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Gierse J, Mandelka E, Medrow A, Bullert B, Gruetzner PA, Franke J, Vetter SY. Comparison of iCT-based navigation and fluoroscopic-guidance for atlantoaxial screw placement in 78 patients with traumatic cervical spine injuries. 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; 33:2304-2313. [PMID: 38635086 DOI: 10.1007/s00586-024-08232-7] [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: 11/14/2023] [Revised: 03/04/2024] [Accepted: 03/16/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND CONTEXT Studies have shown biomechanical superiority of cervical pedicle screw placement over other techniques. However, accurate placement is challenging due to the inherent risk of neurovascular complications. Navigation technology based on intraoperative 3D imaging allows highly accurate screw placement, yet studies specifically investigating screw placement in patients with traumatic atlantoaxial injuries are scarce. The aim of this study was to compare atlantoaxial screw placement as treatment of traumatic instabilities using iCT-based navigation or fluoroscopic-guidance with intraoperative 3D control scans. METHODS This was a retrospective review of patients with traumatic atlantoaxial injuries treated operatively with dorsal stabilization of C1 and C2. Patients were either assigned to the intraoperative navigation or fluoroscopic-guidance group. Screw accuracy, procedure time, and revisions were compared. RESULTS Seventy-eight patients were included in this study with 51 patients in the navigation group and 27 patients in the fluoroscopic-guidance group. In total, 312 screws were placed in C1 and C2. Screw accuracy was high in both groups; however, pedicle perforations > 1 mm occurred significantly more often in the fluoroscopic-guidance group (P = 0.02). Procedure time was on average 23 min shorter in the navigation group (P = 0.02). CONCLUSIONS This study contributes to the available data showing that navigated atlantoaxial screw placement proves to be feasible as well as highly accurate compared to the fluoroscopic-guidance technique without prolonging the time needed for surgery. When comparing these data with other studies, the application of different classification systems for assessment of screw accuracy should be considered.
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Affiliation(s)
- Jula Gierse
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany
| | - Eric Mandelka
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany
| | - Antonia Medrow
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany
| | - Benno Bullert
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany
| | - Paul A Gruetzner
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany
| | - Jochen Franke
- Orthopedics and Trauma Department, Tauernklinikum, Paracelsusstraße 8, 5700, Zell, Austria
| | - Sven Y Vetter
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
- Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany.
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Haemmerli J, Ferdowssian K, Wessels L, Mertens R, Hecht N, Woitzik J, Schneider UC, Bayerl SH, Vajkoczy P, Czabanka M. Comparison of intraoperative CT- and cone beam CT-based spinal navigation for the treatment of atlantoaxial instability. Spine J 2023; 23:1799-1807. [PMID: 37619869 DOI: 10.1016/j.spinee.2023.08.010] [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: 03/20/2023] [Revised: 07/18/2023] [Accepted: 08/13/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND CONTEXT Due to the complexity of neurovascular structures in the atlantoaxial region, spinal navigation for posterior C1-C2 instrumentation is nowadays a helpful tool to increase accuracy of surgery and safety of patients. Many available intraoperative navigation devices have proven their reliability in this part of the spine. Two main imaging techniques are used: intraoperative CT (iCT) and cone beam computed tomography (CBCT). PURPOSE Comparison of iCT- and CBCT-based technologies for navigated posterior instrumentation in C1-C2 instability. STUDY DESIGN Retrospective study. PATIENT SAMPLE A total of 81 consecutive patients from July 2014 to April 2020. OUTCOME MEASURES Screw accuracy and operating time. METHODS Patients with C1-C2 instability received posterior instrumentation using C2 pedicle screws, C1 lateral mass or pedicle screws. All screws were inserted using intraoperative imaging either using iCT or CBCT systems and spinal navigation with autoregistration technology. Following navigated screw insertion, a second intraoperative scan was performed to assess the accuracy of screw placement. Accuracy was defined as the percentage of correctly placed screws or with minor cortical breach (<2 mm) as graded by an independent observer compared to misplaced screws. RESULTS A total of 81 patients with C1-C2 instability were retrospectively analyzed. Of these, 34 patients were operated with the use of iCT and 47 with CBCT. No significant demographic difference was found between groups. In the iCT group, 97.7% of the C1-C2 screws were correctly inserted; 2.3% showed a minor cortical breach (<2 mm); no misplacement (>2 mm). In the CBCT group, 98.9% of screws were correctly inserted; no minor pedicle breach; 1.1% showed misplacement >2 mm. Accuracy of screw placement demonstrated no significant difference between groups. Both technologies allowed sufficient identification of screw misplacement intraoperatively leading to two screw revisions in the iCT and three in the CBCT group. Median time of surgery was significantly shorter using CBCT technology (166.5 minutes [iCT] vs 122 minutes [CBCT]; p<.01). CONCLUSIONS Spinal navigation using either iCT- or CBCT-based systems with autoregistration allows safe and reliable screw placement and intraoperative assessment of screw positioning. Using the herein presented procedural protocols, CBCT systems allow shorter operating time.
