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Bobinski L, Sandberg L, Bylander F, Hållberg H, Berglund A, Duff JM. Safety and efficacy of the new modified technique for c2 nerve root resection in 3d fluoroscopy navigated instrumentation in the cranio-cervical junction. Acta Neurochir (Wien) 2024; 166:368. [PMID: 39278867 PMCID: PMC11402833 DOI: 10.1007/s00701-024-06265-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 09/07/2024] [Indexed: 09/18/2024]
Abstract
PURPOSE Instrumentation of the C1 vertebra requires either mobilization or transection of the C2 nerve root. This study investigates clinical and radiological outcomes and incidences of C2 neuropathic pain after posterior instrumented fusion in the cranio-cervical junction with or without division of the C2 nerve roots. METHODS This retrospective study compared two cohorts of patients who underwent instrumented fusion in the cranio-cervical junction. Fifty patients (22 males and 28 females) were operated with complete resection of C2 nerve root ganglion (Ex group), and fifty-one patients (30 men, 21 women) with C2 nerve roots preservation (No group). RESULTS The incidence of postoperative C2 neuropathy was eight times lower in the Ex group compared to the No group that was statistical significant, p = 0.039. Surgical time was significantly shorter in the No group (p = 0.001). The fusion rates were very high for both groups, without difference between groups (p = 1.0). Autografting from the iliac crest (p = 0.001) as well as postoperative immobilisation with a hard collar (p < 0.001) were required in fewer patients in the Ex group. Also, patients in the Ex group were mobilised faster after surgery (p = 0.49). Overall, complication rates were similar between groups, but the Ex group demonstrated fewer major medical complications (16% vs 31%). Male sex and iliac bone harvesting demonstrated significantly higher OR for development of postoperative complications (p = 0.023 and p = 0.034 respectively) and postoperative mobilization demonstrated significant higher OR for development of postoperative major complications (p = 0.042). CONCLUSIONS Resection of the C2 nerve root ganglion during posterior instrumented fusion of the cranio-cervical junction is safe and rarely leads to C2 neuropathy. The technique tends to mitigate the odds of developing postoperative complications.
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Affiliation(s)
- Lukas Bobinski
- Department of Orthopedics, Spine Section, University Hospital Umeå, Umeå, Sweden.
- Department of Diagnostics and Intervention, Orthopedics, Umeå University, Umeå, Sweden.
| | - Linda Sandberg
- Department of Orthopedics, Spine Section, University Hospital Umeå, Umeå, Sweden
| | - Frida Bylander
- Department of Cardiology, Sunderbyn Hospital, Luleå, Sweden
| | - Hampus Hållberg
- Epistat AB, Statistical Analysis, Uppsala Science Park, Uppsala, Sweden
| | - Anders Berglund
- Epistat AB, Statistical Analysis, Uppsala Science Park, Uppsala, Sweden
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Ou C, Tong Y, Liu J, Shan Z, Chen Y, Huang B, Zhang X, Chen Y, Zhao F. Improving C1 Pedicle Screw Placement for Atlantoaxial Instability with Ultrasonic Bone Burr Assistance. World Neurosurg 2024:S1878-8750(24)01577-8. [PMID: 39270794 DOI: 10.1016/j.wneu.2024.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 09/05/2024] [Indexed: 09/15/2024]
Abstract
OBJECTIVE This study aims to evaluate the safety and efficacy of the ultrasonic bone burr (UBB) in facilitating C1 pedicle screw placement for atlantoaxial instability treatment, compared to the conventional high-speed drill (HSD) technique. METHODS A retrospective analysis was conducted on patients undergoing posterior screw-rod fixation for atlantoaxial instability between December 2017 and July 2023. The patients were divided into 2 groups based on the tools used for screw placement: UBB and HSD. Data on surgical duration, estimated blood loss, spinal cord and arterial injury incidence, screw placement accuracy, neurological status measured by the Japanese Orthopedic Association score, and fusion rates were collected and analyzed. RESULTS Thirteen patients received C1 pedicle screw placement via UBB facilitation, while 8 were treated using the HSD approach. The UBB group showed a significant reduction in blood loss and operation time compared to the HSD group (P = 0.002 and P < 0.001, respectively). No spinal cord or arterial injuries occurred in either group. Optimal screw placement was confirmed in all UBB cases versus 87.5% in the HSD group (P = 0.139). Both groups demonstrated significant improvements in Japanese Orthopedic Association scores with no intergroup difference. The fusion rate was 100% in the UBB group and 87.5% in the HSD group, not statistically different (P = 0.381). CONCLUSIONS UBB is a viable alternative for C1 pedicle screw placement, associated with reduced blood loss and shorter operation time, while achieving comparable clinical outcomes to the conventional HSD method. Nevertheless, further research with a larger sample size is needed.
