1
|
Wan M, Zong R, Tong HY, Zhang ZZ, Zhao B, Yu XG. A morphometric study of the atlanto-occipital joint in adult patients with Chiari malformation type I. Br J Neurosurg 2024; 38:12-15. [PMID: 32969751 DOI: 10.1080/02688697.2020.1823940] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are many morphometric studies on Chiari malformation type I (CMI) patients, most of which focus on the posterior cranial fossa (PCF). Less attention has been paid to the atlanto-occipital joint. In this study, we aim to evaluate the morphological characteristics of the atlanto-occipital joint in CMI patients. MATERIALS AND METHODS The cervical CT imaging data of adult patients diagnosed with CMI but without any bony malformation in craniovertebral junction (CVJ) who were treated by the authors between January 2014 and December 2019 were retrospectively analyzed. The equal number of sex and age-matched healthy individuals were included as the control group. The morphometric analysis was performed by measuring the length and depth of the atlanto-occipital joint, and the depth/length ratio was calculated to evaluate the curvature of the joint. RESULTS A total of 47 patients (15 males and 32 females) were included. The mean age of patients was 47.49 ± 9.01 years (range 19-62 years). The mean depth/length ratio of the atlanto-occipital joint in CMI patients was 0.141 ± 0.065 (range 0.027 - 0.274), which was smaller than that of control individuals (0.228 ± 0.057, range 0.069 - 0.379). And the difference was statistically significant (p < .01). CONCLUSIONS The atlanto-occipital joints in CMI patients are significantly flatter compared with those in healthy controls. This morphological variation could lead to differences of the atlanto-occipital stability between CMI patients and normal population, which may be related to the pathogenesis of CMI.
Collapse
Affiliation(s)
- Ming Wan
- Department of Neurosurgery, Medical School of Chinese PLA, Beijing, PR China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Rui Zong
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Huai-Yu Tong
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Zhi-Zhong Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Bo Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Xin-Guang Yu
- Department of Neurosurgery, Medical School of Chinese PLA, Beijing, PR China
| |
Collapse
|
2
|
Mao G, Kopparapu S, Jin Y, Davidar AD, Hersh AM, Weber-Levine C, Theodore N. Craniocervical instability in patients with Ehlers-Danlos syndrome: controversies in diagnosis and management. Spine J 2022; 22:1944-1952. [PMID: 36028216 DOI: 10.1016/j.spinee.2022.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population.
Collapse
Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Srujan Kopparapu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Yike Jin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.
| |
Collapse
|
3
|
DeNunzio G, Evans T, Beebe ME, Browning J, Koivisto J. Craniocervical Junction Visualization and Radiation Dose Consideration Utilizing Cone Beam Computed Tomography for Upper Cervical Chiropractic Clinical Application a Literature Review. Dose Response 2022; 20:15593258221107515. [PMID: 35719850 PMCID: PMC9201332 DOI: 10.1177/15593258221107515] [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: 11/16/2022]
Abstract
Objectives To highlight the detail obtained on a Cone Beam Computed Tomography (CBCT) scan of the craniocervical junction and its usefulness to Chiropractors who specialize in the upper cervical spine. A review of the dose considerations to patients vs radiography in a chiropractic clinical setting and to review the effective radiation dose to the patient. Methods A review of studies discussing cervical biomechanics, neurovascular structures, and abnormal radiographic findings, was discussed in relation to chiropractic clinical relevance. Further studies were evaluated demonstrating radiation dose to the patient from radiographs compared to CBCT. Results Incidental and abnormal findings of the craniocervical junction were shown to have superior visualization with CBCT compared to radiography. The radiation dose to the patient for similar imaging protocols to the craniocervical junction and cervical spine was equal or less utilizing CBCT when compared to radiographs. Conclusions The use of CBCT for visualization of the craniocervical junction and cervical spine in the chiropractic clinical setting allows for adjunctive visualization of the osseous structures which is germane to clinical protocol. Further with CBCT the effective dose to the patient is equal or less than similar imaging protocols utilizing radiographs to evaluate the craniocervical junction.
Collapse
Affiliation(s)
- Greg DeNunzio
- Sweere Center for Clinical Biomechanics and Applied Ergonomics, Northwestern Health Sciences University, Bloomington, MI, USA
| | - Tyler Evans
- Private Practice, Arete Chiropractic, Portsmouth, NH, USA
| | - Mychal E Beebe
- Private Practice, Arete Chiropractic, Portsmouth, NH, USA
| | | | | |
Collapse
|
4
|
Mugutso D, Warnecke C, Bolognese P, Avshalumov MV. Electromyographic assessment of condylar screw placement during occipitocervical fusion. J Neurosurg Spine 2022; 36:315-324. [PMID: 34560655 DOI: 10.3171/2021.3.spine201793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This is a retrospective study of a series of occipitocervical fusion procedures with condylar screw fixation in which the authors investigated the utility of electromyography (EMG, free-running and triggered) as a reliable tool in assessing the positioning of condylar screws. This series consisted of 197 patients between 15 and 60 years of age who presented with craniocervical instability, and who were treated between October 2014 and December 2017. METHODS Intraoperative free-running EMG was observed at the placement of condylar screws, as well as at realigning of the spine. After placement the condylar screws were stimulated electrically, and the thresholds were recorded. CT scans were obtained intraoperatively soon after screw stimulation, and the results were analyzed by the surgeon in real time. Free-running EMG results and triggered EMG thresholds were tabulated, and the minimum acceptable threshold was established. RESULTS Intraoperative free-running EMG and triggered EMG were able to correlate alerts with condylar screw placement accurately. A triggered EMG threshold of 2.7 mA was found to be a minimum acceptable threshold. A combination criterion of free-running EMG and triggered EMG alerts was found to enable accurate assessment of condylar screw positioning and placement. CONCLUSIONS Intraoperative free-running EMG and triggered EMG were both found to be invaluable utilities in assessing the placement and positioning of condylar screws. Stimulation thresholds below 2.7 mA correlated with a superior or anterior condylar breach. Thresholds in the 2.7-mA to 9.0-mA range were generally acceptable but warranted additional inspection by the surgeon. Threshold values above 9.0 mA corresponded with solid condylar screw placement.
Collapse
Affiliation(s)
- Denmark Mugutso
- 1Neurological Surgery Professional Corporation, Rockville Centre; and
| | - Charles Warnecke
- 1Neurological Surgery Professional Corporation, Rockville Centre; and
| | - Paolo Bolognese
- 1Neurological Surgery Professional Corporation, Rockville Centre; and
- 2Chiari Neurosurgical Center, Mount Sinai South Nassau Hospital, Oceanside, New York
| | | |
Collapse
|
5
|
Kikuta S, Iwanaga J, Ishak B, Dumont AS, Tubbs RS. A Comprehensive Review of the Superficial Anterior Atlanto-Occipital Ligament of the Craniocervical Junction. Kurume Med J 2022; 67:1-4. [PMID: 35095017 DOI: 10.2739/kurumemedj.ms671005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This paper aimed to better describe the anatomy of the superficial anterior atlanto-occipital ligament of the craniocervical junction and discuss this ligament's potential function and clinical implications. A broad literature review on the anatomical features and findings of the superficial anterior atlanto-occipital ligament was performed. The superficial anterior atlanto-occipital ligament is located anterior to the anterior atlanto-occipital membrane. However, the physiological role of the superficial anterior atlanto-occipital ligament is still unclear due to a lack of anatomical and biomechanical studies although one study has suggested that this ligament is a secondary stabilizer of the craniocervical junction. Further studies are needed to clarify the function and anatomy of the superficial anterior atlanto-occipital ligament.
Collapse
Affiliation(s)
- Shogo Kikuta
- Dental and Oral Medical Center, Kurume University School of Medicine
| | - Joe Iwanaga
- Dental and Oral Medical Center, Kurume University School of Medicine.,Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine.,Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System.,Department of Structural & Cellular Biology, Tulane University School of Medicine.,Department of Anatomical Sciences, St. George's University
| |
Collapse
|
6
|
Henderson FC, Rosenbaum R, Narayanan M, Koby M, Tuchman K, Rowe PC, Francomano C. Atlanto-axial rotary instability (Fielding type 1): characteristic clinical and radiological findings, and treatment outcomes following alignment, fusion, and stabilization. Neurosurg Rev 2021; 44:1553-1568. [PMID: 32623537 PMCID: PMC8121728 DOI: 10.1007/s10143-020-01345-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/22/2020] [Accepted: 06/26/2020] [Indexed: 02/05/2023]
Abstract
Atlanto-axial instability (AAI) is common in the connective tissue disorders, such as rheumatoid arthritis, and increasingly recognized in the heritable disorders of Stickler, Loeys-Dietz, Marfan, Morquio, and Ehlers-Danlos (EDS) syndromes, where it typically presents as a rotary subluxation due to incompetence of the alar ligament. This retrospective, IRB-approved study examines 20 subjects with Fielding type 1 rotary subluxation, characterized by anterior subluxation of the facet on one side, with a normal atlanto-dental interval. Subjects diagnosed with a heritable connective tissue disorder, and AAI had failed non-operative treatment and presented with severe headache, neck pain, and characteristic neurological findings. Subjects underwent a modified Goel-Harms posterior C1-C2 screw fixation and fusion without complication. At 15 months, two subjects underwent reoperation following a fall (one) and occipito-atlantal instability (one). Patients reported improvement in the frequency or severity of neck pain (P < 0.001), numbness in the hands and lower extremities (P = 0.001), headaches, pre-syncope, and lightheadedness (all P < 0.01), vertigo and arm weakness (both P = 0.01), and syncope, nausea, joint pain, and exercise tolerance (all P < 0.05). The diagnosis of Fielding type 1 AAI requires directed investigation with dynamic imaging. Alignment and stabilization is associated with improvement of pain, syncopal and near-syncopal episodes, sensorimotor function, and exercise tolerance.
