Basilar Invagination and Atlantoaxial Dislocation: Reduction, Deformity Correction and Realignment Using the DCER (Distraction, Compression, Extension, and Reduction) Technique With Customized Instrumentation and Implants

The technique of distraction, compression, extension, and reduction (DCER) is effective to reduce, realign, and relieve cranio-spinal compression through posterior only approach.Study included all patients with atlantoaxial dislocation and basilar invagination (BI) with occipitalized C1 arch. Study techniques included Nurick grading, computed tomography scan to study atlanto-dental interval, BI, hyper-lordosis, and neck tilt. Sagittal inclination (SI), coronal inclination (CI), cranio-cervical tilt, presence of pseudo-joints, and anomalous vertebral artery were also noted. Patients underwent DCER with/without joint remodeling or extra-articular distraction (EAD) based on the SI being <100°, 100°-160°, or >160° respectively. In cases with pseudo-joints, joint remodeling was performed in type I and EAD in type II. Customized 'bullet shaped' PSC spacers (n=124) and prototype of the universal craniovertebral junction reducer (UCVJR, n=36) were useful.A total of 148 patients with average age 27.25±17.43 years, ranging from 3 to 71 years (87 males) were operated. Nurick's grading improved from 3.14±1.872 to 1.22±1.17 (p<0.0001). Fifty-two percent of total joints (n=154/296 joints) were either type I (19%)/type II (33%) pseudo-j oints. All traditional indices such as Chamberlein line, McRae line, atlanto-dental interval, and Ranawat line improved (p