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Abstract
BACKGROUND AND OBJECTIVE Pediatric cervical spine injuries (CSIs) are rare and differ from adult CSIs. Our objective was to describe CSIs in a large, representative cohort of children. METHODS We conducted a 5-year retrospective review of children <16 years old with CSIs at 17 Pediatric Emergency Care Applied Research Network hospitals. Investigators reviewed imaging reports and consultations to assign CSI type. We described cohort characteristics using means and frequencies and used Fisher's exact test to compare differences between 3 age groups: <2 years, 2 to 7 years, and 8 to 15 years. We used logistic regression to explore the relationship between injury level and age and mechanism of injury and between neurologic outcome and cord involvement, injury level, age, and comorbid injuries. RESULTS A total of 540 children with CSIs were included in the study. CSI level was associated with both age and mechanism of injury. For children <2 and 2 to 7 years old, motor vehicle crash (MVC) was the most common injury mechanism (56%, 37%). Children in these age groups more commonly injured the axial (occiput-C2) region (74%, 78%). In children 8 to 15 years old, sports accounted for as many injuries as MVCs (23%, 23%), and 53% of injuries were subaxial (C3-7). CSIs often necessitated surgical intervention (axial, 39%; subaxial, 30%) and often resulted in neurologic deficits (21%) and death (7%). Neurologic outcome was associated with cord involvement, injury level, age, and comorbid injuries. CONCLUSIONS We demonstrated a high degree of variability of CSI patterns, treatments and outcomes in children. The rarity, variation, and morbidity of pediatric CSIs make prompt recognition and treatment critical.
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Affiliation(s)
| | - David M. Jaffe
- Department of Pediatrics, Division of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis Children’s Hospital, St Louis, Missouri
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Davis Medical Center, Sacramento, California; and
| | - Cody S. Olsen
- The Data Coordinating Center, University of Utah School of Medicine, Salt Lake City, Utah
| | - Julie C. Leonard
- Department of Pediatrics, Division of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis Children’s Hospital, St Louis, Missouri;,Address correspondence to Julie C. Leonard, MD, MPH, One Children’s Place, Campus Box 8116, St Louis, MO 63110. E-mail:
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Udare AS, Bansal D, Patel B, Mondel PK, Aiyer S. Condylus tertius with atlanto-axial rotatory fixation: an unreported association. Skeletal Radiol 2014; 43:535-9. [PMID: 24150830 DOI: 10.1007/s00256-013-1747-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 09/02/2013] [Accepted: 09/22/2013] [Indexed: 02/02/2023]
Abstract
The "condylus tertius" or the "third occipital condyle" is an embryological remnant of the proatlas sclerotome. Anatomically, it is attached to the basion and often articulates with the anterior arch of the atlas and the odontoid apex; hence, it is also called the "median occipital condyle". It is a rare anomaly of the cranio-vertebral junction (CVJ) that can lead to instability and compression of important surrounding neurovascular structures. We report a case of a 16-year-old boy who presented with suboccipital neck pain, torticollis and right sided hemiparesis. Plain radiographs revealed an increased atlanto-dental interspace (ADI) with a retroflexed odontoid. Open mouth view showed asymmetry of the articular processes of the atlas with respect to the dens. Computed tomography (CT) of the CVJ delineated the third occipital condyle. Furthermore, on dynamic CT study, a type 3 atlanto-axial rotatory fixation (AARF) was clearly demonstrated. Magnetic resonance imaging (MRI) of the CVJ revealed severe right-sided spinal cord compression by the retroflexed and rightward deviated dens. It also revealed disruption of the left alar and transverse ligaments. The patient was treated with 8 weeks of cranial traction and reasonable alignment was obtained. This was followed by C1-C2 lateral mass screw fixation and C1-C2 interlaminar wiring to maintain the alignment. A review of the literature did not reveal any cases of condylus tertius associated with non-traumatic AARF. An accurate knowledge of the embryology and imaging features of this rare CVJ anomaly is useful in the prompt diagnosis and management of such patients.
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Machnowska M, Raybaud C. Imaging of the craniovertebral junction anomalies in children. Adv Tech Stand Neurosurg 2014; 40:141-170. [PMID: 24265045 DOI: 10.1007/978-3-319-01065-6_4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The craniovertebral junction (CVJ) is interposed between the unsegmented skull and the segmented spine; it is functionally unique as it allows the complex motion of the head. Because of its unique anatomy, numerous craniometric indices have been devised. Because of its complex embryology, different from that of the adjacent skull and spine, it is commonly the seat of malformations. Because of the mobility of the head, and its relative weight, the craniovertebral junction is vulnerable to trauma. Like the rest of the axial skeleton, it may be affected by many varieties of dysplasia. In addition, the bony craniovertebral junction contains the neural craniovertebral junction and its surrounding CSF: any bony instability or loss of the normal anatomic relationships may therefore compromise the neural axis. In addition, the obstruction of the meningeal spaces at this level can compromise the normal dynamics of the CSF and result in hydrocephalus and/or syringohydromyelia. To image the CVJ, plain X-rays are essentially useless. MR is optimal in depicting the soft tissues (including the neural axis) and the joints, as well as the bone itself. CT still may be important to better demonstrate the bony abnormalities.
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Affiliation(s)
- Matylda Machnowska
- Division of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada,
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Oppenlander ME, Clark JC, Sonntag VKH, Theodore N. Pediatric craniovertebral junction trauma. Adv Tech Stand Neurosurg 2014; 40:333-353. [PMID: 24265053 DOI: 10.1007/978-3-319-01065-6_12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The craniovertebral junction consists of the occiput, atlas, and axis, along with their strong ligamentous attachments. Because of its unique anatomical considerations, trauma to the craniovertebral junction requires specialized care. Children with potential injuries to the craniovertebral junction and cervical spinal cord demand specific considerations compared to adult patients. Prehospital immobilization techniques, diagnostic studies, and spinal injury patterns among young children can be different from those in adults. This review highlights the unique aspects in diagnosis and management of children with real or potential craniovertebral junction injuries.