Collapse
Affiliation(s)
- Fraser C Henderson
- Department of Neurosurgery, University of Maryland Capital Region Health Prince George's Hospital Center, Cheverly, MD, USA.
- Doctors Community Hospital, Lanham, MD, USA.
- Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA.
| | - Robert Rosenbaum
- Department of Neurosurgery, University of Maryland Capital Region Health Prince George's Hospital Center, Cheverly, MD, USA
- Doctors Community Hospital, Lanham, MD, USA
- Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
- Department of Neurosurgery, Walter Reed-Bethesda National Military Medical Center, Bethesda, MD, USA
| | - Malini Narayanan
- Department of Neurosurgery, University of Maryland Capital Region Health Prince George's Hospital Center, Cheverly, MD, USA
- Doctors Community Hospital, Lanham, MD, USA
- Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
| | - Myles Koby
- Doctors Community Hospital, Lanham, MD, USA
| | - Kelly Tuchman
- Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Clair Francomano
- Medical and Molecular Genetics, Indiana University Health Physicians, Indianapolis, IN, USA
| |
Collapse
|
7
|
Goyal N, Jain A. Morphometry of the inferior articular facet of the atlas. CHRISMED JOURNAL OF HEALTH AND RESEARCH 2021. [DOI: 10.4103/cjhr.cjhr_90_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
8
|
Bellabarba C, Karim F, Tavolaro C, Zhou H, Bremjit P, Nguyen QT, Agel J, Bransford RJ. The mandible-C2 angle: a new radiographic assessment of occipitocervical alignment. Spine J 2021; 21:105-113. [PMID: 32673731 DOI: 10.1016/j.spinee.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/28/2020] [Accepted: 07/08/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Occipitocervical fusion is a rare and often challenging surgical procedure. Significant morbidity can result if care is not taken to achieve physiologic alignment. This is especially true for patients needing occipitocervical fusion in the setting of trauma where preoperative alignment is unknown. PURPOSE To assess the radiographic angles normally subtended between the C2 body and the mandible ramus, in a series of patients with neutral physiologic alignment and no pathology, and to assess its validity as a possible intraoperative radiographic tool to determine a neutral craniocervical alignment. DESIGN Validation and reliability study of radiographic parameters. PATIENT SAMPLE Hundred lateral, neutral, cervical radiographs from patients with "normal" radiographic findings. OUTCOME MEASURES Radiographic parameters of occipital-cervical alignment with assessment of reliability and correlation in data. METHODS One hundred neutral lateral cervical spine radiographs in the upright position of patients with no complaints or known pathology were obtained from two medical clinics between December of 2014 and January of 2017. Three physicians, at different levels of spine surgery training, took measurements of radiographic parameters. The new technique used four different angles measured between the C2-body/dens complex and the mandibular ramus (anterior/posterior C2 body and anterior/posterior mandible lines angles), and compared these with the Occipito-C2 angle, which is a validated assessment of occipitocervical alignment. Statistical analysis was performed to assess correlation in data and measure reproducibility. RESULTS Between the three reviewers, the mean±standard deviation were 18.0°±6.5° for Occipito-C2 angle (O-C2A), -4.2°±5.4° for anterior C2-body/anterior mandible line angle (AB/AM), -4.2°±5.9° for anterior C2-body/posterior mandible line angle (AB/PM), 5.1°±5.8° for posterior C2 body/anterior mandible line angle (PB/AM) and 5.6°±6.2° for posterior C2 body/ posterior mandible line angle (PB/PM). Overall the measurements obtained were correlative with an appropriate range for the standard deviation. Mean intraclass correlation coefficient were 0.889 for O-C2A, 0.795 for AB/AM, 0.859 for AB/PM, 0.876 for PB/AM, and 0.750 for PB/PM, showing high interobserver reliability for all the radiographic measures. Across the five techniques, 87%-92% of measurements fell within 10° of the median, 76%-83% fell within 7.5°, and 55%-66% within 5°. CONCLUSIONS The mandible-C2 angle offers a reproducible alternative to the validated O-C2A technique for determining appropriate intraoperative occipitocervical alignment, which may be especially useful when preoperative radiographic alignment is unknown, such as occurs with trauma patients, with the goal of decreasing alignment-related complications in the setting of occipitocervical stabilization.
Collapse
Affiliation(s)
- Carlo Bellabarba
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Farhan Karim
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Celeste Tavolaro
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Haitao Zhou
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Prashoban Bremjit
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Quynh T Nguyen
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Julie Agel
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Richard J Bransford
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA.
| |
Collapse
|
9
|
Germaneau A, Vendeuvre T, Delmotte A, D'Houtaud S, Brèque C, Petureau L, Doumalin P, Dupré JC, Brémand F, Maxy P, Richer JP, Rigoard P. Should we recommend occipital plate fixation using bicortical screws or inverted occipital hooks to optimize occipito-cervical junction fusion? A biomechanical study combining an experimental and analytical approach. Clin Biomech (Bristol, Avon) 2020; 80:105173. [PMID: 33010700 DOI: 10.1016/j.clinbiomech.2020.105173] [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: 01/14/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Occipito-cervical fusion can be necessary in case of cranio-cervical junction instability. Proximal stabilisation is usually ensured by bi-cortical occipital screws implanted through one median or two lateral occipital plate(s). Bone thickness variability as well as the proximity of vasculo-nervous elements can induce substantial morbidity. The choice of site and implant type remains difficult for surgeons and is often empirically based. Given this challenge, implants with smaller pitch to increase bone interfacing are being developed, as is a surgical technique consisting in inverted occipital hook clamps, a potential alternative to plate/screws association. We present here a biomechanical comparison of the different occipito-cervical fusion devices. METHODS We have developed a 3D mark tracking technique to measure experimental mechanical data on implants and occipital bone. Biomechanical tests were performed to study the mechanical stiffness of the occipito-cervical instrumentation on human skulls. Four occipital implant systems were analysed: lateral plates+large pitch screws, lateral plates+hooks, lateral plates+small pitch screws and median plate+small pitch screws. Mechanical responses were analysed using 3D displacement field measurements from optical methods and compared with an analytical model. FINDINGS Paradoxical mechanical responses were observed among the four types of fixations. Lateral plates+small pitch screws appear to show the best accordance of displacement field between bone/implant/system interface providing higher stiffness and an average maximum moment around 50 N.m before fracture. INTERPRETATION Stability of occipito-cervical fixation depends not only on the site of screws implantation and occipital bone thickness but is also directly influenced by the type of occipital implant.
Collapse
Affiliation(s)
- Arnaud Germaneau
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France; Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France.
| | - Tanguy Vendeuvre
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France; Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France
| | - Alexandre Delmotte
- Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France; Centre du Rachis de la Sauvergarde, 69009 Lyon, France
| | - Samuel D'Houtaud
- Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France; Service de Neurochirurgie Clinique, La Rochelle, France
| | - Cyril Brèque
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France; ABS Lab, Université de Poitiers, France
| | - Louis Petureau
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France
| | - Pascal Doumalin
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France
| | | | - Fabrice Brémand
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France
| | - Philippe Maxy
- Medtronic, Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | | | - Philippe Rigoard
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France; Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France
| |
Collapse
|
10
|
Hartmann S, Thomé C, Abramovic A, Lener S, Schmoelz W, Koller J, Koller H. The Effect of Rod Pattern, Outrigger, and Multiple Screw-Rod Constructs for Surgical Stabilization of the 3-Column Destabilized Cervical Spine - A Biomechanical Analysis and Introduction of a Novel Technique. Neurospine 2020; 17:610-629. [PMID: 33022166 PMCID: PMC7538352 DOI: 10.14245/ns.2040436.218] [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: 07/22/2020] [Accepted: 09/10/2020] [Indexed: 11/19/2022] Open
Abstract
Objective Anterior-only reconstructions for cervical multilevel corpectomies are prone to fail under continuous mechanical loading. This study sought to define the mechanical characteristics of different constructs in reducing a range of motion (ROM) of the 3-column destabilized cervical spine, including posterior cobalt-chromium (CoCr)-rods, outrigger-rods (OGR), and a novel triple rod construct using lamina screws (6S3R). The clinical implications of biomechanical findings are discussed in depth from the perspective of the challenges surgeons face cervical deformity correction.
Methods Three-column deficient cervical spinal models were produced based on reconstructed computed tomography scans. The corpectomy defect between C3 and C7 end-level vertebrae was restored with anterior titanium (Ti) mesh-cage. The ROM was evaluated in a customized 6-degree of freedom spine tester. Tests were performed with different rod materials (Ti vs. CoCr), varying diameter rods (3.5 mm vs. 4.0 mm), with and without anterior plating, and using different construct patterns: bilateral rod fixation (standard-group), OGR-group, and 6S3R-Group. Construct stability was expressed in changes and differences of ROM (°).
