PMC9826544_01
Pre-operative cervical X-ray, myelogram computed tomography (CT), and magnetic resource imaging (MRI). (a) Plain X-ray image with flexion showing anterior subluxation of the atlas. The allow indicates displaced the atlas. (b) Even with the neck in a neutral position, an X-ray image shows anterior subluxation of the atlas remains. The allow indicates displaced the atlas. (c) X-ray image with the neck extended showing reduction between the atlas and axis. The allow indicates repositioned the atlas. (d) Sagittal T2-weighted MRI showing the spinal cord compressed by the posterior arc of the atlas. (e and f) Sagittal and axial myelogram CT showing a compressed spinal cord with anterior dislocation of the atlas.
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F1
Lateral X-ray images showed anterior subluxation of the atlas in the neutral and flexion position of the neck that was reduced when the neck was extended (Fig. 1a, b, c). In MRI and myelogram CT, spinal cord was seen severely compressed from the anteriorly displaced posterior arch of the atlas even in a neutral position (Fig. 1d, e, f).
Brain MRI and CT during Normal Pressure Hydrocephalus symptoms. (a) Axial T2-weighted MRI showing the ventricular enlargement and Sylvian fissure enlargement. (b) Coronal Flair MRI showing narrowing of Callosal angle (Callosal angle: 117 degree). (c) CT showing enlargement of a ventricle (Evans index: 0.38)"
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F2
Callosal angle (Callosal angle: 117 ), which suggested NPH (Fig. 2a, b, c). CSF findings were in the normal range, the specific gravity was 1.005, pH was 7.953, sugar concentration was 64 mg/dL, and protein concentration was 46 mg/dL. CSF pressure was 80 mmH2O.
Cervical XP, magnetic resource imaging (MRI) just after the operation. (a) Plain X-ray with neutral position showing reposition of the atlas. (b) MRI showing reposition of the atlas and decompressed spinal cord.
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F3
The atlas and axis were fixed with bilateral transarticular screws after reducing the atlas, followed by an autologous iliac bone graft (Fig. 3a, b).
Cervical XP, computed tomography (CT), magnetic resource imaging (MRI) 6 years after the operation. (a) Plain X-ray image with flexion showing reposition of the atlas. (b) CT showing bony fusion between posterior arc of atlas and lamina of axis. (c and d) Sagittal and axial T2-weighted MRI showing the decompressed spinal cord.
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F4
Post-operative follow-up brain CT showed attenuation of NPH, of which the Evans index improved to 0.32, fusion of the posterior arch of atlas and lamina of the axis, and attenuation of spinal cord compression (Fig. 4a, b, c, d).
Brain computed tomography (CT) and magnetic resource imaging (MRI) 6 years after the operation. (a) Axial T2-weighted MRI showing the ventricular narrowing and normal Sylvian fissure. (b) Coronal flair MRI showing improvement of Callosal angle (Callosal angle: 134 ). (c) CT showing normal width of a ventricle (Evans index: 0.32).
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F5
Images show no recurrence of NPH at last follow-up (Fig. 5a, b, c).