KFS groups. In the syndromic group, all patients had AAD and myelopathy. A pronounced decrease of space available for chord C1 and increase of anterior atlantodental interval were noted compared with other groups. We present a unified treatment algorithm of pediatric anomaly-related PAAD. Syndromic AAD are often accompanied by anterior and central dislocation and myelopathy and atlantooccipital dissociation. These patients require early aggressive surgical treatment. Nonsyndromic and Klippel-Feil syndrome AAD, atlantoaxial subluxation, and atlantoaxial fixation often manifest by local symptoms and need to eliminate CVJ instability. Existing classifications of symptomatic atlantoaxial displacement are not always suitable for patients with CVJ abnormalities.

Surgical Stabilization of a Craniocervical Junction Abnormality with Atlantoaxial Subluxation in a Dog

Surgical Stabilization of a Craniocervical Junction Abnormality with Atlantoaxial Subluxation in a Dog

Risk factors associated with bone loss and occurrence of fragility fractures in rheumatoid arthritis patients

Aim of the workTo investigate the bone mineral density (BMD) in rheumatoid arthritis (RA) Tunisian patients, to identify the risk factors associated with its decrease and to assess the fracture risk. Patients and methodsThe study included 173 patients and 173 matched healthy controls. BMD was assessed by the dual-energy X-ray absorptiometry. The risk of hip fracture (HF) and major osteoporotic fracture (MOF) were assessed using the fracture risk assessment tool (FRAX). The disease activity, radiological severity and functional status were investigated. ResultsThe mean age of patients was 54.1 ± 11.04 years and 141 were females; 71.6% menopausal. Disease duration was 8.2 ± 8 years and disease activity score was 5.54 ± 1.26. Sharp van-der-Heijde (SvdH) score was 113.9 ± 106.8, health assessment questionairre (HAQ) score 1.03 ± 0.9. The BMD was significantly reduced in 138 (79.8%) patients and FRAX was higher compared to control (p < .001). The frequency of osteoporosis (48% vs. 18.5%), the risk of MOF (1.8 ± 2.6 vs. 0.6 ± 0.3) and HF (0.7 ± 1.7 vs. 0.08 ± 0.1) were significantly higher in RA patients than in controls. Bone loss in RA was significantly associated with age, low body mass index (BMI), longer disease duration, rheumatoid factor, SvdH, atlantoaxial subluxation and corticosteroids use. Menopause, low calcium intake, erythrocyte sedimentation rate and HAQ were risk factors for reduced BMD. The risk of MOF and HF was associated with age, menopause, calcium intake, BMI, disease duration, HAQ, SvdH, cumulative dose and duration of corticosteroids. Conclusionbone loss and fragility fracture are frequent in RA and related to disease severity, function impairment and corticosteroids use.

Conservative Treatment in Grisel’s Syndrome Following Tonsillectomy

Grisel’s syndrome is a rare complication that is characterized by non-traumatic atlantoaxial subluxation. It is most commonly seen in children after an upper respiratory tract infection or neck surgery, such as an adenoidectomy, tonsillectomy and mastoidectomy. Grisel’s Syndrome is characterized by torticollis and a limited range of motion of the neck with pain. Here the authors report a case of a Malian 5-year-old girl with Grisel’s syndrome following tonsillectomy. The patient’s complaints were fully resolved after 2 weeks of conservative treatment.

The relationship between the degree of displacement of the atlas to axis and the clinical data in atlanto-axial subluxation due to rheumatoid arthritis.

The most common type of anatomical cervical spine involvement is atlanto-axial subluxation (AAS) in rheumatoid arthritis (RA). The purpose of this study was to clarify the relationship between the displacement of the atlas to axis and the clinical data obtained in patients with AAS due to RA. Fifty patients with AAS due to RA that were treated by surgery are herein reviewed. Based on the findings of preoperative lateral cervical radiographs in the neutral position, the patients were classified into two groups as follows: a 10 + group with an atlanto-dental interval (ADI) of ≧ 10mm, and a 10 - group with an ADI < 10mm. Preoperative lateral cervical radiographs demonstrated 15 cases to belong to the 10 + group, while 35 cases belonged to the 10 - group. In the preoperative MR imaging, an intramedullary high signal intensity was observed in seven cases that belonged to the 10 + group and in four cases belonging to the 10 - group. Regarding the neurological severity, the 10 + group included significantly more cases showing severe neurological deficits before surgery; however, there was no significant difference between the two groups regarding the presence of severe deficits even after surgery. The severe displacement group included significantly more cases showing an intramedullary high signal intensity in the preoperative MR images. Our results also suggest that a severe displacement before surgery affected the presence of neurological deficits before surgery; however, it did not affect the neurological recovery from such severe neurological deficits.

