Atlas Shrugged
The Atlanto-Axial joint is one of the most incredible feats of design. A joint that simultaneously has a rotatory pivot, gliding facets, and above all, houses the most critical continuation of the brain-stem and spinal cord- the cervico- medullary junction.
The first Cervical vertebra is named Atlas, after the mythical giant, who bore the weight of the earth on his neck. This signet shaped ring, with a diameter of an egg, has another small ring bounded by the transverse ligament, into which the slips the finger of the axis. This ring ceremony occurs during gestation and their conjugal relationship remains critical to life. There are relatives and friends, - ligaments, that provide vital support and solidarity to this sacred and solemn bond.
If this bond ever disrupts,it can spell doom. The act of hanging, abruptly tears the ring causing the finger to slip backwards and snuff out life,by ploughing into the cervico-medullary junction, killing instantaneously.
The patent in this case presented with a fracture of the finger- fracture odontoid. The anatomical name is Odontoid, since it resembles a tooth like projection. The young fellow had an accident and fell backwards with his neck bearing the brunt of the impact. He had severe tingling and numbness below the neck, sight weakness of the grip of both his hands, and severe neck pain. Most often, these injuries render this joint very vulnerable which is why, casualty evacuation is done with a rigid immobilisation of the neck. Any movement with a compromised Atlanto-axial joint can result in paralysis of all 4 limbs,or even death.
Just as Hank Rearden,the protagonist of Atlas Shrugged ushered in a Utopian society by his abilities and imagination, my dear friend and colleague Dr Sushil Patkar proposed a new revolutionary idea of fixing and stabilizing this fracture using a plate and screws.
Access to this fractured odontoid through the neck is truly formidable, almost inaccessible. The approach involves reaching out deep inside the neck dissecting ones way between the trachea and the food pipe, the oesophagus in the front, and the carotid artery, the pipeline of the brain behind. The twelfth cranial nerve, that controls the tongue movement has to be cajoled and gently moved aside enroute.
Exposure of the fractured fragments mandates deep retraction,and stripping off the muscles that are attached on either side. When I first heard of this technique, I had passed it off as a mere flight of fancy. But when my colleague showed me the x-rays of a case he had operated, I realised the feasibility and ingenuity of this approach.
I decided to tackle this case by using this innovative technique. I prepared by visiting the dissection hall, and familiarising myself with the anatomical details.
On the day of the surgery, i was a bundle of nerves, as I began the journey to reach the target. Once the incision is taken, some strange power takes over. The intelligence and decision making inevitably migrates to the fingers as they dissect, and deploy an array of tools and devices, almost as an extension of themselves.
By the time I've exposed the fracture site, my assistants' hands are fatigued by retracting. I am also filled with trepidation as I reach out for the micro drill. I'm now planning to drill a hole into the proximal, and then the distal fragment, deep inside the neck. Apologies for sounding like the villain of a Texas Chainsaw horror flick.
I take a deep breath and get on with the job after verifying my position with X ray control. I am on target. I fix the tip of the drill and step on the pad with caution and fear. Caution and fear are the best assistants of a surgeon. They ensure sanity, in a seemingly insane adventure.
I then get the requisite screws, and threading them through the plate, I position the plate across the fractured fragments. A quick recheck with X-rays, and I navigate the screws into the holes made by the drill.
I tighten the screws, gently uttering a prayer. I pep up the sagging hands and morale of my assistants with
'Guys, you are doing a great job. I'm almost there."
The last clockwise rotation of the screwholder confirms adequate purchase into that 1 inch fragment. I feel blessed. . The view of final check X-ray is sheer ecstasy. The Lord has been benevolent and forgiving, despite my trespass and violation of his incredible Creation.
Video uploaded with prior permission of the patient.
The Atlanto-Axial joint is one of the most incredible feats of design. A joint that simultaneously has a rotatory pivot, gliding facets, and above all, houses the most critical continuation of the brain-stem and spinal cord- the cervico- medullary junction.
The first Cervical vertebra is named Atlas, after the mythical giant, who bore the weight of the earth on his neck. This signet shaped ring, with a diameter of an egg, has another small ring bounded by the transverse ligament, into which the slips the finger of the axis. This ring ceremony occurs during gestation and their conjugal relationship remains critical to life. There are relatives and friends, - ligaments, that provide vital support and solidarity to this sacred and solemn bond.
If this bond ever disrupts,it can spell doom. The act of hanging, abruptly tears the ring causing the finger to slip backwards and snuff out life,by ploughing into the cervico-medullary junction, killing instantaneously.
The patent in this case presented with a fracture of the finger- fracture odontoid. The anatomical name is Odontoid, since it resembles a tooth like projection. The young fellow had an accident and fell backwards with his neck bearing the brunt of the impact. He had severe tingling and numbness below the neck, sight weakness of the grip of both his hands, and severe neck pain. Most often, these injuries render this joint very vulnerable which is why, casualty evacuation is done with a rigid immobilisation of the neck. Any movement with a compromised Atlanto-axial joint can result in paralysis of all 4 limbs,or even death.
Just as Hank Rearden,the protagonist of Atlas Shrugged ushered in a Utopian society by his abilities and imagination, my dear friend and colleague Dr Sushil Patkar proposed a new revolutionary idea of fixing and stabilizing this fracture using a plate and screws.
Access to this fractured odontoid through the neck is truly formidable, almost inaccessible. The approach involves reaching out deep inside the neck dissecting ones way between the trachea and the food pipe, the oesophagus in the front, and the carotid artery, the pipeline of the brain behind. The twelfth cranial nerve, that controls the tongue movement has to be cajoled and gently moved aside enroute.
Exposure of the fractured fragments mandates deep retraction,and stripping off the muscles that are attached on either side. When I first heard of this technique, I had passed it off as a mere flight of fancy. But when my colleague showed me the x-rays of a case he had operated, I realised the feasibility and ingenuity of this approach.
I decided to tackle this case by using this innovative technique. I prepared by visiting the dissection hall, and familiarising myself with the anatomical details.
On the day of the surgery, i was a bundle of nerves, as I began the journey to reach the target. Once the incision is taken, some strange power takes over. The intelligence and decision making inevitably migrates to the fingers as they dissect, and deploy an array of tools and devices, almost as an extension of themselves.
By the time I've exposed the fracture site, my assistants' hands are fatigued by retracting. I am also filled with trepidation as I reach out for the micro drill. I'm now planning to drill a hole into the proximal, and then the distal fragment, deep inside the neck. Apologies for sounding like the villain of a Texas Chainsaw horror flick.
I take a deep breath and get on with the job after verifying my position with X ray control. I am on target. I fix the tip of the drill and step on the pad with caution and fear. Caution and fear are the best assistants of a surgeon. They ensure sanity, in a seemingly insane adventure.
I then get the requisite screws, and threading them through the plate, I position the plate across the fractured fragments. A quick recheck with X-rays, and I navigate the screws into the holes made by the drill.
I tighten the screws, gently uttering a prayer. I pep up the sagging hands and morale of my assistants with
'Guys, you are doing a great job. I'm almost there."
The last clockwise rotation of the screwholder confirms adequate purchase into that 1 inch fragment. I feel blessed. . The view of final check X-ray is sheer ecstasy. The Lord has been benevolent and forgiving, despite my trespass and violation of his incredible Creation.
Video uploaded with prior permission of the patient.
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