Atlantoaxial Facet Fixation Using Cervical Facet Cage: Technical Case Report and Review of the Literature

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Shanahan, Ali A. Alattar, H. Westley Phillips, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3909561/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Mar, 2024 Read the published version in Child's Nervous System → Version 1 posted 7 You are reading this latest preprint version Abstract In 1994, the use of interfacet spacer placement was for joint distraction, reduction, and fusion to supplement atlantoaxial or occipitocervical fixation. Here we present a unique case of bilateral atlantoaxial interfacet fixation using cervical facet cages (CFC) in a pediatric patient with basilar invagination. In addition, we review the literature on atlantoaxial facet fixation. We present a 12-year-old boy with Wiedemann-Steiner syndrome who presented with multiple episodes of sudden neck jerking, described as in response to a sensation of being shocked, and guarding against neck motion, found to have basilar invagination with cervicomedullary compression. He underwent an occiput to C3 fusion with C1-2 CFC fixation. We also conducted a literature review identifying all publications using the keywords: “C1” AND “C2” OR “atlantoaxial” AND “facet spacer” OR “DTRAX.” The patient demonstrated postoperative radiographic reduction of his basilar invagination from 6.4 mm to 4.1 mm of superior displacement above the McRae line. There was a 4.5 mm decrease in the atlantodental interval secondary to decreased dens retroflexion. His post-operative course was complicated by worsening of his existing dysphagia but was otherwise unremarkable. His neck symptoms completely resolved. We illustrate the safe use of CFC for atlantoaxial facet distraction, reduction, and instrumented fixation in a pediatric patient with basilar invagination. Review of the literature demonstrates numerous materials can be safely placed as a C1-C2 interfacet spacer including bone grafts, titanium spacers, and anterior cervical discectomy and fusion cages. We argue that CFC may be included in this arsenal even in pediatric patients. C1-C2 facet fixation Interfacet spacers Goel technique Figures Figure 1 Figure 2 Introduction In 1994, Goel et al. first described atlantoaxial fixation using screws and plates with interfacet spacer placement for joint distraction and load bearing [1]. The Goel technique allows for vertical distraction of the C1-C2 joint and thus reduction of the mobile basilar invagination prior to instrumented fixation. The material placed in the interfacetal space has evolved from bone graft to titanium cages and now includes cervical facet cages (CFC). CFCs are titanium implants used to replace damaged facet joints to restore stability and mobility. In this report, we present the first case to our knowledge of C1-C2 fixation using CFC in a pediatric patient for the treatment of basilar invagination as well as a brief review of the literature. Case Report History and Presentation A 12-year-old boy with a history of Wiedemann-Steiner syndrome complicated by AV block requiring a pacemaker, submucosal cleft palate, choanal stenosis, and micrognathia with midface hypoplasia presented with multiple episodes of neck jerking and guarding against neck motion. Persistent dysphagia was also noted. Seizure workup for these episodes was negative and upon examination the patient had a Lhermitte sign with flexion. Computed tomography (CT) scan of his cervical spine revealed basilar invagination with 6.4 mm of superior displacement of the odontoid process above the McRae line, atlantodental interval (ADI) of 5.5 mm, atlantooccipital assimilation, and C2-C3 fusion ( Figure 1a ). CT myelography demonstrated evidence of compression of the cervicomedullary junction by the retroflexed odontoid process ( Figure 1a ). Fig 1 A: Preoperative Computed Tomography (CT) Myelogram Imaging of Cervical Spine. Left image shows a sagittal CT myelogram image. Right image shows an axial CT myelogram image highlighting an altitudinal interval of 5.5mm. B: Postoperative CT Imaging of Cervical Spine. Left Image shows a sagittal CT image highlighting derotation of the dens compared to preop. Right image shows an axial CT highlighting an atlantodental interval of just 1.0mm Surgery The patient was taken to the operating room for an occiput to C3 fusion with placement of bilateral C1-C2 CFC joint interfacet spacers. Pre-position somatosensory evoked potentials (SSEPs) were normal and reliable. Following exposure, the C2 nerve roots were identified and sacrificed. The C1-2 joint was then drilled and two 10 mm x 5.5 mm x 2.5 mm CFCs were placed parallel to the joint under fluoroscopic guidance. The occipital plate was shaped to the curvature of the occiput and three screws, 8, 2, and 8mm were placed. C2 pars screws (20 mm on the left and 22 mm on the right) were placed under image guidance. Finally, image guidance was used to place a left C3 14 mm pedicle screw and a right C3 12 mm pedicle screw. C1 was not instrumented. Intraoperative CT was used to confirm placement of all hardware before 3.5 mm diameter titanium rods were placed on both sides and secured. All bony surfaces were then decorticated prior to placement of fusion supplements including a mixture of allograft demineralized bone matrix putty. Outcome Postoperatively, his neck guarding, and episodic electrical pain resolved, and he remained neurologically at his baseline. The postoperative CT of the cervical spine revealed reduction of his basilar invagination to 4.1 mm of superior