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Muacevic A, Adler JR, Hoffmann JC, Ratusznik JJ, Lambert B, Marco R. Freehand Pre-drilling Technique for Lateral Mass Screw Fixation Is More Efficient and Reliable Versus Sequential Drilling Technique: A Sawbone Analysis. Cureus 2022; 14:e33015. [PMID: 36582419 PMCID: PMC9794439 DOI: 10.7759/cureus.33015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2022] [Indexed: 12/29/2022] Open
Abstract
Background Since posterior cervical fixation with lateral mass screws was introduced in 1979, multiple techniques have been described in the literature. However, no study to date has determined whether pre-drilling all lateral masses prior to screw insertion has a benefit over the traditional sequential drilling and screw insertion on the alignment of the screw-rod construct. This study sought to determine the efficacy and efficiency in achieving alignment with a novel pre-drilling technique compared to the traditional sequential drilling technique. The authors hypothesized that the novel pre-drilling technique could be applied more quickly and precisely than the traditional sequential drilling technique. Methods Eight cervical spine sawbones models were utilized to place 64 lateral mass screws by two surgeons. The pre-drilling technique was utilized to place 32 screws in four models, and the sequential drilling technique was utilized to place the 32 screws in the remaining four models. In the traditional sequential drilling technique, each lateral mass underwent screw tract preparation and insertion before proceeding to the subsequent vertebra. In the pre-drilling technique, all lateral masses were marked and drilled sequentially before screw placement. CT imaging with 3D reconstructions was generated for all models. Variability in screw placement and time taken to fully instrument the models were compared. Results The mean time to completion of the pre-drilling technique was 337 ± 22 seconds compared to 490 ± 22 seconds with the traditional technique (p<0.01). There was a significantly higher variability in the coronal plane within the traditional group between C5 and C6 compared to other adjacent vertebrae (p<0.05). There was no significant difference in the start point variability and the overall tightness of line fit between the techniques. Conclusions Our study suggests that a novel pre-drilling technique for lateral mass screw insertion may be more efficient and reliable than the traditional sequential drilling technique. In addition, this technique may reduce the need for rod contouring or additional implants to optimize the alignment of cervical instrumentation. However, further clinical studies are necessary to validate the potential clinical and radiologic benefits of this described technique.
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Inoue D, Shigematsu H, Matsumori H, Ueda Y, Tanaka Y. Accuracy of Lateral Mass Screw Insertion during Cervical Spine Surgery without Fluoroscopic Guidance and Comparison of Postoperative Screw Loosening Rate among Unicortical and Bicortical Screws Using Computed Tomography. Spine Surg Relat Res 2022; 6:625-630. [PMID: 36561156 PMCID: PMC9747216 DOI: 10.22603/ssrr.2022-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/14/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Pedicle screws (PSs) or lateral mass screws (LMSs) are used in posterior cervical spine fixation. The former are more firmly fixed but are associated with the risk of neurovascular injury and should be inserted using intraoperative imaging or navigation, which may prolong the surgical duration and is not feasible in all hospitals. This prospective clinical study aimed to evaluate the outcomes of LMS insertions without fluoroscopic guidance and screw loosening rates at 6 months postoperatively using computed tomography (CT). Methods We examined 38 patients who underwent posterior cervical spine fusion using 206 LMSs in the C3-C6 range between January 2018 and July 2021. The direction of screw insertion followed the Magerl method, and we inserted screws as bicortically as possible without intraoperative imaging. The screw position was examined using CT at 1 week postoperatively. Screw insertion angles, bicortical insertion rate, facet violation, and neurovascular injury were evaluated. Screw loosening with unicortical and bicortical screws (US and BS, respectively) was investigated using CT at 6 months postoperatively. Results The average LMS length was 14.1 mm. The average axial and sagittal angles were 33.9° and 29.2°, respectively. Among the 206 LMSs inserted, 167 were BS; of these, 94.6% had screw length protrusion of 0-2 mm. Facet violation was observed in 3.4% of all screws but without neurovascular injury. Six months postoperatively, loosening of 25 screws (12.1%) occurred, including 17 (18.3%) USs and 8 (8.39%) BSs. The screw loosening rate was significantly higher in US than for BS (43.6% [17/39] vs. 4.8% [8/167], P<0.01). Conclusions Over 80% of LMSs were inserted bicortically without intraoperative imaging. By devising the screw length selection process, we inserted for screw loosening was more common in US and more likely at the fixed end.