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Affiliation(s)
- Mark E Oppenlander
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
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Abstract
Six consecutive pediatric patients with chronic atlantoaxial rotatory fixation (AARF) underwent posterior fixation. All patients were first treated conservatively such as with a neck collar, traction, Minerva jacket, or halo-vest; however, they failed to achieve successful reduction because of the C2 facet deformity or C1-2 facet fusion. We performed C1-2 fusion using a C1 lateral mass screw and a C2 pedicle screw, a C1-2 transarticular screw, or an occipitocervical fusion using a rod and wiring system. Five patients achieved solid fusion with no torticollis or neck pain by the final follow-up. One patient had mild torticollis after surgery but no pain. Although we believe that with early diagnosis of AARF and appropriate conservative treatment we can avoid surgery, even with conservative treatment from the onset of symptoms, five patients in our series required surgery because conservative treatment did not lead to successful reduction. When conservative treatment for chronic AARF patients fails, C1-2 transarticular fixation, and C1 lateral mass screw and C2 pedicle screw fixation are reliable methods to treat these patients.
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Rozzelle CJ, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Ryken TC, Theodore N, Walters BC, Hadley MN. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 2013; 72 Suppl 2:205-26. [PMID: 23417192 DOI: 10.1227/neu.0b013e318277096c] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Curtis J Rozzelle
- Division of Neurological Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, AL 35294, USA
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Core Curriculum Illustration: marked head rotation following blunt trauma. Emerg Radiol 2013; 20:163-4. [DOI: 10.1007/s10140-013-1104-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 01/07/2013] [Indexed: 10/27/2022]
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Landi A, Pietrantonio A, Marotta N, Mancarella C, Delfini R. Atlantoaxial rotatory dislocation (AARD) in pediatric age: MRI study on conservative treatment with Philadelphia collar--experience of nine consecutive cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 21 Suppl 1:S94-9. [PMID: 22411035 DOI: 10.1007/s00586-012-2216-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 02/19/2012] [Indexed: 01/02/2023]
Abstract
PURPOSE Atlantoaxial rotatory fixation and atlantoaxial rotatory subluxation are the most frequent manifestations of atlantoaxial rotatory dislocation (AARD) in pediatric population and are often treated conservatively. The objective of this study is to correlate the changes highlighted on MRI T2-weighted and STIR sequences with the duration of conservative treatment. METHODS We analyzed nine consecutive patients treated surgically between 1 Jan 2006 and 1 Jan 2010 at the Policlinico Umberto I of Rome. All patients underwent cervical X-ray, computed tomography and magnetic resonance imaging (MRI) (T1 and T2-weighted, STIR, angio MRI). All patients were treated with bed rest, muscle relaxants and cervical collar, and radiological follow-up with MRI and cervical X-ray was performed. RESULTS According to Fielding's classification, we observed seven patients with a type 1 subluxation and two patients with a type II subluxation. In type 1, STIR and T2 sequences showed a hyperintensity in the alar and capsular ligaments and in the posterior ligamentous system, with integrity of the transverse ligament (LTA). In type 2, the hyperintensity also involved the LTA. During the follow-up, MRI showed a progressive reduction until the disappearance of the hyperintensity described, which was followed by a break with orthotic immobilization. CONCLUSIONS MRI with STIR sequences appears to be useful in addressing the duration of conservative treatment in AARD.
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Affiliation(s)
- Alessandro Landi
- Division of Neurosurgery, Department of Neurology and Psychiatry, University of Rome Sapienza, Viale del Policlinico 155, 00161 Rome, Italy.
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Abstract
STUDY DESIGN Retrospective case series of chronic atlantoaxial rotatory fixation (AARF) treated by a novel closed reduction method (remodeling therapy) and review of the literature. OBJECTIVE To describe clinical features of chronic AARF and the rationale of the remodeling therapy. SUMMARY OF BACKGROUND DATA Treatment strategy for chronic recurrent AARF remains controversial. Posterior C1-C2 arthrodesis has been widely used for recurrent unstable AARFs after the closed reduction, and a variety of posterior fusion techniques have been advocated. In contrast, several investigators reported a chronic AARF case treated by a simple traction or closed reduction followed by cervical immobilization. Previously, we have found that a deformity of the superior C2 facet joint (C2 facet deformity) on three dimensional computed tomography (3D CT) reconstructions is a risk factor for recurrent subluxation. In addition, the remodeling of this C2 facet deformity by careful closed manipulation followed by halo fixation (remodeling therapy) could prevent the recurrence of subluxation. METHODS Twelve children with chronic AARF who sustained torticollis for an average of 4.4 months after the onset were referred to our clinic. The mean age at the initial visit was 7.8 years. All patients underwent the remodeling therapy as reported previously. Radiographic findings and clinical courses were retrospectively reviewed. Treatment methodology, pearls, and pitfalls of the remodeling therapy were discussed with review of the literature. RESULTS 3D CT images before reduction revealed persistent atlantoaxial subluxation and the C2 facet deformity in the dislocated side in all cases. Follow-up 3D CT scans demonstrated the remodeling of the C2 facet deformity at an average of 2.4 months after successful reduction of subluxation. Neither recurrence of symptoms nor subluxation was observed at a mean follow-up of 42 months in any case. The cervical range of motion was 73.9° at the dislocated and 83.5° at the contra-dislocated side from the midline. CONCLUSION Chronic irreducible and recurrent unstable AARF should be initially managed by remodeling therapy using the facet deformity sign as a clinical index, if the C1 and C2 have not been osseously fused.
