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Abolfazl Rahimizadeh, Zahed Malekmohammadi, Mona Karimi, Ava Rahimizadeh, Naser AsgariArticle Type:
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran.
Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Abolfazl Rahimizadeh, Zahed Malekmohammadi, Mona Karimi, Ava Rahimizadeh, Naser Asgari. Unstable os odontoideum contributing to cervical myelopathy and obstructive sleep apnea. 28-Jun-2019;10:125
How to cite this URL: Abolfazl Rahimizadeh, Zahed Malekmohammadi, Mona Karimi, Ava Rahimizadeh, Naser Asgari. Unstable os odontoideum contributing to cervical myelopathy and obstructive sleep apnea. 28-Jun-2019;10:125. Available from: http://surgicalneurologyint.com/surgicalint-articles/9437/
Abstract
Case Description: A 36-year-old male with progressive cervicomedullary myelopathy/quadriparesis exhibited obstructive sleep apnea (OSA) attributed to an anteriorly displaced os odontoideum (OO). Atlantoaxial screw-rod stabilization resulted in improvement of both neurological function and OSA.
Conclusion: A symptomatic unstable OO may contribute to suboccipital pain, progressive quadriparesis, vertebrobasilar insufficiency, and OSA. Appropriate operative intervention utilizing atlantoaxial screw-rod stabilization may help to resolve these deficits.
Keywords: Cervical myelopathy, Obstructive sleep apnea, OS odontoideum
INTRODUCTION
Os odontoideum (OO), a traumatic or congenital abnormality of the second cervical vertebrae, is characterized by a separate bony segment with a smooth circumferential margin.[9 ,10 ,12 ] Here, the authors describe a 36-year-old male who developed OSA and a progressive quadriparesis attributed to an unstable OO. Following reduction and stabilization, both his quadriparesis and OSA improved.
CASE REPORT
Radiographic confirmation of OO
The dynamic lateral cervical X-rays showed a free-floating OO that compromised the oropharyngeal airway [ Figure 1b ]. The cervical lordosis was 65 in extension with 27° of atlas angulation [ Figure 1a ]. With neck flexion, the cervical lordosis decreased to −5° and the atlas angulation to 15° [ Figure 1b ].Figure 1:
Dynamic lateral cervical radiographs: (a) in extension, Cobb and atlas angles are 65° and 47°, respectively. (b) In flexion, Cobb and atlas angles are decreased to −5° and 44°, respectively. Since atlas is loose with respect to axis, changes in atlas angle are invaluable in os odontoideum.Figure 2:
(a) T1-weighted sagittal magnetic resonance imaging (MRI) of cervical spine shows an os odontoideum (OO) with atlantoaxial dislocation and narrowing of the cervicomedullary junction. The OO and atlas ring are engulfed in a soft tissue extending from os to axis. The posterior airway space is quite narrow in the MRI taken in neuter position (white dash). (b) T2-weighted sagittal MRI shows myelopathy at the cervicomedullary junction.Figure 3:
Computed tomography scan of the cervical spine, (a) axial view shows atlantoaxial dislocation. (b) Reconstructed sagittal view shows displaced os odontoideum (OO) - atlas ring forward displacement in jigsaw pattern; note posterior airway space is very narrow with the neck in neuter position. (c) Reconstructed coronal view shows the OO.Surgery
The patient underwent a C1-C2 posterior fusion [ Figure 4a ]. Postoperatively, his neurological examine markedly improved, and the OSA disappeared completely. Five years later, he still has experienced no recurrence of OSA [Figure 4b ].Figure 4:
Postoperative lateral cervical X-ray shows C1-C2 screw rod fixation (a) a few days after surgery. (b) Five years after surgery.DISCUSSION
Frequency and etiology of OSA and rarity with OO
OSA is a relatively common but highly morbid condition that affects middle-aged adults (e.g., 9.1% of males and 4% of females).[ 3 , 4 , 14 ] Intraluminal pathologies contributing to upper airway obstruction/OSA most typically include cancers of tongue base, pharynx or supraglottic larynx, an enlarged osteophyte at the level of C2-C3, and diffuse idiopathic skeletal hyperostosis/osteochondroma of the atlas.[ 2 , 5 , 6 , 8 , 11 , 13 , 15 ] Notably, OO is one of the least frequent causes of OSA; in fact, the authors could find only one previously reported example of this in the medical literature.[ 7 ]Surgery for OO
The surgical management of unstable OO requires C1-C2 reduction and fusion/fixation best achieved with the classic Harms technique.[ 1 ] Alternative surgical options include C2- C1 transarticular fixation, application of a translaminar C2 screw instead of a C2 pedicle screw, and the use of an atlas hook instead of a C1 lateral mass screw.[ 9 , 10 , 12 ] Adequate management of instability with relief of C1-C2 cord/brain stem compression may allow for symptoms of OSA to resolve.CONCLUSION
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