1
|
Cai M, Wu Y, Ma R, Chen J, Chen Z, Deng C, Huang X, Ma X, Zou X. Comparison of Transoral Anterior Jefferson-Fracture Reduction Plate and Posterior Screw-Rod Fixation in C1-Ring Osteosynthesis for Unstable Atlas Fractures. Neurospine 2024; 21:544-554. [PMID: 38317544 PMCID: PMC11224759 DOI: 10.14245/ns.2347230.615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVE To compare the clinical outcomes of transoral anterior Jefferson-fracture reduction plate (JeRP) and posterior screw rod (PSR) surgery for unstable atlas fractures via C1-ring osteosynthesis. METHODS From June 2009 to June 2022, 49 consecutive patients with unstable atlas fractures were treated by transoral anterior JeRP fixation (JeRP group) or PSR fixation (PSR group) and followed up at General Hospital of Southern Theatre Command of PLA; 30 males and 19 females were included. The visual analogue scale (VAS) score, Neck Disability Index (NDI), distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMD), Redlund-Johnell value, postoperative complications, and fracture healing rate were retrospectively collected and statistically analyzed. RESULTS Compared with that in the PSR group, the bleeding volume in the JeRP group was lower, and the length of hospital stay was longer. The VAS scores and NDIs of both groups were significantly improved after surgery. The postoperative DAAF and DPAF were significantly smaller after surgery in both groups. Compared with the significantly shorter DPAF in the PSR group, the JeRP group had a smaller DAAF, shorter LMDs and larger Redlund-Johnell value postoperatively and at the final follow-up. The fracture healing rate at 3 months after surgery was significantly greater in the JeRP group (p < 0.05). CONCLUSION Both C1-ring osteosynthesis procedures for treating unstable atlas fractures yield satisfactory clinical outcomes. Transoral anterior JeRP fixation is more effective than PSR fixation for holistic fracture reduction and short-term fracture healing, but the hospital stay is longer.
Collapse
Affiliation(s)
- Mandi Cai
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Yifeng Wu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Rencai Ma
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Junlin Chen
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Zexing Chen
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Chenfu Deng
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Xinzhao Huang
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Xiangyang Ma
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Xiaobao Zou
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| |
Collapse
|
2
|
Niu HG, Zhao CK, Yang K, Tao H, Liu C, Zhang JJ, Shen CL, Zhang YS. Monoaxial Screws Versus Polyaxial Screws Osteosynthesis for Unstable Atlas Fractures: A Retrospective, Comparative Study With a Minimum Follow-Up of 3 years. Global Spine J 2024:21925682241247489. [PMID: 38606957 DOI: 10.1177/21925682241247489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The study aimed to compare the radiological parameters, clinical outcomes, and long-term effects of the posterior osteosynthesis with polyaxial screw-rod system and the monoaxial screw-rod system in the treatment of unstable atlas fractures. METHODS We retrospectively analyzed the clinical data of 33 patients with posterior ORIF for unstable atlas fractures in our hospital from August 2013 to June 2020, with a minimum of 3 years of follow-up. Polyaxial screws (group A) were used in 12 patients and monoaxial screws (group B) in 21 patients. Perioperative data, radiological parameters, and clinical outcomes were collected and compared between the 2 surgical approaches. RESULTS The operative time, blood loss, time of screw-rod system placement, and hospital stay were significantly lower in group A than in group B. At the last follow-up, the visual analog scale (VAS) score and anterior arch reduction rate of the atlas in group A were lower than those in group B, while the lateral mass displacement (LMD) in group A was higher than that in group B. There was no significant difference between Group A and Group B in terms of the anterior atlantodental interval (AADI), posterior arch reduction rate of the atlas, range of motion (ROM), and neck disability index (NDI). CONCLUSIONS Monoaxial screws can achieve better reduction results for unstable atlas fractures, especially for the anterior arch of atlas. However, the surgical operation of monoaxial screws is more complicated than that of polyaxial screws and has more complications. Appropriate implants should be selected for the treatment of unstable atlas fractures based on the type of atlas fracture, the experience of surgeons, and the demands of patients.
Collapse
Affiliation(s)
- He-Gang Niu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Cheng-Kun Zhao
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Kun Yang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Hui Tao
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Chang Liu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Jing-Jing Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Cai-Liang Shen
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Yin-Shun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| |
Collapse
|
3
|
Niu HG, Zhang JJ, Yan YZ, Yang K, Zhang YS. Direct osteosynthesis in the treatment of atlas burst fractures: a systematic review. J Orthop Surg Res 2024; 19:129. [PMID: 38331873 PMCID: PMC10851607 DOI: 10.1186/s13018-024-04571-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/18/2024] [Indexed: 02/10/2024] Open
Abstract
PURPOSE The treatment of unstable atlas fractures remains a controversial topic. The study aims at assessing the prognosis and efficacy of osteosynthesis for unstable atlas fractures through a review of the current literature and additionally aims to compare outcomes between the transoral and posterior approaches. METHODS A systematic review of databases including PubMed, EMBASE, Cochrane, Web of Science, CNKI, and Wanfang was conducted. Titles and abstracts were screened by two reviewers to identify studies meeting pre-defined inclusion criteria for comprehensive analysis. RESULTS The systematic review included 28 articles, 19 employing the posterior approach and 9 utilizing the transoral approach. It covered osteosynthesis in 297 patients with unstable atlas fractures, comprising 169 treated via the posterior approach and 128 via the transoral approach. Analysis revealed high healing rates and clinical improvement in both approaches, evidenced by improvements in the visual analog scale, range of motion, atlantodens interval, and lateral displacement distance post-surgery. CONCLUSION Osteosynthesis offers effective treatment for unstable atlas fractures. Both transoral and posterior approaches can achieve good clinical outcomes for fracture, and biomechanical studies have confirmed that osteosynthesis can maintain the stability of the occipitocervical region, preserve the motor function of the atlantoaxial and occipito-atlantoaxial joints, and greatly improve the quality of life of patients. However, variations exist in the indications and surgical risks associated with each method, necessitating their selection based on a thorough clinical evaluation of the patient's condition.
Collapse
Affiliation(s)
- He-Gang Niu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Jing-Jing Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Yi-Zhu Yan
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Kun Yang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China.
| | - Yin-Shun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China.
| |
Collapse
|
4
|
Portonero I, Lo Bue E, Penner F, Di Perna G, Baldassarre BM, De Marco R, Pesaresi A, Garbossa D, Pecorari G, Zenga F. Lesson learned in endoscopic endonasal dens resection for C1-C2 spinal cord decompression. 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 2024; 33:438-443. [PMID: 37934268 DOI: 10.1007/s00586-023-08001-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 07/01/2023] [Accepted: 10/12/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE Endoscopic endonasal approach (EEA) is the safest and most effective technique for odontoidectomy. Nevertheless, this kind of approach is yet not largely widespread. The aim of this study is to share with the scientific community some tips and tricks with our ten-year-old learned experience in endoscopic endonasal odontoidectomy (EEO), which remains a challenging surgical approach. MATERIAL AND METHODS Our case series consists of twenty-one (10 males, 11 females; age range of 34-84 years) retrospectively analyzed patients with ventral spinal cord compression for non-reducible CVJ malformation, treated with EEA from July 2011 to March 2019. RESULTS The results have recently been reported in a previous paper. The only intraoperative complication observed was intraoperative cerebrospinal fluid (CSF) leak (9.5%), without any sign of post-operative CSF leak. CONCLUSIONS Considering our experience, EEO represents a valid and safe technique to decompress neural cervical structures. Despite its technical complexity, mainly due to the use of endoscope and the challenging surgical area, with this study we encourage the use of EEO displaying our experience-based surgical tips and tricks.
Collapse
Affiliation(s)
- Irene Portonero
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy.
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy.
| | - Enrico Lo Bue
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | - Federica Penner
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | | | - Bianca Maria Baldassarre
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
- UOC Neurochirurgia, Ospedale SS Annunziata, Tartanto, Italy
| | - Raffaele De Marco
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | - Alessandro Pesaresi
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | - Diego Garbossa
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | - Giancarlo Pecorari
- ENT Surgery Unit, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Francesco Zenga
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| |
Collapse
|
5
|
Hou X, Tian Y, Xu N, Li H, Yan M, Wang S, Li W. Overstrain on the longitudinal band of the cruciform ligament during flexion in the setting of sandwich deformity at the craniovertebral junction: a finite element analysis. Spine J 2023; 23:1721-1729. [PMID: 37385409 DOI: 10.1016/j.spinee.2023.06.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/31/2023] [Accepted: 06/17/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND CONTEXT In the setting of "sandwich deformity" (concomitant C1 occipitalization and C2-3 nonsegmentation), the C1-2 joint becomes the only mobile joint in the craniovertebral junction. Atlantoaxial dislocation develops earlier with severer symptoms in sandwich deformity, which has been hypothesized to be due to the repetitive excessive tension in the ligaments between C1 and C2. PURPOSE To elucidate whether and how the major ligaments of the C1-2 joint are affected in sandwich deformity, and to find out the ligament most responsible for the earlier development and severer symptoms of atlantoaxial dislocation in sandwich deformity. STUDY DESIGN A finite element (FE) analysis study. METHODS A three-dimensional FE model from occiput to C5 was established using anatomical data from a thin-slice CT scan of a healthy volunteer. Sandwich deformity was simulated by eliminating any C0-1 and C2-3 segmental motion respectively. Flexion torque was applied, and the range of motion of each segment and the tension sustained by the major ligaments of C1-2 (including the transverse and longitudinal bands of the cruciform ligament, the alar ligaments, and the apical ligament) were analyzed. RESULTS Tension sustained by the longitudinal band of the cruciform ligament and the apical ligament during flexion is significantly larger in the FE model of sandwich deformity. In contrast, tension in the other ligaments is not significantly changed in the sandwich deformity model compared with the normal model. CONCLUSIONS Considering the importance of the longitudinal band of the cruciform ligament to the stability of the C1-2 joint, our findings implicate that the early onset, severe dislocation, and unique clinical manifestations of atlantoaxial dislocation in patients with sandwich deformity are mainly due to the enlarged force loaded on the longitudinal band of the cruciform ligament. CLINICAL SIGNIFICANCE The enlarged force loaded on the longitudinal band of the cruciform ligament can add to its laxity and thus reducing its ability to restrict the cranial migration of the odontoid process. This is in accordance with our clinical experience that dislocation of the atlantoaxial joint in patients with sandwich deformity is mainly craniocaudal, which means severer cranial neuropathy, Chiari deformity, and syringomyelia, and more difficult surgical treatment.
Collapse
Affiliation(s)
- Xiangyu Hou
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, China; Engineering Research Center of Bone and Joint Precision Medicine, 49 North Garden Rd, Haidian District, Beijing, China; Beijing Key Laboratory of Spinal Disease Research, 49 North Garden Rd, Haidian District, Beijing, China
| | - Yinglun Tian
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, China; Engineering Research Center of Bone and Joint Precision Medicine, 49 North Garden Rd, Haidian District, Beijing, China; Beijing Key Laboratory of Spinal Disease Research, 49 North Garden Rd, Haidian District, Beijing, China
| | - Nanfang Xu
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, China; Engineering Research Center of Bone and Joint Precision Medicine, 49 North Garden Rd, Haidian District, Beijing, China; Beijing Key Laboratory of Spinal Disease Research, 49 North Garden Rd, Haidian District, Beijing, China
| | - Hui Li
- Beijing Engineering and Technology Research Center for Medical Endoplants, Building 1, Yard 9, Chengwan Street, Haidian District, Beijing, China
| | - Ming Yan
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, China; Engineering Research Center of Bone and Joint Precision Medicine, 49 North Garden Rd, Haidian District, Beijing, China; Beijing Key Laboratory of Spinal Disease Research, 49 North Garden Rd, Haidian District, Beijing, China
| | - Shenglin Wang
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, China; Engineering Research Center of Bone and Joint Precision Medicine, 49 North Garden Rd, Haidian District, Beijing, China; Beijing Key Laboratory of Spinal Disease Research, 49 North Garden Rd, Haidian District, Beijing, China.
| | - Weishi Li
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, China; Engineering Research Center of Bone and Joint Precision Medicine, 49 North Garden Rd, Haidian District, Beijing, China; Beijing Key Laboratory of Spinal Disease Research, 49 North Garden Rd, Haidian District, Beijing, China
| |
Collapse
|
6
|
Fiester P, Orallo P, Soule E, Rao D, Tavanaiepour D. Utility of Anterior Atlantodens Interval Widening on Cervical Spine CT for Assessing Transverse Atlantal Ligament Injury. Global Spine J 2023; 13:2319-2326. [PMID: 35212239 PMCID: PMC10538329 DOI: 10.1177/21925682221081211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective, cross-sectional. OBJECTIVES To identify trauma patients with confirmed tears of the transverse atlantal ligament on cervical MRI and measure several parameters of atlanto-axial alignment on cervical CT, including the anterior atlantodens interval, to determine which method is most sensitive in predicting transverse atlantal ligament injury. METHODS Adult trauma patients who suffered a transverse atlantal ligament tear on cervical MRI were identified retrospectively. The cervical CT and MRI exams for these patients were reviewed for the following: anterior and lateral atlantodens interval widening, lateral C1 mass offset, C1-C2 rotatory subluxation, and transverse atlantal ligament injuries on cervical MRI. RESULTS Twenty-six patients were identified with a tear of the transverse atlantal ligament on cervical MRI. Twelve percent of these patients demonstrated an anterior dens interval measuring greater than 2 mm, 26% of patients demonstrated lateral mass offset of C1 on C2 (average offset of 2.4 mm), 18% of patients demonstrated an asymmetry greater than 1 mm between the left and right lateral atlantodens interval, and one patient demonstrated atlanto-axial rotation measuring greater than 20%. Ten patients had an accompanying C1 burst fracture and eight patients had a C2 fracture. One patient demonstrated widening of the atlanto-occipital joint space greater than 2 mm indicative of craniocervical dissociation injury. CONCLUSIONS An anterior atlantodens interval measuring greater than 2 mm is an unreliable methodology to screen trauma patients for transverse altantal ligament injuries and atlanto-axial instability. Moreover, C1 lateral mass offset, lateral atlantodens asymmetry, and atlanto-axial rotation were all poor predictors of transverse atlantal ligament tears.