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Beier AD, Vachhrajani S, Bayerl SH, Aguilar CYD, Lamberti-Pasculli M, Drake JM. Rotatory subluxation: experience from the Hospital for Sick Children. J Neurosurg Pediatr 2012; 9:144-8. [PMID: 22295918 DOI: 10.3171/2011.11.peds11147] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Diagnosis and management of atlantoaxial rotatory subluxation (AARS) is challenging because of its variability in clinical presentation. Although several treatment modalities have been employed, there remains no consensus on the most appropriate therapy. The authors explore this issue in their 9-year series on AARS. METHODS Records of patients diagnosed radiologically and clinically with AARS between May 2001 and March 2010 were retrospectively reviewed. Of 40 patients identified, 24 were male and were on average 8.5 years of age (range 15 months-16 years). Causes of AARS included trauma, congenital abnormalities, juvenile rheumatoid arthritis, infection, postsurgical event, and cryptogenic disease. Four patients had dual etiologies. Symptom duration varied: 29 patients had symptoms for less than 4 weeks, 5 patients had symptoms between 1 and 3 months, and 6 patients had symptoms for 3 months or more. RESULTS Treatment with a cervical collar was sufficient in 21 patients. In 1 patient collar management failed and halter traction was used to reduce the subluxation. Seven patients underwent initial halter traction, but in 4 the subluxation progressed and the patients required halo traction. A halo vest was placed in 2 patients on presentation because the rotatory subluxation was severe; both patients required subsequent operative fusion. One patient required decompression and fusion due to severe canal compromise and myelopathy. All patients requiring fusion presented with subacute symptoms. CONCLUSIONS Management of AARS varies due to the spectrum of clinical presentations. Patients presenting acutely without neurological deficits can likely undergo collar therapy; those in whom the subluxation cannot be reduced or who present with a neurological deficit may require traction and/or surgical fixation. Patients presenting subacutely may be more prone to requiring operative intervention.
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Affiliation(s)
- Alexandra D Beier
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada.
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Abstract
Occipitoatlantoaxial rotatory fixation (OAARF) is a rare condition involving fixed rotational subluxation of the atlas in relation to both the occiput and axis. Atlantoaxial rotatory fixation (AARF) appears to precede OAARF in most cases, as untreated AARF may cause compensatory counter-rotation and occipitoaxial fixation at an apparently neutral head position. We report a case of OAARF in an 8-year-old girl with juvenile idiopathic arthritis. Cervical imaging demonstrated slight rightward rotation of the occiput at 7.63° in relation to C-2 and significant rightward rotation of C-1 at 65.90° in relation to the occiput and at 73.53° in relation to C-2. An attempt at closed reduction with halo traction was unsuccessful. Definitive treatment included open reduction, C-1 laminectomy, and occipitocervical internal fixation and fusion.
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Affiliation(s)
- Matthew R Fusco
- Division of Pediatric Neurosurgery, Children's Hospital of Alabama, Birmingham, Alabama, USA.
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Continuous skull traction followed by closed reduction in chronic pediatric atlantoaxial rotatory fixation. Acta Neurochir (Wien) 2011; 153:1443-5. [PMID: 21499974 DOI: 10.1007/s00701-011-1019-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 04/04/2011] [Indexed: 10/18/2022]
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Pediatric cervical spine injuries: a comprehensive review. Childs Nerv Syst 2011; 27:705-17. [PMID: 21104185 DOI: 10.1007/s00381-010-1342-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 11/09/2010] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cervical spine injuries can be life-altering issues in the pediatric population. The aim of the present paper was to review this literature. CONCLUSIONS A comprehensive knowledge of the special anatomy and biomechanics of the spine of children is essential in diagnosis and treating issues related to spine injuries.
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Rajasekaran S, Avadhani A, Parthasarathy S, Shetty AP. Novel technique of reduction of a chronic atlantoaxial rotatory fixation using a temporary transverse transatlantal rod. Spine J 2010; 10:900-4. [PMID: 20869004 DOI: 10.1016/j.spinee.2010.07.395] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 06/14/2010] [Accepted: 07/26/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Chronic atlantoaxial rotatory fixation (AARF) is uncommon as acute AARF is easily reduced either spontaneously or by conservative methods. Various anterior and posterior surgical approaches for a chronic AARF have been reported because of the difficulty encountered in obtaining reduction. PURPOSE To describe a novel technique of reduction of a chronic AARF using a temporary transverse transatlantal rod. STUDY DESIGN Technical report. METHODS A 13-year-old girl presented with an 8-month-old chronic AARF with typical torticollis and "cock-robin" posture of the head with a normal neurology. As closed reduction with skull traction for 2 weeks failed to reduce the deformity, the patient underwent C1-C2 fusion. C1 lateral mass and C2 pedicle screws were inserted under computer navigation. A temporary transverse rod across the atlas and axis was placed to secure a three-column fixation to derotate the subluxed atlas into anatomical alignment. Rods were then connected between the C1 lateral masses and the C2 pedicle screws and fusion obtained with autologous iliac crest grafts. RESULT Anatomic reduction of the atlantoaxial region was obtained without neural compromise, and satisfactory fusion was observed at 6-months follow-up. CONCLUSION A temporary transatlantal rod provides a secure anchor point for easy maneuverability for reduction of a chronic AARF and has the advantage of being used even in the absence of the posterior arch of the atlas.
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Affiliation(s)
- S Rajasekaran
- Department of Orthopaedics and Spine Surgery, Ganga Hospital, 313, Mettupalayam Rd, Coimbatore 641 043, Tamil Nadu, India.
