C2 Nerve Root Preservation During Posterior Fixation for Instability Secondary to Congenital Craniovertebral Junction Anomalies: Feasibility Factors and Related Outcomes.

OBJECTIVE: Patients with instability because of congenital craniovertebral anomalies often have complex C1-C2 osseovascular anomalies. C2 nerve root sacrifice has been described to address such difficult anatomy during posterior C1-C2 fixation and has its own downsides. Its preservation as a recent alternative poses greater surgical challenge, and the considerations differ from other causes of craniovertebral junctional instability; the pertaining outcomes have been scarcely studied. The objective of this study was to prospectively determine the feasibility and outcomes related to C2 nerve root preservation in patients with congenital atlantoaxial dislocation (CAAD) after posterior C1-C2 fixation. METHODS: In this observational study, 63 patients (126 nerve roots) with CAAD after posterior fixation were prospectively assessed. Underlying osseovascular anomalies affecting the feasibility of C2 nerve root preservation, and C2 nerve-related dysfunction at 12 months follow-up were analyzed. RESULTS: The overall C2 nerve root preservation rate was 89.7%. Even in the presence of extreme joint obliquity/spondyloptosis and anomalous vertebral artery, it was feasible in about three fourths. After preservation, 28.3% patients developed new-onset C2 nerve root dysfunction: neuralgia in 2, dysesthesia in 6, and hypoesthesia/paresthesia in 9. The symptoms were not disabling in most patients. CONCLUSIONS: In most patients with CAAD, C2 nerve root preservation is feasible despite an aberrant bony and vascular anatomy. A few patients after nerve root preservation develop related symptoms that are conservatively manageable, with no significant adverse consequences. Given the controversy in the literature on C2 nerve sacrifice-related outcomes, we favor an attempt at C2 nerve root preservation.

The collateral fallout of COVID19 lockdown on patients with head injury from north-west India.

BACKGROUND: The COVID19 lockdown has altered the dynamics of living. Its collateral fallout on head injury care has not been studied in detail, especially from low- and middle-income countries, possibly overwhelmed more than developed nations. Here, we analyze the effects of COVID19 restrictions on head injury patients in a high-volume Indian referral trauma center. METHODS: From the prospective trauma registry, clinico-epidemiological and radiological parameters of patients managed during 190 days before and 190 days during COVID19 phases were studied. As an indicator of care, the inpatient mortality of patients with severe HI was also compared with appropriate statistical analyses. RESULTS: Of the total 3372 patients, there were 83 head injury admissions per week before COVID19 restrictions, which decreased to 33 every week (60% drop) during the lock phases and stabilized at 46 per week during the unlock phases. COVID19 restrictions caused a significant increase in the proportion of patients arriving directly without resuscitation at peripheral centers and later than 6 h of injury. Though the most common mechanism was vehicular, a relative increase in the proportion of assaults was noted during COVID19. There was no change in the distribution of mild, moderate, and severe injuries. Despite a decrease in the percentage of patients with systemic illnesses, severe head injury mortality was significantly more during the lock phases than before COVID19 (59% vs. 47%, p = 0.02). CONCLUSIONS: COVID19 restrictions have amplified the already delayed admission among patients of head injury from north-west India. The severe head injury mortality was significantly greater during lock phases than before COVID19, highlighting the collateral fallout of lockdown. Pandemic control measures in the future should not ignore the concerns of trauma emergency care.

An Unusual Cause of Vertebrobasilar Insufficiency in a Case of Atlantoaxial Dislocation with Anomalous Vertebral Artery.