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Affiliation(s)
- Julien Haemmerli
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Kiarash Ferdowssian
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Lars Wessels
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Robert Mertens
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Ulf C Schneider
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Simon H Bayerl
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany.
| | - Marcus Czabanka
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
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Beyer RS, Nguyen A, Brown NJ, Gendreau JL, Hatter MJ, Pooladzandi O, Pham MH. Spinal robotics in cervical spine surgery: a systematic review with key concepts and technical considerations. J Neurosurg Spine 2023; 38:66-74. [PMID: 36087333 DOI: 10.3171/2022.7.spine22473] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/06/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Spinal robotics for thoracolumbar procedures, predominantly employed for the insertion of pedicle screws, is currently an emerging topic in the literature. The use of robotics in instrumentation of the cervical spine has not been broadly explored. In this review, the authors aimed to coherently synthesize the existing literature of intraoperative robotic use in the cervical spine and explore considerations for future directions and developments in cervical spinal robotics. METHODS A literature search in the Web of Science, Scopus, and PubMed databases was performed for the purpose of retrieving all articles reporting on cervical spine surgery with the use of robotics. For the purposes of this study, randomized controlled trials, nonrandomized controlled trials, retrospective case series, and individual case reports were included. The Newcastle-Ottawa Scale was utilized to assess risk of bias of the studies included in the review. To present and synthesize results, data were extracted from the included articles and analyzed using the PyMARE library for effect-size meta-analysis. RESULTS On careful review, 6 articles published between 2016 and 2022 met the inclusion/exclusion criteria, including 1 randomized controlled trial, 1 nonrandomized controlled trial, 2 case series, and 2 case reports. These studies featured a total of 110 patients meeting the inclusion criteria (mean age 53.9 years, range 29-77 years; 64.5% males). A total of 482 cervical screws were placed with the use of a surgical robot, which yielded an average screw deviation of 0.95 mm. Cervical pedicle screws were the primary screw type used, at a rate of 78.6%. According to the Gertzbein-Robbins classification, 97.7% of screws in this review achieved a clinically acceptable grade. The average duration of surgery, blood loss, and postoperative length of stay were all decreased in minimally invasive robotic surgery relative to open procedures. Only 1 (0.9%) postoperative complication was reported, which was a surgical site infection, and the mean length of follow-up was 2.7 months. No mortality was reported. CONCLUSIONS Robot-assisted cervical screw placement is associated with acceptable rates of clinical grading, operative time, blood loss, and postoperative complications-all of which are equal to or improved relative to the metrics seen in the conventional use of fluoroscopy or computer-assisted navigation for cervical screw placement.
