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Objective: This study aims to describe and analyze the transoral and transnasal approaches for pathologies of the ventral atlas and axis vertebrae, which are considered technically challenging regions for diagnostic biopsy., Methods: A series of transnasal endoscopic approach (TNA) and transoral approach (TOA) biopsies for the pathologies of the first and second cervical vertebrae were conducted and retrospectively analyzed from July 2014 to May 2021. The depth of the biopsy trajectory was measured on computed tomography images for all nine patients (eight males and one female with an average age of 58.11 ± 11.60 years), as were the coronal, sagittal, and vertical biopsy safe ranges. The characteristics of each lesion, including radiographic features, blood supply, and destruction of anterior or posterior vertebral body edges, were evaluated to guide the biopsy. Four biopsy core techniques (BCTs), including "lesion perforating", "aspiration", "cutting-and-scraping" and "biopsy forceps utilization" were elaborated in this study. The biopsy procedures and periprocedural precautions were demonstrated. Patient demographics, clinical data, lesion characteristics, diagnostic yield, and complications were recorded for each case., Results: Eight TOA biopsies for the axis vertebral body and one TNA biopsy for the atlas anterior arch were successfully performed and yielded adequate pathologies. All biopsies were organized based on the preprocedural radiographic measurements, which showed that the average length of biopsy trajectory and coronal, sagittal, and vertical safe biopsy ranges were 85.00 ± 5.88, 20.63 ± 4.75, 16.25 ± 1.49, and 24.63 ± 2.26 mm, respectively, and these corresponding data were 95, 36, 9, and 26 mm in the TNA patient. Six osteolytic lesions (66.7%), one osteoblastic lesion (11.1%), and two mixed lesions (22.2%) were observed, among which seven lesions had a rich blood supply. Biopsy forceps and core needles were utilized to obtain samples in six and three patients, respectively. All the TNA and TOA biopsies were performed with cooperative application of multiple BCTs under compound anatomic and stereotactic navigations. Intraprocedural or postprocedural complications occurred in no patients who underwent the biopsy in the follow-up period (1-39 months). No significant differences were found between the preprocedural and postprocedural blood indexes and visual analogue scale scores., Conclusion: With a sophisticated preprocedural arrangement, cooperative application of BCTs, and careful periprocedural precautions, transnasal endoscopic and transoral biopsies are two feasible, efficient, and well-tolerated procedures that achieve satisfactory diagnostic yield, complication rate, and clinical outcome., (© 2022 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Objective: To explore the treatment strategy and clinical efficacy for os odontoideum complicated with atlantoaxial dislocation., Methods: The clinical data of 17 patients with os odontoideum complicated with atlantoaxial dislocation surgically treated from January 2006 to January 2015 were retrospectively analyzed, including 7 males and 10 females, aged 17 to 53 (43.1±11.3) years old;course of disease was 3 to 27(10.2±6.9) months. All patients received cranial traction before operation, 12 of 14 patients with reducible dislocation were treated by posterior atlantoaxial fixation and fusion, and 2 patients with atlantooccipital deformity were treated by posterior occipitocervical fixation and fusion;3 patients with irreducible alantoaxial dislocation were treated by transoral approach decompression combined with posterior atlantoaxial fixation and fusion. The operation time, intraoperative blood loss and perioperative complications were recorded. Visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) score were used to evaluate the change of neck pain and neurological function. Atlantoaxial joint fusion rate was evaluated by CT scan., Results: The operation time of posterior fixation and fusion ranged from 86 to 170 (92.2±27.5) min, and the intraoperative blood loss was 200-350 (250.7±65.2) ml. No vertebral artery injury and spinal cord injury were recorded. Among the patients underwent atlantoaxial fixation and fusion, 1 patient with reducible dislocation fixed by C 2 laminar screw lost reduction after primary operation, and received anterior release again and finally occipitocervical fusion. All patients were followed up for 15 to 58 (32.0±12.2) months. VAS score was decreased from preoperative 4.2±0.9 to 1.3±0.7 at final follow up and the JOA score was improved from preoperative 11.2±1.2 to 16.9±0.8 at final follow-up. CT scan confirmed that the atlantoaxial or occipitocervical fusion wasgood, and the fusion time was 5 to 9 (6.7±0.6) months., Conclusion: Surgical treatment of os odontoideum complicated with atlantoaxial dislocation can achieve satisfactory results, improve the patient's neurological function and improve the quality of life, however the surgical options needs to be individualized.