Collapse
Affiliation(s)
- Peter Fiester
- Department of Neuroradiology, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Peaches Orallo
- Department of Anesthesiology, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Erik Soule
- Department of Neuroradiology, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Dinesh Rao
- Department of Neuroradiology, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| |
Collapse
|
7
|
Yang K, Niu HG, Tao H, Liu C, Cao Y, Li W, Zhang JJ, Shen CL, Zhang YS. Posterior osteosynthesis with a new self-designed lateral mass screw-plate system for unstable atlas burst fractures. BMC Musculoskelet Disord 2023; 24:108. [PMID: 36759784 PMCID: PMC9909890 DOI: 10.1186/s12891-023-06209-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND In the treatment of unstable atlas fractures using the combined anterior-posterior approach or the posterior monoaxial screw-rod system, factors such as severe trauma or complex surgical procedures still need to be improved despite the favourable reduction effect. This research described and evaluated a new technique for the treatment of unstable atlas fracture using a self-designed lateral mass screw-plate system. METHODS A total of 10 patients with unstable atlas fractures using this new screw-plate system from January 2019 to December 2021 were retrospectively reviewed. All patients underwent posterior open reduction and internal fixation (ORIF) with a self-designed screw-plate system. The medical records and radiographs before and after surgery were noted. Preoperative and postoperative CT scans were used to determine the type of fracture and evaluate the reduction of fracture. RESULTS All 10 patients were successfully operated with this new system, with an average follow-up of 16.7 ± 9.6 months. A total of 10 plates were placed, and all 20 screws were inserted into the atlas lateral masses. The mean operating time was 108.7 ± 20.1 min and the average estimated blood loss was 98.0 ± 41.3 ml. The lateral mass displacement (LMD) averaged 7.1 ± 1.9 mm before surgery and almost achieved satisfactory reduction after surgery. All the fractures achieved bony healing without reduction loss or implant failure. No complications (vertebral artery injury, neurologic deficit, or wound infection) occurred in these 10 patients. At the final follow-up, the anterior atlantodens interval (AADI) was 2.3 ± 0.8 mm and the visual analog scale (VAS) was 0.6 ± 0.7 on average. All patients preserved almost full range of motion of the upper cervical spine and achieved a good clinical outcome at the last follow-up. CONCLUSIONS Posterior osteosynthesis with this new screw-plate system can provide a new therapeutic strategy for unstable atlas fractures with simple and almost satisfactory reduction.
Collapse
Affiliation(s)
- Kun Yang
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - He-gang Niu
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Hui Tao
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Chang Liu
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Yun Cao
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Wei Li
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Jing-jing Zhang
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Cai-liang Shen
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Yin-shun Zhang
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| |
Collapse
|
8
|
Zou X, Yang H, Deng C, Fu S, Chen J, Ma R, Ma X, Xia H. The use of a novel reduction plate in transoral anterior C1-ring osteosynthesis for unstable atlas fractures. Front Surg 2023; 10:1072894. [PMID: 37206357 PMCID: PMC10188962 DOI: 10.3389/fsurg.2023.1072894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Background Transoral anterior C1-ring osteosynthesis has been reported as an effective treatment for unstable atlas fracture, which aims to preserve important C1-C2 motion. However, previous studies have shown that the anterior fixation plates used in this technique were not suitable for the anterior anatomy of the atlas and lacked an intraoperative reduction mechanism. Objective This study aims to evaluate the clinical effects of a novel reduction plate used in transoral anterior C1-ring osteosynthesis for unstable atlas fractures. Methods 30 patients with unstable atlas fractures treated by this technique from June 2011 to June 2016 were included in this study. The patients' clinical data and radiographs were reviewed, and the reduction of the fracture, internal fixation placement, and bone fusion were assessed using pre- and postoperative images. The patients' neurological function, rotatory range of motion, and pain levels were evaluated clinically during follow-up. Results All 30 surgeries were successfully performed, and the average follow-up duration was 23.5 ± 9.5 months (range 9-48 months). One patient suffered atlantoaxial instability during the follow-up and was treated with posterior atlantoaxial fusion. The remaining 29 patients had satisfactory clinical outcomes, with ideal fracture reduction, good screw and plate placement, well-preserved range of motion, neck pain alleviation and solid bone fusion. There were no vascular or neurological complications during the operation or follow-up. Conclusions The use of this novel reduction plate in transoral anterior C1-ring osteosynthesis is a safe and effective surgical option in the treatment of unstable atlas fractures. This technique offers an immediate intraoperative reduction mechanism, which provides satisfactory fracture reduction, bone fusion, and preservation of C1-C2 motion.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Hong Xia
- Correspondence: Xiangyang Ma Hong Xia
| |
Collapse
|
9
|
Gurjar HK, Rai HIS, Mishra S, Garg K. Technical Considerations in Surgical Fixation of Jefferson Fracture. INDIAN JOURNAL OF NEUROTRAUMA 2022. [DOI: 10.1055/s-0042-1759854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AbstractJefferson fracture is defined as the simultaneous disruption of the continuity of the anterior and posterior arches of the atlas vertebra. It generally results from an axial impact to the head. Most of these fractures are amenable to nonoperative management. Significant disruption of the transverse atlantal ligament that is the main stabilizing ligament of the atlantoaxial articulation and contiguous spinal injuries often form the indications for operative intervention in these fractures. The outward and caudal displacement of the C1 lateral masses observed in these fractures often requires significant deviation from the standard operative technique of atlantoaxial fixation when the osseous elements are intact. Accordingly, we have described the surgical nuances relevant to the exposure and instrumentation of the atlantoaxial region in the setting of Jefferson fracture, through our experience in two cases.
Collapse
Affiliation(s)
- Hitesh Kumar Gurjar
- Department of Neurosurgery & Gamma-Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Hitesh Inder Singh Rai
- Department of Neurosurgery & Gamma-Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Shashwat Mishra
- Department of Neurosurgery & Gamma-Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery & Gamma-Knife, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
10
|
Unstable jefferson burst fractures (JBF): Intraoperative stability testing after posterior atlas ring osteosynthesis (C1-RO) allows determination of surgical procedure extent. BRAIN & SPINE 2022; 2:101668. [PMID: 36506288 PMCID: PMC9729808 DOI: 10.1016/j.bas.2022.101668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/03/2022] [Accepted: 10/28/2022] [Indexed: 11/11/2022]
Abstract
Introduction Motion preserving atlas ring osteosynthesis (C1-RO) for unstable Jefferson burst fractures (JBF) with insufficiency of the transverse atlantal ligament (TAL) is under debate. There is controversy about when to apply C1-RO and when further stabilization is needed. Research question Is intraoperative stability testing after C1-RO with restoration of secondary stabilizers feasible, and what are mid-to long-term results of posterior C1-RO vs. C1-C2 ORIF in unstable Jefferson burst fractures with Dickman type I or II transverse atlantal ligament lesions based on intraoperative decision using this stability testing? Material and methods Five consecutive patients with unstable JBF were treated with posterior C1-RO or C1-C2 ORIF based on the findings after intraoperative reduction and posterior C1-RO and stability testing. This newly developed intraoperative stability test based on the findings of biomechanical studies is a fluoroscopically controlled manual C1-C2 test with a force of approximately 50 N posterior-anterior stress and a tilting maneuver after C1-RO with repositioning. Clinical and radiological results of the cases with C1-RO were analyzed 3.5-21 months postoperatively. Results Posterior C1-RO was performed in four patients. One case required C1-C2 fixation due to significant instability. In cases of C1-RO, stable bony fusions of the atlas ring were observed within a year. In flexion-extension views, the anterior atlanto-dental interval (AADI) did not increase until the latest follow-up. No complications were observed. Discussion and conclusion The described intraoperative stability test after posterior C1-RO in unstable JBF enables the determination if C1-RO is sufficient or C1-C2 ORIF is necessary for treatment.
Collapse
|
11
|
Yan L, Du J, Yang J, He B, Hao D, Zheng B, Yang X, Hui H, Liu T, Wang X, Guo H, Chen J, Wang S, Ma S, Dong S. C1-ring osteosynthesis versus C1-2 fixation fusion in the treatment of unstable atlas fractures: a multicenter, prospective, randomized controlled study with 5-year follow-up. J Neurosurg Spine 2022; 37:157-165. [PMID: 35148517 DOI: 10.3171/2021.12.spine211063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of the present study was to compare the long-term effects of posterior C1-ring osteosynthesis and C1-2 fixation fusion in the treatment of unstable atlas fractures. METHODS A multicenter, prospective, randomized controlled trial was conducted to analyze 73 patients with atlas fractures who underwent posterior fixation. The intervention group was treated with C1-ring osteosynthesis, and the control group was treated with C1-2 fixation fusion. The patients were followed up for 6 months, 1 year, 2 years, and 5 years after the operation. RESULTS Fifty-two patients had complete data at the last follow-up. The visual analog scale (VAS) score for neck pain in the intervention group was lower than that in the control group (p < 0.001). The operation time, intraoperative blood loss, radiation dose, bedridden period, hospital stay, and cost in the intervention group were significantly lower than those in the control group (p < 0.001). At the last follow-up, the Neck Disability Index in the intervention group was higher than that of the control group, and the angle of flexion-extension and axial rotation in the intervention group were greater than those in the control group (p < 0.001). CONCLUSIONS In this study, the authors found that posterior C1-ring osteosynthesis is superior to C1-2 fixation fusion in terms of long-term relief of neck pain and preservation of the physiological function of the cervical vertebrae. This technique is a reliable choice for the treatment of unstable C1 fractures.
