What is the appropriate management of this patient at this point?  Will his low back pain be treated conservatively before anything else?  Any reason to go back at the C-spine in the OR?

Maybe an epidural steroid injection for that low back pain.

Conservative mgt for the back pain, if the XR and MRI don’t show an obvious surgical lesion.

I would only operate on the neck if his myelopathy progresses. He needs to be followed in clinic for that. No more skiing or skydiving!

Is this an Atlanto-Axial dislocation that has fused and is his cord simply diplaced left or right of this cut?  I would believe his LBP is unrelated, but with some myleopathy what would the management be (for the meylopathy, not the LBP)?

I’d want to see coronal and/or axial cuts on the MRI and image the low back.

Ok, so I’m going to make certain assumptions that get this guy into the O.R.  I don’t think you HAVE to operate on this guy if his myelopathy is stable over the last 10 years and if he’s old.  The patient has to know he has risk of acute death and quadriplegia with any fall, car accident etc.  If the patient is willing to live with that risk and his myelopathy is stable… so be it.  You could make an argument for bracing… but I think only if he’s unstable… which I’m not sure I’d want to interrogate aggressively.

Now, how do we fix this in the OR?  I’m assuming his cord flattens out behind the tip of that dens and is not shaped like a horsehoe wraping around the dens on either side.  The reason is the less contact the tip of the dens has with the cord the better.  I think I’d read the article Ziya Gokasalan (sp?) wrote about doing odontoidectomies vis anterior cervical approach through a tube/endoscope and use a similar approach.  Bottom line you want to resect the dens safely (which obviously has some risk).  Then flip the patient over and do an Occipital-Cervical fusion probably down to C3.  I’d use C1 lateral mass screws and C2 pars screws and C3 lateral mass screws with an occipital plate and either a bent rod or a rod with a lockable pivot point (forget the company that makes that rod).  Because resecting the dens has risk… and not resecting the dens has risk… how fast his myelopathy is progressing might really be what pushes you one way or the other.  Tough situation. 

Anyone else agree or disagree with my points?