Purpose: The aim of this review is to provide an update of the technical nuances of microsurgical and endoscopic-assisted approaches to the craniovertebral junction (transnasal, transoral, and transcervical), and to report on the available clinical results in order to identify the best strategy., Methods: A nonsystematic update of the reviews and reporting on the anatomical and clinical results of endoscopic-assisted and microsurgical approaches to the craniovertebral junction (CVJ) was performed., Results: Pure endonasal and cervical endoscopic approaches still have some disadvantages, including their steep learning curves and their deeper surgical fields. Endoscopically assisted transoral surgery with 30° endoscopes represents an emerging option compared with standard microsurgical techniques for transoral approaches to the anterior CVJ. This approach should be considered as complementary to, rather than as an alternative to the traditional transoral-transpharyngeal approach., Conclusions: The transoral (microsurgical or video-assisted) approach with sparing of the soft palate still remains the gold standard compared with the "pure" transnasal and transcervical approaches, due to the wider working channel provided by the former technique. The transnasal endoscopic approach alone appears to be superior when the CVJ lesion exceeds the upper limit of the inferior third of the clivus. Of particular interest is the evidence that advances in reduction techniques can avoid the ventral approach.

We present a 52-year-old man with congenital absence of the posterior arch of the atlas and concomitant fusion of the posterior tubercle of the atlas to the spinal process of the axis. He had normal reflexes and no motor deficit. He underwent C3-C7 laminoplasty and achieved good outcome.

Objective: To determine the entry point and screw implant technique in posterior pedicle screw fixation by anatomical measurement of adult dry samples of the axis so as to provide a accurate anatomic foundation for clinical application., Methods: A total of 60 dry adult axis specimens were selected for pedicle screws fixation. The entry point was 1-2 mm lateral to the crossing point of two lines: a vertical line through the midpoint of distance from the junction of pedicle medial and lateral border to lateral mass, and a horizontal line through the junction between the lateral border of inferior articular process and the posterior branch of transverse process. The pedicle screw was inserted at the entry point. The measurement of the anatomic parameters included the height and width of pedicle, the maximum length of the screw path, the minimum distance from screw path to spinal canal and transverse foramen, and the angle of pedicle screw. The data above were provided to determine the surgical feasibility and screw safety., Results: The width of upper, middle, and lower parts of the pedicle was (7.35 ± 0.89), (5.50 ± 1.48), and (3.97 ± 1.01) mm respectively. The pedicle height was (9.94 ± 1.16) mm and maximum length of the screw path was (25.91 ± 1.15) mm. The angle between pedicle screw and coronal plane was (26.95 ± 1.88) degrees and the angle between pedicle screw and transverse plane was (22.81 ± 1.61) degrees. The minimum distance from screw path to spinal canal and transverse foramen was (2.72 ± 0.83) mm and (1.98 ± 0.26) mm respectively., Conclusion: According to the anatomic research, a safe entry point for C2 pedicle screw fixation is determined according to the midpoint of distance from the junction of pedicle medial and lateral border to lateral mass, as well as the junction between the lateral border of inferior articular process and the posterior branch of transverse process, which is confirmed to be effectively and safely performed using the entry point and screw angle of the present study.