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Affiliation(s)
- Ryan S Beyer
- 1Department of Neurological Surgery, University of California, Irvine, Orange
| | - Andrew Nguyen
- 2Department of Neurosurgery, UC San Diego School of Medicine, San Diego
| | - Nolan J Brown
- 1Department of Neurological Surgery, University of California, Irvine, Orange
| | - Julian L Gendreau
- 4Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Matthew J Hatter
- 1Department of Neurological Surgery, University of California, Irvine, Orange
| | - Omead Pooladzandi
- 3Department of Electrical and Computer Engineering, University of California, Los Angeles, California; and
| | - Martin H Pham
- 2Department of Neurosurgery, UC San Diego School of Medicine, San Diego
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Lvov I, Grin A, Talypov A, Smirnov V, Kordonskiy A, Barbakadze Z, Abdrafiev R, Krylov V. Efficacy and Safety of Goel-Harms Technique in Upper Cervical Spine Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 167:e1169-e1184. [PMID: 36089281 DOI: 10.1016/j.wneu.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The main purpose of this systematic review and meta-analysis was to estimate the incidence of implant-associated complications and fusion rates for the Goel-Harms technique (GHT) and to show potential factors affecting the complications and nonunion development. METHODS A systematic search of the PubMed database according to PRISMA guidance was performed. The main inclusion criteria comprised description of fusion rate and/or implant-associated complications rate. RESULTS This systematic review included 86 articles focused on the results of surgery in 4208 patients. The rate of screw-related complications was as follows: 1) vertebral artery (VA) injury, 2.8%; 2) screw malposition in the direction of the VA, 5.8%; and 3) C2 nerve root irritation, 6.1%. The nonunion rate was 4.2%. Transpedicular screw insertion to the C1 and C2 vertebrae were the safest regarding VA injury and correlated with lower blood loss. For C1-C2 fusion, there was no statistical difference for the different bone graft localization. C2 nerve root irritation rate did not depend on screw insertion technique. The use of a freehand technique did not correlate with a high rate of screw-related complications. CONCLUSIONS The Goel-Harms technique is a promising method of C1-C2 fusion, with a relatively low nonunion and VA injury rate. It can be performed safely without C-arm or navigation system assistance. Transpedicular screw insertion trajectories to the C1 and C2 vertebrae were safest regarding VA injury and blood loss volume. Further comparative studies of various C1-C2 stabilization methods with a high level of significance should be carried out to identify the optimal approach.
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Affiliation(s)
- Ivan Lvov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia.
| | - Andrey Grin
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia; Department of Neurosurgery, Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Aleksandr Talypov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - Vladimir Smirnov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - Anton Kordonskiy
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - Zaali Barbakadze
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - Rinat Abdrafiev
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - Vladimir Krylov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia; Department of Neurosurgery, Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Vaishnav AS, Louie P, Gang CH, Iyer S, McAnany S, Albert T, Qureshi SA. Technique, Time Demand, Radiation Exposure, and Outcomes of Skin-anchored Intraoperative 3D Navigation in Minimally Invasive Posterior Cervical Laminoforaminotomy. Clin Spine Surg 2022; 35:31-37. [PMID: 33633002 DOI: 10.1097/bsd.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective review. OBJECTIVE The objective of this study was to describe our technique and evaluate the time demand, radiation exposure, and outcomes of minimally invasive posterior cervical laminoforaminotomy (MI-PCLF) using skin-anchored intraoperative navigation (ION). BACKGROUND Although bone-anchored trackers are most commonly used for ION, a novel technique utilizing noninvasive skin-anchored trackers has recently been described for lumbar surgery and has shown favorable results. There are currently no reports on the use of this technology for cervical surgery. METHODS Time demand, radiation exposure, and perioperative outcomes of MI-PCLF using skin-anchored ION were evaluated. RESULTS Twenty-one patients with 36 operative levels were included. Time for ION setup and operative time were a median of 34 and 62 minutes, respectively. Median radiation to the patient was 2.5 mGy from 10 seconds of fluoroscopy time. Radiation exposure to operating room personnel was negligible because they are behind a protective lead shield during ION image acquisition. There were no intraoperative complications or wrong-level surgeries. One patient required a repeat ION spin, and in 2 patients, ION was abandoned and standard fluoroscopy was used. CONCLUSIONS Skin-anchored ION for MI-PCLF is feasible, safe, and accurate. It results in short operative times, minimal complications, low radiation to the patient, and negligible radiation to operating room personnel.