BACKGROUND: Posterior circulation stroke resulting from atlantoaxial dislocation (AAD), although uncommon, is a well-described entity. The normally coursed V3 segment of the vertebral artery (VA) is likely to be stretched because of C1-C2 dislocation and further compromised by the C1-C2 translational mobility. The persistent first intersegmental artery (PFIA), an anomalous variant does not course through the C1 transverse foramen, but rather crosses the posterior C1-C2 joints and is unlikely to be affected by the C1-C2 dislocation. Therefore, a patient with AAD and anomalous VA presenting with stroke should be evaluated for other etiologies of VA compromise. CASE DESCRIPTION: We report a patient of AAD with PFIA who presented with posterior circulation stroke. Careful radiological evaluation revealed a loose body (LB) adjacent to the medial aspect of the left C1-C2 facet compressing the anomalous VA. Intraoperatively, there was a large LB on the posteromedial border of the joint, compressing the VA. The anomalous VA was mobilized, and the offending element removed followed by fixation of the C1-C2. CONCLUSIONS: One should be aware of such an etiology of arterial compromise in cases of AAD with coexistent anomalous VA. An underlying LB or large osteophytes resulting from instability may be the offending cause, and needs to be dealt with, as fusion alone may not benefit the patient.

Changing Perception but Unaltered Reality: How Effective Is C1-C2 Fixation for Chiari Malformations without Instability?

OBJECTIVE: The recently described C1-C2 fixation without foramen magnum decompression (FMD) for the management of Chiari malformations (CMs) has sparked a controversy. C1-C2 fixation has been reported to be more effective than traditional FMD. However, the results after such a procedure have not been as well validated. We assessed the efficacy of C1-C2 distraction and fusion without FMD in patients with CM and without demonstrable atlantoaxial instability. METHODS: A total of 40 patients with CM had undergone C1-C2 distraction and fusion without FMD. The preoperative and follow-up clinicoradiological data were prospectively compared using the Klekamp neurologic score, visual analog scale, pBC2 index (ventral brainstem compression), and Vaquero index (syringomyelia). RESULTS: Of the 40 patients, 28 (70%) showed improvement in their neurological score and visual analog scale, 8 remained in same status, 3 showed deterioration, and 1 died during the follow-up period. The clinical improvement did not correlate with the severity of ventral cervicomedullary compression or the presence of osseous deformities (assimilated C1 arch, platybasia and basilar invagination) despite the reduction in the mean pBC2 index (7.9 vs. 5.9). The syringomyelia had decreased in 51.7%, with a reduction in the Vaquero index at follow-up (0.48 vs. 0.38). CONCLUSIONS: The overall results after C1-C2 distraction and fusion for CM without instability were not exceptionally better and appeared to be similar to the outcomes reported with FMD. The neurological improvement seen in some patients had possibly resulted from indirect ventral decompression (due to distraction of C1-C2) rather than the stabilization itself. The presence of bony anomalies such as an assimilated C1 arch, platybasia, basilar invagination, and ventral brainstem compression did not significantly influence the outcomes.

Comparative Evaluation of Shear Bond Strength and Microleakage of Two Self-adhering Composite Resins: An in vitro Study.

INTRODUCTION: A good dental cement used as repair material should possess chemical binding, easy handling characteristics, minimal marginal breakdown and minimal polymerization shrinkage, high resistance to wear, high cohesive strength, and good color stability. This study was undertaken to compare the in vitro microleakage and shear bond strength among the newly introduced Prime fill flow and Dyad flow. AIM: The aim of this study was to determine the effect on shear bond strength and microleakage of two self-adhesive composite resin. MATERIALS AND METHODS: Selected specimens were collected and stored in deionized water with an antibactericidal agent, 0.2% sodium azide, until ready to be used and were randomly divided into two groups: group I: Dyad flow and group II: Prime fill flow; specimens were sheared with a universal testing machine, and the results were calculated in megapascal, specimens were sectioned in a mesiodistal direction at four different locations, and analyzed for leakage (dye penetration) using a stereomicroscope. RESULTS: The results of the present study showed that acceptable values for Prime fill flow seemed to have least microleakage and high bond strength as compared with Dyad flow. CONCLUSION: Here, it can be concluded that there was significant difference in the in vitro microleakage and shear bond strength among the Prime fill flow and Dyad flow. CLINICAL SIGNIFICANCE: Self-etch adhesives when compared with total-etch systems have the advantage of reducing the application time and the number of steps in pediatric dentistry. Patients' age and cooperation are not always ideal; the treatment outcome is greatly influenced by the patients' behavior. It is therefore imperative to recede the application time of some materials mostly in pediatric dentistry.