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Affiliation(s)
- Changjiang Ou
- Department of Neurosurgery, The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China; Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yongjun Tong
- Department of Orthopaedics, Zhejiang Hospital, Hangzhou, China
| | - Junhui Liu
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhi Shan
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yilei Chen
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bao Huang
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xuyang Zhang
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yili Chen
- Department of Neurosurgery, The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Fengdong Zhao
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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Klepinowski T, Żyłka N, Pettersson SD, Hanaya J, Pala B, Łątka K, Taterra D, Poncyljusz W, Ogilvy CS, Sagan L. Types of high-riding vertebral artery: a classification system for preoperative planning of C2 instrumentation based on 908 potential screw insertion sites. Spine J 2024:S1529-9430(24)00993-8. [PMID: 39255917 DOI: 10.1016/j.spinee.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 08/05/2024] [Accepted: 08/24/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND CONTEXT Our recent studies indicated that a high-riding vertebral artery (HRVA) is a common variant posing a risk of injuring the vessel during C2 instrumentation. However, several different types fit in the current definition of HRVA, which may require a different strategy for C2 screw placement. PURPOSE To classify HRVA and provide a clinical aid for preoperative planning of C2 instrumentation. A secondary goal was to estimate coexistence of each HRVA type with the ipsilateral narrow C2 pedicle (NP). STUDY DESIGN A retrospective observational study involving radiologic measurements of the estimated number of anonymized cervical computed tomography (CT) scans. STROBE checklist was applied. PATIENT SAMPLE A total of 908 potential screw insertion sites (PSIS) of 454 consecutive cervical CT scans were analyzed. The sample size was estimated using ScalaR SP function in RStudio. OUTCOME MEASURES Three types of HRVA based on a series of C2 vertebral morphological parameters including the C2 isthmus height (C2IsH) and C2 internal height (C2InH). Also, the prevalences of each HRVA type and coexisting NP based on the C2 pedicle width (C2PW). METHODS HRVA was defined as C2IsH of ≤5 mm and/or C2InH of ≤2 mm measured 3 mm lateral to the lateral border of the spinal canal. A narrow pedicle was defined as C2PW of ≤4 mm. Measurements were done using Syn.govia software. Interobserver, intraobserver, and inter-software agreement coefficients for C2IsH, C2InH, and C2PW parameters were adopted from our previous study. K-means cluster analysis was applied. RESULTS Prevalence of at least 1 HRVA was 24.9% (n=113 subjects) and 16.2% of PSIS (n=147 sites). Based on the measurements and K-means clustering, the following 3 types of HRVA have been distinguished: type 1-isthmic with only C2IsH being reduced and normal C2InH; type 2-internal with only C2InH being reduced and C2IsH within normal limits; type 3-isthmo-internal with both C2IsH and C2InH being reduced. Kruskal-Wallis test followed by unadjusted and Bonferroni-adjusted post-hoc multiple comparison analysis detected significant differences across the types. The prevalences of the newly identified types were as follows: 78.2%, 8.8%, and 12.9% for type 1, type 2, and type 3, respectively. 73.9% of type 1 HRVA, 53.8% of type 2 HRVA, and 100% of type 3 HRVA had a concomitant ipsilateral NP. Prediction of the HRVA types by the K-means clustering has been evaluated. Screw placement techniques for each type are proposed and discussed. CONCLUSION We present the first classification system for the high-riding vertebral artery distinguishing 3 types based on the large homogenous cohort, which may serve as an adjunct to preoperative planning of C2 instrumentation. External validation of this classification scheme shall determine its further clinical utility.
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Affiliation(s)
- Tomasz Klepinowski
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland; Department of Neurosurgery, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
| | - Natalia Żyłka
- Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Samuel D Pettersson
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jagoda Hanaya
- Faculty of Medicine, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Bartłomiej Pala
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Kajetan Łątka
- Department of Neurology, St Hedwig's Regional Specialist Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Dominik Taterra
- Department of Orthopedics and Rehabilitation, Jagiellonian University Medical College, Zakopane, Poland
| | - Wojciech Poncyljusz
- Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Leszek Sagan
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
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Ma X, Zou X, Chen Z, Yang H, Chen J, Ma R, Fu S, Xia H. Surgical Failure and Revision Strategy for Atlantoaxial Dislocation: A Retrospective Study of 109 Cases. Spine (Phila Pa 1976) 2024; 49:1116-1124. [PMID: 38053450 DOI: 10.1097/brs.0000000000004894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To classify surgical failures following atlantoaxial dislocation, present strategies for revisions, and evaluate the clinical results of revision surgery. SUMMARY OF BACKGROUND DATA With the increase in atlantoaxial dislocation surgery, the number of surgical failures has gradually risen. However, current reports on atlantoaxial surgical revision are limited in scope. There remains a lack of summary regarding the causes of surgical failure, a detailed classification system, and no proposed strategy for revision surgery. MATERIALS AND METHODS A total of 109 cases of failed surgery following atlantoaxial dislocation were classified according to the reduction immediately after surgery and the fusion status before revision. The reduction, decompression, fusion status, and outcomes following revision surgery were evaluated by x-ray, computed tomography, magnetic resonance imaging, and the Japanese Orthopaedic Association score. The data were analyzed statistically with a paired-samples t test and multivariable logistic regression analysis. RESULTS The 109 patients were classified into three categories of failure: nonreduction with nonfusion (NR-NF, 73 cases), nonreduction with fusion (NR-F, 19 cases), and reduction with nonfusion (R-NF, 17 cases). Sixty-four patients underwent anterior revision, 21 posterior revision, and 24 anteroposterior revision. Postoperative complications were the primary cause of early revisions. After revision, complete decompression was achieved in all cases, anatomical reduction in 89 cases, significant improvement of Japanese Orthopaedic Association score in 77 cases, and fusion achieved in 86 cases. Twelve cases experienced surgical complications and three underwent a second revision. CONCLUSIONS The authors found that NR-NF was the most common type of failure following surgery for atlantoaxial dislocation. Revision strategies can be guided according to the descriptive classification of failure, and revision surgery should focus on achieving adequate reduction, appropriate fixation, and reliable fusion to optimize postsurgical outcomes.
