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Even ventrally situated tumors can most often be approached in this fashion. A dural opening rostral and caudal to the level of the lesion is critical. The arachnoid should initially be preserved to prevent spinal cord herniation. Opening the dura rostral to the lesion first also helps to prevent herniation of the spinal cord if the arachnoid is not preserved. Techniques to allow for gentle manipulation of the spinal cord include wide laminectomies, a lengthy dural opening, sectioning of the dentate ligaments, and, in some cases, nerve root sectioning.

1 one day after open reduction and internal fixation of the C1-C2 joints. 1055/978-1-60406-159-8c009_f002 9 Re d u c t i o n Te c h n i q u e s f o r A t l a n t o a x i a l Ro t a r y S u b l u x a t i o n A C B D Fig. 3 Representations of preoperative computed tomography (CT) scans with reformatted reconstructions. (A) Left C1-C2 joint with the lateral mass of C1 posterior to the C2 superior articular surface. (B) Contralateral right C1-C2 joint with the lateral mass of C1 anterior to the C2 superior articular surface.

Key Principles The key principle for achieving reduction is the gentle re-creation of the injury mechanism followed by manipulation of the affected segments into normal alignment. Expectations Avoidance of neurologic injury with the reduction maneuver. Indications • Unilateral or bilateral facet dislocations or fracture/dislocations that have failed attempted closed reduction • Unilateral or bilateral facet dislocations or fracture/dislocations that have failed attempted open anterior reduction • Unilateral or bilateral facet dislocations or fracture/dislocations with no evidence of a disk herniation on preoperative magnetic resonance imaging (MRI) Contraindications • Hemodynamic instability • Aborted closed reduction in a patient with worsening sensory or motor function who is subsequently noted to have a significant disk herniation on MRI; such a patient requires an anterior diskectomy prior to open posterior reduction Special Considerations After a failed attempt at closed reduction, a cervical spine MRI is mandatory to search for a disk herniation.

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