displacement of the odontoid process above the McRae line, with a decrease of ADI to 1.0 mm due to decreased dens retroflexion, and stable placement of the hardware ( Figure 1b, 2 ). The patient was discharged on post-operative day (POD) 6 with a cervical collar and stable neurologic exam. Unfortunately, he was readmitted with post-operative dysphagia on POD20 and ultimately required percutaneous gastrostomy tube placement for continuous feedings. The patient has followed with otorhinolaryngology for dysphagia management, and he was found to have primarily a food disinterest rather than a mechanical limitation. At three-months post-operation, radiographic imaging confirmed adequate decompression and evidence of bony fusion. At four-months post-operation, the patient was weaned from his cervical collar. He has since resumed oral intake without restrictions. Fig 2 Postoperative X-ray Imaging of Cervical Spine. A: Lateral view of instrumentation. B: Anterior-posterior (AP) view of instrumentation Discussion In this article, we describe the case of a 12-year-old boy with history of Wiedemann-Steiner syndrome with basilar invagination who underwent occiput to C3 fusion with placement of bilateral C1-C2 CFC joint interspacers. Patients often require a combined endoscopic endonasal resection of the odontoid with posterior occipitocervical fusion; however, the indirect spinal canal decompression achieved using C1-C2 CFC joint interspacers with subsequent derotation of the atlantoaxial joint precluded the need for anterior decompression and thereby reduced the risk of additional vascular injury, cerebrospinal fluid leak, dysphagia, and need for tracheostomy. Results of a literature review of posterior facet fixation of the C1-C2 joint are summarized in Table 1 . Goel et al. first reported the use of iliac bone graft for C1-C2 facet fixation in 1994. From 2004-2008 Dr. Goel's group has reported a high rate of sustained radiographic reduction using hydroxyapatite and titanium spacers with a need for an anterior cervical approach for odontoid resection in only 2 of 64 total patients [2-5]. Other authors within this review utilized tricortical bone allografts [6], anterior cervical discectomy and fusion cages [7, 8], and CFC [9, 10] as used in this case report, with similarly low rates of supplementary anterior approaches. Numerous studies have demonstrated the efficacy of CFCs in treating subaxial cervical radiculopathy and augmenting fusion [11, 12]. Few studies have explored the use of CFCs for atlantoaxial fixation, which was an off-label use of the device at the time of the operation [9, 10]. Table 1 Summary of literature review. Reference Indication n Age (years) Intraarticular Facet Fixation Outcomes Goel et al., 1994 [1] Atlanto-axial dislocation 30 Adult Iliac bone graft Improvement or stabilization of neurologic function; no re-operations or new neurological symptoms reported Goel et al. , 2004 [2] Basilar invagination 22 8-50 Iliac bone graft (8 cases), Titanium spacers (4 cases) Sustained distraction and reduction at 6 months; no new neurologic symptoms. Goel et al., 2005 [3] Basilar invagination with Syringomyelia 12 14-50 Titanium spacers Neurological improvement, sustained reduction of distraction and basilar invagination; syringomyelia not assessed. Goel et al., 2005 [4] Persistent basilar invagination previously treated by trans-oral decompression 3 22, 17, 18 Titanium spacers Improved omega angle; clinically improved to be able to walk unassisted. Goel et al., 2008 [5] Basilar invagination 11 N/A Titanium spacers Neurological improvement; sustained reductions of distraction and basilar invagination at 6-month follow-up. Yamagata et al., 2020 [6] Rigid AAS (defined as ADI >5mm) secondary to odontoid dysplasia or os odontoideum 10 5-15 (Mean: 9.6) Tricortical bone graft used as spacer and fulcrum Neurosurgical Cervical Spine Scale (NCSS) scores improved in 6 cases and were maintained in 4 cases; all patients achieved increased C1-C2 height, ADI improvement, and bony fusion on post-operative imaging. Lee et al., 2017 [7] Rheumatoid arthritis, basilar invagination 1 67 ACDF cages Improved pain; maintained bony fusion at 3-year follow-up. Tominaga et al., 2019 [8] Arthritis, basilar invagination 3 85, 75, 43 Corridor anterior cervical cage (Globus Medical Inc., Audubon, PA) Improved EMS scores, walking ability, and reduced neck pain; one case of reoperation due to rod breakage and nonunion. Sommer et al., 2022 [9] Odontoid fractures 5 Median: 79.6 CFC Decrease in VAS pain scores; radiographic evidence of fusion on last follow-up. Sommer et al., 2022 [10] Trauma (4/9), Neoplasm (1/9), Degenerative changes (4/9) 9 Mean: 68.7+/-16.3 Cervical Facet Cage (CFC) Significant decrease in VAS pain scores; all patients achieved bony fusion with no evidence of subsidence at last follow-up. Goel et al., 2005 [13] Fixed atlanto-axial dislocation 19 12-46 (Mean: 22) Hydroxyapatite spacers (16 cases), Titanium spacers (3 cases) 13 patients with acceptable reduction (atlantodental interval<4mm); 4 with clinical improvement but no radiographic reduction; 2 patients underwent trans-oral decompression. Kim et al., 2011 [14] Basilar invagination 2 45, 69 8mm iliac bone autograft, Autograft iliac bone blocks Improved Clark Station, Redlund-Johnell Criterium and Ranawat Criterion Srivastava et al., 2017 [15] Os odontoideum, Basilar invagination, Basilar invagination, Basilar invagination 4 16, 32, 32, 18 Unspecified spacer or wedge bone graft Neurological improvement, improved mJOA scores; stable fusions. Turel et al., 2017 [16] Traumatic fractures (8), Degenerative stenosis (6), C2 neuralgia (2), C1-2 ligamentous subluxation (2), Os odontoideum (1) 19 Median: 69 Machined cortical allograft (FacetLift, Medtronic, Memphis) 94% successful arthrodesis at 6 months; one patient who did not achieve arthrodesis remained asymptomatic. Sai Kiran et al., 2018 [17] Basilar invagination, Os odontoideum 1 44 Unilateral right C1-2 titanium spacer with bone graft Resolution of pre-operative symptoms; no instability on dynamic radiographs at 10-month follow-up. Xu et al., 2019 [18] Alagille syndrome with numerous segmentation abnormalities 1 21 Small cortical bone grafts Complete resolution of preoperative symptoms; persistent fusion and improved alignment on XR. Jain et al., 2022 [19] Odontoid fractures 9 23-52 Unspecified, spacers Resolution of neck pain; complete fracture alignment in 8/9 patients; 1 patient with with grade 4 listhesis and bone loss; stable fusion at a mean follow-up of 16 months. Anand et al. Basilar invagination 1 12 CFC Reduction of basilar invagination, decreased ADI; temporary gastrostomy tube placement to address dysphagia. Our report demonstrates the safe utilization of CFC for atlantoaxial fixation in a pediatric patient. The generalizability of this claim is limited by our singular clinical experience. It is our impression that the relatively small size of the graft limits the magnitude of direct reduction potential, but the shape of the graft and angulation of the C1-C2 joint may allow for a significant amount of de-rotation of a retroflexed odontoid process relative to the C1 anterior arch. Ultimately, our current experience suggests that reduction in ADI via derotation may be more clinically significant than the decompression achieved from reducing the degree of invagination. Conclusion We highlight the potential safety of using CFCs as an atlantoaxial facet distraction, reduction, and fusion tool in a pediatric patient with basilar invagination. While further studies are necessary to corroborate these findings, we show that CFCs can be a powerful tool for posterior-only approach for atlantoaxial reduction and fixation in pediatric populations. Declarations Funding No funding was received for this research. Competing Interest The authors have no relevant financial or non-financial interests to disclose. Consent The University of Pittsburgh Institutional Review Board (IRB) approved the study “Analyses of Neurosurgery Operative Procedures” on July 27, 2020, under the reference number STUDY20050395. Written informed consent was obtained from the patient’s parent for publication of the details of their medical case and any accompanying images. Author Contribution Conception & design: All authorsDrafted the manuscript: All authorsCritical evaluation of the manuscript: All authorsApproved the final version to be published: All authorsAgree to be accountable for all aspects of the work in ensuring that questions related to theaccuracy or integrity of any part of the work are appropriately investigated and resolved: Allauthors. References A. Goel, V. Laheri, Plate and screw fixation for atlanto-axial subluxation, Acta Neurochir (Wien) 129(1–2) (1994) 47–53. A. Goel, Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation, J Neurosurg Spine 1(3) (2004) 281-6. A. Goel, P. Sharma, Craniovertebral junction realignment for the treatment of basilar invagination with syringomyelia: preliminary report of 12 cases, Neurol Med Chir (Tokyo) 45(10) (2005) 512-7; discussion 518. A. Goel, Progressive basilar invagination after transoral odontoidectomy: treatment by atlantoaxial facet distraction and craniovertebral realignment, Spine (Phila Pa 1976) 30(18) (2005) E551-5. A. Goel, A. Shah, Atlantoaxial joint distraction as a treatment for basilar invagination: a report of an experience with 11 cases, Neurol India 56(2) (2008) 144 − 50. T. Yamagata, S. Nishijima, S. Kou, K. Naito, A. Nagm, K. Ishibashi, K. Ohata, T. Takami, Posterior Direct Reduction of Lateral Atlantoaxial Joints for Rigid Pediatric Atlantoaxial Subluxation: A Fulcrum Lever Technique, Spine (Phila Pa 1976) 45(17) (2020) E1119-E1126. J.Y. Lee, S.B. Im, J.H. Jeong, Use of a C1-C2 Facet Spacer to Treat Atlantoaxial Instability and Basilar Invagination Associated with Rheumatoid Arthritis, World Neurosurg 98 (2017) 874 e13-874 e16. H. Tominaga, A. MacDowall, C. Olerud, Surgical treatment of the severely damaged atlantoaxial joint with C1-C2 facet spacers: Three case reports, Medicine (Baltimore) 98(22) (2019) e15827. F. Sommer, S. Kirnaz, J. Goldberg, L. McGrath, Jr., R. Navarro-Ramirez, P. Gadjradj, B. Medary, R. Hartl, Treatment of Odontoid Fractures in Elderly Patients Using C1/C2 Instrumented Fusion Supplemented With Bilateral Atlantoaxial Joint Spacers: A Case Series, Int J Spine Surg 16(3) (2022) 442–449. F. Sommer, S. Kirnaz, J.L. Goldberg, L.B. McGrath, F. Schmidt, P. Gadjradj, B. Medary, R. Hartl, Safety and Feasibility of DTRAX Cervical Cages in the Atlantoaxial Joint for C1/2 Stabilization, Oper Neurosurg (Hagerstown) 22(5) (2022) 322–327. K. Siemionow, P. Janusz, P. Glowka, Cervical cages placed bilaterally in the facet joints from a posterior approach significantly increase foraminal area, Eur Spine J 25(7) (2016) 2279-85. K. Siemionow, P. Janusz, F.M. Phillips, J.A. Youssef, R. Isaacs, M. Tyrakowski, B. McCormack, Clinical and Radiographic Results of Indirect Decompression and Posterior Cervical Fusion for Single-Level Cervical Radiculopathy Using an Expandable Implant with 2-Year Follow-Up, J Neurol Surg A Cent Eur Neurosurg 77(6) (2016) 482–488. A. Goel, A.G. Kulkarni, P. Sharma, Reduction of fixed