Collapse
Affiliation(s)
- Liang Yan
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jinpeng Du
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Junsong Yang
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Baorong He
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Dingjun Hao
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bolong Zheng
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaobin Yang
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Hua Hui
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tuanjiang Liu
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaodong Wang
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Hua Guo
- 2Department of Orthopaedics Surgery, Xi'an Central Hospital, Xi'an, China
| | - Jian Chen
- 3Department of Spine Surgery, Yingchuan Guolong Hospital, Yingchuan, China
| | - Shaofei Wang
- 4Department of Spine Surgery, Baoji Traditional Chinese Medicine Hospital, Baoji, China
| | - Shengzhong Ma
- 5Department of Spine Surgery, The Second Hospital of Shandong University, Jinan, China; and
| | - Shengli Dong
- 6Department of Spine Surgery, General Hospital of Pingmei Shenma Group, Pingdingshan, China
| |
Collapse
|
12
|
Kopparapu S, Mao G, Judy BF, Theodore N. Fifty years later: the "rule of Spence" is finally ready for retirement. J Neurosurg Spine 2022; 37:149-156. [PMID: 35148514 DOI: 10.3171/2021.12.spine211188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
Determination of the optimal approach to traumatic atlas fractures with or without transverse atlantal ligament (TAL) injury requires a nuanced understanding of the biomechanics of the atlantoaxial complex. The "rule of Spence" (ROS) was created in 1970 in a landmark effort to streamline management of burst-type atlas fractures. The ROS states that radiographic evidence of lateral mass displacement (LMD) (i.e., the distance that the C1 lateral masses extend beyond the C2 superior articular processes) greater than 6.9 mm may indicate both a torn TAL and need for surgical management. Since then, the ROS has become ubiquitous in the spine literature about atlas injuries. However, in the decades since the original paper by Spence et al., modern research efforts and imaging advancements have revealed that the ROS is inaccurate on both fronts: it neither accurately predicts a TAL injury nor does it inform surgical decision-making. The purpose of this review was to delineate the history of the ROS, demonstrate its limitations, present findings in the existing literature on ROS and LMD thresholds, and discuss the current landscape of management techniques for TAL injuries, including parameters such as the atlantodental interval and type of injury according to the Dickman classification system and AO Spine upper cervical injury classification system. The ROS was revolutionary for initially investigating and later propelling the biomechanical and clinical understanding of atlas fractures and TAL injuries; however, it is time to retire its legacy as a rule.
Collapse
|
13
|
Shin JW, Suk KS, Kim HS, Yang JH, Kwon JW, Lee HM, Moon SH, Lee BH, Park SJ, Park SR, Kim SK. Direct Internal Fixation for Unstable Atlas Fractures. Yonsei Med J 2022; 63:265-271. [PMID: 35184429 PMCID: PMC8860933 DOI: 10.3349/ymj.2022.63.3.265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/27/2021] [Accepted: 11/30/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To investigate the radiologic and clinical outcomes of direct internal fixation for unstable atlas fractures. MATERIALS AND METHODS This retrospective study included 12 patients with unstable atlas fractures surgically treated using C1 lateral mass screws, rods, and transverse connector constructs. Nine lateral mass fractures with transverse atlantal ligament (TAL) avulsion injury and three 4-part fractures with TAL injury (two avulsion injuries, one TAL substance tear) were treated. Radiologic outcomes included the anterior atlantodental interval (AADI) in flexion and extension cervical spine lateral radiographs at 6 months and 1 year after treatment. CT was also performed to visualize bony healing of the atlas at 6 months and 1 year. Visual Analog Scale (VAS) scores for neck pain, Neck Disability Index (NDI) values, and cervical range of motion (flexion, extension, and rotation) were recorded at 6 months after surgery. RESULTS The mean postoperative extension and flexion AADIs were 3.79±1.56 (mean±SD) and 3.13±1.01 mm, respectively. Then mean AADI was 3.42±1.34 and 3.33±1.24 mm at 6 months and 1 year after surgery, respectively. At 1 year after surgery, 11 patients showed bony healing of the atlas on CT images. Only one patient underwent revision surgery 8 months after primary surgery due to nonunion and instability findings. The mean VAS score for neck pain was 0.92±0.99, and the mean NDI value was 8.08±5.70. CONCLUSION C1 motion-preserving direct internal fixation technique results in good reduction and stabilization of unstable atlas fractures. This technique allows for the preservation of craniocervical and atlantoaxial motion.
Collapse
Affiliation(s)
- Jae-Won Shin
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Soo Suk
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea.
| | - Hak-Sun Kim
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Ho Yang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Won Kwon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hwan-Mo Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Hwan Moon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung-Ho Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Jun Park
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sub-Ri Park
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sun-Kyu Kim
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
14
|
Minardi M, Narducci A, Vercelli GG, Carlino CF, Griva F, Pretti PF. Lag screws for reduction of bilateral lateral mass fractures due to spinal trauma. BRAIN AND SPINE 2022; 2:100877. [PMID: 36248109 PMCID: PMC9559964 DOI: 10.1016/j.bas.2022.100877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/14/2022] [Accepted: 03/04/2022] [Indexed: 11/09/2022]
Abstract
Introduction Bilateral fracture of the C1 lateral mass is a relatively uncommon type of traumatic lesion. Treatment of this kind of fractures is usually conservative, with either external immobilization or traction. Research question Whether surgical management, with placement of lag screws in lateral mass of C1, could represent a first-line treatment. Material and methods We describe a case of 67-years old man with bilateral fractures of lateral mass of Atlas due to road accident trauma without ligament lesion but severe gap between bone edges. We performed Computed Tomography and Magnetic Resonance scans for pre-operative imaging, X-Ray and CT scan for follow-up. Medtronic navigation system was used as intraoperative guidance for screw placement. Results Radiological and clinical results were good, with optimal bone reduction and patient's early return to daily activities. Discussion and conclusion Surgical management remains debateable for isolated C1 lateral mass fractures. Different surgical approaches have been described for atlas fractures, such as transoral anterior C1-ring plate osteosynthesis, posterior osteosynthesis with a lateral mass screw rod, and posterior C1 to C2 fusion and C0 to C2 fusion. Minimally invasive operative treatment with lag screw and reduction of fracture's edges without occiput-C1 or C1-C2 stabilization could be the optimal treatment with good result and decreasing rate of pseudoarthrosis, allowing to avoid Halo-vest discomfort and complications. Bilateral fracture of the C1 lateral mass is relatively uncommon type of traumatic lesion. When gap among fracture's edges is severe there is high rate of not fusion or pseudoarthrosis. Surgical reduction with bilateral lag screw, preserving C1-C2 motion and good results at follow-up imaging.
Collapse
|
15
|
Tu Q, Chen H, Li Z, Chen Y, Xu A, Zhu C, Huang X, Ma X, Wang J, Zhang K, Yin Q, Xu J, Xia H. Anterior reduction and C1-ring osteosynthesis with Jefferson-fracture reduction plate (JeRP) via transoral approach for unstable atlas fractures. BMC Musculoskelet Disord 2021; 22:745. [PMID: 34461878 PMCID: PMC8406960 DOI: 10.1186/s12891-021-04628-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 08/18/2021] [Indexed: 11/14/2022] Open
Abstract
Background To introduce a novel transoral instrumentation in the treatment of unstable fractures of the atlas. Methods From January 2008 to May 2018, 22 patients with unstable C1 fractures who received Jefferson-fracture reduction plate (JeRP) via transoral approach were retrospectively analyzed. The case history and the radiographs before and after surgery were noted. The type of fracture, the reduction of the fracture, and position of the internal fixation were assessed through preoperative and postoperative CT scans. Results All 22 patients successfully underwent anterior C1-ring osteosynthesis using the JeRP system, with a follow-up of 26.84 ± 9.23 months. Among them, 9 patients had transverse atlantal ligament (TAL) injury, including 3 in Dickman type I and 6 in type II. The preoperative lateral mass displacement (LMD) decreased from 7.13 ± 1.46 mm to 1.02 ± 0.65 mm after the operation. Bone union was achieved in all patients without implant failure or loss of reduction. There were no surgery-related complications, such as wound infection, neurological deficit, or vertebral artery injury. However, atlantoaxial dislocation occurred in 3 patients with Dickman type I TAL injury 3 months postoperatively without any neurological symptoms or neck pain. Conclusions Transoral C1-ring osteosynthesis with JeRP is an effective surgical strategy to treat unstable atlas fractures with a safe, direct, and satisfactory reduction. The primary indication for the JeRP system is an unstable fracture (Gehweiler type I/III) or/ and TAL injury (Dickman type II). Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04628-4.
Collapse
Affiliation(s)
- Qiang Tu
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China.,Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China.,The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510010, Guangdong, China
| | - Hu Chen
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China.,The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510010, Guangdong, China
| | - Zhan Li
- Guangzhou University of Chinese Medicine, Guangzhou, 510006, Guangdong, China
| | - Yuyue Chen
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Aihong Xu
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Changrong Zhu
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Xianhua Huang
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Xiangyang Ma
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Jianhua Wang
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Kai Zhang
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Qingshui Yin
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Jianzhong Xu
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Hong Xia
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China. .,The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510010, Guangdong, China.
| |
Collapse
|
16
|
Koller H, Hartmann S, Raphael G, Schmölz W, Orban C, Thome C. Surgical nuances and construct patterns influence construct stiffness in C1-2 stabilizations: a biomechanical study of C1-2 gapping and advanced C1-2 fixation. 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 2021; 30:1596-1606. [PMID: 33893554 DOI: 10.1007/s00586-021-06822-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 02/12/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Stabilization of C1-2 using a Harms-Goel construct with 3.5 mm titanium (Ti) rods has been established as a standard of reference (SOR). A reduction in craniocervical deformities can indicate increased construct stiffness at C1-2. A reduction in C1-2 can result in C1-2 joint gapping. Therefore, the authors sought to study the biomechanical consequences of C1-2 gapping on construct stiffness using different instrumentations, including a novel 6-screw/3-rod (6S3R) construct, to compare the results to the SOR. We hypothesized that different instrument pattern will reveal significant differences in reduction in ROM among constructs tested. METHODS The range of motion (ROM) of instrumented C1-2 polyamide models was analyzed in a six-degree-of-freedom spine tester. The models were loaded with pure moments (2.0 Nm) in axial rotation (AR), flexion extension (FE), and lateral bending (LB). Comparisons of C1-2 construct stiffness among the constructs included variations in rod diameter (3.5 mm vs. 4.0 mm), rod material (Ti. vs. CoCr) and a cross-link (CLX). Construct stiffness was tested with C1-2 facets in contact (Contact Group) and in a 2 mm distracted position (Gapping Group). The ROM (°) was recorded and reported as a percentage of ROM (%ROM) normalized to the SOR. A difference > 30% between the SOR and the %ROM among the constructs was defined as significant. RESULTS Among all constructs, an increase in construct stiffness up to 50% was achieved with the addition of CLX, particularly with a 6S3R construct. These differences showed the greatest effect for the CLX in AR testing and for the 6S3R construct in FE and AR testing. Among all constructs, C1-2 gapping resulted in a significant loss of construct stiffness. A protective effect was shown for the CLX, particularly using a 6S3R construct in AR and FE testing. The selection of rod diameter (3.5 mm vs. 4.0 mm) and rod material (Ti vs. CoCr) did show a constant trend but did not yield significance. CONCLUSION This study is the first to show the loss of construct stiffness at C1-2 with gapping and increased restoration of stability using CLX and 6S3R constructs. In the correction of a craniocervical deformity, nuances in the surgical technique and advanced instrumentation may positively impact construct stability.
Collapse
Affiliation(s)
- Heiko Koller
- Department of Neurosurgery, Technical University of Munich (TUM), Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany. .,Paracelsus Medical University Austria, Salzburg, Austria.
| | - Sebastian Hartmann
- Department of Neurosurgery, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Gmeiner Raphael
- Department of Neurosurgery, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Werner Schmölz
- Department of Trauma Surgery, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Christoph Orban
- Department of Trauma Surgery, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Claudius Thome
- Department of Neurosurgery, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| |
Collapse
|
17
|
Interobserver reliability of the Gehweiler classification and treatment strategies of isolated atlas fractures: an internet-based multicenter survey among spine surgeons. Eur J Trauma Emerg Surg 2020; 48:601-611. [PMID: 32918554 PMCID: PMC8825399 DOI: 10.1007/s00068-020-01494-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/04/2020] [Indexed: 11/20/2022]
Abstract
Purpose Atlas (C1) fractures are commonly rated according to the Gehweiler classification, but literature on its reliability is scarce. In addition, evaluation of fracture stability and choosing the most appropriate treatment regime for C1-injuries are challenging. This study aimed to investigate the interobserver reliability of the Gehweiler classification and to identify whether evaluation of fracture stability as well as the treatment of C1-fractures are consistent among spine surgeons. Methods Computed tomography images of 34 C1-fractures and case-specific information were presented to six experienced spine surgeons. C1-fractures were graded according to the Gehweiler classification, and the suggested treatment regime was recorded in a questionnaire. For data analyses, SPSS was used, and interobserver reliability was calculated using Fleiss’ kappa (κ) statistics. Results We observed a moderate reliability for the Gehweiler classification (κ = 0.50), the evaluation of fracture stability (κ = 0.50), and whether a surgical or non-surgical therapy was indicated (κ = 0.53). Type 1, 2, 3a, and 5 fractures were rated stable and treated non-surgically. Type 3b fractures were rated unstable in 86.7% of cases and treated by surgery in 90% of cases. Atlas osteosynthesis was most frequently recommended (65.4%). Overall, 25.8% of type 4 fractures were rated unstable, and surgery was favoured in 25.8%. Conclusion We found a moderate reliability for the Gehweiler classification and for the evaluation of fracture stability. In particular, diverging treatment strategies for type 3b fractures emphasise the necessity of further clinical and biomechanical investigations to determine the optimal treatment of unstable C1-fractures.
