TO THE EDITOR: We read with interest the study by Shah et al.1describing the surgical results of central or axial atlantoaxial dislocation (CAAD), an entity recently described by the senior author (Shah A, Vutha R, Prasad A, et al. Central or axial atlantoaxial dislocation and craniovertebral junction alterations: a review of 393 patients treated over 12 years.Neurosurg Focus. 2023;54[3]:E13). They proposed that CAAD could be divided into three main groups: group A, cases involving musculoskeletal changes and neural alterations related to the craniocervical junction, such as basilar invagination, Chiari malformation, syringomyelia, atlas assimilation, C2–3 fusion, bifid arch of the atlas, torticollis, and dorsal kyphoscoliosis; group B, CAAD related to subaxial spinal instability and cervical myelopathy; and group C, cases identified by minor clinical observations without other defined pathology entity.
With their compiled data and updated material results, the authors identified 393 patients with group A CAAD. All of them were treated with atlantoaxial fixation without bone decompression. After a mean follow-up of 73 months (range 6–155 months), they reported that no patient had additional surgery, symptom recurrence, implant failure, or infection.
As surgeons, we know that complications and some degree of patient dissatisfaction are inherent to our surgical procedures. In our humble opinion, there are no surgical procedures without inherent complications and with perfect results. It is almost impossible that in 393 atlantoaxial fusions there were no additional surgeries, symptom recurrences, implant failures, or infections. To attest to our opinion, we can see clearly in the same journal issue that all the other studies reported complication rates, and none of them were 100% successful procedures.2–5
另一个重要的观点是,作者recommended the same treatment strategy for a wide range of different craniocervical junction pathologies, despite differences in symptoms and radiological findings. This is contrary to the knowledge obtained by many surgeons around the world who have dedicated decades to the treatment of these entities. To corroborate our point regarding this incongruence, there was no reference in the paper to the amount of knowledge obtained over decades. It seems that C1–2 fusion was the remedy for all pathologies despite their wide range of clinical and radiological presentations.
It has been accepted worldwide that C1–2 instrumented fusion is the treatment of choice in many situations of segmental instability, and the concepts proposed by the senior author regarding basilar invagination create a new paradigm in craniovertebral pathologies. However, in the absence of either segmental instability or deformity, how can one justify the long-term consequences of atlantoaxial fusion (i.e., lack of cervical rotation) based on a theory yet to be proved?
Finally, because the authors did not consider any previously published literature (in the last decades) outside of their perspective, we found the publication of this article in a prestigious journal inappropriate. The risks of extrapolating the results obtained in this study could be harmful for patients with these conditions from both a surgical and a psychological point of view, as one’s expectations may be unrealistic.
Disclosures
The authors report no conflict of interest.
References
-
1 ↑
ShahA,VuthaR,普拉萨德A,GoelA.Central or axial atlantoaxial dislocation and craniovertebral junction alterations: a review of 393 patients treated over 12 years.Neurosurg Focus.2023;54(3):E13.
-
2 ↑
Doğanİ,BayatliE,ErayHA,et al.Single-institution comparative analysis for odontoid resection: posterior transaxis versus anterior transnasal approach.Neurosurg Focus.2023;54(3):E12.
-
3
KassiciehAJ,EstesEM,RumallaK,et al.Thirty-day outcomes for suboccipital decompression in adults with Chiari malformation type I: a frailty-driven perspective from the American College of Surgeons National Surgical Quality Improvement Program.Neurosurg Focus.2023;54(3):E6.
-
4
KlekampJ.Surgery for basilar invagination with and without Chiari I malformation.Neurosurg Focus.2023;54(3):E11.
-
5 ↑
WangB,WangC,ZhangYW,et al.Long-term outcomes of foramen magnum decompression with duraplasty for Chiari malformation type I in adults: a series of 297 patients.Neurosurg Focus.2023;54(3):E5.