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Affiliation(s)
- Daisuke Inoue
- Department of Orthopedic Surgery, Kashiba Asahigaoka Hospital, Kashiba, Japan
| | - Hideki Shigematsu
- Department of Orthopedic Surgery, Nara Medical University Hospital, Kashihara, Japan
| | - Hiroaki Matsumori
- Department of Orthopedic Surgery, Kashiba Asahigaoka Hospital, Kashiba, Japan
| | - Yurito Ueda
- Department of Orthopedic Surgery, Kashiba Asahigaoka Hospital, Kashiba, Japan
| | - Yasuhito Tanaka
- Department of Orthopedic Surgery, Nara Medical University Hospital, Kashihara, Japan
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Matsumoto H, Shimokawa N, Sato H, Takami T. Simple Technique to Place the Lateral Mass Screws in the Revision Surgery after Cervical Laminoplasty for Ossification of the Posterior Longitudinal Ligament. Neurol Med Chir (Tokyo) 2021; 61:667-673. [PMID: 34483199 PMCID: PMC8592811 DOI: 10.2176/nmc.tn.2021-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A lateral mass screw (LMS) is one of the standard anchor screws in posterior cervical fixation. Although the advantage of cervical LMS is that it is easier and safer to place than pedicle screw, it is sometimes difficult for surgeons to confirm the exact point for screw entry and accurate angle in cases of revision surgery. When LMS fixation is performed as revision surgery after cervical laminoplasty or laminectomy, it might be complicated to secure safe placement of the LMSs. We present a simple but practical technique involving a caliper and angle device for revision surgery after cervical laminoplasty for ossification of the posterior longitudinal ligament. In this technique, the distance between the bilateral entry points is ascertained using preoperative CT. Insertion of the screw is guided using the angle device set to 25 degrees. The technique presented here is easy and allows accurate placement of the LMSs in the posterior cervical spine, and is practical even for revision surgery.
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Affiliation(s)
- Hiroaki Matsumoto
- Department of Neurosurgery, Cerebrovascular Research Institute, Yoshida Hospital
| | | | | | - Toshihiro Takami
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University
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C2 pars/pedicle screws in management of craniocervical and upper cervical instability. Asian Spine J 2014; 8:156-60. [PMID: 24761197 PMCID: PMC3996339 DOI: 10.4184/asj.2014.8.2.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 06/11/2013] [Accepted: 07/08/2013] [Indexed: 11/08/2022] Open
Abstract
Study Design A retrospective study. Purpose To evaluate the efficacy and the safety of craniocervical and upper cervical stabilization by using C2 pars/pedicle screw fixations. Overview of Literature The management of craniocervical and upper cervical instability has progressed over the past two decades due to good achievements in the instrumentation and the increased awareness on spinal anatomy and biomechanics. However, there is insufficient studies or solid conclusions on this topic, thus, we tried to investigate and present our findings. Methods Twenty-two patients were operated upon and were followed up from March 2008 to October 2010. One patient had craniocervical instability (post-surgical), 15 patients had atlantoaxial instability of different etiologies (trauma, tumors, inflammatory and degenerative) and 6 patients had hangman fractures. Patients' ages ranged from 18 to 52 years old. with 5 female patients and 17 male patients. Results Radiological follow ups performed immediately post-operation showed good screw positioning and complete reductions in nearly all the cases. All patients were followed up for more than one year. Sound fusions were observed among all patients. Conclusions The use of pars/pedicle screws is a very effective, sound, safe and easy surgical modality for treating craniocervical, atlantoaxial and upper cervical instabilities. Increasing studies for the biomechanics of this important region and longer periods of follow-ups are necessary to document the usefulness of this modality when treating such patients.
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Hu Y, Kepler CK, Albert TJ, Yuan ZS, Ma WH, Gu YJ, Xu RM. Accuracy and complications associated with the freehand C-1 lateral mass screw fixation technique: a radiographic and clinical assessment. J Neurosurg Spine 2013; 18:372-7. [PMID: 23373564 DOI: 10.3171/2013.1.spine12724] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aims of this study were to evaluate a large series of posterior C-1 lateral mass screws (LMSs) to determine accuracy based on CT scanning findings and to assess the perioperative complication rate related to errant screw placement.