Collapse
|
18
|
Zou X, Ouyang B, Wang B, Yang H, Ge S, Chen Y, Ni L, Zhang S, Xia H, Wu Z, Ma X. Motion-preserving treatment of unstable atlas fracture: transoral anterior C1-ring osteosynthesis using a laminoplasty plate. BMC Musculoskelet Disord 2020; 21:538. [PMID: 32787814 PMCID: PMC7425063 DOI: 10.1186/s12891-020-03575-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/06/2020] [Indexed: 11/26/2022] Open
Abstract
Background C1-ring osteosynthesis is a valid alternative to posterior C1–C2 or C0–C2 fusion to preserve important C1–C2 motion in the treatment of unstable atlas fractures. Nevertheless, the fixation instruments used in current studies for transoral anterior C1-ring osteosynthesis were not suitable for anterior anatomy of the atlas or did not have reduction mechanism. We therefore present this report to investigate preliminary clinical effects of transoral anterior C1-ring osteosynthesis using a laminoplasty plate in unstable atlas fractures. Methods From January 2014 to December 2017, 13 patients with unstable atlas fractures were retrospectively reviewed. All patients were treated with transoral anterior C1-ring osteosynthesis using a laminoplasty plate. Pre- and postoperative images were obtained to assess reduction of the fracture, internal fixation placement, and bone union. Neurological function, range of motion, and pain levels were evaluated clinically on follow-up. Results The surgeries were successfully performed in all cases. The average follow-up duration was 16.6 ± 4.4 months (range 12–24 months). One patient suffered screw loosening after operation and underwent replacement operation subsequently. Satisfactory clinical outcomes were achieved in all patients with ideal fracture reduction, reliable plate placement, well-preserved range of motion, and neck pain alleviation. All patients achieved bone union of fractures without loss of reduction or implant failure or C1–C2 instability during the follow-up. No vascular or neurological complication was noted during the operation and follow-up. Conclusions Transoral anterior C1-ring osteosynthesis using a laminoplasty plate is a effective surgical treatment for unstable atlas fractures. This technique has a ingenious reduction mechanism, and can provide satisfactory bone union and preservation of C1–C2 motion.
Collapse
Affiliation(s)
- Xiaobao Zou
- The First School of Clinical Medicine, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China.,Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Beiping Ouyang
- The First School of Clinical Medicine, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China.,Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Binbin Wang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Haozhi Yang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Su Ge
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Yuyue Chen
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Ling Ni
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Shuang Zhang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Hong Xia
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Zenghui Wu
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Xiangyang Ma
- The First School of Clinical Medicine, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China. .,Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China.
| |
Collapse
|
19
|
邹 小, 欧阳 北, 马 向, 陈 育, 葛 苏, 张 双, 倪 菱, 夏 虹, 吴 增. [Progress in treatment of unstable atlas fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:793-796. [PMID: 32538574 PMCID: PMC8171540 DOI: 10.7507/1002-1892.201909129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 04/07/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To summarize the progress in treatment of unstable atlas fracture, the existing problems, and the research direction. METHODS Related literature at home and abroad was reviewed. The stability evaluation of atlas fracture and treatment methods were introduced, and the selection of surgical approach and fixation instruments in treatment of unstable atlas fracture were summarized and analyzed. RESULTS At present, atlas fractures are considered as unstable fractures except single anterior arch fractures with complete transverse ligament or simple posterior arch fractures. The treatment of unstable atlas fracture has been developed from nonsurgical treatment and traditional fusion surgery to single-segment fixation. Nonsurgical treatment is less effective, while traditional fusion surgery has a disadvantage of limited the motion of the upper cervical spine. Single-segment fixation can not only restore and fix the fracture, but also preserve the upper cervical motion function. Single-segment fixation approaches include posterior and transoral approaches, and the fixation instruments are being constantly improved, mainly including screw-rod system, screw-plate system, and plate system. CONCLUSION For unstable atlas fracture, single-segment fixation is an ideal surgical method, and has more advantages when compared with nonsurgical treatment and traditional fusion surgery. Single-segment fixation via transoral approach is more direct for atlas anterior arch fracture reduction, but there is a high risk of infection; and single-segment fixation via posterior approach is less effective for the reduction of atlas anterior arch fracture. Therefore, a better reduction method should be explored.
Collapse
Affiliation(s)
- 小宝 邹
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 北平 欧阳
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 向阳 马
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 育岳 陈
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 苏 葛
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 双 张
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 菱 倪
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 虹 夏
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 增晖 吴
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| |
Collapse
|
20
|
Rajasekaran S, Soundararajan DCR, Shetty AP, Kanna RM. Motion-Preserving Navigated Primary Internal Fixation of Unstable C1 Fractures. Asian Spine J 2020; 14:466-474. [PMID: 32050311 PMCID: PMC7435319 DOI: 10.31616/asj.2019.0189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/06/2019] [Indexed: 11/28/2022] Open
Abstract
Study Design Prospective observational study. Purpose To assess the safety, efficacy, and benefits of computed tomography (CT)-guided C1 fracture fixation. Overview of Literature The surgical management of unstable C1 injuries by occipitocervical and atlantoaxial (AA) fusion compromises motion and function. Monosegmental C1 osteosynthesis negates these drawbacks and provides excellent functional outcomes. Methods The patients were positioned in a prone position, and cranial traction was applied using Mayfield tongs to restore the C0–C2 height and obtain a reduction in the displaced fracture fragments. An intraoperative, CT-based navigation system was used to enable the optimal placement of C1 screws. A transverse rod was then placed connecting the two screws, and controlled compression was applied across the fixation. The patients were prospectively evaluated in terms of their clinical, functional, and radiological outcomes, with a minimal follow-up of 2 years. Results A total of 10 screws were placed in five patients, with a mean follow-up of 40.8 months. The mean duration of surgery was 77±13.96 minutes, and the average blood loss was 84.4±8.04 mL. The mean combined lateral mass dislocation at presentation was 14.6±1.34 mm and following surgery, it was 5.2±1.64 mm, with a correction of 9.4±2.3 mm (p <0.001). The follow-up CT showed excellent placement of screws and sound healing. There were no complications and instances of AA instability. The clinical range of movement at 2 years in degrees was as follows: rotation to the right (73.6°±9.09°), rotation to the left (71.6°±5.59°), flexion (35.4°±4.5°), extension (43.8°±8.19°), and lateral bending on the right (28.4°±10.45°) and left (24.8°±11.77°). Significant improvement was observed in the functional Neck Disability Index from 78±4.4 to 1.6±1.6. All patients returned to their occupation within 3 months. Conclusions Successful C1 reduction and fixation allows a motion-preserving option in unstable atlas fractures. CT navigation permits accurate and adequate monosegmental fixation with excellent clinical and radiological outcomes, and all patients in this study returned to their preoperative functional status.
Collapse
|
21
|
Lekic N, Sheu J, Ennis H, Lebwohl N, Al-Maaieh M. Why you should wear your seatbelt on an airplane: Burst fracture of the atlas (jefferson fracture) due to in-flight turbulence. J Orthop 2020; 17:78-82. [PMID: 31879479 DOI: 10.1016/j.jor.2019.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 05/02/2019] [Accepted: 06/15/2019] [Indexed: 10/26/2022] Open
Abstract
The Jefferson fracture is a burst-type fracture to the atlas first described in 1919, characterized by anterior and posterior fractures of the weak C1 ring caused by a sudden axial load to the vertex of the skull. Here we report a Jefferson fracture caused by head trauma due to mid-flight turbulence in an unrestrained 56-year-old male airline passenger. Imaging revealed a comminuted burst fracture of the atlas with an avulsion fracture of the transverse atlantal ligament. The patient was treated conservatively in a Miami-J collar with close clinical and radiographic follow-up. Lateral flexion-extension radiographs demonstrated fracture stability, and clinically the patient lacked pain or neurologic symptoms at 12 weeks from injury. To our knowledge this is the first report of a Jefferson fracture caused by axial compression attributable to in-flight turbulence. Traditionally associated with automobile crashes and diving headfirst into shallow pools, the axial load results in a compressive force to the atlas and subsequent lateral separation of the two halves of the C1 vertebral ring. The purpose of this case study is to alert providers, aircraft personnel, and passengers of the inherent risk of air travel and the importance of wearing a seatbelt at all times, describe the signs and symptoms of this often-overlooked fracture, and provide general treatment guidelines based on radiographic assessments of fracture stability.
Collapse
Affiliation(s)
- Nikola Lekic
- University of Miami / Jackson Memorial Hospital, Department of Orthopedics, 1400 NW 12th Ave 4th floor Room 4036, Miami, FL, 33136, USA
| | - Jonathan Sheu
- University of Miami Miller School of Medicine, 1600 NW 10th Ave, Room 1140, Miami, FL, 33136, USA
| | - Hayley Ennis
- University of Miami / Jackson Memorial Hospital, Department of Orthopedics, 1400 NW 12th Ave 4th floor Room 4036, Miami, FL, 33136, USA
| | - Nathan Lebwohl
- University of Miami / Jackson Memorial Hospital, Department of Orthopedics, 1400 NW 12th Ave 4th floor Room 4036, Miami, FL, 33136, USA
| | - Motasem Al-Maaieh
- University of Miami / Jackson Memorial Hospital, Department of Orthopedics, 1400 NW 12th Ave 4th floor Room 4036, Miami, FL, 33136, USA
| |
Collapse
|
22
|
Kim WJ, Park JB, Park HJ, Song KJ, Min WK. Clinical and radiological outcomes of conservative treatment for unilateral sagittal split fractures of C1 lateral mass. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2019; 53:402-407. [PMID: 31521456 PMCID: PMC6938995 DOI: 10.1016/j.aott.2019.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/25/2019] [Accepted: 08/22/2019] [Indexed: 11/30/2022]
Abstract
Objective The aim of this study was to assess the effect of transverse atlantal ligament (TAL) integrity on clinical and radiological outcomes in patients with unilateral sagittal split fracture (USSF) of the C1 lateral mass (LM). Methods Twenty-six consecutive patients (16 men and 10 women; mean age: 52 years (range: 32–69)) with C1 LM USSF were included in this study. Sixteen were TAL injury group (nine of type I injuries and seven of type II injuries according to Dickman's classification) and ten were TAL intact group. All cases were conservatively treated with a rigid brace for TAL intact or by halo-vest stabilization for TAL injury for three months. The mean follow-up was 16 months (range, 12–47 months). The results were compared with radiological assessment of fracture healing, LM displacement and Neck visual analog scale. Results At the last follow-up, for TAL intact group, total LM displacement (LMD), unilateral LMD of fracture side, atlanto-dental interval, basion-dental interval, clivus canal angle, and atlanto-occipital joint axis angle were maintained compared to initial presentation. However, for TAL injury group, all radiological parameters were worsened. The worsening of radiological parameters was more severe in type I injury than type II injury except for total LMD and unilateral LMD. Neck visual analog scale significantly decreased and patient's satisfaction was higher in TAL intact group compared to TAL injury group. Conclusion Conservative treatment for USSF of C1 LM with TAL injury failed to achieve healing of the fracture, which resulted in lateral displacement of C1 LM. This caused coronal and sagittal malalignment of occipitocervical junction, resulting in unsatisfactory clinical outcomes. Our results suggest that early surgical stabilization should be considered in USSF of C1 LM with TAL injury, especially type I injury. However, conservative treatment may be sufficient for a USSF of the C1 LM with TAL intact. Level of Evidence Level III, Therapeutic Study.