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Lin CH, Chen CJ, Chen CM, Liao SL, Raung SL, Tsai SW. Treatment of atlantoaxial rotatory fixation with botulinum toxin muscle block and manipulation. J Chin Med Assoc 2010; 73:222-4. [PMID: 20457447 DOI: 10.1016/s1726-4901(10)70047-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 01/18/2010] [Indexed: 11/30/2022] Open
Abstract
Slippage after reduction of atlantoaxial rotatory fixation (AARF) is usually treated with repeated cervical traction and brace immobilization. To date, no data have been published on the management of muscle spasm during treatment. Here, we describe the case of a 7-year-old girl with AARF for 1 month who visited our hospital for treatment. During physical examination, spasm of the sternocleidomastoid muscle was noted. The patient was treated with manipulative reduction, and slippage after reduction was managed with botulinum spasticity block of the sternocleidomastoid and splenius capitis muscles, and repeated manipulation. Cervical orthosis immobilization with a rehabilitation program of isometric contract-relax exercise for the neck was conducted for 3 months. The subject had full recovery from AARF at 1-year follow-up. This report demonstrates that, in selected cases of slippage after reduction from AARF, conservative management with manipulation under anesthesia is a good method, and the muscle components may play a crucial role in AARF.
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Affiliation(s)
- Chia-Hung Lin
- Department of Physical Medicine and Rehabilitation, Taichung Veterans General Hospital, Taiwan, ROC
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Kim B, Iwata K, Sugimoto K, Suzuki S, Ema Y, Tsunobuchi H, Nishiwaki K. Significance of prevention and early treatment of a postoperative twisted neck: atlantoaxial rotatory subluxation after head and neck surgery. J Anesth 2010; 24:598-602. [PMID: 20339878 DOI: 10.1007/s00540-010-0932-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 03/02/2010] [Indexed: 11/30/2022]
Abstract
Atlantoaxial rotatory subluxation (AARS) is an infrequent condition that occurs most commonly in children for unknown reasons. Pediatric surgery, otopharyngeal inflammation, general anesthesia, and extreme rotation of the head are risk factors for development of postsurgical AARS, but AARS can often occur unnoticed, and the syndrome is not well known. We encountered three cases of postoperative AARS that occurred within 7 months; therefore, we have developed guidelines for prevention and early treatment of postoperative AARS. Postoperative AARS cannot be eliminated completely, but informed consent, a preoperative check, an appropriate surgical position, and a postoperative check may reduce the risk and damage related to this condition.
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Affiliation(s)
- Byeoknyeon Kim
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan.
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Abstract
Abstract
OBJECTIVE
Atlantoaxial rotatory fixation (AARF) remains a recondite entity. Our normative study using CT motion analysis shows that there is a high degree of concordance for rotational behavior of C1 and C2 in children 0 to 18 years. C1 always crosses C2 at or near 0 degree. The predictable relationship between C1 and C2 is depicted by 3 distinct regions on the motion curve: when C1 rotates from 0 to 23 degrees, it moves alone while C2 remains stationary at 0 (the single-motion phase). When C1 rotates from 24 to 65 degrees, C1 and C2 move together (the double-motion phase), but C1 always moves faster as C2 is being pulled by yoking ligaments. From 65 degrees onward, C1 and C2 move in unison (the unison-motion phase) with a fixed, maximal separation angle of approximately 43 degrees, the head rotation being carried exclusively by the subaxial segments. Because of this high concordance among patients and a relatively narrow variance from the mean, the physiological composite motion curve can be used as a normal template for the diagnosis and classification of AARF.
METHODS
Using a 3-position CT protocol to obtain the diagnostic motion curve, we identified 3 distinct types of AARF. Type I AARF patients show essentially unaltered (“locked”) C1–C2 coupling regardless of corrective counterrotation, with curves that are horizontal lines in the upper 2 quadrants of the template. Type II AARF patients show reduction of the C1–C2 separation angle with forced correction, but C1 cannot be made to cross C2. Their curves slope downward from the right to left upper quadrants but never traverse the x axis. Type III AARF patients show C1–C2 crossover but only when the head is cranked far to the opposite side. Their motion curves traverse the x axis far left of 0 degree ( C1 < −20). Thus, type I, II, and III AARF are in descending degrees of pathological stickiness. A fourth group of patients showing motion curve features between normal and type III AARF are designated as belonging to a diagnostic gray zone (DGZ). The AARF patients are further classified as acute if treatment is started less than 1 month from the onset of symptoms, as subacute if the delay in treatment is 1 to 3 months, and chronic if treatment delay exceeds 3 months. The treatment protocol for AARF consists of reduction using either halter or caliper traction and then immobilization with brace or halo, depending on the AARF type and chronicity. Recurrent slippage and irreducibility are treated with C1–C2 fusion.
RESULTS
The treatment course and outcome of AARF are analyzed according to the AARF type and chronicity. The difficulty and duration of treatment, the number of recurrent slippage, the rate of irreducibility, the need for halo and fusion, and the percentage ultimately losing normal C1–C2 rotation are significantly greater in type I patients than type III patients, with type II patients somewhere in between. Likewise, all parameters are much worse in patients with any type of chronic AARF than acute AARF. The worse subgroup is chronic type I versus the best subgroup of acute type III. Recurrent AARF patients do much worse than nonrecurrent AARF patients. Recurrence is, in turn, adversely influenced by both the severity (type) and chronicity of AARF. The symptoms of most DGZ patients will resolve with analgesics, but a few remain symptomatic or deteriorate to true AARF requiring the full treatment.
CONCLUSION
Thus, children with painful torticollis should undergo the 3-position CT protocol not only to confirm the diagnosis of AARF but also to grade its severity. Closed reduction with traction should be instituted immediately to avoid the serious consequences of chronicity. Proper typing and reckoning of the pretreatment delay are requisites for selecting treatment modalities. Recurrent dislocation and incomplete reduction should be treated with posterior C1–C2 fusion in the best achievable alignment.