Cartilaginous exostosis developed in the atlantoaxial region of a three-and-a-half-year-old Bernese mountain dog. The dog exhibited ataxia in the hindlimbs and flailing movements in the forelimbs. On survey radiographs of the cervical spine there was a focal calcified mass between the dorsal arch of the atlas and the spinous process of the axis. Lumbar myelography revealed severe dorsal spinal cord compression. The mass was removed surgically and the dog made a complete recovery. Histopathology of the excised mass was consistent with a diagnosis of cartilaginous exostosis.

After tonsillectomy, atlantoaxial subluxation occurred in two patients. Operations had been performed with the use of local anesthesia, and it was assumed that, during the injection of anesthetics, bacteria infected the prevertebral space. The initial symptoms of the prevertebral space infection were neck pain and stiffness; the movements of the neck were minimal, and opening of the mouth caused pain due to spasm of the deep cervical muscles. Both patients had persistent fever. The roentgenographically observed subluxation developed in one to two months after tonsillectomy. One of the patients was treated only with antibiotics; the other patient required atlantoaxial spondylodesis. Healing of the subluxation lasted about six months in both cases.

Two cases of atlanto axial dislocation with late neurological manifestations are reported and the very few cases of the literature are reviewed. The clinical signs are non specific. Excellent lateral tomography must demonstrate the abnormal space between atlas and axis. Surgical treatment includes bone fusion after reduction of the dislocation by cautious skull-traction. The results are excellent if the operation is performed before the onset of severe neurological deficits.

Cervical myelopathy has become commonly recognized as a complication of rheumatoid atlantoaxial subluxation. A small group of patients with atlantoaxial subluxation may have intermittent symptoms associated with change of head position and which are due to vertebral artery compression. Two such cases are reported, one with necropsy findings of infarction in the area supplied by the vertebrobasilar system. The pathogenesis of the symptomatology and infarction is discussed.

The involvement of the cervical spine in rheumatoid arthritis especially after prolonged steroid medication, is one of the most dangerous symptoms of this disease. 62 patients suffering from rheumatoid arthritis of the cervical spine underwent a critical examination regarding clinical signs and neurological symptoms. According to Larsen Theses of the radiological grading of the severity of rheumatoid arthritis, we tried to develop a classification of the involvement of the upper and the low cervical spine. Clinical and neurological signs are then found especially in stadium III and IV. The bony ankylosis (stadium V) must be considered as a spontaneous healing, for all clinical and neurological signs will have vanished. Electromyographical observations showed characteristic patterns for each stadium. According to this classification the conservative and the operative treatment can be chosen.

Thirty-one patients suffering from osteoarthritis of the atlanto-axial joint are described, suggesting that this disease is not particularly uncommon. The most characteristic radiological signs are narrowing of the joint space from loss of articular cartilage, marginal cortical thickening and osteophyte formation. Histological examination in the cadaver has shown thinning and fibrillation of articular cartilage and intra-cartilaginous ossification. The radiological appearances of the atlanto-axial joint are classified in three types, lateral atlanto-axial, atlanto-odontoid and mixed. Peak age distribution occurs between 50 and 69 years of age. Patients complain of occipital pain, a stiff shoulder and paraesthesia of the fingers. Treatment was conservative in all cases except one, a 63-year-old woman with severe occipital pain. A transoral atlanto-axial fusion was performed in this case with marked improvement. The transoral approach allows fixation and curettage of the degenerative lesions.

An analysis of ten recent observations of lateral arthritis of C1-C2 during the course of rheumatoïd arthritis. This lesion, which is not rare, has charactéristic symptoms: localized pain together with occipital (Arnold's) neuralgia and specific blocking of head rotation towards the afflicted side. Frontal per-oral radiography shows joint line lesions most often unilateral, and a displacement of C1 towards the non afflicted side with pseudoinclination of the odontoïd process towards the afflicted side. Sometime more destructive lesions of the lateral masses of the atlas give them a triangular form and this may result eventually in an upwards "vertical" displacement of the odontoïd. The pain usually subsides in a few weeks after a conservative treatment with or without temporary immobilisation by a light removable cervical collar but the loss of the homolateral rotation of the head persists. Besides occipital (Arnold's) neuralgia, there seems to be no other neurologic complications; if they follow, it is due to an associated anteroposterior displacement.