56. Grisel’s syndrome (Non-traumatic atlantoaxial rotatory subluxation), a rare but serious complication of Ehlers Danlos Syndrome

56. Grisel’s syndrome (Non-traumatic atlantoaxial rotatory subluxation), a rare but serious complication of Ehlers Danlos Syndrome

Direct Intraoperative Reduction of Basilar Invagination Associated with Atlantoaxial Subluxation – Technical Note

AbstractIn the present article, we describe a technique of direct intraoperative reduction of congenital atlantoaxial subluxation associated with severe basilar invagination and atlas assimilation. It consists of a wide dissection of the craniovertebral junction, exposing the region between the superior facet of C2 and the occiput (described as a “pseudoarticulation” by some authors). After exposure, a self-rotating small dissector or Kobe is used bilaterally, pushing C2 anteriorly and inferiorly, with reduction of the dislocation, followed by craniovertebral fixation. The technique is safe and eliminates the need for an anterior approach to the odontoid reduction, as well as the need to dissect the C1–2 joint.

Skeletal dysplasias: an overview

Abstract Skeletal dysplasias are a large group of rare diseases, with over 400 distinct entities recognised. Diagnosis is challenging, largely reflecting the rareness of individual conditions; yet collectively these disorders affect as many as 1:3000 individuals. The phenotypic diagnosis of skeletal dysplasia is based on careful clinical evaluation and, critically, on assessment of radiological appearances of the skeleton, which in most cases requires specialist expertise. Powerful modern genetic testing is transforming the approach to diagnosis of rare genetic disease, but does not obviate the need for accurate clinical and radiological evaluation. Management of children with skeletal dysplasias must pay attention to detection and prevention of potentially severe complications, particularly those involving compromise of the central nervous system, such as foramen magnum narrowing or atlanto-axial subluxation. Surgical management aims to treat these complications, but can also enhance function and in some cases address short stature. Targeted molecular treatments are emerging with potential to reverse these disorders, and are already transforming the lives of some children with debilitating diseases. We discuss 5 skeletal dysplasia conditions in more detail: Achondroplasia, Pseudoachondroplasia, Spondyloepiphyseal Dysplasia Congenita, Cartilage Hair Hypoplasia and Hypophosphatasia.

Closed reduction of traumatic atlantoaxial rotatory subluxation with type II odontoid fracture

Abstract Background Traumatic atlantoaxial rotatory subluxation (TAARS) in adults is rare. We present an uncommon case of traumatic atlantoaxial rotatory subluxation with an associated type II odontoid fracture in a neurologically intact patient and describe a novel technique used for a successful closed reduction. Case description A 20-year-old female presented with a decreased level of consciousness after being involved in a motor vehicle accident at highway speeds. A computed tomography (CT) demonstrated atlantoaxial rotatory subluxation and a type II odontoid fracture. CT angiography showed a left V3 vertebral dissection. She was neurologically intact on examination. A halo ring was applied and the patient successfully underwent closed reduction using traction and a novel transoral reduction technique described below. After closed reduction, a C1–C2 posterior instrumented fusion was performed. At 12-weeks follow-up, the patient was asymptomatic, neurologically intact with optimally maintained cervical spine alignment. Conclusion Prompt manual closed reduction can safely be achieved in adults using this novel transoral reduction technique, which we describe for the first time in this report.

Radiological manifestations and surgical outcome of combined upper cervical cord compression and cervical ossification of the posterior longitudinal ligament with a minimum 2-year follow-up.

Combined upper cervical cord compression associated with cervical ossification of the posterior longitudinal ligament (OPLL) is a rare and under-recognized disorder. The aim of this study was to investigate the radiological manifestations and surgical outcome of this combined disease.Between May 2011 and July 2015, patients who underwent surgery for combined upper cervical cord compression and cervical OPLL in our institution were included in this study. After a minimum 2-year follow-up, radiological and clinical data were collected. The etiology of upper cervical cord compression and radiological features of cervical OPLL was determined. Surgical outcome was evaluated with Visual Analogue Scale (VAS), Japanese Orthopedic Association score (JOA), space available for the spinal cord (SAC) at the cephalad adjacent level, occupying ratio of OPLL and cervical lordosis.In total, 24 patients (11 men and 13 women) with a mean age of 57.9 years old were included. The etiology of upper cervical cord compression included craniovertebral junction deformity (n = 10), atlantoaxial subluxation (n = 5), and OPLL extending to C2 level (n = 9). The extent, type, and thickest level of cervical OPLL varied among the patients. Significant improvement of VAS and JOA score was noted postoperatively and at a minimum 2-year follow-up. The result was satisfactory in SAC at the cephalad level and occupying ratio of OPLL. There were no significant differences in C2/C7 lordotic angle at the preoperative, postoperative and the last follow-up examination.In conclusion, the radiological manifestations of combined upper cervical cord compression and cervical OPLL varied among the patients. Satisfied results can be achieved with adequate surgical treatment a minimum 2-year follow-up.