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Journal of Craniovertebral Junction and Spine
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EDITORIAL
Year : 2015  |  Volume : 6  |  Issue : 1  |  Page : 10-11  

C2 ganglion resection for lateral mass fixation techniques


Department of Neurosurgery, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, India

Date of Web Publication17-Feb-2015

Correspondence Address:
Prof. Atul Goel
Department of Neurosurgery, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College Medical College, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-8237.151581

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How to cite this article:
Goel A. C2 ganglion resection for lateral mass fixation techniques. J Craniovert Jun Spine 2015;6:10-1

How to cite this URL:
Goel A. C2 ganglion resection for lateral mass fixation techniques. J Craniovert Jun Spine [serial online] 2015 [cited 2020 Apr 4];6:10-1. Available from: http://www.jcvjs.com/text.asp?2015/6/1/10/151581

Goel and Laheri first described the possibility of safe resection of C2 ganglion for lateral mass atlantoaxial fixation in 1988. [1],[2] This seemingly "small" or "minor" surgical step revolutionized the surgical treatment for atlantoaxial stabilization. Understanding of the anatomy of the C2 ganglion, its relationship to the atlantoaxial facet joints, and the possibility of its safe resection for surgical exposure for lateral mass fixation provided a new dimension to the treatment of craniovertebral junction stabilization. C2 ganglion is positioned posterior to the atlantoaxial joint cavity and is covered by large plexus of venous mesh. C2 ganglion is a large dorsal root ganglion, second in size only to the  Gasserian ganglion More Details. While other spinal ganglia are located in the region of the intervertebral foramina, the C2 ganglion has a unique location posterior to the facet joint between C1 and C2. It has no posterior bony cover. Resection of the ganglion provides a panoramic view of the region for safe insertion of the screws in the facets under direct vision. [3] Wide exposure also opens up the possibility of manually distracting and manipulating the facets. Surgical exposure of the joint in basilar invagination is significantly more difficult as the joints are rostrally located, making the angle of vision acute and the window of exposure relatively narrow. [4],[5] C2 ganglion sectioning is frequently necessary in exposing the joint in the treatment of atlantoaxial dislocation, but it is almost always necessary in the treatment of relatively complex craniovertebral anomalies in general and basilar invagination in particular. As insertion of screws in the facets of  Atlas More Details and axis is riddled with potential issue of vertebral artery injury, wide exposure and performance of all surgical steps under direct vision are key issues in the surgical treatment. More importantly, in complex clinical situations, exposure of the region forms the main issue in the conduct of the surgical procedure.

Over a 25-year period, and resection of the C2 ganglion in several of 1,300 surgically treated cases, we have realized that the procedure is safe and the suboccipital numbness following the procedure is only a minor or inconsequential issue for the patient. Neuralgic pain as a symptom related to ganglion section is never encountered. However, ganglion resection requires fine microsurgical techniques. Extensive venous bleeding from the adjoining venous plexus can make the exposure tedious. Lateral aspect of the ganglion is related to the vertebral artery. [6] The dissection lateral to the edge of ganglion needs to be careful and under direct surgical vision. Working amidst "bloody" field needs to be practiced and learnt. A relatively quick dissection is necessary to expose the C2 ganglion. Judicious cauterization and use of hemostats like gelfoam and Surgicel is crucial to control blood loss and proceed further with the exposure. Some surgeons feel that sectioning of the ganglion can reduce venous bleeding and total volume blood loss. The dural cover of the ganglion is firmly adherent to the underlying neural structures and encountering cerebrospinal fluid egress during the ganglion sectioning is rare.

Despite the fact that there is a possibility of safe and effective resection of the C2 ganglion, techniques have been designed that avoid sectioning of the ganglion. Most of the techniques involve inferior displacement of the ganglion and exposure of the facet of atlas from a superior perspective. The ganglion is thus located inferior to the screw and under the rod/plate implant. Special type of shank screw is used that has a smooth surface in relationship to the ganglion and avoid its injury. Such inferior displacement of the ganglion is a frequently employed technique.

We observed that superior displacement of the ganglion and working underneath this structure provides a wide exposure to the facet of the atlas and the articular cavity. Superior displacement of the ganglion is technically relatively easy. Working subperiosteally over the pedicle of axis and dissecting in the rostral direction displacing the ganglion exposes the articular cavity and the articular surface of the atlantoaxial joint. It is also possible to mobilize the ganglion and displace it superior to the rod/plate implant. Although comparative analysis of sectioning and preservation of the ganglion is not possible, it appears that sectioning of the ganglion may be compatible with better pain control. Stretching of the ganglion that may be necessary during its mobilization may be associated with postoperative neuralgic pains.

Although relatively rare, anomalous vertebral artery coursing in the region can lead to inadvertent laceration. There can be occasions when the vertebral artery physically appears remarkably similar to the C2 ganglion. However, the ganglion is a non-pulsatile, relatively firm, and whitish structure. In case of injury to the vertebral artery in the region of C2 ganglion, wherever possible, direct suturing of the arterial rent should always be attempted. However, the procedure is relatively difficult due to venous bleeding that flood the surgical field. From our experience with several cases of vertebral artery injury during surgery in the region, it is apparent that compromise of the vertebral artery is safe and neural damage due to vascular insufficiency only rare. Even bilateral sacrifice of vertebral arteries may be of no significant clinical consequence. However, the outcome of vertebral artery sacrifice is unpredictable, potentially life threatening, and must be avoided by careful analysis of preoperative imaging and meticulous dissection.

Peripheral nerve sheath tumors frequently involve the C2 nerve and commonly arise in the region of C2 ganglion. [7] The location of the C2 ganglion provides an opportunity for a unique form of surgical access for these tumors without any bone resection. It is crucial to evaluate and understand the dural/meningeal relationship of C2 peripheral nerve sheath tumors and the resultant displacements of the neural structures and vertebral artery before undertaking surgery.

 
   References Top

1.
Goel A, Laheri VK. Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir (Wien) 1994;129:47-53.  Back to cited text no. 1
    
2.
Goel A, Desai KI, Muzumdar DP. Atlantoaxial fixation using plate and screw method: A report of 160 treated patients. Neurosurgery 2002;51:1351-7.  Back to cited text no. 2
    
3.
Goel A. Cervical Ganglion 2 (CG2) neurectomy: A window to the atlantoaxial joint. World Neurosurg 2012;78:78-9.  Back to cited text no. 3
    
4.
Goel A. Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation. J Neurosurg Spine 2004;1:281-6.  Back to cited text no. 4
    
5.
Goel A, Bhatjiwale M, Desai K. Basilar invagination: A study based on 190 surgically treated patients J Neurosurg 1988;88:962-8.  Back to cited text no. 5
    
6.
Cacciola F, Phalke U, Goel A. Vertebral artery in relationship to C1-C2 vertebrae: An anatomical study. Neurol India 2004;52:178-84.  Back to cited text no. 6
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7.
Goel A, Muzumdar D, Nadkarni T, Desai K, Dange N, Chagla A. Retrospective analysis of peripheral nerve sheath tumors of the second cervical nerve root in 60 surgically treated patients. J Neurosurg Spine 2008;8:129-34.  Back to cited text no. 7
    




 

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