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Affiliation(s)
- Dachling Pang
- Department of Pediatric Neurosurgery, University of California, Davis, Regional Center of Pediatric Neurosurgery, Kaiser Foundation Hospitals of Northern California, Oakland, California
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Assessment of two measurement techniques of cervical spine and C1-C2 rotation in the outcome research of axis fractures: a morphometrical analysis using dynamic computed tomography scanning. Spine (Phila Pa 1976) 2010; 35:286-90. [PMID: 20075766 DOI: 10.1097/brs.0b013e3181c911a0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN In vivo study on cervical spine motion. OBJECTIVE To estimate the accuracy of clinical measurements, using a handheld goniometer for the assessment of total cervical neck rotation in outcome research of patients with C2 fractures and particularly odontoid fractures. Investigation on whether functional computed tomography (CT)-scanning is decisive in the investigation of functional outcome after C2 fractures. SUMMARY OF BACKGROUND DATA Pertinent literature exists concerning indications, techniques, complications of treatment, and risk factors for nonunion in C2 fractures; however, there are scarce data regarding the functional outcome in C2 fractures. Only a few studies assess functional outcome in terms of clinical outcome vehicles and clinical investigation of axial neck rotation, using a handheld goniometer. Measurements of axial neck rotation using a handheld goniometer are assumed not sufficient to compare the results of treatment strategies for C2-fractures or elucidate the ability for posttreatment rotation of C1-C2. METHODS The authors selected a homogenous group of 35 patients treated for C2 fractures using nonsurgical and surgical techniques. 69% of patients had odontoid fractures. Mean age of patients was 52 years. Patients were subjected to clinical assessment of axial cervical range of motion for rotation, using a handheld goniometer. Patients were also subjected to functional CT-scanning and measurements of total neck and atlantoaxial rotation were performed according to an established protocol. RESULTS With clinical measurements mean range of motion for left and right axial neck rotation was both 56 degrees. According to the functional CT scans, the mean left-sided and right-sided axial neck rotation was 48.6 degrees and 52.0 degrees. The mean for left- and right-sided atlantoaxial rotation was 20.2 degrees and 20.6 degrees. Total axial atlantoaxial rotation on CT scans was 40.3 degrees and total axial neck rotation was 103.3 degrees. In comparison to age and gender matched normal individuals total cervical neck rotation was reduced to a mean of 69.5%. The differences between total axial neck rotation assessed using a handheld goniometer and with functional CT-scanning were strongly significant (P < 0.0001). In addition, there was no statistically significant correlation between the clinically assessed total neck rotation to either the left or the right side and the ipsilateral percentage atlantoaxial rotation of total head neck rotation. CONCLUSION The current study demonstrated that for the comparison of functional outcome after different therapies of C2 fractures clinical measurements do not serve for reliable data on total neck rotation and particularly atlantoaxial rotation and the percentage of C1-C2 rotation of total neck rotation. The use of dynamic CT-scans in the analysis of functional outcome after C2 fractures is strongly recommended.
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Abstract
OBJECTIVES To describe the spectrum of pathologies responsible for neck ailments in a primary care pediatric emergency setting and evaluate their outcome. METHODS All children aged 16 years or younger, who presented to the emergency department of the Children's Hospital of Lausanne during a 1-year period, were retrospectively identified and charts were reviewed. Causes of neck complaints were classified as traumatic (group 1), infectious (group 2), postural (group 3), or miscellaneous (group 4) according to the final diagnosis. History and physical examination findings, radiological and laboratory results, as well as patient outcomes were recorded. RESULTS During the study period, 28,722 children were observed in the emergency department, and 170 were identified as having neck complaints. The number of patients with neck ailments in group 1 was 105 (62%). Group 2 contained 33 patients (19%), of which 28 (16.5%) had a viral infection and 5 (2.9%) had a bacterial infection. Group 3 contained 30 children (17.6%) and group 4 contained 2 children (1.2%). Cervical spine radiography was performed on an emergency basis in 60 children (57 in group 1, 2 in group 2, and 1 in group 3). Significant abnormalities were observed in 6 children. Cervical computed tomography (CT) was performed in 9 children, from which 5 were in group 1, 3 were in group 2, and 1 was in group 4. The CT scan revealed pathologic findings in 6 children. Follow-up data were available in 135 patients (79.4%), of which 129 (95.6%) experienced complete recovery in less than 2 weeks. Admission to the hospital was necessary in 4 children (1 in group 1 and 3 in group 2), including 2 for emergency surgical drainage of retropharyngeal abscesses. One child with posttraumatic torticollis was treated conservatively as an outpatient and recovered in 7 weeks. One child was had his/her condition eventually diagnosed with osteoid osteoma and treated with oral nonsteroidal anti-inflammatory drug. CONCLUSIONS Most cases of neck ailments in children presenting to the emergency department were due to trauma or infection, which were effectively managed as outpatients. When signs and symptoms suggested an emergent cause, CT provided a definitive diagnosis. The evaluation of a child presenting with acute neck complaints should be based on history and physical examination. Plain radiographs and CT scan are contributive in selected cases.
