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BACKGROUND:Sectioning of the C2 nerve root allows for direct visualization of the C1-2 joint and may facilitate arthrodesis. OBJECTIVE:To determine the clinical and functional consequences of C2 nerve root sectioning during placement of C1 lateral mass screws. METHODS:All patients undergoing C1 lateral mass screw fixation were included in this prospective study. A standard questionnaire was used to determine the severity of occipital numbness/pain and its effect on quality of life (QOL). Domains of the neck disability index were used to assess the disability related to C2 symptoms. RESULTS:A total of 28 patients were included (C2 transection, 8; C2 preservation, 20). A trend of decreased blood loss and length of surgery was observed in the C2 transection cohort. Occipital numbness was reported by 4 (50.0%) patients after C2 transection. Occipital neuralgia was reported by 7 (35.0%) patients with C2 preservation. None of the patients with numbness after C2 transection reported being “bothered” by it. All patients with occipital neuralgia after C2 sparing reported being “bothered” by it, and 57.1% reported a moderate to severe effect on QOL. The use of medication was reported by 5 (71.4%) patients with neuralgia vs none with numbness. Mean disability was significantly higher with neuralgia vs numbness (P = .016). CONCLUSION:C2 nerve root transection is associated with increased occipital numbness but this has no effect on patient-reported outcomes and QOL. C2 nerve root preservation can be associated with occipital neuralgia, which has a negative impact on patient disability and QOL. C2 nerve root transection has no negative consequences during C1-2 stabilization. ABBREVIATIONS:NDI, neck disability indexQOL, quality of life

The aim of this study was to explore whether reported pain and functional disability in whiplashassociated disorders (WAD) patients is associated with lesions to specific soft tissue structures in the upper cervical spine, as assessed by MRI. Pre-selected structures for MRI assessment included the alar ligaments, the transverse ligament, the tectorial and the posterior atlanto-occipital membranes. The questionnaire employed was a modification of the Oswestry Low Back Pain Index. It was comprised of ten single items related to pain and activity of daily living. Ninety-two whiplash patients and 30 control persons, randomly drawn, were included. WAD patients reported significantly more pain and functional disability than the controls, both for total score and each of the ten single items. In the WAD patients, MRI lesions to the alar ligaments showed the most consistent association to the reported pain and disability. Lesions to other structures often occurred in combination with lesions to the alar ligaments. Lesions to the transverse ligament and to the posterior atlanto-occipital membrane also appeared to be related to the NDI score, although the association was weaker than for the alar ligament. The disability score increased with increasing number of abnormal (grade 2–3) structures. These results indicate that symptoms and complaints among WAD patients can be linked with structural abnormalities in ligaments and membranes in the upper cervical spine, in particular the alar ligaments.

Background Patients with atlantoaxial dislocation combined with atlas occipitalization often present with variations in the anatomy of the vertebral artery and bone, posing potential risks during the implantation of the C2 pedicle screws during surgery. Objective Based on comprehensive preoperative imaging evaluation, this study investigates the blood supply, course, and relationship with bone of the vertebral artery in patients with atlantoaxial dislocation combined with atlas occipitalization, aiming to provide reference for safe implantation of internal fixation. Methods Imaging data of 77 patients with atlantoaxial dislocation combined with atlas occipitalization from October 2015 to December 2023 at the First Affiliated Hospital of the University of Science and Technology of China were collected, including CT, CT angiography, and MRI. The blood supply, course, and relationship with surrounding structure of the vertebral artery were analyzed using PACS and RadiAnt software. Results There were 18 males and 59 females, with an average age of 48.5 ± 10.5 years (range: 17–71 years). Forty-one cases (53.2%) were associated with congenital C2-3 fusion(Klippel-Feil syndrome). Vertebral artery blood supply was predominantly unilateral (including single blood supply) in 56 cases (72.7%), with left-sided predominance (62.5%). Segment V3 course variations of the vertebral artery were common, with 47 cases (35.6%) not entering the transverse foramen of C1. High-riding vertebral arteries were present in 36 cases (46.8%), with 22 cases (61.1%) associated with congenital C2-3 fusion. The average width of the axis pedicle on the high-riding side was 2.13 ± 1.2 mm, and the height of the isthmus was ≤ 5 mm, with an average of 2.55 ± 1.07 mm. There was a loose gap on the lateral side of the vertebral artery within the transverse foramen, with an average of 2.1 mm, and the corresponding width of the subarachnoid space on the inner side of the axis pedicle was 3.48 mm. Conclusion Comprehensive preoperative imaging evaluation can reduce the risk of vertebral artery injury during surgery in patients with congenital atlantoaxial dislocation combined with atlas occipitalization, and provide feasible and optimized internal fixation solutions.