Collapse
Affiliation(s)
- Whoan Jeang Kim
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, South Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Heui-Jeon Park
- Department of Orthopaedic Surgery, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Kyung-Jin Song
- Department of Orthopaedic Surgery, College of Medicine, Chonbuk National University, Jeonju, South Korea
| | - Woo-Kie Min
- Department of Orthopaedic Surgery, Kyungbuk National University, Daegu, South Korea
| |
Collapse
|
23
|
"Rule of Spence" and Dickman's Classification of Transverse Atlantal Ligament Injury Revisited: Discrepancy of Prediction on Atlantoaxial Stability Based on Clinical Outcome of Nonoperative Treatment for Atlas Fractures. Spine (Phila Pa 1976) 2019; 44:E306-E314. [PMID: 30222691 DOI: 10.1097/brs.0000000000002877] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
UNLABELLED Detailed clinical information of 13 adult patients with acute atlantal fractures underwent nonoperative treatment was retrospectively studied. "Rule of Spence" was found inaccurate in predicting either integrity of transverse atlantal ligament (TAL) or atlantoaxial stability, whereas Dickman's classification of TAL injury was more superior to "rule of Spence" on both prediction. STUDY DESIGN A retrospective study. OBJECTIVE To evaluate the prediction accuracy of "Rule of Spence" and Dickman's classification of the transverse atlantal ligament (TAL) injury on clinical outcomes (mainly focused on atlantoaxial stability) of atlas fractures treated nonoperatively. SUMMARY OF BACKGROUND DATA TAL is regarded as primary stabilizer of the atlantoaxial complex. Atlas fractures are categorized as unstable and stable according to TAL injury or not. "Rule of Spence" and Dickman's classification have been widely used to evaluate the integrity of TAL indirectly or directly. However, there is controversy about how to interpret and apply these image measures appropriately in treatment decision making, and comparing the two measures in same cohort has been lack. METHODS From January 2013 to December 2015, 13 adult patients with atlas fractures, treated nonoperatively at acute posttraumatic phase and followed up for at least 2 years, were enrolled in the study. Lateral mass offset (LMO) and TAL injury were measured by radiography. Atlantoaxial stability, pain in occipital region, limitation of cervical motion, neurological dysfunction, and quality of daily life were evaluated as clinical outcomes. RESULTS LMO less than 6.9 mm was inaccurate either to exclud TAL injury (4/8, 50% failed) or to predict clinical outcomes (2/8, 25% failed), whereas LMO greater than 6.9 mm was accurate to determine TAL injury (5/5, 100% succeeded) but not to predict atlantoaxial stability (4/5, 80% failed). Two cases with Dickman's classification type I injury (100%) failed to restore C1-2 stability and six of seven type II (85.7%) succeeded. Three patients were indicated for fusion surgery due to instability, and one due to traumatic arthritis. Overall clinical outcomes were satisfactory as pain and quality of life were considered. CONCLUSION Dickman's classification of TAL injury is of higher superiority to "Rule of Spence" in term of the accuracy of predicting atlantoaxial stability of nonoperatively treated atlas fractures. LEVEL OF EVIDENCE 4.
Collapse
|
24
|
Gelinas-Phaneuf N, Stienen MN, Park J. Posterior open reduction and internal fixation of C1 fractures: the C-clamp technique. Acta Neurochir (Wien) 2018; 160:2451-2457. [PMID: 30393819 DOI: 10.1007/s00701-018-3710-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/16/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The treatment of isolated atlas (C1) fractures is still controversial. The surgical management usually involves an arthrodesis of the atlanto-axial (C1-C2) joint with or without occipital fixation. We reviewed the senior author's series of posterior only open reduction and internal fixation (ORIF) of isolated C1 fractures. METHODS Retrospective analysis of consecutive patients with isolated C1 fractures, treated in one institution by posterior only ORIF between 2005 and 2017. All fractures of C1 with concomitant C2 or occipital condyle fractures were excluded. The C1 arch was reduced with C1 lateral mass screws, connected with a transverse rod in a C-clamp fashion. We analyzed neck pain on the visual analog scale (VAS) and imaging signs of instability on follow-up. RESULTS We identified eight patients, six males, and two females with a mean age of 37.9 years (range 20-71 years). All were neurologically intact before surgery, none had a documented transverse ligament disruption, and the mean gap between the fractured pieces was 5.3 mm. Five patients were treated < 72 h of injury, two patients had failed halo vest for 8-10 weeks, and one patient was operated after 6 months because of painful pseudarthrosis despite wearing a hard collar. One patient developed a transient neurological deficit due to vertebral artery dissection that had resolved completely at time of follow-up. The mean follow-up after surgery was 12.6 months (range 1-49 months) and mean preoperative neck pain (VAS 5.1) was significantly decreased (VAS 0.8; p < 0.001). On follow-up radiological evaluation, no instability was noted in any patient. CONCLUSIONS Posterior ORIF of C1 fractures may be an option for patients who fail or do not wish to pursue conservative management. The particular advantage of this technique over C1-C2 arthrodesis is the preserved range of rotational motion. Mono-axial screws seem to provide better reduction capacity.
Collapse
|
25
|
Lleu M, Charles YP, Blondel B, Barresi L, Nicot B, Challier V, Godard J, Kouyoumdjian P, Lonjon N, Marinho P, Freitas E, Schuller S, Fuentes S, Allia J, Berthiller J, Barrey C. C1 fracture: Analysis of consolidation and complications rates in a prospective multicenter series. Orthop Traumatol Surg Res 2018; 104:1049-1054. [PMID: 30193984 DOI: 10.1016/j.otsr.2018.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/14/2018] [Accepted: 06/04/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Three types of C1 fracture have been described, according to location: type 1 (anterior or posterior arc), type 2 (Jefferson: anterior and posterior arc), and type 3 (lateral mass). Stability depends on transverse ligament integrity. The main aim of the present study was to analyze complications and consolidation rates according to fracture type, age and treatment. MATERIAL AND METHODS The French Society of Spinal Surgery (SFCR) performed a multicenter prospective study on C1-C2 trauma. All patients with recent fracture diagnosed on CT were included. Consolidation on CT was studied at 3 months and 1 year. Medical, neurologic, infectious and mechanical complications were inventoried using the KEOPS data-base. RESULTS Sixty-three of the 417 patients (15.1%) had C1 fracture: type 1 (33.3%), type 2 (38.1%), or type 3 (28.6%). The transverse ligament was intact in 53.9% of cases. Treatment was non-operative in 63.5% of cases, surgical in 27.0%, and surgical after failure of non-operative treatment in 9.5%. There were 8 medical complications, more frequently in patients aged >70 years, following surgery (p<0.0001). The consolidation rate was 84.2% with non-operative treatment, 100% for primary surgery, and 33.3% for secondary surgery (p=0.002). There were 10 cases of non-union, in 4.8% of type 1, 13.6% of type 2 and 33.3% of type 3 fractures (p=0.001). CONCLUSION Medical complications showed association with age and with type of treatment. Non-operative treatment was suited to types 1, 2 and 3 with minimal displacement and intact transverse ligament. C1-C2 fusion was suited to displaced unstable type 2 fracture. Displaced type 3 fracture incurred risk of non-union. Early surgery may be recommended. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Maxime Lleu
- Service de neurochirurgie, CHU de Dijon, 14, rue Paul-Gaffarel, 21000 Dijon cedex, France.
| | - Yann Philippe Charles
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, BP 426, 67091 Strasbourg cedex, France
| | - Benjamin Blondel
- Unité de chirurgie du Rachis, université Aix-Marseille, CHU de Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Laurent Barresi
- Unité de chirurgie rachidienne, CHU de Nice, institut universitaire de l'appareil locomoteur et du sport, hôpital pasteur 2, 30, voie Romaine, 06001 Nice, France
| | - Benjamin Nicot
- Département de neurochirurgie, CHU de Grenoble, avenue Maquis-du-Grésivaudan, 38700 La Tronche, France
| | - Vincent Challier
- Unité d'orthopédie-traumatologie Rachis I, CHU de Bordeaux, hôpital Tripode, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
| | - Joël Godard
- Service de neurochirurgie, hôpital Jean-Minjoz, 3, boulevard A. Fleming, 25030 Besançon cedex, France
| | - Pascal Kouyoumdjian
- Service d'orthopédie-traumatologie, CHU de Nîmes, avenue du Pr. Debré, 30000 Nîmes, France
| | - Nicolas Lonjon
- Service de neurochirurgie, hôpital Gui de Chauliac, 80, avenue Augustin-Fliche, 34090 Montpellier, France
| | - Paulo Marinho
- Service de neurochirurgie, CHRU de Lille, hôpital Roger-Salengro, rue Emile-Laine, 59037 Lille, France
| | - Eurico Freitas
- Service de neurochirurgie C et chirurgie du Rachis, université Claude-Bernard Lyon 1, hôpital P. Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
| | - Sébastien Schuller
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, BP 426, 67091 Strasbourg cedex, France
| | - Stéphane Fuentes
- Unité de chirurgie du Rachis, université Aix-Marseille, CHU de Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Jérémy Allia
- Unité de chirurgie rachidienne, CHU de Nice, institut universitaire de l'appareil locomoteur et du sport, hôpital pasteur 2, 30, voie Romaine, 06001 Nice, France
| | - Julien Berthiller
- Hospices civils de Lyon, pôle IMER, 162, avenue Lacassagne, 69424 Lyon cedex 03, France
| | - Cédric Barrey
- Service de neurochirurgie C et chirurgie du Rachis, université Claude-Bernard Lyon 1, hôpital P. Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
| |
Collapse
|
26
|
Abstract
Fractures of the C1 vertebrae (atlas) are commonly the result of falls and other trauma, which cause hyperextension, or axial compression of the cervical spine. Although historically thought as a benign injury with lower neurological risks, current data suggests that this may not hold true for geriatric patients (aged 65 y and older) who may be predisposed to these fractures even after lower-energy trauma such as ground-level falls. Advancements in orthopedic trauma care has increased our diagnostic abilities to identify and manage patients with C1 fractures and other upper cervical spine trauma. However, there are no universal treatment guidelines based on level I trials. Current treatment ranges from nonoperative to operative management depending on fracture-pattern and integrity of the surrounding ligaments. Furthermore, in the elderly patients these fractures present a unique dilemma due to preexisting comorbidities and contraindications to various treatment modalities. C1 fractures warrant greater recognition to provide optimal treatment to patients and minimize the risk for developing complications. The goal of this review is to highlight the most updated treatment guidelines and to discuss the complications of both operative and nonoperative management of C1 fractures especially among the elderly patient population.
Collapse
|
27
|
Keskil S, Göksel M, Yüksel U. Transoral screw and wire fixation for unstable anterior ½ atlas fracture. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 8:364-368. [PMID: 29403251 PMCID: PMC5763596 DOI: 10.4103/jcvjs.jcvjs_94_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Study Design: Atlas fractures are evaluated according to the fracture type and ligamentous injury. External immobilization may result in fracture nonunion. Objective: The ideal treatment method for non-stabilized atlas fractures is limited fixation without restricting the range of motion of the atlantoaxial and atlantooccipital joints. Summary of Background Data: Such a result can be established by using either anterior fixation or posterior lateral mass fixation. However, none of these techniques can fully address anterior 1/2 atlas fractures such as in this case. Materials and Methods: A transoral technique in which bilateral screws were placed intralaminarly and connected with wire was used to reduce and stabilize an anterior 1/2 fracture of C1. Result: Radiological studies after the surgery showed good cervical alignment, no screw or wire failure and good reduction with fusion of anterior arcus of C1. Conclusions: Internal immobilization by this screw and wire osteosynthesis technique protects the mobility of the atlanto-occipital and atlantoaxial joints. The main advantage is that neither the twisted wires inserted under the anterior lamina, nor the laterally placed screw heads interfere with midline wound closure; unlike the plate/cage and rod systems used together with anterior screws. A computer navigation system with intraoperative 3D imaging facilities will be of benefit for safe placement of the screw, however we preferred a free-hand technique, as the starting point was at the fracture line along the trajectory of the routinely accessible anterior lamina.
