1、Celebration forthe second WuHan international orthopedic peak forum,Recognition and Treatment of Complex Atlantoaxial Dislocation,The Orthopedic Hospital of General Hospital of Guangzhou CommondQing-shui Yin, Hong Xia, Zeng-hui Wu, Xiang-yang Ma, Kai Zhang, Jian-hua Wang, Fu-zhi Ai, Xiao-hong Mai, L
2、ei Wan,The atlantoaxial dislocation that complicating with other complex factors, and can not be treated with conventional method was denominated as Complex Atlantoaxial Dislocation.,Preface,Concept,Information and Method,74 cases, 36 male, 38 female, with average age of 34 years( 2 to 54 years)Comp
3、lex congenital abnormality 39 cases Osteoporosis 7 cases The diameter of the pedicle of vertebral arch of the atlantoaxial was too small 8 cases Rebuilding of the redislaction after the operation of atlantoaxial 10 cases,Complex trauma 3 cases Refractoriness rotation fixation 4 cases Tumor 3 cases,G
4、eneral information,Treatment Methods,Different especial treatment was used to treat different complex condition. TARP-III surgery (Transoral anterior approach for the fixation of C2 with the antidromic pedicle screw Deep grinding decompression technology with TARP-III surgery Posterior atlantoaxial
5、screw and stick fixation of lateral mass of C1-2 and lamina of axial Transoral extended mandibulectomy for TARP surgery Transoral extended palate for enlarging approach for the severe invaginated tooth of epistropheus Precise personal surgery with the guidance of CAD-RP technology Revision for TARP
6、surgery The therapeutic principle and purpose were reduction, decompression and stabilization still.,Information and Method,Results,68 cases got anatomy reduction, 6 cases got close to anatomy reduction, and all of them got sufficient decompression. The improvement rate of canalis vertebralis decomp
7、ression reached at 86%, and the improvement rate of spinal cord function reached at 77.8% Complications: 3 cases of intracranial infection because of leakage of cerebrospinal fluid, and two of them were healing well after intrathecal injection for one month. 1 case of delayed infection (6 weeks afte
8、r sugery), Untreated death due to return home There was no other complication.,Information and Method,Typical Cases,Diagnosis: Postoperation of basilar impression(posterior approach)Atlantoaxial dislocation Symptoms: paresis, deglutitio impedita, bucking for drink water, can not take food normally,
9、taking nasogastric feeding tube daily. Imageology and complex factor: Bone scar rounding the dens, and the dens could not reduction normally, the brain stem and spinal cord were compressed.,Case1 Huang XX，male，26 years，ID：399280,Typical Case 1,YQS,Pre-Op CT,Pre-Op MR,Stem Cord Angle (128),128,Typica
10、l Case1,Bone scar rounding the dens.,YQS,Typical Case1,Treatment: Transoral atlantoaxial reduction and fixation Special Treatment: Deeply grinding the callus that around the tooth of epistropheus, with sufficient solution for TARP-III surgery. Result: atlantoaxial got anatomy reduction, relief of ce
11、rvical spinal cord compression after TARP internal fixation, Cornua of spinal cord was normal, and the funciton of the nerve function recover greatly, and could walk and swallow normally.,Typical Case1,open mouth,expose, release and decompress,install TARP,Carry out TARP operation,release, reduce, d
12、ecompress and fix at the same time,Post-Op,TARP III fixation, C1/C2 get reduction,Typical case 1,Pre-op ,Post-op ,典型病例 case 2,the spinal cord was decompression fully,Diagnosis: Malunion of the fracture of the dens, Atlantoaxial dislocation, Old fracture of articulatio mandibularis with joint stiffne
13、ss. Symptoms: could not open mouth, paresis. Imageology and complex factor: The gastro of the cervical spinal cord was compressed.The articulatio mandibularis wasstiffness.difficult in opening mouth,Case 2 Zhang ，male，38year，ID：344686,Typical Case,Transoral extended mandibulectomy for TARP surgery,Y
14、QS,YQS,YQS,Typical Case 2,X-ray of postoperation at A-P Position,X-ray of postoperation at LP,C2 got two cortexes fixation,X-ray of preoperation at LP,Atlantoaxial anatomy reduction,YQS,YQS,YQS,Typical Case 2,MRI of Postoperation,MRI of Preoperation,the spinal cord was decompression fully.,YQS,YQS,T
15、ypical Case 2,Diagnosis: Rupture of the ligamentum transversum, Atlantoaxial dislocation Symptoms: neck pain, limitation of motion. Imageology and complex factor: The diameter of the pedicle of vertebral arch of the atlantoaxial was too small, and the patient was too young.,Case 3 Liu X，female，4 yea
16、rs，ID：387798,YQS,Typical Case,Three-dimensional model of C2 and design of Screw path.,YQS,YQS,Typical Case 3,imitate placing screw in pedicle of C1/2 preoperatively,YQS,YQS,Typical Case 3,Drilling and placing screw followed by the conduct of targeting template intraoperatively,YQS,Typical Case 3,Pos