Objectives The type of atlantodental space tissue in patients with atlantoaxial dislocation (AAD) can help doctors understand the possibility of reduction before surgery. However, relevant research on this topic is lacking. In this study, we aimed to summarise the atlantodental space classification of patients with AAD using magnetic resonance imaging (MRI) and explore their clinical characteristics. Materials and methods Preoperative 3T cervical MR images of patients who underwent posterior reduction and fixation surgery for non-traumatic AAD between 1 September 2012 and 31 July 2023 were collected. Two radiologists read and recorded the MRI results based on the standard protocol. The kappa value was used to evaluate intra- and inter-observer agreements. The patient’s age, sex, body mass index, clinical symptoms, Japanese Orthopaedic Association (JOA) score, and visual analogue scale information were obtained from medical records. Results A total of 135 patients with AAD (mean age, 51.3 ± 14.0 years, 52 men) were included in the analysis. The inter-observer agreement between the two readers was 0.818 ( P  < 0.0001). The intra-observer consistencies were 0.882 ( P  < 0.0001) and 0.896 ( P  < 0.0001). Patients with inflexible tissue signs exhibit more irreducible in hyperextension position, and their range of motion of ADI is smaller. These patients were older and had a higher incidence of abnormal spinal cord signals and JOA scores. Conclusions Novel MRI signs exhibited high inter- and intra-observer consistency and were associated with patient age, abnormal spinal cord signals, reducibility, range of motion of ADI, and symptoms.

Background context Studies have shown biomechanical superiority of cervical pedicle screw placement over other techniques. However, accurate placement is challenging due to the inherent risk of neurovascular complications. Navigation technology based on intraoperative 3D imaging allows highly accurate screw placement, yet studies specifically investigating screw placement in patients with traumatic atlantoaxial injuries are scarce. The aim of this study was to compare atlantoaxial screw placement as treatment of traumatic instabilities using iCT-based navigation or fluoroscopic-guidance with intraoperative 3D control scans. Methods This was a retrospective review of patients with traumatic atlantoaxial injuries treated operatively with dorsal stabilization of C1 and C2. Patients were either assigned to the intraoperative navigation or fluoroscopic-guidance group. Screw accuracy, procedure time, and revisions were compared. Results Seventy-eight patients were included in this study with 51 patients in the navigation group and 27 patients in the fluoroscopic-guidance group. In total, 312 screws were placed in C1 and C2. Screw accuracy was high in both groups; however, pedicle perforations > 1 mm occurred significantly more often in the fluoroscopic-guidance group ( P = 0.02). Procedure time was on average 23 min shorter in the navigation group ( P = 0.02). Conclusions This study contributes to the available data showing that navigated atlantoaxial screw placement proves to be feasible as well as highly accurate compared to the fluoroscopic-guidance technique without prolonging the time needed for surgery. When comparing these data with other studies, the application of different classification systems for assessment of screw accuracy should be considered.

Fracture of the anterior arch of the atlas, accompanied by posterior atlantoaxial dislocation, typically presents on CT imaging as the odontoid process penetrating through and causing a high-energy shear fracture of the anterior arch. This injury may occur with or without retained fracture fragments. Its characteristic appearance resembles that of a plough traversing the earth, and it has historically been termed the plough fracture. Published case reports documenting this specific fracture pattern remain extremely rare in the literature. In our research group's earlier study on traumatic posterior atlantoaxial dislocation (TPAD), this fracture pattern was categorized as anterior arch fracture type TPAD (TPAD-AOT Type III). It was further subclassified based on transverse ligament integrity into: (1) Anterior arch fracture type TPAD with intact transverse ligament, and (2) Anterior arch fracture type TPAD with transverse ligament injury, reflecting a progressive increase in instability severity across these subtypes. Hyperflexion and hyperextension injury mechanisms play significant roles in the pathogenesis of this fracture pattern, with definitive diagnosis typically established via CT imaging. The integrity of the transverse ligament is critical for atlantoaxial stability. For patients with an intact transverse ligament, rigid external fixation or internal fixation may be indicated based on fracture displacement and reducibility. However, in cases with transverse ligament injury, posterior C1-C2 fusion typically achieves favourable functional outcomes.