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70
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Koller H, Acosta F, Forstner R, Zenner J, Resch H, Tauber M, Lederer S, Auffarth A, Hitzl W. C2-fractures: part II. A morphometrical analysis of computerized atlantoaxial motion, anatomical alignment and related clinical outcomes. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18:1135-53. [PMID: 19224254 PMCID: PMC2899496 DOI: 10.1007/s00586-009-0901-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Revised: 11/09/2008] [Accepted: 01/24/2009] [Indexed: 01/22/2023]
Abstract
Knowledge on the outcome of C2-fractures is founded on heterogenous samples with cross-sectional outcome assessment focusing on union rates, complications and technical concerns related to surgical treatment. Reproducible clinical and functional outcome assessments are scant. Validated generic and disease specific outcome measures were rarely applied. Therefore, the aim of the current study is to investigate the radiographic, functional and clinical outcome of a patient sample with C2-fractures. Out of a consecutive series of 121 patients with C2 fractures, 44 met strict inclusion criteria and 35 patients with C2-fractures treated either nonsurgically or surgically with motion-preserving techniques were surveyed. Outcome analysis included validated measures (SF-36, NPDI, CSOQ), and a functional CT-scanning protocol for the evaluation of C1-2 rotation and alignment. Mean follow-up was 64 months and mean age of patients was 52 years. Classification of C2-fractures at injury was performed using a detailed morphological description: 24 patients had odontoid fractures type II or III, 18 patients had fracture patterns involving the vertebral body and 11 included a dislocated or a burst lateral mass fracture. Thirty-one percent of patients were treated with a halo, 34% with a Philadelphia collar and 34% had anterior odontoid screw fixation. At follow-up mean atlantoaxial rotation in left and right head position was 20.2 degrees and 20.6 degrees, respectively. According to the classification system of posttreatment C2-alignment established by our group in part I of the C2-fracture study project, mean malunion score was 2.8 points. In 49% of patients the fractures healed in anatomical shape or with mild malalignment. In 51% fractures healed with moderate or severe malalignment. Self-rated outcome was excellent or good in 65% of patients and moderate or poor in 35%. The raw data of varying nuances allow for comparison in future benchmark studies and metaanalysis. Detailed investigation of C2-fracture morphology, posttreatment C2-alignment and atlantoaxial rotation allowed a unique outcome analysis that focused on the identification of risk factors for poor outcome and the interdependencies of outcome variables that should be addressed in studies on C2-fractures. We recognized that reduced rotation of C1-2 per se was not a concern for the patients. However, patients with worse clinical outcomes had reduced total neck rotation and rotation C1-2. In turn, C2-fractures, especially fractures affecting the lateral mass that healed with atlantoaxial deformity and malunion, had higher incidence of atlantoaxial degeneration and osteoarthritis. Patients with increased severity of C2-malunion and new onset atlantoaxial arthritis had worse clinical outcomes and significantly reduced rotation C1-2. The current study offers detailed insight into the radiographical, functional and clinical outcome of C2-fractures. It significantly adds to the understanding of C2-fractures.
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Affiliation(s)
- Heiko Koller
- Department for Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria.
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71
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Crostelli M, Mariani M, Mazza O, Ascani E. Cervical fixation in the pediatric patient: our experience. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18 Suppl 1:20-8. [PMID: 19404690 DOI: 10.1007/s00586-009-0980-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/14/2009] [Indexed: 01/22/2023]
Abstract
The surgical management of cervical instability in children is a challenging issue. Although the indications for internal fixation are similar to those for adults, accurate pre-surgery study and sharp surgical techniques are necessary because of the size of such patients' anatomy, their peculiar tissue biology and the wide spectrum of diseases requiring cervical fusion. Our case study is made up of 31 patients, 15 male and 16 female, with an average age of 7 years and 6 months (2 years and 6 months to 18 years) who underwent cervical fusion for instability. Their physical condition presented various different pathologies ranging from congenital deformity, systemic skeletal disease, tumors, trauma, post-surgery instability. We performed occipito-cervical fusion in 11 cases, 5 of which involved stabilization at the cranium-vertebral junction. We used instrumentation in 13 cases (3 sublaminar wiring, 10 rigid adult instrumentation). We used rigid adult instrumentation in three patients under 10 years of age, treated by rod, occipital screws and sublaminar hook instrumentation in steel C0-C2 (9-year-old male, affected by os odontoideum in Down's syndrome; male of 7 years and 10 months, affected by os odontoideum in Down's syndrome; female of 4 years and 6 months with occipito-cervical stenosis and C0-C2 instability in Hurler's syndrome). We operated on two patients under 3 years of age, using sublaminar wiring with bone precursors and allograft at level C0-C2 (one of these was a 30-month-old male with post-traumatic instability C0-C2, while the other was a 17-month-old male with C0-C2 instability in Larsen's syndrome). The average follow-up age was 7 years and 1 month (between 1 and 18 years). Cervical fusion was assessed by X-ray examinations at 4th and 12th weeks and at 6th and 12th months after surgery. Where implants could allow, RMN examination was performed at 1st month after surgery. In the other cases, in which implants do not allow RMN to be performed, CT scan and standard X-rays were carried out, and new X-rays were performed every other year. We experienced two cases of sublaminar wiring rupture without impairment of bone fusion. No patient suffered major complications (infection and osteomyelitis, rigid instrumentation mobilization, incomplete fusion with instability, neurologic impairment, insufficient cervical spine range of movement to cope with everyday life activities, cervical pain). Even though most authors still indicate that rigid instrumentation should be performed in cases over 10 years of age and sublaminar wiring in cases over 3 years of age, our findings demonstrate that this age limit can be lowered. We have treated children under 10 years of age by rigid adult instrumentation and under 36 months of age by wiring. The anatomic size of the patient is the most important factor in determining the use of instrument arthrodesis to treat pediatric cervical spine instability. Although not easy, it is possible and preferable in many cases to adapt fixation to child cervical spine even in very young patients.
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Affiliation(s)
- Marco Crostelli
- Vertebral Disease Operative Unit, Pediatric Surgery Department, Bambino Gesù Pediatric Hospital, Palidoro, Rome, Italy.