atlantoaxial dislocation in 24 cases: technical note, J Neurosurg Spine 2(4) (2005) 505-9. I.S. Kim, J.T. Hong, J.H. Sung, J.H. Byun, Vertical reduction using atlantoaxial facet spacer in basilar invagination with atlantoaxial instability, J Korean Neurosurg Soc 50(6) (2011) 528 − 31. A.K. Srivastava, S. Behari, J. Sardhara, K.K. Das, Simultaneous odontoid excision with bilateral posterior C1-2 distraction and stabilization utilizing bilateral posterolateral corridors and a single posterior midline incision, Neurol India 65(5) (2017) 1068–1075. M.K. Turel, M.G. Kerolus, V.C. Traynelis, Machined cervical interfacet allograft spacers for the management of atlantoaxial instability, J Craniovertebr Junction Spine 8(4) (2017) 332–337. N.A. Sai Kiran, V.A. Kiran Kumar, L. Sivaraju, V.A. Kumar, C.R. Reddy, A. Agrawal, Management Issues in a Case of Congenital Craniovertebral Junction Anomaly with Aberrant Retropharyngeal Midline Course of Bilateral Cervical Internal Carotid Arteries at C1-C2, World Neurosurg 114 (2018) 94–98. R. Xu, Y. Xia, P.G. Passias, T. Protopsaltis, D.M. Sciubba, Occipitocervical Osteotomies and Interfacet Grafts for Reduction of Occipitocervical Kyphosis and Basilar Invagination, World Neurosurg 127 (2019) 391–396. A.K. Jain, M. Tawari, L. Rathore, D. Sahana, H. Mishra, S. Kumar, R.K. Sahu, An experience with Goel-Harms C1-C2 fixation for type II odontoid fractures, J Craniovertebr Junction Spine 13(2) (2022) 175–181. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Mar, 2024 Read the published version in Child's Nervous System → Version 1 posted Editorial decision: Accepted 26 Feb, 2024 Reviews received at journal 10 Feb, 2024 Reviewers agreed at journal 09 Feb, 2024 Reviewers invited by journal 08 Feb, 2024 Submission checks completed at journal 31 Jan, 2024 Editor assigned by journal 31 Jan, 2024 First submitted to journal 29 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3909561","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":270224986,"identity":"9789a0a3-fd9d-4ab1-9284-f3e75563be87","order_by":0,"name":"Sharath Kumar Anand","email":"","orcid":"","institution":"University of Pittsburgh Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Sharath","middleName":"Kumar","lastName":"Anand","suffix":""},{"id":270224987,"identity":"d6a53c4b-259d-4f4b-a864-98bdab10c5eb","order_by":1,"name":"Regan M. 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Right image shows an axial CT myelogram image highlighting an altitudinal interval of 5.5mm. B: Postoperative CT Imaging of Cervical Spine. Left Image shows a sagittal CT image highlighting derotation of the dens compared to preop. Right image shows an axial CT highlighting an atlantodental interval of just 1.0mm\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3909561/v1/dab01db1f1911960b3c5cf7c.jpg"},{"id":50565386,"identity":"e0450626-9d39-42ae-8a14-88c1bb2772e2","added_by":"auto","created_at":"2024-02-02 15:08:36","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":67125,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative X-ray Imaging of Cervical Spine. A: Lateral view of instrumentation. B: Anterior-posterior (AP) view of instrumentation\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3909561/v1/9c0983fd6667d444d58bf87d.jpg"},{"id":52844097,"identity":"74625f58-f16c-48d8-8dff-2378a8ae4c28","added_by":"auto","created_at":"2024-03-17 16:03:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":371528,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3909561/v1/834d5185-b730-4356-a8ac-7281c478942a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Atlantoaxial Facet Fixation Using Cervical Facet Cage: Technical Case Report and Review of the Literature","fulltext":[{"header":"Introduction","content":" \u003cp\u003eIn 1994, Goel \u003cem\u003eet al.\u003c/em\u003e first described atlantoaxial fixation using screws and plates with interfacet spacer placement for joint distraction and load bearing [1]. The Goel technique allows for vertical distraction of the C1-C2 joint and thus reduction of the mobile basilar invagination prior to instrumented fixation. The material placed in the interfacetal space has evolved from bone graft to titanium cages and now includes cervical facet cages (CFC). CFCs are titanium implants used to replace damaged facet joints to restore stability and mobility. In this report, we present the first case to our knowledge of C1-C2 fixation using CFC in a pediatric patient for the treatment of basilar invagination as well as a brief review of the literature.\u003c/p\u003e "},{"header":"Case Report","content":"\u003cp\u003e\u003cem\u003eHistory and Presentation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA 12-year-old boy with a history of Wiedemann-Steiner syndrome complicated by AV block requiring a pacemaker, submucosal cleft palate, choanal stenosis, and micrognathia with midface hypoplasia presented with multiple episodes of neck jerking and guarding against neck motion. Persistent dysphagia was also noted. Seizure workup for these episodes was negative and upon examination the patient had a Lhermitte sign with flexion. Computed tomography (CT) scan of his cervical spine revealed basilar invagination with 6.4 mm of superior displacement of the odontoid process above the McRae line, atlantodental interval (ADI) of 5.5 mm, atlantooccipital assimilation, and C2-C3 fusion (\u003cstrong\u003eFigure 1a\u003c/strong\u003e). CT myelography demonstrated evidence of compression of the cervicomedullary junction by the retroflexed odontoid process (\u003cstrong\u003eFigure 1a\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e