Methods
Accuracy of screw placement was evaluated using postoperative CT scans obtained in 196 patients with atlantoaxial instability. Radiographic analysis included measurement of preoperative and postoperative CT scans to evaluate relevant anatomy and classify accuracy of instrumentation placement. Screws were graded using the following definitions: Type I, screw threads completely within the bone (ideal); Type II, less than half the diameter of the screw violates the surrounding cortex (safe); and Type III, clear violation of transverse foramen or spinal canal (unacceptable).
Results
A total of 390 C-1 LMSs were placed, but 32 screws (8.2%) were excluded from accuracy measurements because of a lack of postoperative CT scans; patients in these cases were still included in the assessment of potential clinical complications based on clinical records. Of the 358 evaluable screws with postoperative CT scanning, 85.5% of screws (Type I) were rated as being in the ideal position, 11.7% of screws (Type II) were rated as occupying a safe position, and 10 screws (2.8%) were unacceptable (Type III). Overall, 97.2% of screws were rated Type I or II. Of the 10 screws that were unacceptable on postoperative CT scans, there were no known associated neurological or vertebral artery (VA) injuries. Seven unacceptable screws erred medially into the spinal canal, and 2 patients underwent revision surgery for medial screws. In 2 patients, unilateral C-1 LMSs penetrated the C-1 anterior cortex by approximately 4 mm. Neither patient with anterior C-1 penetration had evidence of internal carotid artery or hypoglossal nerve injury. Computed tomography scanning showed partial entry of C-1 LMSs into the VA foramen of C-1 in 10 cases; no occlusion, associated aneurysm, or fistula of the VA was found. Two patients complained of postoperative occipital neuralgia. This was transient in one patient and resolved by 2 months after surgery. The second patient developed persistent neuralgia, which remained 2 years after surgery, necessitating referral to the pain service.
Conclusions
The technique for freehand C-1 LMS fixation appears to be safe and effective without intraoperative fluoroscopy guidance. Preoperative planning and determination of the ideal screw insertion point, the ideal trajectory, and screw length are the most important considerations. In addition, fewer malpositioned screws were inserted as the study progressed, suggesting a learning curve to the technique.
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Affiliation(s)
- Yong Hu
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
| | - Christopher K. Kepler
- 2Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, Pennsylvania
| | - Todd J. Albert
- 2Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, Pennsylvania
| | - Zhen-shan Yuan
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
| | - Wei-hu Ma
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
| | - Yong-jie Gu
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
| | - Rong-ming Xu
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
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Al-Shamy G, Cherian J, Mata JA, Patel AJ, Hwang SW, Jea A. Computed tomography morphometric analysis for lateral mass screw placement in the pediatric subaxial cervical spine. J Neurosurg Spine 2012; 17:390-6. [DOI: 10.3171/2012.8.spine12767] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Lateral mass screws are routinely placed throughout the subaxial cervical spine in adults, but there are few clinical or radiographic studies regarding lateral mass fixation in children. The morphology of pediatric cervical lateral masses may be associated with greater difficulty in obtaining adequate purchase. The authors examined the lateral masses of the subaxial cervical spine in pediatric patients to define morphometric differences compared with adults, establish guidelines for lateral mass instrumentation in children, and define potential limitations of this technique in the pediatric age group.
Methods
Morphometric analysis was performed on CT of the lateral masses of C3–7 in 56 boys and 14 girls. Measurements were obtained in the axial, coronal, and sagittal planes.
Results
For most levels and measurements, results in boys and girls did not differ significantly; the few values that were significantly different are not likely to be clinically significant. On the other hand, younger (< 8 years of age) and older children (≥ 8 years of age) differed significantly at every level and measurement except for facet angularity. Sagittal diagonal, a measurement that closely estimates screw length, was found to increase at each successive caudal level from C-3 to C-7, similar to the adult population. A screw acceptance analysis found that all patients ≥ 4 years of age could accept at least a 3.5 × 10 mm lateral mass screw.