A 26-year-old female developed a unilateral hypoglossal nerve palsy in association with tuberculosis of the first cervical vertebra. The extensive soft tissue and bony abnormalities were demonstrated only by computerized axial tomography. Involvement of the hypoglossal nerve within the skull by tuberculous granulation tissue was the most likely mechanism for the nerve palsy.

Pyogenic osteomyelitis rarely affects the first and second cervical vertebrae, and when it does it can progress to abscess formation, compressing the spinal cord. If the process is unrecognized, it can be fatal. The cases of five patients are reported. Two patients were treated by anterior débridement and posterior cervical-occipital arthrodesis; one, by transoral drainage; one, by posterior cervical-occipital arthrodesis; and the fifth, by posterior atlanto-axial arthrodesis. The causative organism was Staphylococcus aureus in four patients and Pasteurella multocida in one. In all patients, intravenous antibiotics were used, followed by prolonged administration of oral antibiotics. All five patients recovered.

Eleven patients with documented Morquio's syndrome who had dysplasia of the odontoid process and resulting atlanto-axial instability were reviewed. They were found to be at risk for acute traumatic quadriparesis, chronic myelopathy of a variable and often rapid rate of progression, and sudden death by respiratory arrest. The evidence suggests that early prophylactic posterior cervical fusion is indicated for patients with this malformation and that once quadriparesis is established, recovery of function is limited.

Pathological features are described, and clinico-pathological correlations are made, in 11 patients presenting the unusual combination of chronic compressive myelopathy of the upper cervical cord due to congenital atlanto-axial dislocation, and sudden haematomyelia and respiratory arrest developing at open surgery for release of pressure on the medullospinal tissues, or as a postoperative catstrophe. Necropsy and histological examination confirmed that the neuropathological substrate of intermittent or progressive quadriplegia and sensory changes (mainly deep sensory loss) was degeneration of the lateral and posterior columns. Loss of anterior horn cells of the lower cervical and upper dorsal cord led to weakness of hand and arm muscles. Acute paracentral haemorrhages occurring at the C1 to C2 or medullospinal level, in the territory of distribution of the sulcal branches of the spinal artery (due to sudden release of pressure at operation) were responsible for postoperative paralysis and sensory loss below C2 segment. In terms of the bony anomaly (dissected at necropsy), the cases fell into 2 sibgroups: a) The majority with the odontoid attached to the body of the axis, but short and ill developed, at times accompanied by other bony anomalies and a poorly formed transverse ligament. This tended to produce a fixed type of dislocation with a higher level (medullospinal) and more severe compression of the CNS. b) Fewer cases with a well formed but detached odontoid, producing a less severe myelopathy at a lower level (C1-C2), and generally more readily reducible on extension.

In seventeen cases of irreducible atlanto-axial rotatory subluxation (here called fixation), the striking features were the delay in diagnosis and the persistent clinical and roentgenographic deformities. All patients had torticollis and restricted, often painful neck motion, and seven young patients with long-standing deformity had flattening on one side of the face. The diagnosis was suggested by the plain roentgenograms and tomograms and confirmed by persistence of the deformity as demonstrated by cineroentgenography. Treatment included skull traction, followed by atlanto-axial arthrodesis if necessary. Of the thirteen patients treated by atlanto-axial arthrodesis, eleven had good results, one had a fair result, and one had not been followed for long enough to determine the result. Of the remaining four patients, one treated conservatively had not been followed for long enough to evaluate the result, two declined surgery, and one died while in traction as the result of cord transection produced by further rotation of the atlas on the axis despite the traction.