 Now, we will go on to C1 C2 fusion. So, this area itself is a complex ok. If anything with damages patient becomes quadriplegic or a patient may die and see what those time external immobilization next is internal immobilization. Internal itself is a rigid immobilization is the latest show. So, what we have come with a external immobilization to internal immobilization without any rest following surgery patient can go back without any problems. When we interfere there is always some amount of complication will be there that we have to taken into granted. This is the one which is a more complex one. So, when you are shown the lower surface of the occipital condyle it was like a convexity facing downwards. It was so much bulged when it is a bulged the another one to receive one we should be a quite opposite side. So, if you have a normal anatomy in your brain while doing surgery whatever problem if it comes you can adjust the things and proceed. So, it is totally a distorted I cannot do and all these things that has to be avoided see this is the convexity see how nicely it is like a curve only. So, why this curve because for the nodding moment ok to accommodate this convexity of the condyle see how depth it is ok. So, because of this even two facets as if you look this bone anterior facet and posterior facet like the it is not. So, because for the movement of this it is adjusted to that environment ok you see here in this deeper part whereas, if you go in the opposite side it is more or less little flat ok the same way when the C2 when it comes in contact with that is also little flat because for the natural movement of it. So, occipital atlantic joint as 13 degree lateral flexion. So, only 30 degrees, but when you do flexion extension it will be going up to more range of movements and there is no rotation in that joint play then atlantic joint if you take only 10 degree flexion and 90 degree rotation you can go up to the full lateral part that is 90 degree rotation, but no nodding movements. Till 1910 immobilization was the main step what I was telling you only external immobilization, but it is not a rigid one once you take it out again patient will go back to the same original state. Then mixture and osgold these are the persons they have done a lot of work for this instabilization. The first surgical treatment of tying posterior arch of C1 and spinous process of C2 with a silk thread then in 1939 galleys technique it came and blokes these are all the techniques one after the other. Then subsequently rigid screw fixation now what we are depending on rigid screw fixation. See rigid screw fixation using screw and plate and rod these do not enter into spinal canal see that is the beauty of this. See when you are putting the wire it has to go into the canal see those times we were doing wiring galleys techniques and all brooks techniques so patient may be quadriplegic if he is moving he may not be breathing. So those are the complications what we encounter so to prevent any injury to the spinal dura. So they have gone outside the dura so that is the technique what plates and screws which is playing and we do not need of any posterior element for the stability for the bone. See these are the examples of that. So this is three level condyles C1 and C2 fusion this is just I am showing you how the orientation I showed the things and how what is the direction of the screws. These are the types of techniques see trans-articular technique it is little difficult when you compare to C1 and C2 fusion because the angulation is so much see the direction of the screw trans-articular screw see it has gone through the joint okay. So you have to elevate it whereas in other thing is it is a sagittal direction see this is what place we have to select when we are putting the screws. This is the cantilever means you know what is the meaning of cantilever see every house will have a cantilever. So this is the projected part the house is the fixed one the one we give say forever window there will be little projection see to park your vehicle there is again some more projection but how it holds because the rigid column that holds the strength here which is the strength lateral mass is the one which is holding see that when I was reading this lumber fusion and all the main strength of when you have passed a screw the for 60% of the strength which is taken up by the pedicle and marrow the cortex is only 20% anterior cortex and a posterior cortex it is 40 the main strength is in the marrow say what we say it goes so freely and all when you are screws it gives as if you are going in a water like that but that is the one which gives a more strength that is the one which is a productive strength cortex is it will not reproduce like that but this is the marrow which is the one which is producing so much of cells see here our great man Goyal is the person who popularized the technique C1 and C2 he has used the plate not the rod okay the plate is little space occupying like that so rod is not that so much of space for occupying in this narrow space that is the one arms and Nelcar he they use this plate and rod subsequently this bilateral when there is an anomaly in the facet joint itself so what to do again we have to do fix it fix the things so in that they have passed the screw along the lamina so on each side they have passed the lamina and fixed for this poster element is mandatory for this trans lamina one whereas other C1 C2 that the descent required posterior or the lamina so what I do when I am fixing I take that part itself as a graft so instead of taking a bone graft from the rib or from the alia crest there only a take usually C2 spinous process is quite big you take this C2 spinous process split it and put on either side for as a graft this is some of the indications and all it varies in abroad rheumatoid arthritis is the one which is more often is seen but in India tuberculosis but tuberculosis if you do like this pull out is more often is seen this whole bone is inflamed so purchase will be very very poor so when you are drilling the bone it is very easy for you but the purchase rate is very less so naturally when the after this we will be putting him on get it that will cause fibrosis and give some little stability for the patient not actually our plate and screw and this is the one at length of dislocation eight years time very bright here see this is measuring the isthmus what is the size of the isthmus the best thing is see you should not enter into the canal or into the vertebral foramen so in between the things you have to use your common sense and posse so before operation also you will be measuring what is the length of the articular facet joint ok antroposterior and transverse this is in the opposite side see that is the one what I am seeing the C1 mass this is nearly about 5 millimeters from the medial part of the lateral mass this is after doing that after that I have placed this screws on both sides now we have a distractors also so even if there is any basilar invasion you can put the distractor and you can once you distract it will come into alignment this is all very simple see if you get a case do not miss