Collapse
Affiliation(s)
- Semih Keskil
- Department of Neurosurgery, Kırıkkale University Medical School, Kırıkkale, Turkey
| | - Murat Göksel
- Department of Neurosurgery, Kırıkkale University Medical School, Kırıkkale, Turkey
| | - Ulas Yüksel
- Department of Neurosurgery, Kırıkkale University Medical School, Kırıkkale, Turkey
| |
Collapse
|
28
|
Zhang YS, Zhang JX, Yang QG, Li W, Tao H, Shen CL. Posterior osteosynthesis with monoaxial lateral mass screw-rod system for unstable C1 burst fractures. Spine J 2018; 18:107-114. [PMID: 28739475 DOI: 10.1016/j.spinee.2017.06.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/21/2017] [Accepted: 06/27/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical treatment for unstable atlas fractures has evolved in recent decades from C1-C2 or C0-C2 fusion to motion-preservation techniques of open reduction and internal fixation (ORIF). However, regardless of a transoral or a posterior approach, the reduction is still not satisfactory. PURPOSE The article describes and evaluates a new technique for treating unstable atlas fractures by using a monoaxial screw-rod system. STUDY DESIGN This is a retrospective study. PATIENT SAMPLE The sample includes adult patients with unstable C1 fractures treated with a posterior monoaxial screw-rod system. OUTCOME MEASURES The outcome measures included a visual analog pain scale, radiographic reduction (lateral mass displacement [LMD]), maintenance of reduction, C1-C2 instability (anterior atlantodens interval), and complications. MATERIALS AND METHODS From August 2013 to May 2016, nine consecutive patients with unstable atlas fractures were retrospectively reviewed. All patients were treated with posterior ORIF by using a monoaxial screw-rod system. The medical records and the preoperative and postoperative radiographs were reviewed. Preoperative and postoperative computed tomography scans were used to specify the fracture types and to assess the reduction. RESULTS All nine patients with a mean age of 50.3 years successfully underwent surgery with this technique, and a follow-up of 17.4±9.3 months was performed. Transverse atlantal ligament (TAL) injury was found in eight of the nine patients: one of type I and seven of type II. The preoperative LMD averaged 7.0±2.2 mm and was restored completely after surgery; all the fractures achieved bony healing without loss of reduction or implant failure. None of the patients had complications of neurologic deficit, vertebral artery injury, or wound infection associated with the surgical procedure. Two patients complained of greater occipital nerve neuralgia after the operation, which gradually disappeared in 1 month. All patients had a well-preserved range of motion of the upper cervical spine at the final follow-up. CONCLUSIONS Posterior osteosynthesis with a monoaxial screw-rod system is capable of an almost anatomical reduction for the unstable atlas fractures. The TAL incompetence may not be a contraindication to ORIF for C1 fractures, but the long-term effect of C1-C2 instability remains to be further investigated.
Collapse
Affiliation(s)
- Yin-Shun Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jian-Xiang Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qing-Guo Yang
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wei Li
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hui Tao
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Cai-Liang Shen
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China.
| |
Collapse
|
29
|
Endoscopic Endonasal Odontoidectomy with Anterior C1 Arch Preservation in Rheumatoid Arthritis: Long-Term Follow-Up and Further Technical Improvement by Anterior Endoscopic C1-C2 Screw Fixation and Fusion. World Neurosurg 2017; 107:820-829. [DOI: 10.1016/j.wneu.2017.08.063] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 08/06/2017] [Accepted: 08/10/2017] [Indexed: 12/19/2022]
|
30
|
Abstract
Most atlas fractures are the result of compression forces. They are often combined with fractures of the axis and especially with the odontoid process. Multiple classification systems for atlas fractures have been described. For an adequate diagnosis, a computed tomography is mandatory. To distinguish between stable and unstable atlas injury, it is necessary to evaluate the integrity of the transverse atlantal ligament (TAL) by magnetic resonance imaging and to classify the TAL lesion. Studies comparing conservative and operative management of unstable atlas fractures are unfortunately not available in the literature; neither are studies comparing different operative treatment strategies. Hence all treatment recommendations are based on low level evidence. Most of atlas fractures are stable and will be successfully managed by immobilization in a soft/hard collar. Unstable atlas fractures may be treated conservatively by halo-fixation, but nowadays more and more surgeons prefer surgery because of the potential discomfort and complications of halo-traction. Atlas fractures with a midsubstance ligamentous disruption of TAL or severe bony ligamentous avulsion can be treated by a C1/2 fusion. Unstable atlas fractures with moderate bony ligamentous avulsion may be treated by atlas osteosynthesis. Although the evidence for the different treatment strategies of atlas fractures is low, atlas osteosynthesis has the potential to change treatment philosophies. The reasons for this are described in this review.
Collapse
|
31
|
Scholz M, Kandziora F, Hildebrand F, Kobbe P. [Injuries of the upper cervical spine : Update on diagnostics and management]. Unfallchirurg 2017; 120:683-700. [PMID: 28776221 DOI: 10.1007/s00113-017-0380-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Injuries to the upper cervical spine represent a diagnostic and therapeutic challenge to the treating surgeon due to the complex anatomical relationships and biomechanical features. In this further education article the diagnostic principles, established classifications and therapeutic recommendations as well as injury-specific characteristics of bony and ligamentous injuries to the upper cervical spine (C0-C2) are presented.
Collapse
Affiliation(s)
- Matti Scholz
- BG Unfallklink Frankfurt am Main gGmbH, Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt, Deutschland
| | - Frank Kandziora
- BG Unfallklink Frankfurt am Main gGmbH, Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt, Deutschland
| | - Frank Hildebrand
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Philipp Kobbe
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| |
Collapse
|
32
|
Resolution of traumatic vertebral artery dissection and occlusion after repositioning and posterior C1-ring osteosynthesis of a displaced Jefferson burst fracture. Acta Neurochir (Wien) 2017; 159:1561-1564. [PMID: 28660396 DOI: 10.1007/s00701-017-3241-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/31/2017] [Indexed: 11/27/2022]
Abstract
A 70-year-old male sustained a Jefferson burst fracture with unilateral vertebral artery dissection and occlusion by displaced fragments. We performed reduction and posterior C1-ring osteosynthesis. We present a description of the intraoperative manual assessment of atlantoaxial stability. The vertebral artery was found with a good anterograde flow posteroperatively, and MRA showed reperfusion of the vessel. The patient was free of pain with preserved C1-C2 rotation after 6 weeks. Function-preserving posterior C1-ring osteosynthesis after reduction in a displaced Jefferson burst fracture complicated by vertebral artery dissection and occlusion may restore blood flow.
Collapse
|
33
|
Woods RO, Inceoglu S, Akpolat YT, Cheng WK, Jabo B, Danisa O. C1 Lateral Mass Displacement and Transverse Atlantal Ligament Failure in Jefferson's Fracture: A Biomechanical Study of the “Rule of Spence”. Neurosurgery 2017; 82:226-231. [DOI: 10.1093/neuros/nyx194] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 03/22/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Jefferson's fracture, first described in 1927, represents a bursting fracture of the C1 ring with lateral displacement of the lateral masses. It has been determined that if the total lateral mass displacement (LMD) exceeds 6.9 mm, there is high likelihood of transverse atlantal ligament (TAL) rupture, and if LMD is less than 5.7 mm TAL injury is unlikely. Several recent radiographic studies have questioned the accuracy and validity of the “rule of Spence” and it lacks biomechanical support.
OBJECTIVE
To determine the amount of LMD necessary for TAL failure using modern biomechanical techniques.
METHODS
Using a universal material testing machine, cadaveric TALs were stretched laterally until failure. A high-resolution, high-speed camera was utilized to measure the displacement of the lateral masses upon TAL failure.
RESULTS
Eleven cadaveric specimens were tested (n = 11). The average LMD upon TAL failure was 3.2 mm (±1.2 mm). The average force required to cause failure of the TAL was 242 N (±82 N). From our data analysis, if LMD exceeds 3.8 mm, there is high probability of TAL failure.
CONCLUSION
Our findings suggest that although the rule of Spence is a conceptually valid measure of TAL integrity, TAL failure occurs at a significantly lower value than previously reported (P < .001). Based on our literature review and findings, LMD is not a reliable independent indicator for TAL failure and should be used as an adjunctive tool to magnetic resonance imaging rather an absolute rule.
Collapse
Affiliation(s)
- Rafeek O Woods
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Serkan Inceoglu
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Yusuf T Akpolat
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Wayne K Cheng
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Brice Jabo
- Department of Epidemiology and Biostatistics, Loma Linda University, School of Public Health, Loma Linda, California
| | - Olumide Danisa
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, California
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California
| |
Collapse
|
34
|
Xue D, Chen Q, Chen G, Zhuo W, Li F. Posterior arthrodesis of C1-C3 for the stabilization of multiple unstable upper cervical fractures with spinal cord compromise: A case report and literature review. Medicine (Baltimore) 2017; 96:e5841. [PMID: 28072744 PMCID: PMC5228704 DOI: 10.1097/md.0000000000005841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Multiple fractures of the atlas and axis are rare. The management of multiple fragment axis fractures and unstable atlas fractures is still challenging for the spinal surgeon. There are no published reports of similar fractures with 3-part fracture of axis associated with an unstable atlas fracture. CASE SUMMARY We present a patient with concurrent axis and atlas fractures, which have not been reported. The patient suffered hyperextension injury with neck pain and numbness of the bilateral upper extremity associated with weakness after a 2-m fall. The axis fractures included an odontoid type IIA fracture and traumatic spondylolisthesis of C2-C3. The atlas fracture was unstable. The neurological examination manifested as central canal syndrome, which was due to the hyperextension injury of cervical spine and spondylolisthesis of C2-C3. The patient was diagnosed as multiple unstable upper cervical fractures with spinal cord compromise. We performed posterior arthrodesis of C1-C3. Postoperatively, the patient showed neurological improvement, and C1-C3 had fused at the 3-month follow-up. CONCLUSION Posterior arthrodesis of C1-C3 could provide a stable fixation for the 3 parts of axis (an odontoid type IIA fracture and traumatic spondylolisthesis of C2-C3) combined an unstable atlas fracture. Both the patient and the doctor were satisfied with the results of the treatment. So posterior arthrodesis of C1-C3 is a suitable treatment option for the treatment of a concurrent unstable atlas fracture and multiple fractures of the axis.
Collapse
|
35
|
Mead LB, Millhouse PW, Krystal J, Vaccaro AR. C1 fractures: a review of diagnoses, management options, and outcomes. Curr Rev Musculoskelet Med 2016; 9:255-62. [PMID: 27357228 DOI: 10.1007/s12178-016-9356-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The atlas is subject to fracture under axial load, often due to traumatic injuries such as shallow dives and automobile accidents. These fractures account for 2-13 % of injuries to the cervical spine [Marcon RM et al. Clinics (Sao Paulo) 68(11):1455-61, 2013]. Fractures of the C1 vertebra are often difficult to diagnose, as there is often no neurological deficit or easily identifiable findings on radiographs. However, injuries to the atlas can be associated with vertebral artery injury and atlantoaxial or atlanto-occipital instability, making prompt and accurate diagnosis imperative. A detailed understanding of the anatomy, inherent stability, and common injury patterns is essential for any surgeon treating spinal trauma. This chapter explores the diagnosis and management of C1 fractures, as well as outcomes after treatment.
Collapse
Affiliation(s)
- Loren B Mead
- Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Paul W Millhouse
- Thomas Jefferson University, 1015 Walnut St. Curtis 501, Philadelphia, PA, 19107, USA
| | - Jonathan Krystal
- Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| |
Collapse
|
36
|
Iacoangeli M, Di Rienzo A, Colasanti R, Re M, Nasi D, Nocchi N, Alvaro L, di Somma L, Dobran M, Specchia N, Scerrati M. Endoscopic Transnasal Odontoidectomy With Anterior C1 Arch Preservation and Anterior Vertebral Column Reconstruction in Patients With Irreducible Bulbomedullary Compression by Complex Craniovertebral Junction Abnormalities: Operative Nuance. Oper Neurosurg (Hagerstown) 2016; 12:222-230. [DOI: 10.1227/neu.0000000000001330] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 03/14/2016] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND
During the past decades, the transoral transpharyngeal approach has been advocated as the standard route for the removal of odontoid causing an irreducible symptomatic neural compression. However, it may be potentially associated with a significant built-in morbidity because of the splitting of the soft palate for an adequate working angle, tracheostomy, and incision of the oral mucosa, causing exposure to a higher risk of infection by oral flora.
OBJECTIVE
To describe our experience with the minimally invasive pure endoscopic transnasal odontoidectomy in patients with bulbomedullary compression affected by complex anterior craniovertebral junction abnormalities.
METHODS
Five patients underwent a pure endoscopic neuronavigation-assisted transnasal odontoidectomy with anterior C1 arch preservation. Moreover, the anterior cervical spine column was reconstructed by filling the gap between the C1 arch and the residual C2 body with autologous/artificial bone. Neither tracheostomy nor enteral tube feeding were needed in any case.
RESULTS
A postoperative neurological improvement was observed in all patients. Postoperative imaging confirmed a satisfactory spinal cord decompression with cervical anterior column arthrodesis, and without evidence of instability at follow-up, so far.
CONCLUSION
The endoscopic transnasal approach seems to represent an efficient and safe alternative to the transoral route for the resection of odontoid process causing irreducible bulbomedullary compression. It provides a straightforward and minimally invasive natural surgical corridor to the anterior craniocervical junction, allowing a better working angle with preservation of spine biomechanics, while minimizing potential comorbidities.
