C1-C2 coronal and sagittal joint angle based treatment algorithm for the need of transoral odointectomy in complex craniovertebral junction anomalies with Clinico-Radiological outcome analysis.

OBJECTIVE: Craniovertebral junction (CVJ) pathology by virtue of its complexity is a surgical challenge in the realm of neurosurgery. We analyzed the need for transoral odointectomy in view of their C1-C2 joint coronal and sagittal angle of 58 patients with complex CVJ anomalies treated surgically. The clinical and radiological outcome of the patients was assessed and a treatment algorithm is proposed. METHODS: A total of 58 cases were included in the Prospective study over the period of 2 years. Patients were evaluated clinically, investigated, and operated with reduction and rigid internal fixation with screws and rod. The clinical outcome was measured by Modified Japanese orthopedic association score(mJOA) and radiologically by conventional craniometrics indices. Paired 't' test used for statistical analysis. RESULTS: Mean age of patients: 30 years, with mean, follow up: 20.5 months. 46(80%) patients were operated by posterior and 12(20%) by combined approach (anterior transoral with posterior). Occipitocervial fixation was done in 15(25.8%) cases and C1-C2 fixation in 43(74.2%) cases. As compared to patients with low coronal angle, the patient with coronal angle >65° needed anterior decompression (87.5%) and all (100%) had Occipitocervical fixation. Clinical outcome analysis showed significant improvement in mean mJOA score (preop 11.9 Vs postop 14.6) after surgery. All craniometrics indices were significantly improved after surgery. The overall complication rate was 10% with a mortality of 1.7%. 6 months follow up completed in all patients with a 100% fusion rate. CONCLUSION: Occipitocervical fixation and anterior decompression is required in increased C1-C2 joint CA (>65°) for bony realignment and adequate decompression. Measurement of C1-C2 joint coronal and sagittal angle in complex CVJ anomalies will easily anticipate the surgeon regarding the need for anterior decompression inform of transoral odointectomy.

Risk Factor Assessment and Outcomes of Intra Procedural Rupture of Intracranial Aneurysm During Endovascular Treatment: A Race Against Time.

AIM: To identify the risk factors for aneurysmal intra-procedural rupture (IPR) of intracranial aneurysms suring endovascular treatment, and to discuss its management and outcomes. MATERIAL AND METHODS: A total of 106 patients with cerebral aneurysm who have undergone endovascular treatment (EVT) were included in this study, with a mean follow-up period of 17.2 months. Risk factors for IPR, such as the aneurysm?s location, size and morphology, etc. were evaluated, and the chi-squared test was used for statistical analysis. Clinical outcomes were assessed using the modified Rankin scale (mRS) at 15 months. RESULTS: Among all 106 patients who have undergone EVT, five (4.7%) had aneurysmal IPR as well as ruptured aneurysms with subarachnoid haemorrhage (SAH). Among those five patients, primary coiling was performed in three cases and balloon/stentassisted coiling was performed in two cases, with complete occlusion of the aneurysmal sac achieved in four (4/5) patients. Clinical follow-up with the mRS scores of the patients revealed mortality in one patient (20%), favourable outcomes in three patients (60%) and unfavourable outcomes in one patient (20%). CONCLUSION: Aneurysmal IPR is considered a rare but important complication of endovascular coiling that is associated with poor clinical outcomes. Several risk factors are significantly associated with IPR, such as small-sized aneurysm ( < 3.5 mm), presence of bleb and parent vessel tortuosity. Acom location, irregular shape and past episode of SAH also increase the risk of IPR, but such association was found to be statistically insignificant in our study. Although IPR is considered a devastating complication, good clinical outcomes can be achieved with early detection and proper management using rapid aneurysmal coil packing and occlusion.

C1 lateral mass reduction screws for treating atlantoaxial dislocations: Bringing ease by modification.

Objective: The C1-C2 fixation technique revolutionized the management of complex craniovertebral junction (CVJ) anomalies. Presently used polyaxial screw and rod systems have inadvertent technical difficulties in rod fitting and reduction of atlantoaxial dislocations (AAD) requiring forceful joint handling. The purpose of this study is to analyze the use of a specially designed "reduction screw" in C1 lateral mass in C1-C2 fixation for treating AAD with or without basilar invagination (BI). Study Design: This is a retrospective cohort study in which long lateral mass reduction screws were used for C1-C2 fixation. Materials and Methods: Eighteen patients diagnosed with congenital AAD with or without BI treated with C1-C2 fixations using C1 reduction lateral mass were included in the study. The outcome was measured clinically by the modified Japanese Orthopedic Association score and radiologically by conventional craniometric indices. Results: Among all cases included in the study, 72% (13/18) are males and 18% (5/18) are females with average age at presentation of 33.5 years. Among 18 cases of AAD, 84% (15/18) of patients have BI, 22% (4/18) have Chiari Type 1 malformation, and one patient has Klipple-Feil syndrome. Symptomatic improvement is noted in all patients following surgery. Adequate reduction of AAD with normalization of radiological indices was also achieved in all 18 (100%) patients. Conclusion: C1 lateral mass reduction screw in C1-C2 fixation helps in reduction of AAD and BI (Type A) even in difficult cases of CVJ anomalies with intraoperative technical ease, reduced operative time, no need for special instruments or complex maneuvers, and avoiding potential neurological injury.

Double Anchoring Technique of Occipito-Cervical Fixation Using Innovative Occipital Plate: A Preliminary Study.

Background: Occipito-cervical fixation (OCF) provides immediate rigid fixation to cranio-vertebral junction (CVJ); however, in current practice, the optimal occipito-cervical fixation method is arguable. Aim: The aim of this study was to test the safety and efficacy of a newly designed inside-outside occipital (OC) plate system for the treatment of cranio-vertebral junction instability. Material and Methods: Thirty-two patients of CVJ instability were treated using this new OC plate system. Safety and efficacy of this new OC plate was evaluated radiologically and clinically. Results: Follow-up period ranged from 9 to 23 months. During the follow-up, no implant failure, recurrent subluxation, or newly developed instability at adjacent levels occurred, except in one patient in whom C2 screw pullout occurred due to trauma. All patients showed a satisfactory fusion at three months follow-up examination. Conclusions: These preliminary results suggest that this OC plate system is a simple, safe, and effective method for providing immediate internal rigid fixation of the CV junction. Long-term results are needed to determine the superiority of this OC plate over other methods of occipital fixation.