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Rocha R, Sawa AGU, Baek S, Safavi-Abbasi S, Hattendorf F, Sonntag VKH, Crawford NR. Atlantoaxial rotatory subluxation with ligamentous disruption: a biomechanical comparison of current fusion methods. Neurosurgery 2009; 64:ons137-43; discussion ons143-4. [PMID: 19240563 DOI: 10.1227/01.neu.0000335778.31497.5b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We evaluated the biomechanical effects of 4 instrumented configurations after induced atlantoaxial rotatory subluxation: transarticular screw fixation (T/A) and polyaxial C1 lateral mass and C2 pedicle screw and rod fixation (LC1-PC2) for atlantoaxial arthrodesis with unilateral and bilateral instrumentation. METHODS Three-dimensional intervertebral motion was tracked stereophotogrammetrically while 14 human cadaveric spine specimens underwent nonconstraining pure moment loading. Nondestructive loads were applied quasi-statistically in 0.25-Nm increments to a maximum load of 1.5 Nm during flexion-extension, right and left axial rotation, and right and left lateral bending. Hyperrotation injuries were created using torsional loads applied during left axial rotation until visible failure occurred. RESULTS In the normal condition, the values for angular range of motion, lax zone (zone of ligamentous laxity), and stiff zone (zone of ligamentous stretching) were similar in both groups in all directions of loading, with no significant differences (P > 0.05) between groups at C0-C1 or C1-C2. Both instrumentation systems (bilateral configurations) substantially stabilized angular motion at C1-C2 (P < 0.05) during all loading modes for the T/A group, and during all but right lateral bending (P = 0.072) for the LC1-PC2 group. The mean failure load for both intact and instrumented specimens was slightly greater, but not significant for the LC1-PC2 group compared with the T/A group (P > 0.14). CONCLUSION Both methods fixated atlantoaxial subluxation equally well. Compared with unilateral instrumentation, a bilateral configuration with the LC1-PC2 technique significantly increased stability during extension (P < 0.05). During axial rotation, bilateral T/A screws significantly increased stability compared with unilateral fixation (P < 0.02).
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Affiliation(s)
- Rogério Rocha
- Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Gore PA, Chang S, Theodore N. Cervical spine injuries in children: attention to radiographic differences and stability compared to those in the adult patient. Semin Pediatr Neurol 2009; 16:42-58. [PMID: 19410157 DOI: 10.1016/j.spen.2009.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The relative rarity of pediatric cervical spine injuries can impede rapid response and efficient care of this patient population. An understanding of the unique anatomical, radiographic, and biomechanical characteristics of the pediatric cervical spine is essential to the appropriate care of these challenging patients. Patterns of injury, diagnosis, and issues related to operative and nonoperative management are discussed with a focus on the developing spine. Our aim is to improve the understanding of traumatic cervical spine injuries in children for all practitioners involved with their care.
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Affiliation(s)
- Pankaj A Gore
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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Klimo P, Ware ML, Gupta N, Brockmeyer D. Cervical spine trauma in the pediatric patient. Neurosurg Clin N Am 2008; 18:599-620. [PMID: 17991586 DOI: 10.1016/j.nec.2007.09.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Injuries to the pediatric cervical spine occur infrequently. Numerous unique anatomic and biomechanical features of the pediatric spine render it much more flexible than the adult spine. These features give rise to significant differences in the presentation, diagnosis, treatment, and prognosis of pediatric cervical trauma compared with adults. Younger children more often suffer injury to the upper cervical spine with greater neurologic injury and fewer fractures. Once the child reaches the age of 10 years, he or she develops a more adult-type spine, and injuries are thus more similar to those seen in the adult population. The unique anatomic and biomechanical differences in the pediatric spine are discussed, along with the various common and unique injuries.
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Affiliation(s)
- Paul Klimo
- 88th Medical Group, 4881 Sugar Maple Drive, Wright-Patterson Air Force Base, OH 45431, USA.
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Abstract
Abstract
OBJECTIVE
The diagnosis of atlanto-occipital dislocation (AOD) remains problematic as a result of a lack of reliable radiodiagnostic criteria. In Part 1 of the AOD series, we showed that the normal occiput–C1 joint in children has an extremely narrow joint gap (condyle–C1 interval [CCI]) with great left-right symmetry. In Part 2, we used a CCI of 4 mm or greater measured on reformatted computed tomographic (CT) scans as the indicator for AOD and tested the diagnostic sensitivity and specificity of CCI against published criteria. The clinical manifestation, neuroimaging findings, management, and outcome of our series of patients with AOD are also reported.
METHOD
For diagnostic sensitivity, we applied the CCI criterion on 16 patients who fulfilled one or more accepted radiodiagnostic criteria of AOD and who showed clinical and imaging hallmarks of the syndrome. All 16 patients had plain cervical spine x-rays, head CT scans, axial cervical spine CT scans with reconstruction, and magnetic resonance imaging scans. The diagnostic yield and false-negative rate of CCI were compared with those of four published “standard” tests, namely Wholey's dens-basion interval, Powers' ratio, Harris' basion-axis interval, and Sun's interspinous ratio. The diagnostic value of “nonstandard” indicators such as cervicomedullary deficits, tectorial membrane and other ligamentous damage, perimedullary subarachnoid hemorrhage, and extra-axial blood at C1−C2 were also assessed. For diagnostic specificity, we applied CCI and the “standard” and “nonstandard” tests on 10 patients from five classes of non-AOD upper cervical injuries. The false-positive diagnostic rates for AOD of all respective tests were documented.
