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Comprehensive drilling of the C1-2 facets to achieve direct posterior reduction in irreducible atlantoaxial dislocation.

OBJECT
The cause of irreducibility in irreducible atlantoaxial dislocation (AAD) appears to be the orientation of the C1-2 facets. The current management strategies for irreducible AAD are directed at removing the cause of irreducibility followed by fusion, rather than transoral decompression and posterior fusion. The technique described in this paper addresses C1-2 facet mobilization by facetectomies to aid intraoperative manipulation.


METHODS
Using this technique, reduction was achieved in 19 patients with congenital irreducible AAD treated between January 2011 and December 2013. The C1-2 joints were studied preoperatively, and particular attention was paid to the facet orientation. Intraoperatively, oblique C1-2 joints were opened widely, and extensive drilling of the facets was performed to make them close to flat and parallel to each other, converting an irreducible AAD to a reducible one. Anomalous vertebral arteries (VAs) were addressed appropriately. Further reduction was then achieved after vertical distraction and joint manipulation.


RESULTS
Adequate facet drilling was achieved in all but 2 patients, due to VA injury in 1 patient and an acute sagittal angle operated on 2 years previously in the other patient. Complete reduction could be achieved in 17 patients and partial in the remaining 2. All patients showed clinical improvement. Two patients showed partial redislocation due to graft subsidence. The fusion rates were excellent.


CONCLUSIONS
Comprehensive drilling of the C1-2 facets appears to be a logical and effective technique for achieving direct posterior reduction in irreducible AAD. The extensive drilling makes large surfaces raw, increasing fusion rates.