Conclusions
Lateral mass screw fixation is feasible in the pediatric cervical spine, particularly in children age 4 years old or older. Lateral mass screw fixation is feasible even at the C-7 level, where pedicle screw placement has been advised in lieu of lateral mass screws because of the small size and steep trajectory of the C-7 lateral mass. Nonetheless, all pediatric patients should undergo high-resolution, thin-slice CT preoperatively to assess suitability for lateral mass screw fixation.
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Affiliation(s)
- George Al-Shamy
- 1Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas and
| | - Jacob Cherian
- 1Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas and
| | - Javier A. Mata
- 1Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas and
| | - Akash J. Patel
- 1Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas and
| | - Steven W. Hwang
- 2Division of Pediatric Neurosurgery, Floating Children's Hospital, Department of Neurosurgery, Tufts University, Boston, Massachusetts
| | - Andrew Jea
- 1Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas and
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7
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Arnold PM. Editorial: Lateral mass screws. J Neurosurg Spine 2012; 17:388-9; author respnse 388-9. [PMID: 22978437 DOI: 10.3171/2012.8.spine12768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Shaw MN, Morel EP, Utter PA, Gussous YM, Ginoux L, Berglund LJ, Gay RE, Krauss WE. Transverse connectors providing increased stability to the cervical spine rod-screw construct: an in vitro human cadaveric study. J Neurosurg Spine 2011; 14:719-25. [DOI: 10.3171/2011.1.spine10411] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The object of this study was to determine if the addition of transverse connectors (TCs) to a rod-screw construct leads to increased stabilization of the cervical spine.
Methods
Eleven human cadaveric cervical spines (C2–T1) were used to examine the effect of adding connectors to a C3–7 rod-screw construct in 3 models of instability: 1) C3–6 wide laminectomy, 2) wide laminectomy and 50% foraminotomy at C4–5 and C5–6, and 3) wide laminectomy with full medial to lateral foraminotomy. Following each destabilization procedure, specimens were tested with no TC, 1 TC between the C-5 screws, and 2 TCs between the C-4 and C-6 screws. Testing of the connectors was conducted in random order. Specimens were subjected to ± 2 Nm of torque in flexion and extension, lateral bending, and axial rotation. Range of motion was determined for each experimental condition. Statistical comparisons were made between the destabilized and intact conditions, and between the addition of TCs and the absence of TCs.
Results
The progressive destabilization procedures significantly increased motion. The addition of TCs did not significantly change motion in flexion and extension. Lateral bending was significantly decreased with 2 connectors, but not with 1 connector. The greatest effect was on axial rotation. In general, 2 TCs were more restrictive than 1 TC, and decreased motion 10% more than fixation alone.
Conclusions
Regardless of the degree of cervical destabilization, 1 or 2 TCs decreased motion compared with rods and screws alone. Axial rotation was most affected. Transverse connectors effectively increase the rigidity of rod-screw constructs in the cervical spine. Severe cervical instability can be overcome with the use of 2 TCs, but in cases in which 2 cannot be used, 1 should be adequate and superior to none.
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Affiliation(s)
| | | | | | | | | | | | - Ralph E. Gay
- 1Biomechanics Laboratory, and
- 3Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
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9
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Abdullah KG, Nowacki AS, Steinmetz MP, Wang JC, Mroz TE. Factors affecting lateral mass screw placement at C-7. J Neurosurg Spine 2011; 14:405-11. [PMID: 21235304 DOI: 10.3171/2010.11.spine09776] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The C-7 lateral mass has been considered difficult to fit with instrumentation because of its unique anatomy. Of the methods that exist for placing lateral mass screws, none particularly accommodates this anatomical variation. The authors have related 12 distinct morphological measures of the C-7 lateral mass to the ability to place a lateral mass screw using the Magerl, Roy-Camille, and a modified Roy-Camille method.
Methods
Using CT scans, the authors performed virtual screw placement of lateral mass screws at the C-7 level in 25 male and 25 female patients. Complications recorded included foraminal and articular process violations, inability to achieve bony purchase, and inability to place a screw longer than 6 mm. Violations were monitored in the coronal, axial, and sagittal planes. The Roy-Camille technique was applied starting directly in the middle of the lateral mass, as defined by Pait's quadrants, with an axial angle of 15° lateral and a sagittal angle of 90°. The Magerl technique was performed by starting in the inferior portion of the top right square of Pait's quadrants and angling 25° laterally in the axial plane with a 45° cephalad angle in the sagittal plane. In a modified method, the starting point is similar to the Magerl technique in the top right square of Pait's quadrant and then angling 15° laterally in the axial plane. In the sagittal plane, a 90° angle is taken perpendicular to the dorsal portion of the lateral mass, as in the traditional Roy-Camille technique.
