Posterior Direct Reduction of Lateral Atlantoaxial Joints for Rigid Pediatric Atlantoaxial Subluxation: A Fulcrum Lever Technique

Study Design.Clinical case series.Objective.To present a surgical technique and results of posterior direct reduction of lateral atlantoaxial joints for rigid pediatric atlantoaxial subluxation (AAS) using a fulcrum lever technique.Summary of Background Data.The surgical treatment of pediatric rigid AAS is still technically challenging. Several factors contribute to the surgical difficulty, such as small vertebrae, incomplete bone formation, dysplasia, the difficulty of reduction and external fixation are considered as a surgical daunting challenge. Herein, the surgical technique of posterior direct reduction of lateral atlantoaxial joints for rigid pediatric AAS using a fulcrum lever technique is presented.Methods.This retrospective study included 10 pediatric patients with rigid AAS who underwent posterior direct reduction of bilateral C1/2 facet joints via a fulcrum lever technique. The indication for surgery was the presence of neurological symptoms and spinal cord atrophy with an intramedullary high signal at the C1 level on T2-weighted magnetic resonance (MR) images. The surgical procedure consisted of three steps: (1) opening and distraction of the C1/2 facet joints and placement of tricortical bone as a spacer and fulcrum; (2) placement of C1 and C2 screws; and finally, (3) compression between the C1 posterior arch and C2 lamina and constructing C1/2 fusion. All patients underwent the neurological and radiological evaluations before and after surgery.Results.Eight of 10 patients demonstrated genetic disorders, either Down syndrome or chondrodysplasia punctate. Besides, all cases documented congenital anomaly of the odontoid process. Bilateral C1 lateral mass screws were successfully placed in all cases. No evidence of postoperative neurovascular complications. Radiological evaluation showed the corrections and bony fusions of C1/2 facet joint in all cases.Conclusion.The fulcrum lever technique for rigid pediatric AAS can be one of the effective surgical solutions to this challenging pediatric spinal disorder.Level of Evidence: 4.