Collapse
Affiliation(s)
- Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Alessandro Di Rienzo
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Roberto Colasanti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Re
- Department of ENT Surgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Niccolò Nocchi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Lorenzo Alvaro
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Lucia di Somma
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Nicola Specchia
- Department of Orthopedic Surgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| |
Collapse
|
37
|
Bednar DA, Almansoori KA. Solitary C1 Posterior Fixation for Unstable Isolated Atlas Fractures: Case Report and Systematic Review of the Literature. Global Spine J 2016; 6:375-82. [PMID: 27190741 PMCID: PMC4868582 DOI: 10.1055/s-0035-1564806] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 08/19/2015] [Indexed: 11/11/2022] Open
Abstract
Study Design A systematic review of the literature. Objectives To review the published results to date of motion-preserving direct reconstruction of C1 ring fractures with combined coronal plane displacement of at least 7 mm (rule of Spence) and so at risk for Dickman type I or II disruption of the transverse atlantal ligament (TAL). Methods A structured literature review prompted by successful management of a typical case. Results To date only 65 such cases are reported and follow-up is almost uniformly short. Although reported clinical success is uniform, the case mix is heterogenous and confirmation/classification of ligamentous injury at baseline is often lacking. Conclusions Direct C1 stabilization shows promise as a "more selective" option in managing displaced atlas fractures with probable TAL disruption but cannot yet be recommended as a practice standard. Prospective clinical studies are indicated and should be structured so as to differentiate between Dickman type I and type II injuries of the TAL.
Collapse
Affiliation(s)
- Drew A. Bednar
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Khaled A. Almansoori
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
38
|
Shimizu T, Otsuki B, Fujibayashi S, Takemoto M, Ito H, Sakamoto T, Adachi T, Matsuda S. Spontaneous anterior arch fracture of the atlas following C1 laminectomy without fusion: A report of three cases and finite element analysis. J Orthop Sci 2016; 21:306-15. [PMID: 26995501 DOI: 10.1016/j.jos.2016.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 02/04/2016] [Accepted: 02/16/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Only four cases of anterior arch fracture after C1 laminectomy without fusion have been previously reported. Although atlas fractures commonly occur in response to high-energy trauma, no obvious trauma that could cause the fracture was observed in these reported cases. The purpose of this study was to elucidate the biomechanical mechanism of anterior arch fracture of the atlas following C1 laminectomy and present three cases of this fracture. METHODS Three cases of fracture of the anterior arch of the atlas following C1 laminectomy were retrospectively reviewed. Three atlas models (an intact model, a laminectomy model, and a transverse ligament-resected model) were created from computed tomography data of each case using a three-dimensional finite element method. Axial load was applied on the superior facet to mimic four conditions (neutral, flexion, extension, lateral bending). The distribution of von Mises stress in the anterior arch and the displacement of the posterior arch were compared among the three models. RESULTS In all three cases, the anterior arch fracture clinically occurred after C1 laminectomy despite there being no obvious inciting trauma. During the finite element analysis, increased stress was observed in all postures of the laminectomy model as compared with the intact model. The stress-concentrated location observed in the finite element model was consistent with the fracture sites that were clinically observed. In terms of loading condition, much higher stress was observed in extension and lateral bending as compared with other postures. There were no significant differences in stress distribution between the laminectomy model and the transverse ligament-resected laminectomy model. CONCLUSIONS Stress distribution concentrates in the anterior arch after C1 laminectomy, leading to fracture of the anterior arch despite no inciting trauma. There may be more frequent occult fractures observed after C1 laminectomy than has been reported. Therefore, surgeons should recognize anterior arch fracture as a possible complication of C1 laminectomy without fusion.
Collapse
Affiliation(s)
- Takayoshi Shimizu
- Department of Orthopedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Bungo Otsuki
- Department of Orthopedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shunsuke Fujibayashi
- Department of Orthopedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mitsuru Takemoto
- Department of Orthopedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideo Ito
- Department of Orthopedic Surgery, Kyoto Shimogamo Hospital, Kyoto, Japan
| | - Takeshi Sakamoto
- Department of Orthopedic Surgery, Osaka Red Cross Hospital, Osaka, Japan
| | - Taiji Adachi
- Department of Biomechanics, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| |
Collapse
|
39
|
Re M, Iacoangeli M, Di Somma L, Alvaro L, Nasi D, Magliulo G, Gioacchini FM, Fradeani D, Scerrati M. Endoscopic endonasal approach to the craniocervical junction: the importance of anterior C1 arch preservation or its reconstruction. ACTA OTORHINOLARYNGOLOGICA ITALICA 2016; 36:107-18. [PMID: 27196075 PMCID: PMC4907157 DOI: 10.14639/0392-100x-647] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 10/19/2015] [Indexed: 12/02/2022]
Abstract
We report our experience with the endoscopic endonasal approaches (EEA) for different craniocervical junction (CCJ) disorders to analyse outcomes and demonstrate the importance and feasibility of anterior C1 arch preservation or its reconstruction. Between January 2009 and December 2013, 10 patients underwent an endoscopic endonasal approach for different CCJ pathologies at our Institution. In 8 patients we were able to preserve the anterior C1 arch, while in 2 post-traumatic cases we reconstructed it. The CCJ disorders included 4 cases of irreducible anterior bulbo-medullary compression secondary to rheumatoid arthritis or CCJ anomalies, 4 cases of inveterate fractures of C1 and/or C2 and 2 tumours. Pre- and postoperative neuroradiological evaluation was always obtained by magnetic resonance imaging (MRI), computed tomographic (CT) scanning and dynamic cranio-vertebral junction x-ray. Pre- and postoperative neurologic disability assessment was obtained by Ranawat classification for patients with rheumatoid arthritis and by Nurick classification for the others. At a mean follow-up of 31 months (range: 14-73 months), an improvement of at least one Ranawat or Nurick classification level was observed in 6 patients, while in another 4 patients neurological conditions were stable. Radiological follow-up revealed an adequate bulbo-medullary decompression in all patients and a regular bone fusion in cases of C1 and/or C2 fractures. In all patients spinal stability was preserved and none required subsequent posterior fixation. The endoscopic endonasal surgery provided adequate exposure and a low morbidity minimally invasive approach to the antero-medial located lesions of the CCJ, resulting in a safe, effective and well-tolerated procedure. This approach allowed preservation of the anterior C1 arch and the avoidance of a posterior fixation in all patients of this series, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.
Collapse
Affiliation(s)
- M Re
- Department of Otorhinolaryngology, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M Iacoangeli
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - L Di Somma
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - L Alvaro
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - D Nasi
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - G Magliulo
- Organi di Senso Department, University ''la Sapienza'', Rome, Italy
| | - F M Gioacchini
- Department of Otorhinolaryngology, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - D Fradeani
- Department of Otorhinolaryngology, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M Scerrati
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| |
Collapse
|
40
|
Shatsky J, Bellabarba C, Nguyen Q, Bransford RJ. A retrospective review of fixation of C1 ring fractures--does the transverse atlantal ligament (TAL) really matter? Spine J 2016; 16:372-9. [PMID: 26656168 DOI: 10.1016/j.spinee.2015.11.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 09/10/2015] [Accepted: 11/18/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In contrast to the majority of outcome data, many consider C1 fractures to be benign injuries and so have advocated for conservative management, except in the case of concomitant transverse atlantal ligament (TAL) injury where C1-C2 or occiput-C2 fusions are recommended. PURPOSE Our goal was to evaluate a series of unstable C1 fractures treated with C1 open reduction and internal fixation (ORIF) to assess clinical and radiographic outcomes by determining the success of reduction and pain relief. STUDY DESIGN/SETTING This is a retrospective cohort review. PATIENT SAMPLE The sample includes adult patients with unstable C1 fractures treated with open reduction and primary internal fixation. OUTCOME MEASURES Primary outcome measures included visual analog pain scale (VAS), radiographic reduction (lateral mass displacement), maintenance of reduction, C1-C2 instability, and complications. METHODS A retrospective review of all patients with C1 fractures between September 2002 and September 2013 identified 12 consecutive patients from a level I trauma center who were treated with primary internal fixation without fusion. Electronic medical records and preoperative and postoperative radiographs were reviewed. The surgical technique consisted of a posterior cervical approach to the C1 arch and open reduction using bilateral C1 lateral mass screws connected transversely with a rod. Pre- and postoperative computed tomography scans were used to assess reduction. Long-term follow-up flexion and extension radiographs were used to assess C1-C2 stability. The authors did not receive relevant funding in relation to this research. RESULTS Twelve patients underwent C1 ORIF, with a mean age of 43 (9 males and 3 females) and a mean follow-up of 17 months. Transverse atlantal ligament was found to be disrupted with type I or type II injury in 11 of the 12 patients: 5 type I and 6 type II. Preoperative lateral mass displacement averaged 7.1 mm, with postoperative displacement after reduction averaging 2.4 mm (p-value <.001). The VAS score averaged 0.7 at latest follow-up. No patients went on to develop C1-C2 instability on final flexion-extension films. No patients had a complication that resulted in neurologic deficit or vascular injury associated with the procedure. No patients were found to have late sequelae of malunion or loss of reduction. Two surgically related complications occurred, namely one patient with errant screw requiring return to the operating room (OR) and one with arthrosis of the occipital-C1 joint. CONCLUSIONS Although a small series, early evidence suggests that patients with unstable C1 ring fractures can be successfully managed with primary ORIF. Open reduction and internal fixation results in a stable construct that maintains reduction, results in excellent pain control, and does not lead to C1-C2 instability. In our series, we have not observed the presence of TAL injury to adversely affect outcomes, and thus do not believe it is a contraindication to ORIF. Comparative studies comparing internal fixation with non-operative, C1-C2, or occiput-C2 fusions would yield more insight into optimal treatment options for these fractures.
Collapse
Affiliation(s)
- Joshua Shatsky
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA.
| | - Carlo Bellabarba
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA
| | - Quynh Nguyen
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA
| | - Richard J Bransford
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA
| |
Collapse
|
41
|
Endoscopic Endonasal Approach to the Odontoid Pathologies. World Neurosurg 2016; 89:394-403. [PMID: 26868425 DOI: 10.1016/j.wneu.2016.02.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/01/2016] [Accepted: 02/02/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Surgical anterior decompression represents the treatment of choice for symptomatic irreducible ventral craniovertebral junction (CVJ) compression. With the refinement of the endoscopic techniques, the endonasal route has been proposed as alternative to the classic transoral approach to CVJ. Some reports assess the effectiveness and safety of endoscopic endonasal approaches to CVJ pathologies. MATERIALS AND METHODS From July 2011 to February 2014, 12 patients with symptomatic nonreducible ventral spinal cord compression underwent purely 3-dimensional endoscopic endonasal odontoidectomy in our department. The surgical technique is described. RESULTS A good brainstem-medullary decompression was achieved in all patients. In 10 of 12 patients the endotracheal tube was removed just after the procedure with good recovery of the respiratory function. We report no cases of velopharyngeal insufficiency. In 5 of 12 patients the preservation of C1 anterior was achieved, without the need for posterior cervical fixation. DISCUSSION AND CONCLUSIONS Endoscopic endonasal odontoidectomy has proven to be safe and effective in selected patients. Soft and hard palate preservation dramatically reduces the risk of postoperative velopharyngeal insufficiency. Moreover, the endonasal endoscopic approach provides a direct access to the dens. Three-dimensional high-definition endoscope, laser, and ultrasound bony curettes revealed to be useful tools for this approach that, however, remains a demanding one.
Collapse
|
42
|
Zenga F, Marengo N, Pacca P, Pecorari G, Ducati A. C1 anterior arch preservation in transnasal odontoidectomy using three-dimensional endoscope: A case report. Surg Neurol Int 2015; 6:192. [PMID: 26759737 PMCID: PMC4697203 DOI: 10.4103/2152-7806.172696] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/02/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The transoral ventral corridor is the most common approach used to reach the craniovertebral junction (CVJ). Over the last decade, many case reports have demonstrated the transnasal corridor to the odontoid peg represents a practicable route to remove the tip of the odontoid process. The biomechanical consequences of the traditional odontoidectomy led to the necessity of a cervical spine stabilization. Preserving the inferior portion of the C1 anterior arch should prevent instability. CASE DESCRIPTION This is the first report in which the technique to remove the tip of the odontoid while preserving the C1 anterior arch is described by means of a three-dimensional (3D) endoscope. A 53-year-old man underwent a transnasal 3D endoscopic approach because of a complex CVJ malformation. The upper-medial portion of the C1 anterior arch was removed preserving its continuity, and the odontoidectomy was performed. After surgery, a dynamic X-ray scan showed no difference in CVJ motility in comparison with the preoperative one. CONCLUSIONS The stereoscopic perception augmented the precision of the surgical gesture in the deep field. The importance of a 3D view relates to the depth of field, which a two-dimensional endoscopy cannot provide. This affects the preservation of the C1 anterior arch because of the presence of critical structures that are exposed to potential damage if not displayed.
