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We discussed the clinical entity of “axial” or “central” atlantoaxial instability.and axis and direct observation of status of facets and the joint by physical assessment and evidence and manual manipulation of the bones of the region.As multiple level bone removal has been identified to result in instability in the long-run, a host of stabilization procedures have been discussed.
A number of genetic, dietary, environmental, and systemic issues have been identified to be the possible factors that lead to the formation of abnormal calcification/ossification of the posterior longitudinal ligament that encroach into the spinal canal, compress the spinal cord, and lead to progressive symptoms related to myelopathy.
Location of the ossification anterior to the spinal cord and posterior to single or multiple vertebral bodies make direct surgical resection a challenging and dangerous surgical issue.
Over several decades, the pathogenesis of cervical spondylosis has been convincingly related to primary disc degeneration, disc space reduction, and subsequent relentlessly progressive pathological processes such as osteophyte formation, ligamentum flavum hypertrophy, facetal retrolisthesis, and similar such events that eventually result in spinal and neural canal stenosis and related neurological symptoms and deficits.
Decompression of the neural structures by removal of the offending bone and soft-tissue elements by anterior cervical route by single or multiple level corpectomy or by posterior route by laminectomy or foraminotomy or by laminoplasty is the accepted and widely practiced mode of surgical treatment.
It was realized that multiple segmental spinal instability was also the nodal and primary pathogenetic issue in cases with OPLL.
Atlantoaxial instability was relatively more often associated than in cases with only cervical spondylosis.On the basis of our experience, we identified that facetal distraction resulted in or has the potential to result in regression of all the known pathological spinal events such as osteophyte formation, ligamentum flavum hypertrophy, increase in the disc space height, and increase in the spinal canal and neural foraminal height.As we progress in our clinical understanding, we realize that “only-fixation” of the involved spinal segments by transarticular technique of facetal fixation and the operation aimed at arthrodesis of the affected segments was the optimum and rational surgical treatment. J Craniovert Jun Spine [serial online] 2018 [cited 2019 Sep 7];9:1-2. 2018/9/1/1/230612 There has been an ongoing discussion for decades about the causal relationships between ossification of posterior longitudinal ligament (OPLL) and cervical spondylosis. Ossification of posterior longitudinal ligament and cervical spondylosis: Same cause - Same treatment.Identification and treatment of atlantoaxial instability forms an important component of surgical treatment.Atlantoaxial instability might not be identified by conventionally described radiological characters such as abnormal alteration of atlantodental interval on dynamic imaging or any evidence of dural or neural compression.A number of surgical strategies have been described that focus on decompressing the compressed spinal cord.The need for stabilization of the spinal segments following bone and soft-tissue decompression continues to be a subject of intense clinical discussion.It was observed that there was no need for any distraction or decompression of spinal bone or soft-tissue elements.Our current understanding is that in several cases of multilevel cervical spinal degeneration, particularly those presenting with severe symptoms related to myelopathy have instability of the atlantoaxial joint.