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Affiliation(s)
| | | | | | - Sravisht Iyer
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | - Steven McAnany
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | - Todd Albert
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
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Tatter C, Fletcher-Sandersjöö A, Persson O, Burström G, Edström E, Elmi-Terander A. Fluoroscopy-Assisted C1-C2 Posterior Fixation for Atlantoaxial Instability: A Single-Center Case Series of 78 Patients. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010114. [PMID: 35056423 PMCID: PMC8779556 DOI: 10.3390/medicina58010114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 01/10/2022] [Indexed: 04/21/2023]
Abstract
Background and Objectives: Posterior C1-C2 fixation, with trans-articular screws (TAS) or screw-rod-construct (SRC), is the main surgical technique for atlantoaxial instability, and can be performed with a fluoroscopy-assisted free-handed technique or 3D navigation. This study aimed to evaluate complications, radiological and functional outcome in patients treated with a fluoroscopy-assisted technique. Materials and Methods: A single-center consecutive cohort study was conducted of all adult patients who underwent posterior C1-C2 fixation, using TAS or CRS, between 2005-2019. Results: Seventy-eight patients were included, with a median follow-up time of 6.8 years. Trauma was the most common injury mechanism (64%), and cervicalgia the predominant preoperative symptom (88%). TAS was used in 33%, and SRC in 67% of cases. Surgery was associated with a significant reduction in cervicalgia (from 88% to 26%, p < 0.001). The most common complications were vertebral artery injury (n = 2, 2.6%), and screw malposition (n = 5, 6.7%, of which 2 were TAS and 3 were SRC). No patients deteriorated in their functional status following surgery. Conclusions: Fluoroscopy-assisted C1-C2 fixation with TAS or SRC is a safe and effective treatment for atlantoaxial instability, with a low complication rate, few surgical revisions, and pain relief in the majority of the cases.
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Affiliation(s)
- Charles Tatter
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
- Correspondence: ; Tel.: +46-8-517-74-126
| | - Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Oscar Persson
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Gustav Burström
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Erik Edström
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
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Patkar S. Unstable odontoid fractures: technical appraisal of anterior extrapharyangeal open reduction internal fixation for irreducible unstable odontoid fractures. Patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21501. [PMID: 36061093 PMCID: PMC9435568 DOI: 10.3171/case21501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Displaced odontoid fractures that are irreducible with traction and have cervicomedullary compression by the displaced distal fracture fragment or deformity caused by facetal malalignment require early realignment and stabilization. Realignment with ultimate solid fracture fusion and atlantoaxial joint fusion, in some situations, are the aims of surgery. Fifteen such patients were treated with direct anterior extrapharyngeal open reduction and realignment of displaced fracture fragments with realignment of the atlantoaxial facets, followed by a variable screw placement (VSP) plate in compression mode across the fracture or anterior atlantoaxial fixation (transarticular screws or atlantoaxial plate screw construct) or both. OBSERVATIONS Anatomical realignment with rigid fixation was achieved in all patients. Fracture fusion without implant failure was observed in 100% of the patients at 6 months, with 1 unrelated mortality. Minimum follow-up has been 6 months in 14 patients and a maximum of 3 years in 4 patients, with 1 unrelated mortality. LESSONS Most irreducible unstable odontoid fractures can be anatomically realigned by anterior extrapharyngeal approach by facet joint manipulation. Plate (VSP) and screws permit rigid fixation in compression mode with 100% fusion. Any associated atlantoaxial instability can be treated from the same exposure.