Results The largest reduction of ROM was noticed in the 6S3R-group compared to the standard- and the OGR-group. All differences observed were emphasized with an increasing number of corpectomy levels and if anterior plating was not added. For all simulated 1-, 2-, and 3-level corpectomy constructs, the OGR-group revealed decreased ROM for all motion directions compared to the standard-group. An increase of construct stiffness was also recorded for increased rod diameter (4.0 mm) and stiffer rod material (CoCr), though these effects lacked behind the more advanced construct pattern.
Conclusion A novel reconstructive technique, the 6S3R-construct, was shown to outperform all other constructs and might resemble a new standard of reference for advanced posterior fixation.
Collapse
Affiliation(s)
- Sebastian Hartmann
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Anto Abramovic
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sara Lener
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Schmoelz
- Department of Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Juliane Koller
- Department of Orthopedic Surgery, Schoen Clinic Vogtareuth, Vogtareuth, Germany
| | - Heiko Koller
- Department of Neurosurgery, Rechts der Isar, Technische Universität München, Germany
| |
Collapse
|
11
|
Paholpak P, Vega A, Formanek B, Tamai K, Wang JC, Buser Z. Impact of cervical sagittal balance and cervical spine alignment on craniocervical junction motion: an analysis using upright multi-positional MRI. 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 2020; 30:444-453. [PMID: 32770266 DOI: 10.1007/s00586-020-06559-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/13/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the effect of cervical sagittal alignment on craniocervical junction kinematic. METHODS We retrospectively reviewed 359 patients (119 cervical lordosis, 38 cervical sagittal imbalances, 111 cervical straight, and 91 cervical kyphosis) who underwent cervical spine multi-positional magnetic resonance imaging (mMRI). The C2-7 angle, disc degeneration grading and cSVA were analyzed in neutral position. The C3-5 OCI, O-C2 angle, and OCD were analyzed in neutral, flexion, and extension position. The Kruskal-Wallis test was used to detect difference among four groups. The post hoc analysis was performed by Mann-Whitney U test. RESULTS The cervical sagittal imbalance, cervical straight, and cervical kyphosis groups had significantly more lordosis angle in C3 and C4 OCI and O-C2 angle than the cervical lordosis group (p < 0.0125). Head motion in relation to C2, C3, and C4 (O-C2 angle, C3-4 OCI) in the kyphosis group was significantly greater than in the cervical lordosis group (p < 0.0125). The cervical sagittal imbalance group showed significantly increased O-C2 angle than the cervical lordosis group (p = 0.008). Regression analysis showed that an increase in O-C2 angle by one unit had a relative risk of 4.3% and 3.5% for a patient to be in the cervical sagittal imbalance and cervical kyphosis groups, respectively. CONCLUSIONS Cervical sagittal alignment affected craniocervical junction motion with the head exhibiting greater extension and motion in the cervical sagittal imbalance and cervical kyphosis groups. Motion of the head in relation to C2 can be used to predict the cervical sagittal alignment.
Collapse
Affiliation(s)
- Permsak Paholpak
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 Biggy Street, NRT-4513, Los Angeles, CA, 90033, USA.,Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Andrew Vega
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 Biggy Street, NRT-4513, Los Angeles, CA, 90033, USA
| | - Blake Formanek
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 Biggy Street, NRT-4513, Los Angeles, CA, 90033, USA
| | - Koji Tamai
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 Biggy Street, NRT-4513, Los Angeles, CA, 90033, USA
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 Biggy Street, NRT-4513, Los Angeles, CA, 90033, USA
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 Biggy Street, NRT-4513, Los Angeles, CA, 90033, USA.
| |
Collapse
|
12
|
Occipital Condyle Screw Placement in Patients with Chiari Malformation: A Radiographic Feasibility Analysis and Cadaveric Demonstration. World Neurosurg 2020; 136:470-478. [PMID: 32204299 DOI: 10.1016/j.wneu.2020.01.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/15/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Patients who undergo decompression surgery for Chiari malformation frequently require occipitocervical fixation. This is typically performed with occipital plates, which may cause intracranial injuries due to multiple fixation points. We undertook this study to assess the feasibility of occipital condyle (OC) screw placement as an alternative method of occipitocervical fixation in this patient population. METHODS Using a cadaveric model with navigational assistance, we performed the complete surgical procedure for occipitocervical fixation with OC screws. We then performed a morphometric analysis using measurements from computed tomography scans of 49 patients (32 adult, 17 pediatric) who had undergone occipitocervical fusion with instrumentation following decompression surgery for Chiari malformation. Bilateral morphometric data were analyzed for the adult and pediatric subgroups separately, as well as for the overall group. RESULTS The surgical procedure was successfully performed in the cadaveric model, demonstrating the feasibility of the proposed method. Ninety-eight OCs were studied in the morphometric analysis, and 80 (81.6%) met our eligibility criteria for OC screw placement. However, in 14.1% of adult OCs and 26.5% of pediatric OCs studied, placement of condylar screws would have been challenging or unsafe, according to our criteria. CONCLUSIONS Our findings suggest that OC screws provide a useful option for occipitocervical fixation in a substantial proportion of patients with Chiari malformation. However, rigorous preoperative analysis would be essential to identify appropriate candidates for this technique and exclude those in whom it should not be attempted. Additional study is warranted.
Collapse
|
13
|
Wenning KE, Hoffmann MF. Does isolated atlantoaxial fusion result in better clinical outcome compared to occipitocervical fusion? J Orthop Surg Res 2020; 15:8. [PMID: 31918713 PMCID: PMC6953136 DOI: 10.1186/s13018-019-1525-y] [Citation(s) in RCA: 9] [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: 10/12/2019] [Accepted: 12/18/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The C0 to C2 region is the keystone for range of motion in the upper cervical spine. Posterior procedures usually include a fusion of at least one segment. Atlantoaxial fusion (AAF) only inhibits any motion in the C1/C2 segment whereas occipitocervical fusion (OCF) additionally interferes with the C0/C1 segment. The purpose of our study was to investigate clinical outcome of patients that underwent OCF or AAF for upper cervical spine injuries. METHODS Over a 5-year period (2010-2015), consecutive patients with upper cervical spine disorders were retrospectively identified as having been treated with OCF or AAF. The Numeric Pain Rating Scale (NPRS) and the Neck Disability Index (NDI) were used to evaluate postoperative neck pain and health restrictions. Demographics, follow-up, and clinical outcome parameters were evaluated. Infection, hematoma, screw malpositioning, and deaths were used as complication variables. Follow-up was at least 6 months postoperatively. RESULTS Ninety-six patients (male = 42, female = 54) underwent stabilization of the upper cervical spine. OCF was performed in 44 patients (45.8%), and 52 patients (54.2%) were treated with AAF. Patients with OCF were diagnosed with more comorbidities (p = 0.01). Follow-up was shorter in the OCF group compared to the AAF group (6.3 months and 14.3 months; p = 0.01). No differences were found related to infection (OCF 4.5%; AAF 7.7%) and revision rate (OCF 13.6%; AAF 17.3%; p > 0.05). Regarding bother and disability, no differences were discovered utilizing the NDI score (AAF 21.4%; OCF 37.4%; p > 0.05). A reduction of disability measured by the NDI was observed with greater follow-up for all patients (p = 0.01). CONCLUSION Theoretically, AAF provides greater range of motion by preserving the C0/C1 motion segment resulting in less disability. The current study did not show any significant differences regarding clinical outcome measured by the NDI compared to OCF. No differences were found regarding complication and infection rates in both groups. Both techniques provide a stable treatment with comparable clinical outcome.
Collapse
Affiliation(s)
- Katharina E Wenning
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789, Bochum, Germany.
| | - Martin F Hoffmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789, Bochum, Germany
| |
Collapse
|
14
|
Lehrman JN, Narayanan M, Cavallo C, Newcomb AGUS, Zhao X, Kelly BP, Crawford NR, Nakaji P. Evaluation of abnormal styloid anatomy as a cause of internal jugular vein compression using a 3D-printed model: a laboratory investigation. J Clin Neurosci 2019; 72:386-391. [PMID: 31883814 DOI: 10.1016/j.jocn.2019.11.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/30/2019] [Indexed: 11/27/2022]
Abstract
This study used a 3-dimensional (3D) craniocervical junction model of styloidogenic jugular venous compression (SJVC) syndrome to simulate and evaluate intracranial pressure (ICP) after internal jugular vein (IJV) compression by an elongated styloid process during axial rotation. The 3D-printed model created using data from an SJVC-syndrome patient included an articulating occipital-cervical junction, simplified arteriovenous system, gauge to measure simulated ICP, fixed obstruction simulating left-sided venous occlusion, and right-sided vascular tubing to simulate IJV compression. The model was rotated axially to its extreme right and left; maximum degree of motion and pressure were recorded for 3 cycles. Measurements were repeated after styloid resection in 25% increments. The extreme right rotation (11°) of the intact styloid condition yielded a mean pressure of 15.34 ± 2.85 mmHg. After 25% styloid resection, extreme rotation (11°) yielded 13.96 ± 2.88 mmHg. After 50%, extreme rotation increased to 16° yielding 17.41 ± 3.52 mmHg; 11° rotation was 2.76 ± 1.96 mmHg. After 75%, extreme rotation increased to 19° yielding -0.86 ± 1.08 mmHg; 16° and 11° rotation yielded -0.69 ± 1.19 and -0.86 ± 1.08 mmHg, respectively. After 100%, extreme rotation to 19° yielded -1.21 ± 0.60 mmHg; 16° and 11° rotation yielded -0.34 ± 0.30 and 0.00 ± 0.00 mmHg, respectively. Extreme left rotations (11°) yielded mean pressures of -0.17 ± 0.00 (intact), -0.17 ± 0.30 (25%), 2.24 ± 0.79 (50%), 0.34 ± 0.30 (75%), and 0.17 ± 0.30 mmHg (100%). Simulated ICP increased proportionally to maximum ipsilateral axial rotation, and was highest after 50% styloid resection. Contralateral axial rotation did not increase pressure. IJV compression was relieved at 75% resection, suggesting that partial (75%) or complete styloidectomy is a potentially efficacious treatment for SJVC syndrome.
