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• W156788448 abstract "We thank the Editor for sending us the interesting and useful comment made by Salunke et al1 regarding our paper.2 Although we appreciate their paper and its contribution to the existing body of literature, we would like to note the following: Although their paper described the abnormal values for reducible and irreducible atlantoaxial dislocation (AAD), it did not mention any values for controls. The paper mentioned that their values were significant compared with those in controls without actually mentioning the values of controls. Our study clearly mentions the values of controls for the indices that we described. These include (1) sagittal inclination (SI) mean, normal 87.15 ± 5.65°; in patients with basilar invagination (BI) and AAD, 127.1 ± 22.05° (P < .01); (2) craniocervical tilt (CCT); mean, normal: 60.2 ± 9.2°; in patients with BI and AAD, 84.0 ± 15.1° (P < .01); (3) mean coronal inclination, 110.3 ± 4.23°; in patients with BI and AAD, 121.15 ± 14.6° (P < .3 for BI only). We believe that it is important to mention the normal quantitative values, which make comparisons and its application for surgical strategies useful. The older indices such as Wackenheim's clival canal line (WL),3,4 McRae's lines (ML),5 Chamberlain's line (CL), and modified Ranawat's line (RL) proved to be useful for surgeons as they provided quantitative baseline values for comparison with the corresponding values in patients having BI and AAD. Their paper did not mention any comparison with the older existing indices cited above. Our paper compared our indices with all the older existing indices like WL, CL, RL, and ML. Using receiver-operating characteristic curves, we found that the distance from the CL with zero as the cutoff had the best sensitivity and specificity. Thus, our paper was the first to demonstrate a correlation between our described joint indices with the degree of severity of BI and AAD (as measured by WL, CL, RL, and ML). An earlier paper by Yin et al,6 although providing descriptions of 4 types of joint sloping in the sagittal direction, again did not provide any quantitative measurements. Both the coronal angle and sagittal angle measured by Salunke et al1 used the medial most points of foramen magnum and hard palate, respectively. Although these are accurate, when the C1 is fused with the occiput, the measurements become erroneous when C1 arch is not occipitalized. Their argument that they perform computed tomography scans with patients in the neutral position when the C1 is not fused with C2 does not hold true, as many of these patients present with torticollis and severe fixed rotatory abnormalities. In contrast, for SI described by us,2 we used the posterior border of the C2 and dens as a referential plane, which is part of the same anatomic structure and remains constant whether the C1 is fused with occiput or not. The measurement of SI2 is quite easy. We have now performed it in hundreds of patients, and it is now a routine technique of measurement (Figures 1 and 2). It does not require any special sequences and can be performed either digitally or on film, thus avoiding any additional imaging.2 We have very rarely encountered a retroverted dens, which has made the measurement of SI difficult. However, if we do encounter a retroverted dens, we extrapolate the line along the posterior border of the C2 body upward and use it as a reference line for measuring SI (this was mentioned in our earlier publications).2,7 Similar to measuring CI,2 we have used the midpoints of uncinate processes of C2 and C3 (Figure 3), which is again very easy to perform on all routine imaging.FIGURE 1: The method of calculating the sagittal joint inclination. This is actually the angle between the long axis of the odontoid process and the surface of the C1-2 joint. However, because the odontoid process is in the midline and the C1-2 joint is at the level of parasagittal section, the method to measure this angle is shown. A, C, step I. In the midsagittal section, a line is drawn along the posterior border of the odontoid process (line A). Next, a line is drawn parallel to the border of the image (line B), which now subtends an angle (ang) (A). C, The value of the ang is 78.9°. B, D, step II. This is performed in the parasagittal section where the joints are seen. In this step, a line is first drawn parallel to the border of the image (line B1 [C, D]). Now the same value of angle is constructed as in ang (called here as ang1 [B]) with another line A1 that now passes along a point on the posterior border of the C2 joint surface. Step III: This is also performed in the parasagittal section (B, D). In this step, a line is now drawn passing parallel to the C2 facet joint (line C [C, D]). The angle is now subtended between the lines A1 and C is called the sagittal joint inclination (SI). In this case, the SI is about 90.6°. In our series, values of SI in normal individuals were 87.15 ± 5.65°; in patients with BI and AAD, they were 127.1 ± 22.05° (P < .01 for both BI and AAD). Please note that the horizontal line B that is drawn in the midsagittal section (A, C) should be parallel to the border of the film. It may be drawn at any distance from the lower border of the image on the film. Since computed tomography is performed on the patient at the same point in time, this line will have the same referential value in midsagittal and parasagittal sections. Hence, this line is useful to measure the angle between the long axis of odontoid process and the C1-2 joint, which is the sagittal joint inclination. From Chandra et al.2 Reprinted with permission from Wolters Kluwer.FIGURE 2: The method to measure the coronal joint inclination, which is actually the angle between the long axis of odontoid process and the C1-2 joints in the coronal plane. In the midcoronal section where the C1-2 joint is seen well, the midpoints of the 2 lines joining the uncinate processes of C2 and C3, respectively, are first marked (here being E1 and E2 [A, C]. A line joining these 2 points (called line D [A, C]) is now drawn extending upward. Another line (line F) is now drawn parallel to the upper border of the C2 joint, which now joins the line D (B, D). The angle subtended between the lines D and F is called the coronal inclination (CI). The normal value of coronal inclination in our series was 110.3 ± 4.23° and in patients with basilar invagination and basilar invagination was 121.15 14.6° (mean P value between right and left joints was .2). From Chandra et al. 2 Reprinted with permission from Wolters Kluwer.FIGURE 3: Schematic diagram showing our method of measuring the sagittal inclination (SI) and craniocervical tilt (CCT). SI is measured as the angle between the line drawn along the upper border of the C2 joint and that drawn along the posterior border of the odontoid process. Since our method uses the anatomic structures of the C2, the SI is not influenced by whether C1 is occipitalized. CCT is measured as an angle between the line drawn along the anterior border of the clivus and the anterior border of odontoid process. See text for normal values. From Chandra et al. 2 Reprinted with permission from Wolters Kluwer.We have again found CCT to be a very useful parameter (Figure 3). Following the surgical technique of distraction, compression, extension, and reduction (DCER),7,8 its improvement provides very useful input for the degree of correction of the deformity, which was not possible with a transoral procedure followed by posterior instrumented fixation. This does not vary in flexion and extension, as the measurement is performed in only irreducible cases in which x-rays of flexion and extension of the neck do not show any variation. CCT is thus a measure of deformity at the craniovertebral junction. To summarize, we reiterate the novelty of our paper, stating that it is the first paper demonstrating quantitative normative and abnormal values for the C1-2 joints providing an accurate measurement, not only to measure the degree of its abnormality, but also to demonstrate its improvement after DCER. It is also the first study of its kind to show a correlation with the previously described indices (WL, ML, CL, and RL) and the degree of severity of BI and AAD. Having said this, we appreciate the efforts of Salunke et al1 and others6 who have demonstrated, along with our paper, the importance of understanding joint anatomy in patients with BI and AAD. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article." @default.
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• W156788448 date "2015-03-01" @default.
• W156788448 modified "2023-09-26" @default.
• W156788448 title "In Reply" @default.
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