it please do it the technique I will tell you how to do that also so after loosely if you put all these things subsequently you have to put a distractor so that you can distract if there is any basilar invasion otherwise no need of doing all see this is following surgery see that is the one oblique we have taken how it will be see when you are doing first time blood loss is the most distressing part because that is the weird flexors are there it is very very friable so in the initial part if you do not use injury to the vertebral artery is the most common part ok better you do under microscope because you are all trained under microscope when you use the microscope say now when you are incising the muscles from the tubercle and also C2 and partly C3 see once you take out little laterally make a cut that means just inside the periosteum once you get the periosteum it becomes a white line like this then that slide the periosteum it will become a a vasculose if you do not cut it then bold diet you will be there you will be getting the hemostasis so sub periosteum dissection is the most important part of dissection when you are choosing for atlantic dislocation or whatever it may be in that or wherever it may be so sub periosteum even in lumbar area also if you enter into a muscle plane you will have it so if you enter into sub periosteum plane no if there is any bleeding from the emissary vessels you can plug with the bone max that will completes your surgery without any blood transfusion otherwise we have to transpose in the beginning especially when you are doing 10 years 12 years like that transposing 3 liters 4 liters blood digits of not a good thing so in case of our pediatric CH group so periosteum is not adherent or calcified lighting so easy to get separated and in that bargain when you are reflecting so vertebral artery also it can be easily stripped out along his wife means I will call it as a wife because easy to control if you put a carton at there it will not make any noise at all subsequently you put a gel foam it will stop whereas artery is not that it will flush your face one that it will be spurting so live so you will not be seeing anything so that is the thing so we have to select the point say this is the you know this is the vertebral artery which runs this is the upper part you will not touching this part at all okay so our business is under the things so you trace it all along like this when there is a rotary component this finest process will be like this see what I showed it is like this this comes just under the lamina of L2 will be in a problem whether it is a facet or something else or we will be going far later because normal point only our hand will be going but here when there is a rotation it will come into this point C2 laminar part so after that you can once the patient is on traction easily under the general anesthesia it will rotate okay so this is the area you are interested this is the facet so enter opposite diameter of this is 20 millimeter average 20 plus millimeters the transverse is also nearly about 15 millimeters like that it comes this the height will be around 5 millimeters this height also is very important okay below the arch so where our screws will go so about 5 millimeter you take it from medial to lateral so that is the point of entry you have to go obliquely see these are all facets are obliquely placed so you have to go along the oblique okay then if you take a C2 if there is any C2 practice some patient may come with only pain but if you take a x-ray this will be completely in front of the C3 okay but without any neurological deficit that is the porc intraarticle fracture there is congenital malformation or like that or is a stretch factor so here this is the joint okay so when you are seeing the patient when you are dissected out the muscle you will nicely you are seeing the upper and lower part here is the bleeding lot of veins which are come subperiostally if you elevate you are most safe and come nearer to foramen once you come to nearer to foramen there will be a dip you stop there only do not go further lateral so it is about only about 2-3 centimeters from the midline that is the only dissection what you are doing it okay this is the pedicle so we are not bother about the pedicle here we are bother about the isthmus where so this is how it will be looking like that during surgery it may be because of like this okay this canal may be narrow so with your manipulation and all during surgery it may reduce by itself okay once it is reduced the middle part of the isthmus you look at how do you will identify during surgery see you have to go medial to this arch okay medial to arch means next to that is dura so that will be more safer zone when you are not seeing that is the way you have to identify otherwise where is the isthmus and all you will be wasting your time so it will see to also it will be coming through this this is the picture okay so when you are doing surgery you will be seeing like this this is a spinous process so come all along it see you are you are starting here just you cut here vertically like this you will get a white line completely you strip of the periastome so you will not be seeing the that horizontal part of the vertebral artery during surgery don't try to see also okay then here also when you put a vertical line you will get a periastome easily you strip it off as you come towards laterally you will see the C2 C2 is the one which gives a problem for visualization of the C1 C2 joint as you start stripping the periastome as you come so medially just it will give away that is the articular facet which breaks and you are entering to the joint okay so because there is a dislocation sometimes it may come like this can you see like this see this is the way dislocation what you are doing surgery see you are coming like this you are seeing only a dip but the upper part that is C1 which will come like this anterior so once you see this this articular surface can be removed just you cauterize both upper and lower part then you select that particular part so you are seeing the medial and lateral part this is about nearly about 6 to 7 millimeter okay this height also about 6 millimeter that is why we are choosing 3.5 millimeter diameter screws the length varies length you have to measure before surgery only what is the length of this so using this length whether to use your lag screws or not if you are cut the C2 root then you can use without lag screws you can straight away you can go when you are not cutting this usually I do not cut the C2 unless otherwise so I will depress the C2 now see the pedicle pedicle means C1 lateral mass make a hole in that then you extend that subsequently you can pause complications apart from vertebral artery injury there will be no neurological if you do not remove the C2 that will be also will be intact if you cut hypostasia is the one which is the causing problem otherwise no problem fusion rate also is good I told you what is the bone I use only a spinous process of C2 split it anyway this is spinous process is quite thick take the one half of it to put it into the joint space thank you thank you