Collapse
Affiliation(s)
- Jennifer N Lehrman
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Mohan Narayanan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Anna G U S Newcomb
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Brian P Kelly
- Spinal Biomechanics Laboratory, Department of Neurosurgery Research, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | | | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States.
| |
Collapse
|
15
|
Henderson FC, Francomano CA, Koby M, Tuchman K, Adcock J, Patel S. Cervical medullary syndrome secondary to craniocervical instability and ventral brainstem compression in hereditary hypermobility connective tissue disorders: 5-year follow-up after craniocervical reduction, fusion, and stabilization. Neurosurg Rev 2019; 42:915-936. [PMID: 30627832 PMCID: PMC6821667 DOI: 10.1007/s10143-018-01070-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/28/2018] [Accepted: 12/10/2018] [Indexed: 02/07/2023]
Abstract
A great deal of literature has drawn attention to the "complex Chiari," wherein the presence of instability or ventral brainstem compression prompts consideration for addressing both concerns at the time of surgery. This report addresses the clinical and radiological features and surgical outcomes in a consecutive series of subjects with hereditary connective tissue disorders (HCTD) and Chiari malformation. In 2011 and 2012, 22 consecutive patients with cervical medullary syndrome and geneticist-confirmed hereditary connective tissue disorder (HCTD), with Chiari malformation (type 1 or 0) and kyphotic clivo-axial angle (CXA) enrolled in the IRB-approved study (IRB# 10-036-06: GBMC). Two subjects were excluded on the basis of previous cranio-spinal fusion or unrelated medical issues. Symptoms, patient satisfaction, and work status were assessed by a third-party questionnaire, pain by visual analog scale (0-10/10), neurologic exams by neurosurgeon, function by Karnofsky performance scale (KPS). Pre- and post-operative radiological measurements of clivo-axial angle (CXA), the Grabb-Mapstone-Oakes measurement, and Harris measurements were made independently by neuroradiologist, with pre- and post-operative imaging (MRI and CT), 10/20 with weight-bearing, flexion, and extension MRI. All subjects underwent open reduction, stabilization occiput to C2, and fusion with rib autograft. There was 100% follow-up (20/20) at 2 and 5 years. Patients were satisfied with the surgery and would do it again given the same circumstances (100%). Statistically significant improvement was seen with headache (8.2/10 pre-op to 4.5/10 post-op, p < 0.001, vertigo (92%), imbalance (82%), dysarthria (80%), dizziness (70%), memory problems (69%), walking problems (69%), function (KPS) (p < 0.001). Neurological deficits improved in all subjects. The CXA average improved from 127° to 148° (p < 0.001). The Grabb-Oakes and Harris measurements returned to normal. Fusion occurred in 100%. There were no significant differences between the 2- and 5-year period. Two patients returned to surgery for a superficial wound infections, and two required transfusion. All patients who had rib harvests had pain related that procedure (3/10), which abated by 5 years. The results support the literature, that open reduction of the kyphotic CXA to lessen ventral brainstem deformity, and fusion/stabilization to restore stability in patients with HCTD is feasible, associated with a low surgical morbidity, and results in enduring improvement in pain and function. Rib harvest resulted in pain for several years in almost all subjects.
Collapse
Affiliation(s)
- Fraser C Henderson
- Doctor's Community Hospital, Lanham, MD, USA.
- The Metropolitan Neurosurgery Group, LLC, Silver Spring, MD, USA.
| | | | - M Koby
- Doctor's Community Hospital, Lanham, MD, USA
| | - K Tuchman
- The Metropolitan Neurosurgery Group, LLC, Silver Spring, MD, USA
| | - J Adcock
- Harvey Institute of Human Genetics, Greater Baltimore Medical Center, Baltimore, MD, USA
| | - S Patel
- Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
16
|
Karaaslan B, Börcek AÖ, Uçar M, Aykol Ş. Can the Etiopathogenesis of Chiari Malformation Be Craniocervical Junction Stabilization Difference? Morphometric Analysis of Craniocervical Junction Ligaments. World Neurosurg 2019; 128:e1096-e1101. [PMID: 31103770 DOI: 10.1016/j.wneu.2019.05.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The craniocervical junction permits a certain amount of mobility for the cervical spine. The biomechanical properties of occipital bone-atlas joint mainly depend on the bony structure, and atlas-axis joint biomechanical properties mainly depend on ligamentous structure. The underlying etiologic factor of Chiari malformation (CM) is debatable. Nowadays, some researchers argue that stabilization difference is one of the suspicious factors for etiopathogenesis. We aim to analyze the ligamentous morphometric differences of CM. METHODS Magnetic resonance images of 93 adult healthy subjects (n = 93) without any craniocervical junction development abnormalities and 25 (n = 25) adult patients with craniocervical junction development abnormalities (Arnold CM) were evaluated. Length, width, and length-width ratios of ligaments were evaluated. RESULTS Length of transverse ligament (mean: 23 ± 3.6 [range: 12.1-31.4]) in the normal population was significantly longer than transverse ligament length in CM patients (mean: 21.3 ± 2.5 [range: 17.2-24.9]). Length of alar ligament (mean: 10.7 ± 2 [range: 5.1-15.4]) in the normal population was significantly longer than alar ligament length in CM patients (mean: 8.8 ± 3.8 [range: 1.1-16.6]) (P = 0.007). CONCLUSIONS Craniocervical ligaments play an important role in maintaining stability and motion capacity of this region. This study promoted better understanding of craniocervical junction anomalies and provided data that facilitate performing more precise surgical treatment.
Collapse
Affiliation(s)
- Burak Karaaslan
- Department of Neurosurgery, Çubuk Halil Şıvgın State Hospital, Ankara, Turkey.
| | - Alp Özgün Börcek
- Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Murat Uçar
- Department of Radiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Şükrü Aykol
- Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
17
|
|
18
|
Kikuta S, Iwanaga J, Oskouian RJ, Tubbs RS. A new variant ligament of the atlantooccipital joint: the lateral oblique atlantooccipital ligament. 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 2019; 28:1188-1191. [PMID: 30783803 DOI: 10.1007/s00586-019-05919-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/05/2019] [Accepted: 02/12/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE During routine dissection of the anterior craniocervical junction (CCJ), a variant ligament just anterior to the articular capsule of the atlantooccipital joint was observed. To our knowledge, no literature has previously described this ligament. Therefore, the aim of this study was to clarify the anatomy, incidence, and biomechanics of this undescribed structure of the anterior atlantooccipital joint. METHODS Twenty-six sides from 13 fresh-frozen adult cadavers were used for this study and the morphology of the variant ligament examined. When present, its length, width, thickness, and the angle from the midline of the CCJ were measured. RESULTS The variant ligament identified, when present, is distinct and located anterior to the atlantooccipital joint capsule traveling between the occipital bone and the transverse process of the atlas. The ligament was found on 12 of 26 sides (46.2%). The mean length of the ligament was 32.0 ± 5.5 mm. The ligament became taut with contralateral lateral flexion and the ipsilateral rotation of the atlantooccipital joint. CONCLUSIONS We propose that this ligament may be termed the lateral oblique atlantooccipital ligament. To date, this structure has not been described in any textbooks or reports in the extant medical literature. Although its function is not clear, based on its course and connections, it might function as a secondary stabilizer of the atlantooccipital joint. As the stability of the craniocervical junction is of paramount importance, knowledge of normal and variant anatomical structures in this region is important for the surgeon treating patients with pathology of this region. These slides can be retrieved under Electronic Supplementary Material.
Collapse
Affiliation(s)
- Shogo Kikuta
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
- Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Joe Iwanaga
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA.
- Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Fukuoka, Japan.
- Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Fukuoka, Japan.
| | - Rod J Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - R Shane Tubbs
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| |
Collapse
|
19
|
Abstract
Occipitocervical fusion (OCF) is indicated for instability at the craniocervical junction (CCJ). Numerous surgical techniques, which evolved over 90 years, as well as unique anatomic and kinematic relationships of this region present a challenge to the neurosurgeon. The current standard involves internal rigid fixation by polyaxial screws in cervical spine, contoured rods and occipital plate. Such approach precludes the need of postoperative external stabilization, lesser number of involved spinal segments, and provides 95-100% fusion rates. New surgical techniques such as occipital condyle screw or transarticular occipito-condylar screws address limitations of occipital fixation such as variable lateral occipital bone thickness and dural sinus anatomy. As the C0-C1-C2 complex is the most mobile portion of the cervical spine (40% of flexion-extension, 60% of rotation and 10% of lateral bending) stabilization leads to substantial reduction of neck movements. Preoperative assessment of vertebral artery anatomical variations and feasibility of screw insertion as well as visualization with intraoperative fluoroscopy are necessary. Placement of structural and supplemental bone graft around the decorticated bony elements is an essential step of every OCF procedure as the ultimate goal of stabilization with implants is to provide immobilization until bony fusion can develop.