Results
Of all the morphological methods analyzed, only a combined measure of intrusion of the T-1 facet and the overall length of the C-7 lateral mass was statistically associated with screw placement, and only in the Roy-Camille technique. Use of the Magerl technique allowed screw placement in 28 patients; use of the Roy-Camille technique allowed placement in 24 patients; and use of the modified technique allowed placement in 46 patients. No screw placement by any method was possible in 4 patients.
Conclusions
There is only one distinct anatomical ratio that was shown to affect lateral mass screw placement at C-7. This ratio incorporates the overall length of the lateral mass and the amount of space occupied by the T-1 facet at C-7. Based on this virtual study, a modified Roy-Camille technique that utilizes a higher starting point may decrease the complication rate at C-7 by avoiding placement of the lateral mass screw into the T1 facet.
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Affiliation(s)
- Kalil G Abdullah
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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11
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Ahn H, Fehlings MG. Prevention, identification, and treatment of perioperative spinal cord injury. Neurosurg Focus 2009; 25:E15. [PMID: 18980475 DOI: 10.3171/foc.2008.25.11.e15] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this report, the authors suggest evidence-based approaches to minimize the chance of perioperative spinal cord injury (POSCI) and optimize outcome in the event of a POSCI. METHODS A systematic review of the basic science and clinical literature is presented. RESULTS Authors of clinical studies have assessed intraoperative monitoring to minimize the chance of POSCI. Furthermore, preoperative factors and intraoperative issues that place patients at increased risk of POSCI have been identified, including developmental stenosis, ankylosing spondylitis, preexisting myelopathy, and severe deformity with spinal cord compromise. However, no studies have assessed methods to optimize outcomes specifically after POSCIs. There are a number of studies focussed on the pathophysiology of SCI and the minimization of secondary damage. These basic science and clinical studies are reviewed, and treatment options outlined in this article. CONCLUSIONS There are a number of treatment options, including maintenance of mean arterial blood pressure > 80 mm Hg, starting methylprednisolone treatment preoperatively, and multimodality monitoring to help prevent POSCI occurrence, minimize secondary damage, and potentially improve the clinical outcome of after a POSCI. Further prospective cohort studies are needed to delineate incidence rate, current practice patterns for preventing injury and minimizing the clinical consequences of POSCI, factors that may increase the risk of POSCI, and determinants of clinical outcome in the event of a POSCI.
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Affiliation(s)
- Henry Ahn
- Division of Orthopaedic Surgery, University of Toronto Spine Program, Toronto, Canada
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Jea A, Johnson KK, Whitehead WE, Luerssen TG. Translaminar screw fixation in the subaxial pediatric cervical spine. J Neurosurg Pediatr 2008; 2:386-90. [PMID: 19035682 DOI: 10.3171/ped.2008.2.12.386] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The use of spinal instrumentation to stabilize the occipitocervical junction in pediatric patients has increased and evolved in recent years. Wiring techniques have now given way to screw-rod or screw-plate techniques with or without postoperative external immobilization. Although C-2 translaminar screws have been used in these constructs, subaxial translaminar screws have not, to date, been described in either the pediatric or adult patient populations. The authors describe the feasibility of translaminar screw placement in the C-3 lamina. Rigid fixation with translaminar screws offers an alternative to subaxial fixation with lateral mass screws, allowing for formation of biomechanically sound spinal constructs and minimizing potential neurovascular morbidity. Their use requires careful analysis of preoperative imaging studies, intact posterior elements, and avoidance of violation of the inner laminar wall.
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Affiliation(s)
- Andrew Jea
- Pediatric Neuro-Spine Program, Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.
