HEALTHWATCH
In `no man's land'
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The cranio-vertebral junction is usually a problem area for surgery. But recently some patients have been operated on successfully.
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COMPLETE SUCCESS: After the surgery.
THE junction of the skull and spine, known as Cranio-vertebral junction, comprises the base of the skull — mainly the occipital bone surrounding the foramen magnum and first two spines of the seven cervical spines that form the neck bones.
This area is a vital one because the brainstem, which is responsible for our breathing and control of pulse and blood pressure, passes through the foramen magnum and forms the spinal cord.
Adjacent to this are the major blood vessels supplying the brain, which enter through the foramen magnum. An injury in this area can lead to sudden death or total paralysis of both the hands and legs. Surgeons normally use the "Anterior Transcervical Approach" behind the food pipe and windpipe to approach the cervical spine to deal with the segments C3 to T1. This has not gained popularity for problems above C3.
Difficult and dangerous
Surgical exposure of the front aspect has always been considered difficult and dangerous. Various surgical approaches from the front and back have been used with variable results. The dreaded complications of surgery can occur from the time of induction of anaesthesia itself.
Recently two different patients, with different problems, were operated on successfully and are also doing well on follow up. The first was a middle-aged woman with neck pain. She was not able to hold her head erect. She used to support her chin to keep her head erect.
The patient came with a diagnosis of a lesion of the C3 body and was using a cervical collar to support her neck. Further investigations like Magnetic Resonance Imaging of the spine actually revealed a tumour located only on the C3 body of the spine.
This patient was operated through the front. The C3 body tumour was completely removed and the vacant space replaced with an artificial cage that was impacted between the C2 vertebra and C4 vertebra.
If the cage slipped, it could have damaged the vital structures like windpipe, food pipe, spinal cord and major blood vessels supplying the brain (carotid arteries) and the spine. So it was stabilised using titanium plates and screws. The titanium plate was fixed above the C2 and below the C4 using two screws passed through the vertebra.
Follow up
The biopsy report revealed the tumour to be an extremely rare form of Langerhan's histiocytosis. Consistent long-term follow-up of more than a year has shown the patient doing extremely well and able to walk without having to hold her chin. There is no recurrence of the tumour.
The second patient was an Omani lady who sustained a severe head and spine injury. She was comatose for more than three weeks.
Though she recovered from this, she had difficulty in walking and holding her head erect. She was informed that it was extremely difficult to operate on the spine and was advised a cervical collar with bed rest for months. Investigations revealed she had a fracture of the C2 spine with instability.
This fracture of C2 spine (Axis) is called "Hangman's fracture", since it occurs during hanging when the brain-spinal cord junction is transected leading to instantaneous death. It is a very rare fracture and the patient was extremely lucky to survive.
Treatment
When this fracture is unstable, surgery is the treatment of choice. Various types of surgery have been advocated and stabilising from the front is considered the ideal treatment but is a high-risk one because the spinal cord can be transected during the surgery leading to instant death.
This patient again was successfully operated through the front of the neck and her spine was stabilised using a bone graft taken from the hip. The spine was fixed with a titanium plate, as in the first case, extending from C2 to C3 using screws passing through each of the vertebra.
Following the surgery, the patient was able to walk with support and is gradually improving. She is able to hold her head erect and stand.
Another young gentleman with "Hangman's fracture" was also operated on successfully.
Other cases
There were other cases — a young schoolboy who sustained injury with a fracture involving the C2 spine while practising martial arts and an elderly lady who had a similar fracture after twisting her neck — that were also successfully operated on.
The follow-up of these cases ranging from few months to more than two years has shown an excellent outcome with the patients returning to their normal life.
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The CV junction
The anatomy and biomechanics of the junction of the skull with the first three cervical vertebrae are unique to human beings.
The head and neck have to be freely mobile for all functions of the body and have to be stable. The atlas (first cervical vertebra) acts as the bearing between the head and cervical spine allowing free movement.
This complex area has a multitude of disease process that may require surgical treatment.
Patients with cranio-vertebral junction diseases seek medical treatment at a very late stage. Early medical intervention will prevent permanent neurological disability.
These patients constitute a high-risk category for anaesthesia and surgery when they come in the advanced stage of the disease.
DR. U.S. SRINIVASAN
The writer is Chief Neurosurgeon and Head, Department of Neurosurgery, MIOT Hospitals, Chennai.
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