The battle against an invisible enemy
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LETTER TO THE EDITOR - NEUROSURGICAL TECHNIQUE EVALUATION
The battle against an invisible enemy Manjul Tripathi 1
&
Sandeep Mohindra 1
Received: 14 June 2020 / Accepted: 26 August 2020 # Springer-Verlag GmbH Austria, part of Springer Nature 2020
We have read with great interest the article by Arthur Wagner et al., “Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis [1].” The article discusses a controversial topic of “to do, how much to do, or not to do.” It provides a critical evaluation of the iconoclastic theory by Goel of onesize-fits-all management for all kinds of craniovertebral (CVJ) anomalies [2]. Every new concept has to prove its mettle and for it to be university acceptable, the reproducibility of the results remains a basic requirement. This statement remains especially valid in the field of neurosurgery where we deal with extremely unforgiving neural tissues in the close vicinity of critical neurovascular structures, and the results vary with the experience and the competence of surgeon. This article is a review of the publications supporting or refuting the hypothesis based on their respective clinical results on this abnormality. Not only the concepts but also the personalities evolve with the time and the experience. Till late 80s, the concept of atlantoaxial dislocation (AAD) was categorized into reducible and non-reducible ones [3]. For the first time, Goel conceptualized all AADs reducible irrespective of their radiological appearance. The axis of management shifted from midline to facetal joint complex, and the world later witnessed a revolutionary change in the management of the CVJ anomalies especially AAD and basilar invagination by putting the spacers into the joints and fixing the C1 C2 complex [4]. This concept had other implications; transoral ventral decompression This article is part of the Topical Collection on Neurosurgical technique evaluation * Manjul Tripathi [email protected] Sandeep Mohindra [email protected] 1
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Neurosurgery Office, Nehru Hospital, 5th Floor, Chandigarh 160012, India
practically became a part of the history and omission of occipital area from the fixation complex helped people enjoy their extended range of neck movements with improved neurological status and better quality of life. His recent hypothesis on Chiari malformation type I(CMI) terming “type III instability” and “Nature’s protective air bag” mechanism has garnered similar kind of controversy [2]. Even before the introduction of this hypothesis, the management of CMI was never straightforward and the literature is exhausted with cafeteria choices of management options, some with objective and mostly with subjective assessment of outcomes with skewed risk benefit profiles [1]. Goel et al. have convincingly reported high resolution of CM1 with an excellent neurological improvement only with C1C2 fixation. The biggest
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