RESULTS
The CCI criterion was positive in all 16 patients with AOD with a diagnostic sensitivity of 100%. Fourteen patients had bilateral AOD with disruption and widening of both OC1 joints. Two patients had unilateral AOD with only one joint wider than 4 mm. The abnormal CCI varied from 5 to 34 mm. Eight patients showed blatant left-right joint asymmetry in either CCI or anatomic conformation. The diagnostic sensitivities for the “standard” tests are as follows: Wholey's, 50%; Powers', 37.5%; Harris', 31%; and Sun's, 25%, with false-negative rates of 50, 62.5, 69, and 75%, respectively. The sensitivities for the “nonstandard” indicators are: tectorial membrane damage, 71%; perimedullary blood, 63%; and C1−C2 extra-axial blood, 75%, with false-negative rates of 29, 37, and 25%, respectively. Fifteen patients with AOD had occiput-cervical fusion. There were one early and two delayed deaths (19% mortality); two patients (12%) had complete or severe residual high quadriplegia, but 11 children (69%) enjoyed excellent neurological recovery. CCI was normal in all 10 patients with non-AOD upper cervical injuries with a diagnostic specificity of 100%. The false-positive rates for the four “standard” tests were: Sun's, 60%; Harris', 50%; Wholey's, 30%; and Powers', 10%; for the “nonstandard” indicator, the rates were: cervicomedullary deficits, 70%; tectorial membrane damage, 40%; C1−C2 extra-axial blood, 40%; and perimedullary blood, 30%.
CONCLUSION
The CCI criterion has the highest diagnostic sensitivity and specificity for AOD among all other radiodiagnostic criteria and indicators. CCI is easily computed from reconstructed CT scans, has almost no logistical or technical distortions, can capture occiput–C1 joint dislocation in all three planes, and is unaffected by congenital anomalies or maturation changes of adjacent structures. Because CCI is the only test that directly measures the integrity of the actual joint injured in AOD and a widened CCI cannot be concealed by postinjury changes in the head and neck relationship, it surpasses others that use changeable landmarks.
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Affiliation(s)
- Dachling Pang
- Department of Paediatric Neurosurgery, University of California, Davis, Davis, California, and Department of Pediatric Neurosurgery, Regional Centre of Pediatric Neurosurgery, Kaiser Foundation Hospitals of Northern California, Oakland, California
| | | | - John Zovickian
- Regional Centre of Pediatric Neurosurgery, Kaiser Foundation Hospitals of Northern California, Oakland, California
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Duan S, Ye F, Kang J. Three-dimensional CT study on normal anatomical features of atlanto-axial joints. Surg Radiol Anat 2006; 29:83-8. [PMID: 17180634 DOI: 10.1007/s00276-006-0166-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 11/06/2006] [Indexed: 11/29/2022]
Abstract
It has long been a research hotspot to diagnose atlanto-axial disorder by observing the shape and motions of atlanto-axial joints. The basis for correlative studies is to ascertain the normal anatomic features of atlanto-axial joints. In our study, 33 normal subjects were examined for atlanto-axial joints, by three-dimensional CT (3D-CT) in functional positions (neutral, left and right rotary position). The contraposition between superior and inferior articular facets of lateral atlanto-axial joints (AFLAJ), including its shape and type, the width of rotational facets displacement (RFD), head's rotational angle (HRA) and rotational angle at C(1-2) (RAC(1-2)) were observed and measured on 3D-CT images. In neutral position, a complete contraposition of AFLAJ was found in 25 subjects as well as a basic contraposition in 8. In rotary position, the width of RFD was between 6.16 and 8.68 mm, the angle of HRA was between 30.2 degrees and 45.8 degrees , and RAC(1-2) between 26.7 degrees and 38.9 degrees . There is no significant difference in RFD, HRA or RAC(1-2) (P > 0.05) in between levorotatory and dextrogyrate orientation, and there is a positive correlation between RFD and RAC(1-2) (r = 0.5078, P < 0.05). Our study results show that the contraposition of AFLAJ can be clearly displayed by 3D-CT, and complete or basic contraposition in neutral position and symmetry RFD, HRA and RAC(1-2) in rotary position, are the normal anatomic features of atlanto-axial joints.
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Affiliation(s)
- Shaoyin Duan
- Medical Imaging Department, Zhongshan Hospital of Xiamen University, Xiamen, 361004, China.
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Ishii K, Chiba K, Maruiwa H, Nakamura M, Matsumoto M, Toyama Y. Pathognomonic radiological signs for predicting prognosis in patients with chronic atlantoaxial rotatory fixation. J Neurosurg Spine 2006; 5:385-91. [PMID: 17120886 DOI: 10.3171/spi.2006.5.5.385] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECT The authors conducted a study to assess the correlation between radiological features and clinical courses in patients with chronic atlantoaxial rotatory fixation (AARF) and to determine diagnostic imaging signs for predicting prognosis. METHODS There were 24 patients (eight boys and 16 girls) whose mean age was 7.8 years (range 4-14 years) and in whom AARF was diagnosed. The mean follow-up duration was 3.7 years (range 5 weeks-12 years). There were two groups of patients: 15 patients who visited the hospital less than 8 weeks after symptom (torticollis) onset comprised the acute group, and nine patients in whom the diagnosis of AARF was established later than 3 months after symptom onset comprised the chronic group. The chronic group was divided into two subgroups: those in whom the closed reduction could be achieved and those in whom it could not. Clinical data and radiographic studies, including plain radiographs and plain and three-dimensional (3D) computed tomography (CT) reconstructions, were reviewed retrospectively. A deformity of the superior C-2 facet joint was frequently observed in the group of patients with chronic AARF (p < 0.0001). This sign represented a risk factor for recurrent dislocation (p = 0.0003, Fisher exact test). Prominent lateral inclination of C-1 was an impeding factor for reduction of chronic AARF (p < 0.0001, analysis of variance with Fisher post hoc test). Greater than 20 degrees of lateral inclination of the atlas indicated an irreducible subluxation (p = 0.0023, Fisher exact test). CONCLUSIONS Both facet joint deformity and lateral inclination observed on 3D CT reconstructions can be useful signs to predict the prognosis and the treatment of choice in patients with chronic AARFs.
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Affiliation(s)
- Ken Ishii
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan.
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