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Affiliation(s)
- Sushil Patkar
- Department of Neurosurgery, Poona Hospital & Research Centre, Maharashtra, India
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Kleinstück FS, Fekete TF, Loibl M, Jeszenszky D, Haschtmann D, Porchet F, Mannion AF. Patient-rated outcome after atlantoaxial (C1-C2) fusion: more than a decade of evaluation of 2-year outcomes in 126 patients. 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; 30:3620-3630. [PMID: 34477947 DOI: 10.1007/s00586-021-06959-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/30/2021] [Accepted: 08/07/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Various surgical techniques have been introduced for atlantoaxial (C1-C2) fusion, the most common being Magerl's (transarticular) or the Harms/Goel screw fixation. Common indications include degenerative osteoarthritis (OA), trauma or rheumatoid arthritis (RA). Only few, small studies have evaluated patient-reported outcomes after C1-C2 fusion. We investigated 2-year outcomes in a large series of consecutive patients undergoing isolated C1-C2 fusion. METHODS We analysed prospectively collected data (2005-2016) from our Spine outcomes database, collected within the framework of EUROSPINE's Spine Tango Registry. It included 126 patients (34 (27%) men, 92 (73%) women; mean (SD) age 67 ± 19 y) who had undergone first-time isolated C1-C2 fusion (61% Magerl, 39% Harms(-Goel)) at least 2 years ago for OA (83 (66%)), RA (20 (16%)), fracture (15 (12%)) or other (8 (6%)). Patients completed the multidimensional Core Outcome Measures Index (COMI; 0-10) and various single item outcomes. RESULTS Questionnaires were returned by 118/126 (94%) patients, 2 years post-operative. Mean COMI scores showed a significant reduction from baseline: 6.9 ± 2.4 to 2.7 ± 2.5 (p < 0.0001). Overall, 75% patients achieved the MCIC of ≥ 2.2 points reduction in COMI and 88% reported a good global outcome. 91% patients were satisfied/very satisfied with their care. Self-reported complications were declared by 16% patients and further surgery at the same segment, by 2.5%. CONCLUSION In this large series with almost complete follow-up, C1-C2 fusion showed extremely good results. Despite the complexity of the intervention, outcomes surpassed those typically reported for simple procedures such as ACDF and lumbar discectomy, suggesting reservations about the procedure should perhaps be reviewed.
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Affiliation(s)
- F S Kleinstück
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - T F Fekete
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland.
| | - M Loibl
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - D Jeszenszky
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - D Haschtmann
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - F Porchet
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - A F Mannion
- Spine Center Division, Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
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9
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Ghaith AK, Yolcu YU, Alvi MA, Bhandarkar AR, Sebastian AS, Freedman BA, Bydon M. Rate and Characteristics of Vertebral Artery Injury Following C1-C2 Posterior Cervical Fusion: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 148:118-126. [PMID: 33516865 DOI: 10.1016/j.wneu.2020.12.165] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intraoperative vascular injuries in the cervical spine are rare, but carry significant morbidity and mortality when they do occur. There is a need to better characterize the risk of vertebral artery injury (VAI) after posterior C1-C2 fusion. The aim of this study was to investigate the rate of VAI in patients undergoing posterior C1-C2 cervical fusion. METHODS An electronic database search was performed to identify studies that reported rates of VAI following posterior cervical fusion at C1-C2 level. Patient-specific risk factors, surgical indication, surgical technique, and other data were collected for each study. Forest plots were created to outline the pooled ratios of VAI in the literature. RESULTS Eleven studies with 773 patients were identified. Mean age of patients was 48.47 years (range, 6-78 years), and most patients were female (61.7%, n = 399). Trauma was the most frequent indication for surgery (18.8%, n = 146), followed by inflammatory processes affecting the vertebrae (13.2%, n = 102). The rate of VAI per patient was 2% (95% confidence interval = 1%-4%) among 773 patients, while injury rate per screw was 1% (95% confidence interval = 0%-2%) among 2238 screws placed. CONCLUSIONS The rate of VAI after C1-C2 posterior cervical fusion was found to be 2% for each operated patient and 1% for each screw placed.
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Affiliation(s)
- Abdul Karim Ghaith
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Yagiz U Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Archis R Bhandarkar
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arjun S Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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