Occipitocervical surgery rescue: The "Catcher's Mitt" technique.

Abstract

Instability of the occipitocervical junction may compress neural elements, resulting in progressive disability. After the Kickstand Rod technique was developed to correct for thoracolumbar scoliosis, the Candy Cane construct was developed for chin-on-chest deformity at the cervicothoracic junction as a similar three-rod approach. Demonstrated is a four-rod iteration utilized to stabilize the occipitocervical junction and correct condylar instability, termed the Catcher's Mitt technique. A 34-year-old woman with Goldenhar syndrome, hemihypertrophy, and a complex neurosurgical history including Chiari decompression, clival chordoma resection, and a previous cervical fusion presented with quadriparesis, dysphagia, and bilateral upper extremity paresthesias. She was found to have pontomedullary and craniocervical instability with occipital translation and subluxation of the atlantooccipital joint, contributing to her neurological decline. A single midline incision and periosteal dissection exposed her prior O to C6 instrumented fusion. Existing rods were replaced, and a third plate-rod was placed on the right from O to C6. On the left, a fourth plate rod was positioned from C1 to C6. Four top-loading connectors secured the accessory rods to the primary construct. After confirming a stable lordotic alignment, distraction across the accessory rods was used to assist with coronal correction. The Catcher's Mitt construct improved this patient's sagittal and coronal plane deformity. Postoperatively, the cervical sagittal vertical axis improved by 25 mm and the chin-brow angle by 20 mm. Significant improvements in functional status were achieved at 2-year follow-up. A one-stage posterior approach with construct augmentation using third and fourth accessory rods can correct atlantooccipital subluxation following failed occipitocervical fusion.