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Despite the severe degree of abnormalities seen, the rate of instability after the ventral deformities are resected by the transoral approach is not always associated with initial instability; therefore, posterior occipitocervical fusion may not be necessary. Congenital anomalies are more stable than rheumatoid or traumatic dislocations; 25% of my pts did not require stabilization, despite adequate decompression, as suggested by their clinical improvement. I do not excise ligamentous structures, if stabilization is not planned. Radiological assessment of instability is extremely difficult after ventral decompression as the bony landmarks (anterior arch of atlas and dens) have been excised. Posterior fixation techniques is the mainstay. In my experience, absolute indications for stabilization are 1) History of precipitating trauma, 2) Symptoms suggestive of instability, such as suboccipital pain (occipital neuralgia), and worsening deficits on neck flexion, 3) Radiological suggestion of instability, 4) Patients under 40 years of age, Ideal stabilization system is yet to come. After 20 yrs of CVJ surgery, I prefer old fashioned wires and rods for stabilization(including the above two extensive decompressions). They provide adequate stability and preserve satisfactory neck movements, unlike the currently popular transpedicular and transarticular screws which provide the maximum stability but the resultant, near total, obliteration of motion is not accepted by many patients. They may require cervical collar for longer period than the pts with pedicle/ lateral masas screws. That's why, perhaps, the companies are coming up with dynamic screws!To support my views I give following refs: Menezes AH, VanGilder JC. Transoral transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg. 1988 Dec;69(6):895-903. PubMed PMID: 3193195. Level of Evidence: Undefined. PMID: 3193195 (Link to Abstract)Mummaneni PV, Haid RW. Atlantoaxial fixation: overview of all techniques.Neurol India. 2005 Dec;53(4):408-15. Review. PubMed PMID: 16565531. Level of Evidence: Undefined. PMID: 16565531 (Link to Abstract)Naderi S, Crawford NR, Song GS, Sonntag VK, Dickman CA. Biomechanical comparison of C1-C2 posterior fixations. Cable, graft, and screw combinations. Spine (Phila Pa 1976). 1998 Sep 15;23(18):1946-55; discussion 1955-6. PubMedPMID: 9779526. Level of Evidence: Undefined. PMID: 9779526 (Link to Abstract)Dickman CA, Crawford NR, Paramore CG. Biomechanical characteristics of C1-2cable fixations. J Neurosurg. 1996 Aug;85(2):316-22. PubMed PMID: 8755762. Level of Evidence: Undefined. PMID: 8755762 (Link to Abstract)Dickman CA, Locantro J, Fessier RG : The influence of transoral odonotoid resection on stability of the craniovertebral junction. J Neurosurg 1992; 77 : 525-530. Dickman CA, Crawford NR, Brantley AGU, Sonntag VKH. Biomechanical effects of transoral odontoidectomy. Neurosurgery, 1995; 6:1146-1153. Dickman CA, Crawford NR, Brantley AG, Sonntag VK. Biomechanical effects of transoral odontoidectomy. Neurosurgery. 1995 Jun;36(6):1146-52; discussion 1152-3.Song GC, Cho KS, Yoo DS, Huh PW, Lee SB. Surgical treatment of craniovertebral junction instability : clinical outcomes and effectiveness in personal experience. J Korean Neurosurg Soc. 2010 Jul;48(1):37-45. Epub 2010 Jul 31.
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