PMC8248012_01
(a) Preoperative CT scan showing basilar invagination. (b) CT scan showing occipitocervical fusion with occipital plate screwed to the occipital bone and four screws inserted bilaterally in dysmorphic articular masses of C3 and C4. (c) C3 and C4 screws pull out. (d) CT scan performed after the second surgery: cervical articular screws were taken out and laminar clamps added to C3 and C4 laminae bilaterally.
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F1
MR and CT studies documented BI, CCJI, and spinal cord compression [Figure 1a]. After informed consent, She was first treated with an occipitocervical fusion (C0-C3/C4) [Figure 1b]. The CT scan now showed pull-out of the cervical articular screws [Figure 1c]. The second surgery included removal of the articular screws and the application of bilateral C0-C3/C4 laminar clamps [Figure 1d].
Scalp ulcer before the scalp and periosteal turn-down surgery.
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F2
However, the CSF fistula persisted postoperatively, warranting the placement of a spinal drain 3 days later [Figure 2].
(a) A left pedicled, rotation scalp flap was performed adjacent to the expected defect, large enough to allow its edges to comfortably inset into the skin defect. The margins of the flap were incised down to the pericranium. (b) The flap was raised in the avascular subgaleal plane and the pericranial rotation flap was elevated and rotated over the hardware. (c) The flap, including skin and galea, was elevated over the pericranium and rotated to reach the defect without tension. (d) Penrose drain was placed exiting at the cranial extremity of the wound.
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F3
Penrose drain was maintained for 24 h [Figure 3]. Postoperatively, the wound healed adequately.
Surgical wound after pericranial rotation flap surgery. (a) Three days after the procedure. (b) At six months follow-up.
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F4
Six months later, she fully recovered neurological function without further infection or wound breakdown [Figure 4].