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Sciubba DM, Chaichana KL, Woodworth GF, McGirt MJ, Gokaslan ZL, Jallo GI. Factors associated with cervical instability requiring fusion after cervical laminectomy for intradural tumor resection. J Neurosurg Spine 2008; 8:413-9. [PMID: 18447686 DOI: 10.3171/spi/2008/8/5/413] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The indications remain unclear for fusion at the time of cervical laminectomy for intradural tumor resection. To identify patients who may benefit from initial fusion, the authors assessed clinical, radiological/imaging, and operative factors associated with subsequent symptomatic cervical instability requiring fusion after cervical laminectomy for intradural tumor resection.
Methods
The authors reviewed 10 years of data obtained in patients who underwent cervical laminectomy without fusion for intradural tumor resection and who had normal spinal stability and alignment preoperatively. The association of pre- and intraoperative variables with the subsequent need for fusion for progressive symptomatic cervical instability was assessed using logistic regression analysis, and percentages were compared using Fisher exact tests when appropriate.
Results
Thirty-two patients (mean age 41 ± 17 years) underwent cervical laminectomy without fusion for resection of an intradural tumor (18 intramedullary and 14 extramedullary). Each increasing number of laminectomies performed was associated with a 3.1-fold increase in the likelihood of subsequent vertebral instability (odds ratio 3.114, 95% confidence interval 1.207–8.034, p = 0.02). At a mean follow-up interval of 25.2 months, 33% (4 of 12) of the patients who had undergone a ≥ 3-level laminectomy required subsequent fusion compared with 5% (1 of 20) who had undergone a ≤ 2-level laminectomy (p = 0.03). Four (36%) of 11 patients initially presenting with myelopathic motor disturbance required subsequent fusion compared with 1 (5%) of 21 presenting initially with myelopathic sensory or radicular symptoms (p = 0.02). Age, the presence of a syrinx, intramedullary tumor, C-2 laminectomy, C-7 laminectomy, and laminoplasty were not associated with subsequent symptomatic instability requiring fusion.
Conclusions
In the authors' experience with intradural cervical tumor resection, patients presenting with myelopathic motor symptoms or those undergoing a ≥ 3-level cervical laminectomy had an increased likelihood of developing subsequent symptomatic instability requiring fusion. A ≥ 3-level laminectomy with myelopathic motor symptoms may herald patients most likely to benefit from cervical fusion at the time of tumor resection.
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Bilsky MH, Boakye M, Collignon F, Kraus D, Boland P. Operative management of metastatic and malignant primary subaxial cervical tumors. J Neurosurg Spine 2005; 2:256-64. [PMID: 15796349 DOI: 10.3171/spi.2005.2.3.0256] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The authors describe the preoperative assessment, intraoperative strategies, and long-term outcomes in 41 consecutive patients who underwent spinal reconstruction after resection of subaxial cervical neoplasms.
Methods. Thirty-three tumors were metastatic and eight were primary. Preoperative studies included direct laryngoscopy and vertebral artery (VA) balloon occlusion tests in selected patients. Based on the tumor location, approaches included 12 anterior, 13 posterior, and 16 combined. All patients underwent aggressive intralesional resection and spinal reconstruction. In 12 patients, the VA was dissected from the periphery of the tumor, two cases of which required ligation. Fibula allograft and an anterior rigid plate fixation were most commonly used for anterior reconstruction. Posterior reconstruction was initially performed using lateral mass plates (LMPs) in 13 patients and screw/rod systems in the remaining patients.
At follow up, pain level improved to mild or was absent in 39 patients (95%) who had presented with moderate or severe pain. The American Spinal Injury Association (ASIA) Scale scores were stable in 25 patients who presented with ASIA Score E and improved in 14 patients (88%) who presented with ASIA Score B, C, or D. Functional radiculopathy significantly improved in 16 (94%) of 17 patients.
Complications occurred in 10 patients (24%) and included three fixation failures requiring revision. Two fixation failures involved cervical LMP screw pullout. The overall mean survival duration was 8.6 months for patients with metastatic tumors and 33.4 months for primary tumors.
Conclusions. Surgery for the treatment of subaxial spine neoplasms is effective for relieving pain, encouraging functional nerve root recovery, and preserving spinal cord function with acceptable complication rates.
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Affiliation(s)
- Mark H Bilsky
- Neurosurgery, Head and Neck, and Orthopedic Services, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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