Supplementary Comment on “Craniovertebral Junction Realignment for the Treatment of Basilar Invagination With Syringomyelia：Preliminary Report of 12 Cases”

This article on craniovertebral junction realignment is something that many of us have done, even for cases with syringomyelia. What is different about this operation is that they placed metallic devices within the joints at the C1-2 level. Placing a device and/or bone in that joint could well be a good idea in those patients where there is partial or complete occipitalization of the atlas. This was present in eight of their patients. For their other patients, I am not sure it is necessary, and there are other ways we can treat that. Out standard of care is to bring these patients in and put them in long traction, at low weights with the head of the bed up about 25-35 degrees. That way they breathe easily. This procedure is done in patients who come in with significant neurologic problems, like basilar impression. Depending on the pathology dictates whether we do a cranial-cervical fusion or just a C1-2 fusion. Where this paper is important is in those patients who have occipitalization of C-1 and you are really trying to stabilize the C1-2 area. We have placed bone in the joint. We have never placed a metal device. Admittedly, with the venous plexus it is a bit difficult on some patients. We then use the titanium screws posteriorly. Sometimes we even add a mid-line wire of C-1 down to C-2 to hold the graft in tight. In the long run, you need a very strong fusion. So we use the old “belt and suspenders” approach. These patients are a challenge. They are lucky that the other patients didn't need a transoral decompression. We have found that is only required in about 5% of the patients when they present with significant neurologic deficits and MRIs as shown in Fig.1C. This is a supplementary comment on an article published in Neurologia medico-chirurgica Vol.45, No.10, pp 512-518.