Collapse
|
20
|
Kikuta S, Iwanaga J, Watanabe K, Tubbs RS. Superficial anterior atlanto-occipital ligament: Anatomy of a forgotten structure with relevance to craniocervical stability. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2019; 10:42-45. [PMID: 31000980 PMCID: PMC6469323 DOI: 10.4103/jcvjs.jcvjs_110_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Introduction The superficial anterior atlanto-occipital ligament (SAAOL) is a narrowband located anterior to the anterior atlanto-occipital membrane. Nearly forgotten, it has not been well described in older anatomical textbooks and is missing in the current anatomical literature. As all of the binding structures of the craniocervical junction (CCJ) are important in maintaining stability, this study aims to clarify the anatomy and potential function of the SAAOL. Materials and Methods The CCJ from ten fresh-frozen cadavers was studied. These specimens were derived from three males and seven females, and the age at death ranged from 57 to 91 years (mean, 79.8 years). The length, width, and thickness of the SAAOL were measured. In five specimens, the force to failure was recorded. Results The SAAOL was found between the anterior tubercle of the atlas and the occiput and located as central thick fibers in front of the anterior atlanto-occipital membrane in 9 (90%) specimens. In one specimen, the vertical band to the occipital bone did not attach to the anterior tubercle of the atlas, but extended to the anterior aspect of the axis. The mean length, width, and thickness of the SAAOL were 19.8, 6.2, and 0.6 mm, respectively. The force to failure for the ligament was 38.8 N. Conclusion The SAAOL was a constant structure of the anterior atlanto-occipital joint. This ligament seems to be a secondary stabilizer of the CCJ by limiting the extension of CCJ. Knowledge of this ligament may help in further understanding of craniocervical stability.
Collapse
Affiliation(s)
- Shogo Kikuta
- Seattle Science Foundation, Seattle, WA, USA.,Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, WA, USA.,Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Fukuoka, Japan.,Department of Anatomy, Division of Gross and Clinical Anatomy, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Koichi Watanabe
- Department of Anatomy, Division of Gross and Clinical Anatomy, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, WA, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
| |
Collapse
|
21
|
Ríos L, Palancar C, Pastor F, Llidó S, Sanchís-Gimeno JA, Bastir M. Shape change in the atlas with congenital midline non-union of its posterior arch: a morphometric geometric study. Spine J 2017; 17:1523-1528. [PMID: 28571788 DOI: 10.1016/j.spinee.2017.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/04/2017] [Accepted: 05/08/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The congenital midline non-union of the posterior arch of the atlas is a developmental variant present at a frequency ranging from 0.7% to 3.9%. Most of the reported cases correspond to incidental findings during routine medical examination. In cases of posterior non-union, hypertrophy of the anterior arch and cortical bone thickening of the posterior arches have been observed and interpreted as adaptive responses of the atlas to increased mechanical stress. PURPOSE We sought to determine if the congenital non-union of the posterior arch results in a change in the shape of the atlas. STUDY DESIGN/SETTING This study is an analysis of the first cervical vertebrae from osteological collections through morphometric geometric techniques. METHODS A total of 21 vertebrae were scanned with a high-resolution three-dimensional scanner (Artec Space Spider, Artec Group, Luxembourg). To capture vertebral shape, 19 landmarks and 100 semilandmarks were placed on the vertebrae. Procrustes superimposition was applied to obtain size and shape data (MorphoJ 1.02; Klingenberg, 2011), which were analyzed through principal component analysis (PCA) and mean shape comparisons. RESULTS The PCA resulted in two components explaining 22.32% and 18.8% of the total shape variance. The graphic plotting of both components indicates a clear shape difference between the control atlas and the atlas with posterior non-union. This observation was supported by statistically significant differences in mean shape comparisons between both types of vertebra (p<.0001). Changes in shape were observed in the superior and inferior articular facets, the transverse processes, and the neural canal between the control and non-union vertebrae. CONCLUSIONS Non-union of the posterior arch of the atlas is associated with significant changes in the shape of the vertebra.
Collapse
Affiliation(s)
- Luis Ríos
- Paleoanthropology Group, Department of Paleobiology, Museo Nacional de Ciencias Naturales, CSIC, José Gutierrez Abascal 2, 28006 Madrid, Spain.
| | - Carlos Palancar
- Paleoanthropology Group, Department of Paleobiology, Museo Nacional de Ciencias Naturales, CSIC, José Gutierrez Abascal 2, 28006 Madrid, Spain
| | - Francisco Pastor
- Anatomical Museum, Department of Anatomy and Radiology, Faculty of Medicine, University of Valladolid, Av. Ramón y Cajal 7, 47005 Valladolid, Spain
| | - Susana Llidó
- Department of Anatomy and Human Embryology, Faculty of Medicine, University of Valencia, Av. Blasco Ibanez 15, E46010 Valencia, Spain
| | - Juan Alberto Sanchís-Gimeno
- Department of Anatomy and Human Embryology, Faculty of Medicine, University of Valencia, Av. Blasco Ibanez 15, E46010 Valencia, Spain
| | - Markus Bastir
- Paleoanthropology Group, Department of Paleobiology, Museo Nacional de Ciencias Naturales, CSIC, José Gutierrez Abascal 2, 28006 Madrid, Spain
| |
Collapse
|
22
|
Neva J, Smith BW, Joseph JR, Park P. Use of Intraoperative Navigation for Reconstruction of the C1 Lateral Mass After Resection of Aneurysmal Bone Cyst. World Neurosurg 2017; 102:693.e21-693.e27. [PMID: 28408261 DOI: 10.1016/j.wneu.2017.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 03/31/2017] [Accepted: 04/01/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Aneurysmal bone cysts (ABCs) are rare blood-filled cystic lesions that are found in the long bones and spine. Here, we present a case of an ABC found in the lateral mass and lamina of C1. Lesions in this area provide a surgical challenge because of its difficulty to access as well as its need for reconstruction. We describe a novel use of intraoperative navigation (ION) to assist in the placement of a C1 lateral mass titanium cage. CASE DESCRIPTION An 18-year-old female patient presented with headaches and progressive neck pain. Imaging revealed a large cystic lesion involving the C1 lamina and right lateral mass. The patient underwent ION-assisted aggressive intralesional resection of the ABC and reconstruction of the C1 lateral mass with a static titanium cage, supplemented with posterior fusion from the occiput to C3. At 2-year follow-up, there was no evidence of recurrence and the hardware remained intact. CONCLUSIONS ION is a useful aid in assessing the extent of tumor resection and performing cage reconstruction of the C1 lateral mass.
Collapse
Affiliation(s)
- Jennifer Neva
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Brandon W Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jacob R Joseph
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
23
|
Felbaum DR, Ryan JE, Stemer AB, Anaizi AN. Bilateral Subaxial Rotational Vertebral Artery Occlusion in a Setting of a Prior Cervical Construct. World Neurosurg 2017; 97:762.e5-762.e10. [DOI: 10.1016/j.wneu.2016.08.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 08/27/2016] [Accepted: 08/30/2016] [Indexed: 11/28/2022]
|
24
|
Peciu-Florianu I, Chittur Viswanathan G, Barges-Coll J, Castillo-Velázquez GA, Zambelli PY, Duff JM. Bilateral C-1 lateral mass reconstruction following radical resection of a giant osteoblastoma of the atlas: case report. J Neurosurg Spine 2016; 26:307-312. [PMID: 27834626 DOI: 10.3171/2016.8.spine16319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Osteoblastoma is a rare, benign, osteoid-producing, and slow-growing primary bone tumor, typically arising in long bones or in the spine, with a slight male predominance. This report describes the surgical treatment of a giant C-1 (atlantal) osteoblastoma diagnosed in a young male patient with neurofibromatosis Type 1. The authors describe the clinical presentation, the surgical procedure for complete excision and stabilization, and results as of the 1-year follow-up. They detail a bilateral occipitoaxial spinal interarticular stabilization technique that they used after complete tumor excision. To the best of their knowledge, this is the first case of bilateral C-1 lateral mass reconstruction by this technique to be reported in the literature.
Collapse
Affiliation(s)
| | | | | | | | - Pierre-Yves Zambelli
- Division of Paediatric Orthopedics, University Hospital of Lausanne.,Faculty of Biology and Medicine, University of Lausanne, Switzerland; and
| | - John M Duff
- Neurosurgical Service, Department of Clinical Neurosciences and.,Faculty of Biology and Medicine, University of Lausanne, Switzerland; and
| |
Collapse
|
25
|
Yin YH, Qiao GY, Yu XG. Surgical Treatment of Occipitocervical Dislocation with Atlas Assimilation and Klippel-Feil Syndrome Using Occipitalized C1 Lateral Mass and C2 Fixation and Reduction Technique. World Neurosurg 2016; 95:46-52. [PMID: 27465418 DOI: 10.1016/j.wneu.2016.07.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/13/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To introduce and assess a surgical treatment of occipitocervical (OC) dislocation with atlas assimilation and Klippel-Feil syndrome (KFS) using occipitalized C1 lateral mass and C2 fixation and reduction technique. METHODS From January 2007 to August 2013, 58 symptomatic patients with OC dislocation and KFS of C2-3 congenital fusion and atlas assimilation were surgically treated in our institution via this technique. After opening the C1-2 facet joints via a posterior approach, OC reduction was conducted by intraoperative manipulation and C1 lateral mass and C2 pedicle screw and rod fixation. The instrument position, fusion status, and clinical outcome were analyzed. RESULTS The average follow-up was 36 months (range, 18-52 months). Radiologically, effective reduction was achieved in 56 patients (96.6%) and <50% reduction in 2 (3.4%) who had additional transoral decompression. Neurologic improvement and solid bone fusion were achieved in all patients. The clinical symptoms improved for all patients, with the averaged Japanese Orthopedic Association myelopathy scores increasing from 11.5 to 15.6 (P < 0.01). CONCLUSIONS In patients with OC dislocation and KFS of C2-3 fusion and atlas assimilation, posterior manipulative reduction combined with occipitalized C1 lateral mass and C2 fixation provides a reliable and effective treatment.
