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• W2322184584 abstract "To the Editor: We read with great interest the article published in Neurosurgery in June 2013 entitled “Distraction, Compression, and Extension Reduction of Basilar Invagination and Atlantoaxial Dislocation: A Novel Pilot Technique.”1 By inserting a joint spacer and using it as a pivot, this novel technique combined distraction, compression, and extension movement of C1-C2 joints to achieve the reduction of both basilar invagination (BI) and atlantoaxial dislocation (AAD) in patients with developmental irreducible AAD-associated BI. The technique may make a new step in the reduction of BI and AAD in these patients through the posterior direction. However, we have some different opinions in some details of the technique: First, the authors prefer the C2 laminar screw over the C2 pedicular screw, and consider the thin C2 arch or deformed C2 arch not allowing the placement of a translaminar screw as one of the exclusion criteria. However, the C2 pedicular screw provides a theoretically stronger purchase than the laminar screw, and is not so difficult to place to avoid it, except for a high-riding vertebral artery. Although the C2 lamina is bulky in most cases of developmental anomalies, the C2 pedicular screw can be a good alternative; a thin C2 arch or a deformed C2 arch not allowing placement of a translaminar screw should not be considered as an exclusion criterion. The authors consider that a translaminar screw provides a longer lever arm, thus reducing the screw bone tension. Nevertheless, a translaminar screw forms a more oblique line with a C1 mass screw than a C2 pedicular screw. This makes it more difficult for the clamp to provide compressive force. And at the same time, it needs a longer rod and would make it more difficult to combine the screws with the rod. In addition, the longer rod is not really in the direction of the lever line for reduction. Further, a translaminar screw is only several millimeters posterior to a pedicular screw. That means the real longer lever arm in the direction of reduction is limited. Second, using the distraction, compression, and extension reduction technique, the authors were able to reduce the AAD completely in 94% of cases, and BI satisfactorily in all cases. They feel that this technique may be used satisfactorily in all cases of BI and AAD. We guess that the patients operated on by the authors might be cases with less severely inclined lateral joints. As mentioned in the article, in 1 patient, the spacer slipped forward from the joint space and could not be retrieved. In our observation, in many patients with irreducible AAD, the lateral joints between C1 and C2 are not dislocated.2 AAD only indicates increase of the interval between the apex of the odontoid process and anterior arch of the atlas in the center joint. The reduction of AAD is often based on dislocation of the lateral joints. That is one of the reasons that complete reduction could not be achieved in 100% of patients and why the spacer slipped forward from the joint space. We believe the spacer could be used effectively as a fulcrum in cases with lateral joints in horizontal or near-horizontal direction. But even in this condition, to maintain the spacer in a satisfactory location is still a problem when the joint is severely dislocated. In addition, in many cases, the lateral joints are in an oblique direction on the sagittal surface,3 and the spacer could not be used as effectively as a fulcrum. In some patients, the lateral joints are even vertical in direction. We do not think these patients could achieve satisfactory reduction with any currently available technique. 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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• W2322184584 date "2015-02-01" @default.
• W2322184584 modified "2023-09-23" @default.
• W2322184584 title "Letter" @default.
• W2322184584 cites W2020250604 @default.
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• W2322184584 doi "https://doi.org/10.1227/neu.0000000000000603" @default.
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