Dr. Abhijit Pawar: Complex Spine Surgery With Dislocation Of Cranio - Vertebral Junction With Paraplegia In Young Child

16 years old male Akash sustained injury to his head while playing Kabbadi. The injury was neglected. He had a dislocation of this cranium (skull) over his cervical spine. By the time he arrived in Kokilaben he was not able to walk due to paralysis. Young paralyzed child was investigated at Kokilaben. MRI and CT scan was done and it showed an old complete dislocation of first cervical vertebrae over the 2nd cervical vertebrae with severe spinal cord compression. The second cervical vertebrae had migrated in the cranium as a result of dislocation.

Fig.1.Dislocation of C1 over C2 with spinal cord compression

Challenges in such patient

Cranio- Vertebral junction is a very precarious area with lot of vital centers of brain including the respiratory center. The dislocation was old and was a challenging task to reduce the dislocation. Parents of Akash had taken several opinion all over Maharashtra and came to Kokilaben Hospital with some hope that Akash would walk again.

Fig.2. Migration of C2 in the Cranium

The nature of complexity was discussed in details with parents. There was a risk of complete paralysis or even respiratory compromise post surgery. The surgery was planned in 2 steps

Stage 1: Transoral release of the dislocation was done along with the plastic surgery team.

Stage 2: Patient was tilted at the same day and the posterior aspect was exposed from the skull to upper cervical spine. Screw were placed in the Cranium and first and 2nd Cervical Vertebrae . Decompression of the cranio vertebral junction was done. All nerves were continuously monitored during the procedure to ensure safe spine surgery. The dislocation was reduced with rods placed between the skull and cervical vertebrae. Special care was taken not to injure the vertebral artery and other vital neural structures. Surgery was uneventful and Aakash was out of anesthesia.

Fig.3. Reduction of dislocation and alignment restored.
Patient recovered well and started walking normally.

At the end of one month with physiotherapy Aakash had completely recovered. He was back to school and sports. For the parents to see paralyzed Aakash walk was a dream come true. The complex spine surgery was successful with Aakash a completely normal child now.