Collapse
Affiliation(s)
- Yi-Heng Yin
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Guang-Yu Qiao
- Department of Neurosurgery, PLA General Hospital, Beijing, China.
| | - Xin-Guang Yu
- Department of Neurosurgery, PLA General Hospital, Beijing, China.
| |
Collapse
|
26
|
Lu T, Liu C, Dong J, Lu M, Li H, He X. Cervical screw placement using rapid prototyping drill templates for navigation: a literature review. Int J Comput Assist Radiol Surg 2016; 11:2231-2240. [PMID: 27160327 DOI: 10.1007/s11548-016-1414-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 04/29/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Due to the high screw malposition rate and the potential risk of neurovascular injury in cervical fixation surgeries, guided tools, mainly computer-assisted surgery navigation systems and rapid prototyping drill templates (RPDTs) have increasingly been developed to help surgeons improve screw placement accuracy. Although RPDTs have been used in cervical surgeries for almost 2 decades, no specific review has been performed detailing the state of this technique. Thus, in the current review, we fully discuss the status of applying RPDTs in cervical surgeries. METHODS Studies that tested the accuracy and reliability of RPDTs in guiding cervical screw placements were included in this review. The fabrication workflow and usage of RPDTs, the accuracy and reliability of using RPDTs for screw and plate placement, the advantages and disadvantages of RPDTs and their prospects for future applications as a part of cervical fixation instrumentation are discussed. RESULTS As the design of RPDTs becomes more rational, the accuracy and reliability of these devices have significantly improved in cervical fixation surgeries. Moreover, RPDTs decrease the intraoperative radiation exposure for surgeons and patients relative to conventional methods. However, some disadvantages also exist. The fabrication of RPDTs is time-consuming, and the time required to learn the related software is long. CONCLUSION We believe that because of their merits, the RPDT technique is worth promoting for use in cervical surgeries. However, the time-consuming fabrication workflow and the long period required to learn the related software might limit its widespread use. In the future, the workflow should be simplified to reduce the extra workload for surgeons. Moreover, more clinical studies with high-level evidence are still needed to further test its accuracy and feasibility.
Collapse
Affiliation(s)
- Teng Lu
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi Province, China
| | - Chao Liu
- Department of Neurology, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi Province, China
| | - Jun Dong
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi Province, China
| | - Meng Lu
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi Province, China
| | - Haopeng Li
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi Province, China
| | - Xijing He
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi Province, China.
| |
Collapse
|
27
|
A Computed Tomographic Morphometric Study of the Pediatric Occipital Bone Thickness: Implications for Pediatric Occipitocervical Fusion. Spine (Phila Pa 1976) 2015; 40:1564-71. [PMID: 26731701 DOI: 10.1097/brs.0000000000001091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study is a computed tomographic-based morphometric analysis of the pediatric occipital bones as related to pediatric occipitocervical fusion. OBJECTIVE To quantify reference data concerning the thicknesses of the immature occipital bones to guide the pediatric occipitocervical fusion. SUMMARY OF BACKGROUND DATA To the best of our knowledge, no published study has provided insight into the thicknesses of pediatric occiputs with different age groups. METHODS 80 pediatric patients were divided into 4 age groups, and their occiputs were studied on Philips Brilliance 256 iCT scan. RESULTS The mean thickness ± standard deviations of the pediatric occipital bones with different age groups is shown. The median and the paramedian regions are always thicker than the more lateral regions at each age group and the thickest point in the occiputs is mostly at the external occipital protuberance. The mean thickness of occiputs showed an obvious significant difference between each 2 age groups and no significant difference between male and female in different age groups except the group 4. CONCLUSION Our investigation provides insight into the anatomy of occiputs in pediatric population and preoperative CT evaluation must be required to further decrease the risk of occipitocervical fusion.
Collapse
|
28
|
Riedinger B, Bürki A, Stahl C, Howard J, Forterre F. Biomechanical Evaluation of the Stabilizing Function of Three Atlantoaxial Implants Under Shear Loading: A Canine Cadaveric Study. Vet Surg 2015; 44:957-63. [PMID: 26413939 DOI: 10.1111/vsu.12402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the biomechanical properties of a ventral transarticular lag screw fixation technique, a new dorsal atlantoaxial instability (AAI) clamp, and a new ventral AAI hook plate under sagittal shear loading after transection of the ligaments of the atlantoaxial joint. STUDY DESIGN Cadaveric biomechanical study. ANIMALS Canine cadavers (n = 10). MATERIALS AND METHODS The occipitoatlantoaxial region of Beagles euthanatized for reasons unrelated to the study was prepared leaving only ligamentous structures and the joint capsules between the first 2 cervical vertebrae (C1 and C2). The atlanto-occipital joints were stabilized with 2 transarticular diverging positive threaded K-wires. The occipital bone and the caudal end of C2 were embedded in polymethylmethacrylate and loaded in shear to a force of 50 Newtons. The range of motion (ROM) and neutral zone (NZ) of the atlantoaxial joint were determined after 3 loading cycles with atlantoaxial ligaments intact, after ligament transection, and after fixation with each implant. The testing order of implants was randomly assigned. The implants tested last were subjected to failure testing. RESULTS All stabilization procedures decreased the ROM and NZ of the atlantoaxial joint compared to transected ligament specimens. Only stabilization with transarticular lag screws and ventral plates produced a significant reduction of ROM compare to intact specimens. CONCLUSION Fixation with transarticular lag screws and a ventral hook plate was biomechanically similar and provided more rigidity compared to dorsal clamp fixation. Further load cycling to failure tests and clinical studies are required before making clinical recommendations.
Collapse
Affiliation(s)
- Benoit Riedinger
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Alexander Bürki
- Institute for Surgical Technology and Biomechanics, University of Berne, Berne, Switzerland
| | - Christina Stahl
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Judith Howard
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Franck Forterre
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| |
Collapse
|
29
|
Lopez AJ, Scheer JK, Leibl KE, Smith ZA, Dlouhy BJ, Dahdaleh NS. Anatomy and biomechanics of the craniovertebral junction. Neurosurg Focus 2015; 38:E2. [DOI: 10.3171/2015.1.focus14807] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The craniovertebral junction (CVJ) has unique anatomical structures that separate it from the subaxial cervical spine. In addition to housing vital neural and vascular structures, the majority of cranial flexion, extension, and axial rotation is accomplished at the CVJ. A complex combination of osseous and ligamentous supports allow for stability despite a large degree of motion. An understanding of anatomy and biomechanics is essential to effectively evaluate and address the various pathological processes that may affect this region. Therefore, the authors present an up-to-date narrative review of CVJ anatomy, normal and pathological biomechanics, and fixation techniques.
Collapse
Affiliation(s)
- Alejandro J. Lopez
- 1Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; and
| | - Justin K. Scheer
- 1Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; and
| | - Kayla E. Leibl
- 1Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; and
| | - Zachary A. Smith
- 1Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; and
| | - Brian J. Dlouhy
- 2Department of Neurological Surgery, The University of Iowa, Carver School of Medicine, Iowa City, Iowa
| | - Nader S. Dahdaleh
- 1Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; and
| |
Collapse
|
30
|
Clarke MJ, Zadnik PL, Groves ML, Sciubba DM, Witham TF, Bydon A, Gokaslan ZL, Wolinsky JP. Fusion following lateral mass reconstruction in the cervical spine. J Neurosurg Spine 2014; 22:139-50. [PMID: 25431961 DOI: 10.3171/2014.10.spine13858] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Recently, aggressive surgical techniques and a push toward en bloc resections of certain tumors have resulted in a need for creative spinal column reconstruction. Iatrogenic instability following these resections requires a thoughtful approach to adequately transfer load-bearing forces from the skull and upper cervical spine to the subaxial spine. METHODS The authors present a series of 7 cases in which lateral mass reconstruction with a cage or fibular strut graft was used to provide load-bearing support, including 1 case of bilateral cage placement. RESULTS The authors discuss the surgical nuances of en bloc resection of high cervical tumors and explain their technique for lateral mass cage placement. Additionally, they provide their rationale for the use of these constructs throughout the craniocervical junction and subaxial spine. CONCLUSIONS Lateral mass reconstruction provides a potential alternative or adjuvant method of restoring the load-bearing capabilities of the cervical spine.