Collapse
Affiliation(s)
- Francesco Zenga
- Department of Neurosciences, Molinette University Hospital, Via Cherasco 15, 10126 Torino, Italy
| | - Nicola Marengo
- Department of Neurosciences, Molinette University Hospital, Via Cherasco 15, 10126 Torino, Italy
| | - Paolo Pacca
- Department of Neurosciences, Molinette University Hospital, Via Cherasco 15, 10126 Torino, Italy
| | - Giancarlo Pecorari
- Department of Surgical Sciences, First ENT Division, Molinette University Hospital, Via Genova 3, 10126 Torino, Italy
| | - Alessandro Ducati
- Department of Neurosciences, Molinette University Hospital, Via Cherasco 15, 10126 Torino, Italy
| |
Collapse
|
43
|
Kim MS, Kim JY, Kim IS, Cho KS, Kim SD, Lee HJ, Kim JT, Hong JT. The effect of C1 bursting fracture on comparative anatomical relationship between the internal carotid artery and the atlas. 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 2015; 25:103-109. [PMID: 25753004 DOI: 10.1007/s00586-015-3848-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 12/30/2014] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To describe the effect of the C1 bursting fracture on the location of the internal carotid artery (ICA) around the atlas. METHODS The authors analyzed the morphology of the atlas and the ICA in 15 patients with C1 bursting fracture and compared with control group (77 patients) without any pathology. All patients were evaluated with CT angiography for the anatomical assessment. The laterality of the ICA, the distances of the ICA from the midline, anterior tubercle, and ventral surface of the C1 lateral mass were compared between two groups. The distance between the lateral margin of the longus capitis muscle and the inner edge of the transverse foramen was also measured. RESULTS Medially located ICA was more common in the C1 bursting fracture group than control group (76.7 vs 42.8 %). There were no significant differences between 2 groups for the distance from the midline, anterior tubercle, and ventral surface of the C1 lateral mass, respectively. The distance of the longus capitis muscle to transverse foramen was 2.52 ± 2.09 and 4.15 ± 3.09 mm in each group, and there was statistically significant difference (p < 0.01). CONCLUSIONS Lateral displacement of the bony structure of C1 bursting fracture changes the relative location of the ICA medially, which increase the injury risk during the bicortical C1 screw insertion. These data suggest that CT angiography or enhanced CT scans can give critical information to choose the ideal fixation technique and the proper trajectory of the screws for C1 bursting fracture.
Collapse
|
44
|
Li-jun L, Ying-chao H, Ming-jie Y, Jie P, Jun T, Dong-sheng Z. Biomechanical analysis of the longitudinal ligament of upper cervical spine in maintaining atlantoaxial stability. Spinal Cord 2014; 52:342-7. [DOI: 10.1038/sc.2014.8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 01/07/2014] [Accepted: 01/13/2014] [Indexed: 11/09/2022]
|
45
|
Abstract
BACKGROUND Majority of C1 fractures can be effectively treated conservatively by immobilization or traction unless there is an injury to the transverse ligament. Conservative treatment usually involves a long period of immobilization in a halo-vest. Surgical intervention generally involves fusion, eliminating the motion of the upper cervical spine. We describe the treatment of unstable Jefferson fractures designed to avoid these problems of both conservative and invasive methods. MATERIALS AND METHODS A retrospective review of 12 patients with unstable Jefferson fractures treated with transoral osteosynthesis of C1 between July 2008 and December 2011 was performed. A steel plate and C1 lateral mass screw fixation were used to repair the unstable Jefferson fractures. Our study group included eight males and four females with an average age of 33 years (range 23-62 years). RESULTS Patients were followed up for an average of 16 months after surgery. Range of motion of the cervical spine was by and large physiologic: Average flexion 35° (range 28-40°), average extension 42° (range 30-48°). Lateral bending to the right and left averaged 30° and 28° respectively (range 12-36° and 14-32° respectively). The average postoperative rotation of the atlantoaxial joint, evaluated by functional computed tomography scan was 60° (range 35-72°). Total average lateral displacement of the lateral masses was 7.0 mm before surgery (range 5-12 mm), which improved to 3.5 mm after surgery (range 1-6.5 mm). The total average difference of the atlanto-dens interval in flexion and extension after surgery was 1.0 mm (range 1-3 mm). CONCLUSIONS Transoral osteosynthesis of the anterior ring using C1 lateral mass screws is a viable option for treating unstable Jefferson fractures, which allows maintenance of rotation at the C1-C2 joint and restoration of congruency of the atlanto-occipital and atlantoaxial joints.
Collapse
Affiliation(s)
- Yong Hu
- Department of Spinal Surgery, Ningbo No. 6 Hospital, Ningbo 315040, Zhejiang Province, People's Republic of China
| | - Todd J Albert
- Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, Pennsylvania 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, Pennsylvania 19107, USA
| | - Wei-Hu Ma
- Department of Spinal Surgery, Ningbo No. 6 Hospital, Ningbo 315040, Zhejiang Province, People's Republic of China
| | - Zhen-Shan Yuan
- Department of Spinal Surgery, Ningbo No. 6 Hospital, Ningbo 315040, Zhejiang Province, People's Republic of China
| | - Wei-Xin Dong
- Department of Spinal Surgery, Ningbo No. 6 Hospital, Ningbo 315040, Zhejiang Province, People's Republic of China
| |
Collapse
|
46
|
Ma W, Xu N, Hu Y, Li G, Zhao L, Sun S, Jiang W, Liu G, Gu Y, Liu J. Unstable atlas fracture treatment by anterior plate C1-ring osteosynthesis using a transoral approach. 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 2013; 22:2232-9. [PMID: 23775293 PMCID: PMC3804683 DOI: 10.1007/s00586-013-2870-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 03/14/2013] [Accepted: 06/07/2013] [Indexed: 10/26/2022]
Abstract
STUDY DESIGN A retrospective study was conducted to evaluate anterior plate fixation of unstable atlas fractures using a transoral approach. OBJECTIVE To further investigate the safety and efficacy of this surgical technique, as there is currently a paucity of available data. While most atlas fractures can be managed by external immobilization with favorable results, surgery is usually preferable in highly unstable cases. Surgical stabilization is most commonly achieved using a posterior approach with fixation of C1-C2 or C0-C2, but these techniques usually result in loss of joint function and cannot fully stabilize anterior arch fractures of the atlas. Although a transoral approach circumvents these issues, only nine cases were described in the literature to our knowledge. METHODS Twenty patients with unstable atlas fractures were treated with this technique during a 6-year period. Screw and plate placement, bone fusion, and integrity of spinal cord and vertebral arteries were assessed via intraoperative and follow-up imaging. Neurologic function, range of motion, strength, pain levels, and signs of infection were assessed clinically upon follow-up. RESULTS There were no incidents of screw loosening or breakage, plate displacement, spinal cord injury, or vertebral artery injury. A total of 20 plates were placed and all 40 screws were inserted into the atlas lateral masses. CT scans demonstrated that two screws were placed too close to the vertebral artery canal, but without clinical consequences. Imaging demonstrated that bone fusion was achieved in all cases by 6 months postoperatively, without intervertebral instability. No plate-related complications were observed in any patients during the follow-up period. CONCLUSIONS C1 anterior plate fixation using a transoral approach appears to be a safe, reliable, and function-preserving surgical method for the management of unstable atlas fractures. For this type of fracture, a transoral approach with anterior fixation should be considered as an alternative to posterior approaches or conservative treatments.
Collapse
Affiliation(s)
- Weihu Ma
- Department of Orthopedics, Sixth Hospital of Ningbo, 1059 Zhongshan East Road, Ningbo, 315040, People's Republic of China,
| | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Iacoangeli M, Gladi M, Alvaro L, Di Rienzo A, Specchia N, Scerrati M. Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis. Spine J 2013; 13:542-8. [PMID: 23453575 DOI: 10.1016/j.spinee.2013.01.043] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 09/27/2012] [Accepted: 01/25/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Rheumatoid arthritis is the most common inflammatory disease involving the spine with predilection for the craniovertebral segment. Surgery is usually reserved to patients with symptomatic craniovertebral junction (CVJ) instability, basilar invagination, or upper spinal cord compression by rheumatoid pannus. Anterior approaches are indicated in cases of irreducible ventral bulbo-medullary compression. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA). PURPOSE The aim of this article is to demonstrate the feasibility of performing an odontoidectomy and a rheumatoid pannus removal by a minimally invasive EEA, preserving the anterior C1 arch continuity and avoiding a posterior fixation procedure. STUDY DESIGN Technical description and cohort report. METHODS We report three cases of elderly patients with a long history of rheumatoid arthritis and irreducible anterior bulbo-medullary compression secondary to basilar invagination and/or rheumatoid pannus. Anterior decompression was achieved by an endonasal image-guided fully endoscopic approach. RESULTS Neurological improvement and adequate bulbo-medullary decompression were obtained in all cases. The anterior C1 arch continuity was preserved, and none of the patients required a subsequent posterior fixation. CONCLUSIONS Anterior decompression by a minimally invasive EEA could represent an innovative option for the treatment of irreducible ventral CVJ lesions in elderly patients with rheumatoid arthritis. This approach permits the preservation of the anterior C1 arch and the avoidance of a posterior fixation, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.
Collapse
Affiliation(s)
- Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy.
| | | | | | | | | | | |
Collapse
|
48
|
Iacoangeli M, Di Rienzo A, Alvaro L, Scerrati M. Fully endoscopic endonasal anterior C1 arch reconstruction as a function preserving surgical option for unstable atlas fractures. Acta Neurochir (Wien) 2012; 154:1825-6. [PMID: 22922979 DOI: 10.1007/s00701-012-1471-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 08/05/2012] [Indexed: 11/30/2022]
|
49
|
Abstract
The atlantoaxial motion segment, which is responsible for half of the rotational motion in the cervical spine, is a complex junction of the first (C1) and second (C2) cervical vertebrae. Destabilization of this joint is multifactorial and can lead to pathologic motion with neurologic sequelae. Posterior spinal fixation of the C1-C2 articulation in the presence of instability has been well described in the literature. Early reports of interspinous/interlaminar wiring have evolved into modern-day pedicle screw/translaminar constructs, with excellent results. The success of a C1-C2 posterior fusion rests on appropriate indications and surgical techniques.
Collapse
|
50
|
Direct posterior c1 lateral mass screws compression reduction and osteosynthesis in the treatment of unstable jefferson fractures. Spine (Phila Pa 1976) 2011; 36:E1046-51. [PMID: 21289552 DOI: 10.1097/brs.0b013e3181fef78c] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Technical case report. OBJECTIVE To investigate a new concept and surgical technique in the treatment of unstable Jefferson fractures, which preserves the motion of upper cervical spine, avoiding fusion. SUMMARY OF BACKGROUND DATA The management of unstable Jefferson fractures remains controversial. Conservative treatment usually involves a long time of immobilization in halo vest, whereas surgical intervention generally performs fusion, eliminating the range of motion of upper cervical spine. METHODS Two patients with unstable Jefferson fractures were surgically treated via direct posterior C1 lateral mass screws compression reduction and osteosynthesis technique, aiming at restoring the C0-C2 height and maintaining the vertical ligamentous tension for C0-C1-C2 complex stability despite the incompetent transverse ligament, achieving physiologic repair instead of traditional fusion. The clinical and radiographic results were documented. RESULTS The postoperative CT showed that C1 lateral mass screws were well positioned. At 1-year follow-up, plain radiographs, and CT scan revealed no implant failure, good cervical alignment, and bony healing of the fractures; no C1-C2 instability was observed on the flexion-extension radiographs. The patients were completely pain-free, with full range of motion of the cervical spine. CONCLUSION The ideal treatment of unstable Jefferson fractures is expected to preserve the function of C0-C1-C2. Unstable Jefferson fractures involve the concomitant failure of the vertical ligamentous tension because of the loss of C0-C2 height. Reduction of the displaced lateral masses to restore the C0-C2 height and maintain the ligamentous tension is the key to the surgery. Direct posterior C1 lateral mass screws compression reduction and osteosynthesis is a valid technique, avoiding fusion of upper cervical spine.
Collapse
|