A: Preoperative Computed Tomography (CT) Myelogram Imaging of Cervical Spine. Left image shows a sagittal CT myelogram image. Right image shows an axial CT myelogram image highlighting an altitudinal interval of 5.5mm. B: Postoperative CT Imaging of Cervical Spine. Left Image shows a sagittal CT image highlighting derotation of the dens compared to preop. Right image shows an axial CT highlighting an atlantodental interval of just 1.0mm\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSurgery\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe patient was taken to the operating room for an occiput to C3 fusion with placement of bilateral C1-C2 CFC joint interfacet spacers. Pre-position somatosensory evoked potentials (SSEPs) were normal and reliable. Following exposure, the C2 nerve roots were identified and sacrificed. The C1-2 joint was then drilled and two 10 mm x 5.5 mm x 2.5 mm CFCs were placed parallel to the joint under fluoroscopic guidance. The occipital plate was shaped to the curvature of the occiput and three screws, 8, 2, and 8mm were placed. \u0026nbsp;C2 pars screws (20 mm on the left and 22 mm on the right) were placed under image guidance. Finally, image guidance was used to place a left C3 14 mm pedicle screw and a right C3 12 mm pedicle screw. C1 was not instrumented. Intraoperative CT was used to confirm placement of all hardware before 3.5 mm diameter titanium rods were placed on both sides and secured. \u0026nbsp;All bony surfaces were then decorticated prior to placement of fusion supplements including a mixture of allograft demineralized bone matrix putty.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOutcome\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePostoperatively, his neck guarding, and episodic electrical pain resolved, and he remained neurologically at his baseline. The postoperative CT of the cervical spine revealed reduction of his basilar invagination to 4.1 mm of superior displacement of the odontoid process above the McRae line, with a decrease of ADI to 1.0 mm due to decreased dens retroflexion, and stable placement of the hardware (\u003cstrong\u003eFigure 1b, 2\u003c/strong\u003e). The patient was discharged on post-operative day (POD) 6 with a cervical collar and stable neurologic exam. \u0026nbsp;Unfortunately, he was readmitted with post-operative dysphagia on POD20 and ultimately required percutaneous gastrostomy tube placement for continuous feedings. The patient has followed with otorhinolaryngology for dysphagia management, and he was found to have primarily a food disinterest rather than a mechanical limitation. At three-months post-operation, radiographic imaging confirmed adequate decompression and evidence of bony fusion. At four-months post-operation, the patient was weaned from his cervical collar. He has since resumed oral intake without restrictions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ePostoperative X-ray Imaging of Cervical Spine. A: Lateral view of instrumentation. B: Anterior-posterior (AP) view of instrumentation\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this article, we describe the case of a 12-year-old boy with history of Wiedemann-Steiner syndrome with basilar invagination who underwent occiput to C3 fusion with placement of bilateral C1-C2 CFC joint interspacers. Patients often require a combined endoscopic endonasal resection of the odontoid with posterior occipitocervical fusion; however, the indirect spinal canal decompression achieved using C1-C2 CFC joint interspacers with subsequent derotation of the atlantoaxial joint precluded the need for anterior decompression and thereby reduced the risk of additional vascular injury, cerebrospinal fluid leak, dysphagia, and need for tracheostomy.\u003c/p\u003e\n\u003cp\u003eResults of a literature review of posterior facet fixation of the C1-C2 joint are summarized in \u003cstrong\u003eTable 1\u003c/strong\u003e. \u0026nbsp;Goel \u003cem\u003eet al.\u003c/em\u003e first reported the use of iliac bone graft for C1-C2 facet fixation in 1994. From 2004-2008 Dr. Goel\u0026apos;s group has reported a high rate of sustained radiographic reduction using hydroxyapatite and titanium spacers with a need for an anterior cervical approach for odontoid resection in only 2 of 64 total patients [2-5]. Other authors within this review utilized tricortical bone allografts [6], anterior cervical discectomy and fusion cages [7, 8], and CFC [9, 10] as used in this case report, with similarly low rates of supplementary anterior approaches. Numerous studies have demonstrated the efficacy of CFCs in treating subaxial cervical radiculopathy and augmenting fusion [11, 12]. Few studies have explored the use of CFCs for atlantoaxial fixation, which was an off-label use of the device at the time of the operation [9, 10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eSummary of literature review.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"708\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraarticular Facet Fixation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGoel et al., 1994\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[1]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eAtlanto-axial dislocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003eAdult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eIliac bone graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eImprovement or stabilization of neurologic function; no re-operations or new neurological symptoms reported\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGoel et al.