Collapse
|
31
|
Bobinski L, Levivier M, Duff JM. Occipitoaxial spinal interarticular stabilization with vertebral artery preservation for atlantal lateral mass failure. J Neurosurg Spine 2014; 22:134-8. [PMID: 25415481 DOI: 10.3171/2014.10.spine14131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The treatment of craniocervical instability caused by diverse conditions remains challenging. Different techniques have been described to stabilize the craniocervical junction. The authors present 2 cases in which tumoral destruction of the C-1 lateral mass caused craniocervical instability. A one-stage occipitoaxial spinal interarticular stabilization (OASIS) technique with titanium cages and posterior occipitocervical instrumentation was used to reconstruct the C-1 lateral mass and stabilize the craniocervical junction. The ipsilateral vertebral artery was preserved. The OASIS technique offers single-stage tumor resection, C-1 lateral mass reconstruction, and stabilization with a loadsharing construct. It could be an option in the treatment of select cases of C-1 lateral mass failure.
Collapse
Affiliation(s)
- Lukas Bobinski
- Neurosurgical Service, Department of Clinical Neurosciences, CHUV, Lausanne, Switzerland
| | | | | |
Collapse
|
32
|
Abstract
STUDY DESIGN Retrospective review/case series. OBJECTIVE This study aims to present the clinical feasibility of condylar fixation in occipitocervical (OC) fusion. Here, we present the largest clinical series to date of patients who underwent OC fusion via cervicocondylar fixation using a polyaxial screw/rod construct. SUMMARY OF BACKGROUND DATA The novel technique using the occipital condyles as the sole cranial fixation point has been described. Both cadaveric and biomechanical studies, in recent literature, have shown technical feasibility and surgical safety of condylar fixation. METHODS We retrospectively reviewed a prospectively acquired database of all patients treated with OC fusion via cervicocondylar fixation at our institution between 2007 and 2011. All patients were scheduled for follow-up postoperatively at weeks 2, 6, 12, 24, and annually thereafter. Outcome measures included estimated blood loss, operative time, complications, integrity of the construct, and fusion rates. Exclusion criteria included condylar fracture, previous cervical fusion, or vertebral artery injury. Enrolled patients subsequently underwent posterior OC fixation using occipital condyle, C1 lateral mass, and/or C2 pars interarticularis screw fixation. Subaxial cervical fixation consisted of lateral mass screw placement. Intraoperative fluoroscopy and hypoglossal monitoring were used. RESULTS We identified 12 consecutive patients who underwent OC fusion using the occipital condyle as the cranial fixation point using polyaxial screws. The mean operative time was 283 minutes (192-416). The mean total blood loss was 229 mL (100-400). Mean follow-up was 21.4 months (4-39). One patient suffered from a superficial wound infection. There were no neural or vascular complications. Radiographic evidence of OC fusion was noted for all patients with >6-month follow-up. CONCLUSIONS OC fusion using occipital condylar screws is a feasible alternative to current occipital plate fixation. Condylar screw fixation can be performed safely with successful arthrodesis as a treatment for OC instability in patients.
Collapse
|
33
|
Reber K, Bürki A, Vizcaino Reves N, Stoffel M, Gendron K, Ferguson SJ, Forterre F. Biomechanical evaluation of the stabilizing function of the atlantoaxial ligaments under shear loading: A canine cadaveric study. Vet Surg 2013; 42:918-23. [DOI: 10.1111/j.1532-950x.2013.12064.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 04/07/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Katrine Reber
- Department Clinical Veterinary Medicine, Vetsuisse Faculty; Institute for Surgical Technology and Biomechanics, University of Bern; Bern Switzerland
| | - Alexander Bürki
- MEM Research Center; Institute for Surgical Technology and Biomechanics, University of Bern; Bern Switzerland
| | - Nuria Vizcaino Reves
- Department Clinical Veterinary Medicine, Vetsuisse Faculty; Institute for Surgical Technology and Biomechanics, University of Bern; Bern Switzerland
| | - Michael Stoffel
- Department Clinical Veterinary Medicine, Vetsuisse Faculty; Institute for Surgical Technology and Biomechanics, University of Bern; Bern Switzerland
| | - Karine Gendron
- Department Clinical Veterinary Medicine, Vetsuisse Faculty; Institute for Surgical Technology and Biomechanics, University of Bern; Bern Switzerland
| | - Stephen J Ferguson
- MEM Research Center; Institute for Surgical Technology and Biomechanics, University of Bern; Bern Switzerland
| | - Franck Forterre
- Department Clinical Veterinary Medicine, Vetsuisse Faculty; Institute for Surgical Technology and Biomechanics, University of Bern; Bern Switzerland
| |
Collapse
|
34
|
Hwang SW, Gressot LV, Chern JJ, Relyea K, Jea A. Complications of occipital screw placement for occipitocervical fusion in children. J Neurosurg Pediatr 2012; 9:586-93. [PMID: 22656247 DOI: 10.3171/2012.2.peds11497] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Occipitocervical stabilization in the pediatric age group remains a challenge because of the regional anatomy, poor occipital bone purchase, and, in some instances, significant thinning of the occipital bone. Multiple bicortical fixation points to the occipital bone may be required to increase construct rigidity. The authors evaluated the complications of bicortical occipital screw placement in children with occipital fusion constructs. METHODS The records of 20 consecutive pediatric patients who had undergone occipitocervical fusion between September 1, 2007, and November 30, 2010, at Texas Children's Hospital were reviewed. RESULTS The patients consisted of 10 girls and 10 boys, ranging in age from 10 months to 16 years (mean ± SD, 7.7 ± 5.1 years). Two patients were lost to follow-up, 2 died for reasons unrelated to the surgery, and the remaining patients had at least 3 months of follow-up (mean 14 ± 11.8 months) with evaluation via dynamic radiography and CT. Four patients experienced 8 complications: 2 CSF leaks, 2 vigorous venous bleedings, worsening of quadriparesis, wound infection, radiographic pseudarthrosis, and transient dysphagia. Among 114 screws, there were 2 cases of intraoperative dural venous sinus injury and 2 cases of intraoperative CSF leakage, without clinical sequelae from these complications. Only 1 case of radiographic pseudarthrosis was identified in a patient with skeletal dysplasia and a prior failed C1-2 posterior arthrodesis. There were no difficulties with wound healing because of prominent occipital instrumentation, and there was only 1 wound infection. CONCLUSIONS Data in this report confirm that including bicortical occipital screw placement in occipitocervical constructs in children may result in a high fusion rate but at the cost of a notable complication rate.
Collapse
Affiliation(s)
- Steven W Hwang
- Pediatric Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | | | | | | | | |
Collapse
|
35
|
Tubbs RS, Hallock JD, Radcliff V, Naftel RP, Mortazavi M, Shoja MM, Loukas M, Cohen-Gadol AA. Ligaments of the craniocervical junction. J Neurosurg Spine 2011; 14:697-709. [PMID: 21395398 DOI: 10.3171/2011.1.spine10612] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The specialized ligaments of the craniocervical junction must allow for stability yet functional movement. Because injury to these important structures usually results in death or morbidity, the neurosurgeon should possess a thorough understanding of the anatomy and function of these ligaments. To the authors' knowledge, a comprehensive review of these structures is not available in the medical literature. The aim of the current study was to distill the available literature on each of these structures into one offering.
Collapse
Affiliation(s)
- R Shane Tubbs
- Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama 35233, USA.
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Surgical treatment for atlantooccipital osteoarthritis: a case report of two 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 2010; 20 Suppl 2:S243-7. [PMID: 21125298 DOI: 10.1007/s00586-010-1636-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Revised: 10/27/2010] [Accepted: 11/14/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND/PURPOSE Although rarely discussed in the literature and difficult to evaluate on plain radiographs, atlantooccipital osteoarthritis can be a source of persistent suboccipital pain. Our objective in this report is to describe two cases with atlantooccipital (O-C1) osteoarthritis treated with posterior occipitocervical fusion. METHODS AND RESULTS Two patients presented with unilateral suboccipital pain, which was refractory to conservative treatment. One patient suffered from long-standing rheumatoid arthritis while the other patient did not have pertinent medical issues. After non-diagnostic plain film imaging, CT scan demonstrated unilateral osteoarthritis of the atlantooccipital and atlantoaxial joint in both patients who subsequently underwent posterior O-C2 fusion with resolution of their preoperative symptoms. CONCLUSIONS This is, to our knowledge, the first case report which specifically focused on surgical treatment of atlantooccipital osteoarthritis. Occipitocervical fusion is a treatment option for patients with atlantooccipital osteoarthritis when suboccipital pain is not responsive to conservative treatment.