17、t-Op X-ray ： ideal location of the screws,Typical Case 3,Post-Op CT：the screw path was normal,YQS,Typical Case 3,Postoperative photograph of baby,Typical Case 3,Case 4 Zeng X，male，1years，ID：421125,Case History：wry neck 2 months with unsteady walking 5 weeks Diagnosis：tumor of the dens, atlantoaxial
18、dislocation. Operation Intended：Atlantoaxial Posterior pedicle screw fixation,Typical Case4,CT：deconstruction of the dens,Typical Case4,A model for atlas and axial screw insertion was disigned through CAD-RP technique.,Typical Case4,Typical Case4,Post-Op X-ray ： ideal location of the screws,Post-op
19、CT,pre-op CT,Typical Case4,Post-op,Diagnosis：Basilar invagination Symptoms：neck pain, numbness and debilitation of limbs Complex Factors：deeply internalizing of the dens， The gastro of the cervical spinal cord was compressed .Syringomyelia,Case 5 Li XX，female，35years，ID：417423,Typical Case5,Pre-Op M
20、R,Typical Case5,Stem Cord Angle less than normal The gastro of the cervical spinal cord was compressed Syringomyelia,Treatment：Transoral atlantoaxial decompression and fixation Special Treatment：TARP-III surgery Result：symptoms disappeared after operation. MRI showed complete decompression of cervic
21、al spinal cord, Stem Cord Angle back to normal, and improvement of Syringomyelia.,Typical Case 5,Post-Op,Reduction of the densIdeal location of TARP-III,Typical Case5,Post-Op MR,Stem Cord Angle back to normal Decompression of the spinal cord Disappear of Syringomyelia,Typical Case5,Pre-Op MR,Diagnos
22、is ：failure Apofix operation，redislocation of the atlantoaxial vertebra ，Imageology and complex factor: spinal compression followed by postoperative redislocation of the atlantoaxial vertebra with posterior approach,Case 6 Huang X，F，41years ，ID：364950,YQS,Typical Case 6,Compressed spinal cord seriou
23、sly,YQS,Typical Case 6,Remove posterior internal fixation Anterior TARP internal fixation revision,preoperative,Post-Op: anatomical reduction,YQS,YQS,YQS,Typical Case 6,preoperative,Complete decompression of spinal cord,Spinal compression was relieved after atlantoaxial reduction, but amyelotrophy,Y
24、QS,YQS,Typical Case 6,Discussion,Discussion,Abnormity of the craniocervical junction Bone scar rounding the dens, bony fusion of C1.2 Basilar impression， the dens greatly internalized into the intracalvarium，operation through posterior approach was done before. Malunion of the fracture of the dens,
25、Atlantoaxial dislocation, old fracture of articulatio mandibularis with joint stiffness. osteoporosis The diameter of the pedicle of vertebral arch of the atlantoaxial was too small Redislocation of the atlantoaxial vertebra after operation through anterior and posterior approaches.,Complex Factors,
26、Table 2 Complex factors of complex atlantoaxial dislocation and special treatment protocol,Discussion,Critical technique,TARP-III operation(C2 retro-pedicle screw fixation) Deep-part grinding and decompressing technique CAD-RP technique Enlarging approach（mandibular or palate cleaving）,Reduction: lo
27、ngitudinal brace,Key Points 1 TARP-III fixation(C2 retro-pedicle screw method),Reduction: Horizontal pushing,Key Points 1 TARP-III fixation(C2 retro-pedicle screw method),TARP reductor with unique effect,动 画,Key Points 1 TARP-III fixation(C2 retro-pedicle screw method),TARP III (C2 retro-pedicle scr
28、ew),Key Points 1,TARP II (C2 vertebra screw),TARP-III fixation(C2 retro-pedicle screw method),Polyaxial self-locking mechanism,Polyaxial pilot drill,Inner rings,threads,Important contribution of TARP-III,C2 retro-pedicle screw method which provides Rigid Fixation. polyaxial self-locking mechanism ma
29、kes the procedure simple. Instant reduction, decompression and fixation,indication cases of almost nonrecoverable dislocation of the atlantoaxial vertebra or filling with osteotylus around Dens significance Deep-part grinding the Dens, the postsuperior border and slope of odontoid vertebra，arriving
30、at direct decompression（invasive decompression） Combining with TARP，so as to make nonrecoverable dislocation of the atlantoaxial vertebra arriving at reduction and direct decompression （ noninvasive decompression ）,Key Point 2,Deep-part grinding and decompressing technique,Indications Patient with t
31、he dysmorphia of craniovertebral junction，complicated anatomic structure Patient with dislocation of the atlantoaxial vertebra with drilling difficultly in routine operation CT scan:diameter of pedicle4.0mm C1/C2 pedicle dysmorphia C1/C2 rotation dislocation Pediatric patients,CAD-RP technique,Key P
32、oint 3,Indication Rigor of Articulatio mandibularis ，difficult in opening mouth Disease refer to C3/4 Basilar impression，deeper embolism of the Dens Disease refer to slope of odontoid vertebra,Enlarging approach,Key Point 4,YQS,YQS,Conclusion,For cases of complex atlantoaxial dislocation, we must fully understand and actively deal with, not to give up. Mastering these four critical techniques, some complicated dislocation of the atlantoaxial vertebra should be treated effectively.,Thanks!,