\u003c/strong\u003e\u003cstrong\u003e, 2004\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eBasilar invagination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e8-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eIliac bone graft (8 cases),\u003c/p\u003e\n \u003cp\u003eTitanium spacers (4 cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eSustained distraction and reduction at 6 months; no new neurologic symptoms. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGoel et al., 2005\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[3]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eBasilar invagination with Syringomyelia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e14-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eTitanium spacers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eNeurological improvement, sustained reduction of distraction and basilar invagination; syringomyelia not assessed. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGoel et al., 2005\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[4]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003ePersistent basilar invagination previously treated by trans-oral decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e22, 17, 18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eTitanium spacers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eImproved omega angle; clinically improved to be able to walk unassisted. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGoel et al., 2008\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[5]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eBasilar invagination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eTitanium spacers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eNeurological improvement; sustained reductions of distraction and basilar invagination at 6-month follow-up.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYamagata et al., 2020\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[6]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eRigid AAS (defined as ADI \u0026gt;5mm) secondary to odontoid dysplasia or os odontoideum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e5-15\u003c/p\u003e\n \u003cp\u003e(Mean: 9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eTricortical bone graft used as spacer and fulcrum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eNeurosurgical Cervical Spine Scale (NCSS) scores improved in 6 cases and were maintained in 4 cases; all patients achieved increased C1-C2 height, ADI improvement, and bony fusion on post-operative imaging.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLee et al., 2017 \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[7]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eRheumatoid arthritis, basilar invagination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eACDF cages\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eImproved pain; maintained bony fusion at 3-year follow-up.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTominaga et al., 2019\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[8]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eArthritis, basilar invagination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e85, 75, 43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eCorridor anterior cervical cage (Globus Medical Inc., Audubon, PA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eImproved EMS scores, walking ability, and reduced neck pain; one case of reoperation due to rod breakage and nonunion.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSommer et al., 2022\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eOdontoid fractures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003eMedian: 79.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eCFC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eDecrease in VAS pain scores; radiographic evidence of fusion on last follow-up. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSommer et al., 2022\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[10]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eTrauma (4/9), Neoplasm (1/9), Degenerative changes (4/9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003eMean: 68.7+/-16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eCervical Facet Cage (CFC)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eSignificant decrease in VAS pain scores; all patients achieved bony fusion with no evidence of subsidence at last follow-up. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGoel et al., 2005\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[13]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eFixed atlanto-axial dislocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e12-46\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Mean: 22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eHydroxyapatite spacers (16 cases), Titanium spacers (3 cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003e13 patients with acceptable reduction (atlantodental interval\u0026lt;4mm); 4 with clinical improvement but no radiographic reduction; 2 patients underwent trans-oral decompression.