Collapse
|
37
|
Koller H, Schmidt R, Mayer M, Hitzl W, Zenner J, Midderhoff S, Middendorf S, Graf N, Gräf N, Resch H, Wilke HJ, Willke HJ. The stabilizing potential of anterior, posterior and combined techniques for the reconstruction of a 2-level cervical corpectomy model: biomechanical study and first results of ATPS prototyping. 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 2010; 19:2137-48. [PMID: 20589516 PMCID: PMC2997200 DOI: 10.1007/s00586-010-1503-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 03/13/2010] [Accepted: 06/16/2010] [Indexed: 10/19/2022]
Abstract
Clinical studies reported frequent failure with anterior instrumented multilevel cervical corpectomies. Hence, posterior augmentation was recommended but necessitates a second approach. Thus, an author group evaluated the feasibility, pull-out characteristics, and accuracy of anterior transpedicular screw (ATPS) fixation. Although first success with clinical application of ATPS has already been reported, no data exist on biomechanical characteristics of an ATPS-plate system enabling transpedicular end-level fixation in advanced instabilities. Therefore, we evaluated biomechanical qualities of an ATPS prototype C4-C7 for reduction of range of motion (ROM) and primary stability in a non-destructive setup among five constructs: anterior plate, posterior all-lateral mass screw construct, posterior construct with lateral mass screws C5 + C6 and end-level fixation using pedicle screws unilaterally or bilaterally, and a 360° construct. 12 human spines C3-T1 were divided into two groups. Four constructs were tested in group 1 and three in group 2; the ATPS prototypes were tested in both groups. Specimens were subjected to flexibility test in a spine motion tester at intact state and after 2-level corpectomy C5-C6 with subsequent reconstruction using a distractable cage and one of the osteosynthesis mentioned above. ROM in flexion-extension, axial rotation, and lateral bending was reported as normalized values. All instrumentations but the anterior plate showed significant reduction of ROM for all directions compared to the intact state. The 360° construct outperformed all others in terms of reducing ROM. While there were no significant differences between the 360° and posterior constructs in flexion-extension and lateral bending, the 360° constructs were significantly more stable in axial rotation. Concerning primary stability of ATPS prototypes, there were no significant differences compared to posterior-only constructs in flexion-extension and axial rotation. The 360° construct showed significant differences to the ATPS prototypes in flexion-extension, while no significant differences existed in axial rotation. But in lateral bending, the ATPS prototype and the anterior plate performed significantly worse than the posterior constructs. ATPS was shown to confer increased primary stability compared to the anterior plate in flexion-extension and axial rotation with the latter yielding significance. We showed that primary stability after 2-level corpectomy reconstruction using ATPS prototypes compared favorably to posterior systems and superior to anterior plates. From the biomechanical point, the 360° instrumentation was shown the most efficient for reconstruction of 2-level corpectomies. Further studies will elucidate whether fatigue testing will enhance the benefit of transpedicular anchorage with posterior constructs and ATPS.
Collapse
Affiliation(s)
- Heiko Koller
- Department for Traumatology and Sport Injuries, Paracelsus Medical University, Salzburg, Austria.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Bekelis K, Duhaime AC, Missios S, Belden C, Simmons N. Placement of occipital condyle screws for occipitocervical fixation in a pediatric patient with occipitocervical instability after decompression for Chiari malformation. J Neurosurg Pediatr 2010; 6:171-6. [PMID: 20672939 DOI: 10.3171/2010.4.peds09551] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In cadaveric studies and recently in one adult patient the occipital condyle has been studied as an option to allow bone purchase by fixation devices. In the current case the authors describe the use of occipital condyle screws in a child undergoing occipitocervical fixation. To the best of the authors' knowledge this case is the first reported instance of this technique in a pediatric patient. This girl had a history of posterior fossa decompression for Chiari malformation Type I when she was 22 months of age. When she was 6 years old she presented with neck pain on flexion and extension of her head. Magnetic resonance imaging in flexion and extension revealed occipitocervical instability. She underwent an occiput to C-2 posterior arthrodesis with bilateral screw placement in the occipital condyles, C-2 lamina, and C-1 lateral masses. Postoperatively, she was neurologically intact. Computed tomography demonstrated a stable construct, and her cervical pain had resolved on follow-up.
Collapse
Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
| | | | | | | | | |
Collapse
|
39
|
Craniocervical fixation with occipital condyle screws: biomechanical analysis of a novel technique. Spine (Phila Pa 1976) 2010; 35:931-8. [PMID: 20375778 DOI: 10.1097/brs.0b013e3181c16f9a] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A human cadaveric biomechanical study comparing craniocervical fixation techniques. OBJECTIVE To quantitatively compare the biomechanical stability of a new technique for occipitocervical fixation using the occipital condyles with an established method for craniocervical spine fusion. SUMMARY OF BACKGROUND DATA Stabilization of the occipitocervical junction remains a challenge. The occiput does not easily accommodate instrumentation because of access and spatial constraints. In fact, the area available for the implant fixation is limited and can be restricted further when a suboccipital craniectomy has been performed, posing a challenge to current fixation techniques. Occipital screws are also associated with the potential for intracranial complications. METHODS Six fresh frozen cadaveric specimens occiput-C4 were tested intact, after destabilization and after fixation as follows: (1) occipital plate with C1 lateral mass screws and C2 pars screws and (2) occipital condyle screws with C1 lateral mass screws and C2 pars screws. Specimens were loaded in a custom spine testing apparatus and subjected to the following tests, all performed under 50-N unconstrained axial preload: flexion, extension, lateral bending, and axial rotation at 1.5 Nm. The constructs were statistically compared with a one-way analysis of variance and compared with the intact condition. RESULTS Motions were reduced by approximately 80% compared with the intact condition for both configurations under all motions. There were no statistically significant differences in the range of motion (ROM) between the 2 instrumentation conditions. The mean values indicated decreased ROM with the novel occipital condyle screw construct in comparison with the standard occipital plate and rod system. CONCLUSION Craniocervical stabilization using occipital condyle screws as the sole cephalad fixation point is biomechanically equivalent with regard to the modes tested (ROM and stiffness) to the standard occipital plate construct.
Collapse
|
40
|
Abstract
Abstract
THE CRANIOVERTEBRAL JUNCTION is a complex region that incorporates the occiput–C1–C2 portions of the spine. It is a transition between the cranium and the mobile cervical spine that permits significant motion. The motions afforded and the anatomy are vastly different at the occiput–C1 and C1–C2 articulations. These differences make treating pathology in this region very difficult. Problems include bony fixation of the cranium and the cervical spine (specifically C1 and C2), which limits complex motions, and limited bony sites available for arthrodesis. A thorough knowledge of the normal anatomy and biomechanics is required for fixation of this region. Moreover, an understanding of pathologic motions and the biomechanics of fixation is needed for successful construct design and good patient outcome.
Collapse
Affiliation(s)
- Michael P. Steinmetz
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Thomas E. Mroz
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward C. Benzel
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
41
|
Uribe JS, Ramos E, Baaj A, Youssef AS, Vale FL. Occipital Cervical Stabilization Using Occipital Condyles for Cranial Fixation: Technical Case Report. Neurosurgery 2009; 65:E1216-7; discussion E1217. [DOI: 10.1227/01.neu.0000349207.98394.fa] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AbstractOBJECTIVEPresentation of a successful case of craniocervical stabilization involving a novel surgical technique using the occipital condyles as the sole cranial fixation points.CLINICAL PRESENTATIONA 22-year-old man presented in a delayed fashion with neck pain after a motor vehicle accident. Evaluation revealed a type 2 odontoid fracture with pseudarthrosis and displacement of the dens superiorly and cranial settling of the dens.INTERVENTIONThe patient underwent posterior occipitocervical fixation with a polyaxial screw rod construct using the occipital condyle, C1 lateral mass, and C2 pars articularis for fixation. The patient had no immediate postoperative deficits. At the time of the 12-month follow-up examination, the patient was neurologically intact with a solid occipitocervical fusion.CONCLUSIONCraniocervical stabilization using occipital condyle screws as the sole cephalad fixation points is a feasible option and can be used safely without neurovascular complication in the treatment of craniocervical instability.
Collapse
Affiliation(s)
- Juan S. Uribe
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Edwin Ramos
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Ali Baaj
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - A. Samy Youssef
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Fernando L. Vale
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| |
Collapse
|
42
|
Feasibility of occipital condyle screw placement for occipitocervical fixation: a cadaveric study and description of a novel technique. ACTA ACUST UNITED AC 2009; 21:540-6. [PMID: 19057245 DOI: 10.1097/bsd.0b013e31816d655e] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Occipital-cervical (OC) stabilization using occipital condyle fixation with a polyaxial screw-rod construct is described. OBJECTIVES To describe a novel technique and initial radiographic results for posterior OC fixation using the occipital condyles for cranial fixation. SUMMARY OF BACKGROUND DATA Stabilization of the OC junction remains a challenge. Owing to the regional anatomy and the poor occipital bone purchase, multiple attachment points to the occipital bone are required to increase construct rigidity. To address these issues, we propose a novel OC fixation technique using polyaxial occipital condyle screws for cranial purchase. METHODS The OC junction was exposed posteriorly in silicone-injected cadaver heads. Polyaxial titanium screws (3.5 mm) were inserted bicortically solely into the occipital condyles; C1 lateral masses and C2 pedicles, or transarticularly through C1-C2, followed by fixation to a 3-mm rod. Drilling was guided by anatomic landmarks and fluoroscopy. Computerized tomography scans were obtained. Condylar screw angles and lengths were analyzed with respect to historical morphometric condyle measurements and with respect to neurovascular structures. RESULTS The condylar entry point was 4 to 5-mm lateral to the foramen magnum on the axial plane, and 1 to 2-mm rostral to the atlantooccipital joint. The mean angle of medialization was 17 degrees (range: 12 to 22 degrees). In the sagittal plane, the maximal superior screw angulation was 5 degrees. The mean screw length to obtain bicortical purchase was 22 mm (range: 20 to 24 mm). The hypoglossal canal was uninterrupted during its full course. The jugular bulb, carotid, and vertebral arteries were not injured by condyle screw placement. No fractures were identified. CONCLUSION Condyle screws can be placed without injury to neurovascular structures. OC junction fixation using polyaxial occipital condyle screws is feasible and can be considered a salvage technique or an alternative where other fixation techniques are not available.
Collapse
|