Background This study reports on the surgical technique used and clinical outcomes obtained during the treatment of basilar invagination (BI) without atlantoaxial dislocation (AAD) through the correction of the clivus canal angle (CCA) using interfacet distraction and fixation. Methods Nineteen cases with BI without AAD treated by the correction of the clivus canal angle were retrospectively analyzed. Pre- and postoperative computed tomography scans and three-dimensional reconstruction views were obtained to measure the size of the CCA, pB-C2 distance, and degree of BI. Chiari malformation and syringomyelia were evaluated by magnetic resonance imaging (MRI). The clinical outcomes for all patients were measured using the Japanese Orthopedic Association (JOA) scale. The CCA was corrected by using interfacet distraction and fixation techniques. The Wilcoxon test was used to compare pre- and postoperative measurements. Results All the patients were followed up for 24.95 ± 5.22 months (range 12-36 months); no patient suffered intraoperative nerve or vascular injury. Clinical symptoms improved in 17 patients (89.5%). The mean JOA score increased from 12.32 ± 1.89 to 14.37 ± 1.30 (Z = -3.655, P  < 0.001). The mean CCA improved from 129.34 ± 8.52° preoperatively to 139.75 ± 8.86° postoperatively (Z = -3.824, P  < 0.001). The mean pB-C2 decreased from 7.47 ± 2.21 to 5.68 ± 3.13 (Z = -3.060, P  = 0.002). Syringomyelia was significantly reduced in 10 out of 13 patients by the first follow-up year. All patients achieved bony fusion. Conclusion Posterior interfacet distraction and fixation to correct the CCA is a feasible and effective method for treating BI without AAD.

Purpose The aim of this study is to introduce a new technique for the rapid and accurate reduction of traumatic atlantoaxial dislocation (TAAD) and to investigate its radiological and clinical outcomes. Methods The clinical outcomes of 18 patients who were diagnosed with acute TAAD and underwent rapid transoropharyngeal closed reduction in our hospital were retrospectively analyzed from January 2015 to December 2020. Following general anaesthesia, all patients were immediately treated with oropharyngeal reduction under somatosensory evoked potential monitoring. The Japanese Orthopedic Association score, neck disability index and visual analog scale score for neck pain were used to evaluate clinical efficacy. Atlantodental distance, posterior atlantodental interval, and the clivus-canal angle were used to assess reduction and spinal cord compression. Results The mean follow-up time was 23.3 months, with a range of 13–38 months. No neurovascular injury occurred during the operations. For all patients, the closed reduction method through the oropharynx under general anaesthesia was successful, and the success rate of reduction was 100%. All patients recovered uneventfully with marked improvement in clinical outcomes and imaging parameters ( P < 0.01). Two patients developed mild postoperative dysphagia. One patient developed postoperative fever and pulmonary infection. Conclusion Rapid trans-oropharyngeal closed reduction can safely, effectively, and rapidly reduce acute TAAD. This method provides a new strategy for treatment of the condition.

Background Irreducible atlantoaxial dislocation (IAAD) is a potentially life-threatening condition and remains surgically challenging. In selected patients, anterior C1-2 release followed by posterior reduction and fusion is effective, but traditional transoral anterior release is technically demanding. Endoscopy and plasma radiofrequency ablation (PRA) may improve visualization and soft tissue handling in a confined corridor, but their combined use for IAAD has been rarely reported. This study aimed to describe an endoscopic-assisted transoral atlantoaxial joint release using PRA and to report preliminary feasibility, procedural safety, and clinical/radiographic outcomes in patients with IAAD. Methods We retrospectively reviewed five consecutive patients with IAAD who underwent endoscopic-assisted transoral C1–2 release using PRA, followed by posterior reduction and fusion. Clinical outcomes were assessed with the Japanese Orthopaedic Association (JOA) score and Odom criteria. Radiographic correction was evaluated using the clivus–axial angle (CAA) and cervicomedullary angle (CMA). Perioperative outcomes included operative time, blood loss, airway management, wound healing, and approach-related complications. Fusion was assessed on follow-up computed tomography. Results The mean age was 57.4 years, and the mean follow-up was 33 months. Two patients had restricted mouth opening. Mean total operative time was 229 min (transoral stage 130 min), with a mean estimated blood loss of 170 mL. All patients were extubated in the operating room; none required reintubation, tracheostomy, or intensive care. No cerebrospinal fluid leak, neurological deterioration, posterior pharyngeal wound complication, surgical site infection, dysphagia, or implant-related failure occurred. CAA improved from 117.9° to 143.0°, and CMA improved from 128.5° to 152.9°. Solid fusion was achieved in all cases. JOA scores improved from 8.2 to 14.2, and 80% of patients were rated excellent/good by Odom criteria. Conclusions This proof-of-concept series suggests that endoscopic-assisted transoral C1–2 release using PRA can facilitate subsequent posterior reduction and fusion in selected IAAD patients, including those with restricted mouth opening, with encouraging early safety and clinical/radiographic improvement. Given the small retrospective, non-comparative design and the inability to disentangle PRA-related effects from adjunctive drilling, larger multicenter comparative studies are needed to validate these preliminary findings and clarify the specific contribution of PRA within the procedure.