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKim et al., 2011 \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[14]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eBasilar invagination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e45, 69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003e8mm iliac bone autograft,\u003c/p\u003e\n \u003cp\u003eAutograft iliac bone blocks\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eImproved Clark Station, Redlund-Johnell Criterium and Ranawat Criterion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSrivastava et al., 2017\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[15]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eOs odontoideum, Basilar invagination, Basilar invagination, Basilar invagination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e16, 32, 32, 18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eUnspecified spacer or wedge bone graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eNeurological improvement, improved mJOA scores; stable fusions.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTurel et al., 2017\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[16]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eTraumatic fractures (8), Degenerative stenosis (6), C2 neuralgia (2), C1-2 ligamentous subluxation (2), Os odontoideum (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003eMedian: 69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eMachined cortical allograft (FacetLift, Medtronic, Memphis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003e94% successful arthrodesis at 6 months; one patient who did not achieve arthrodesis remained asymptomatic.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSai Kiran et al., 2018\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[17]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eBasilar invagination, Os odontoideum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eUnilateral right C1-2 titanium spacer with bone graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eResolution of pre-operative symptoms; no instability on dynamic radiographs at 10-month follow-up.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eXu et al., 2019\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[18]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eAlagille syndrome with numerous segmentation abnormalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eSmall cortical bone grafts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eComplete resolution of preoperative symptoms; persistent fusion and improved alignment on XR. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eJain et al., 2022\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[19]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eOdontoid fractures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e23-52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eUnspecified, spacers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eResolution of neck pain; complete fracture alignment in 8/9 patients; 1 patient with\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ewith grade 4 listhesis and bone loss; stable fusion at a mean follow-up of 16 months.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnand et al.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003eBasilar invagination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.237288135593221%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.627118644067797%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.728813559322035%\" valign=\"top\"\u003e\n \u003cp\u003eCFC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8135593220339%\" valign=\"top\"\u003e\n \u003cp\u003eReduction of basilar invagination, decreased ADI; temporary gastrostomy tube placement to address dysphagia.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOur report demonstrates the safe utilization of CFC for atlantoaxial fixation in a pediatric patient. The generalizability of this claim is limited by our singular clinical experience. It is our impression that the relatively small size of the graft limits the magnitude of direct reduction potential, but the shape of the graft and angulation of the C1-C2 joint may allow for a significant amount of de-rotation of a retroflexed odontoid process relative to the C1 anterior arch. Ultimately, our current experience suggests that reduction in ADI via derotation may be more clinically significant than the decompression achieved from reducing the degree of invagination.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe highlight the potential safety of using CFCs as an atlantoaxial facet distraction, reduction, and fusion tool in a pediatric patient with basilar invagination. While further studies are necessary to corroborate these findings, we show that CFCs can be a powerful tool for posterior-only approach for atlantoaxial reduction and fixation in pediatric populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting Interest\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe University of Pittsburgh Institutional Review Board (IRB) approved the study \u0026ldquo;Analyses of Neurosurgery Operative Procedures\u0026rdquo; on July 27, 2020, under the reference number STUDY20050395. Written informed consent was obtained from the patient\u0026rsquo;s parent for publication of the details of their medical case and any accompanying images.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConception \u0026amp; design: All authorsDrafted the manuscript: All authorsCritical evaluation of the manuscript: All authorsApproved the final version to be published: All authorsAgree to be accountable for all aspects of the work in ensuring that questions related to theaccuracy or integrity of any part of the work are appropriately investigated and resolved: Allauthors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eA. Goel, V. Laheri, Plate and screw fixation for atlanto-axial subluxation, Acta Neurochir (Wien) 129(1\u0026ndash;2) (1994) 47\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA. 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Byun, Vertical reduction using atlantoaxial facet spacer in basilar invagination with atlantoaxial instability, J Korean Neurosurg Soc 50(6) (2011) 528\u0026thinsp;\u0026minus;\u0026thinsp;31.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA.K. Srivastava, S. Behari, J. Sardhara, K.K. Das, Simultaneous odontoid excision with bilateral posterior C1-2 distraction and stabilization utilizing bilateral posterolateral corridors and a single posterior midline incision, Neurol India 65(5) (2017) 1068\u0026ndash;1075.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eM.K. Turel, M.G. Kerolus, V.C. Traynelis, Machined cervical interfacet allograft spacers for the management of atlantoaxial instability, J Craniovertebr Junction Spine 8(4) (2017) 332\u0026ndash;337.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eN.A. Sai Kiran, V.A. Kiran Kumar, L. Sivaraju, V.A. Kumar, C.R. Reddy, A. Agrawal, Management Issues in a Case of Congenital Craniovertebral Junction Anomaly with Aberrant Retropharyngeal Midline Course of Bilateral Cervical Internal Carotid Arteries at C1-C2, World Neurosurg 114 (2018) 94\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eR. Xu, Y. Xia, P.G. Passias, T. Protopsaltis, D.M. Sciubba, Occipitocervical Osteotomies and Interfacet Grafts for Reduction of Occipitocervical Kyphosis and Basilar Invagination, World Neurosurg 127 (2019) 391\u0026ndash;396.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA.K. Jain, M. Tawari, L. Rathore, D. Sahana, H. Mishra, S. Kumar, R.K. Sahu, An experience with Goel-Harms C1-C2 fixation for type II odontoid fractures, J Craniovertebr Junction Spine 13(2) (2022) 175\u0026ndash;181.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"C1-C2 facet fixation, Interfacet spacers, Goel technique","lastPublishedDoi":"10.21203/rs.3.rs-3909561/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3909561/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn 1994, the use of interfacet spacer placement was for joint distraction, reduction, and fusion to supplement atlantoaxial or occipitocervical fixation. Here we present a unique case of bilateral atlantoaxial interfacet fixation using cervical facet cages (CFC) in a pediatric patient with basilar invagination. In addition, we review the literature on atlantoaxial facet fixation.\u003c/p\u003e \u003cp\u003eWe present a 12-year-old boy with Wiedemann-Steiner syndrome who presented with multiple episodes of sudden neck jerking, described as in response to a sensation of being shocked, and guarding against neck motion, found to have basilar invagination with cervicomedullary compression. He underwent an occiput to C3 fusion with C1-2 CFC fixation. We also conducted a literature review identifying all publications using the keywords: \u0026ldquo;C1\u0026rdquo; AND \u0026ldquo;C2\u0026rdquo; OR \u0026ldquo;atlantoaxial\u0026rdquo; AND \u0026ldquo;facet spacer\u0026rdquo; OR \u0026ldquo;DTRAX.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe patient demonstrated postoperative radiographic reduction of his basilar invagination from 6.4 mm to 4.1 mm of superior displacement above the McRae line. There was a 4.5 mm decrease in the atlantodental interval secondary to decreased dens retroflexion. His post-operative course was complicated by worsening of his existing dysphagia but was otherwise unremarkable. His neck symptoms completely resolved.\u003c/p\u003e \u003cp\u003eWe illustrate the safe use of CFC for atlantoaxial facet distraction, reduction, and instrumented fixation in a pediatric patient with basilar invagination. Review of the literature demonstrates numerous materials can be safely placed as a C1-C2 interfacet spacer including bone grafts, titanium spacers, and anterior cervical discectomy and fusion cages. We argue that CFC may be included in this arsenal even in pediatric patients.\u003c/p\u003e","manuscriptTitle":"Atlantoaxial Facet Fixation Using Cervical Facet Cage: Technical Case Report and Review of the Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-02 15:08:31","doi":"10.21203/rs.3.rs-3909561/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2024-02-26T17:37:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-10T11:00:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1eb3c572-3691-4864-9046-f4c8b668c2d5","date":"2024-02-09T07:47:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-08T18:10:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-31T10:30:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-31T10:30:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2024-01-30T02:31:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7bd14e73-ca64-48dc-be3b-fdae51b942ec","owner":[],"postedDate":"February 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-03-17T16:03:18+00:00","versionOfRecord":{"articleIdentity":"rs-3909561","link":"https://doi.org/10.1007/s00381-024-06339-2","journal":{"identity":"childs-nervous-system","isVorOnly":false,"title":"Child's Nervous System"},"publishedOn":"2024-03-14 16:03:18","publishedOnDateReadable":"March 14th, 2024"},"versionCreatedAt":"2024-02-02 15:08:31","video":"","vorDoi":"10.1007/s00381-024-06339-2","vorDoiUrl":"https://doi.org/10.1007/s00381-024-06339-2","workflowStages":[]},"version":"v1","identity":"rs-3909561","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3909561","identity":"rs-3909561","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}