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Affiliation(s)
- Xiangyang Ma
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, People's Republic of China
- Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Xiaobao Zou
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
| | - Zexing Chen
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, People's Republic of China
| | - Haozhi Yang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
| | - Junlin Chen
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, People's Republic of China
| | - Rencai Ma
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
- Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Suochao Fu
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
| | - Hong Xia
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
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Xu Z, Wu J, Chen F, Ding Y, Ni B, Xu P, Guo Q. Atlantoaxial intra-articular cage fusion by posterior intermuscular approach for treating reducible atlantoaxial dislocation: a technique note with case series. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:3060-3068. [PMID: 38816537 DOI: 10.1007/s00586-024-08318-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/29/2024] [Accepted: 05/16/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE To evaluate the clinical feasibility of atlantoaxial intra-articular cage (AIC) fusion via intermuscular approach for treating reducible atlantoaxial dislocation (AAD). METHODS An analysis was conducted on the data of 10 patients who underwent C1-C2 segmental fixation and AIC fusion for AAD by unilateral intermuscular approach and contralateral open approach. Outcome assessments included Japanese Orthopaedic Association score (JOA) and Visual Analog Scale Score for Neck Pain (VASSNP). The duration of surgical exposure, screw insertion and cage insertion, and postoperative drainage volume were also compared between two approaches. Bone fusion was evaluated through computed tomography (CT) reconstruction. Postoperative paravertebral tissue edema was evaluated by paravertebral tissue cross-sectional area (CSA) and signal intensity on T2 weighted sequence of magnetic resonance imaging (MRI) at 3 days postoperatively. RESULTS The intermuscular approach exhibited a longer exposure time but lower drainage postoperatively compared to the open approach (P < 0.05). After operation, JOA scores significant improved (P < 0.05), while VASSNP scores significantly decreased (P < 0.05). There was no significant difference in preoperative CSA between two approaches (P > 0.05). However, compared to the open approach, the intermuscular approach exhibited less CSA (P < 0.05) and lower T2 signal intensity on MRI postoperatively, indicating less invasive to the paravertebral tissues. CONCLUSIONS AIC fusion by intermuscular approach is an effective and safe technique in the treatment of reducible AAD. Intermuscular approach could reduce the postoperative drainage volume and the extent of paravertebral tissue edema compared to open approach.
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Affiliation(s)
- Zhenji Xu
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China
| | - Ji Wu
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China
| | - Fei Chen
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China
| | - Yiyang Ding
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China
| | - Bin Ni
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China
| | - Peng Xu
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China.
| | - Qunfeng Guo
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, People's Republic of China.
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Sussman JH, Albayar A, Saylany A, Budihal BR, Romeo D, Xu J, Rosenow J, Heary RF, Welch WC. The FDA Reclassification of Cervical Pedicle and Lateral Mass Screws: A Case Study in Regulatory History. Ther Innov Regul Sci 2024; 58:614-621. [PMID: 38622455 PMCID: PMC11169039 DOI: 10.1007/s43441-024-00654-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/10/2024] [Indexed: 04/17/2024]
Abstract
The classification of medical devices by the Food and Drug Administration (FDA) involves rigorous scrutiny from specialized panels that designate devices as Class I, II, or III depending on their levels of relative risk to patient health. Posterior rigid pedicle screw systems were first classified by the FDA in 1984 and have since revolutionized the treatment of many spine pathologies. Despite this early classification by the FDA, posterior cervical pedicle and lateral mass screws were not reclassified from unclassified to Class III and then to Class II until 2019, nearly 35 years after their initial classification. This reclassification process involved a decades-long interplay between the FDA, formal panels, manufacturers, academic leaders, practicing physicians, and patients. It was delayed by lawsuits and a paucity of data demonstrating the ability to improve outcomes for cervical spinal pathologies. The off-label use of thoracolumbar pedicle screw rigid fixation systems by early adopters assisted manufacturers and professional organizations in providing the necessary data for the reclassification process. This case study highlights the collaboration between physicians and professional organizations in facilitating FDA reclassification and underscores changes to the current classification process that could avoid the prolonged dichotomy between common medical practice and FDA guidelines.
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Affiliation(s)
- Jonathan H Sussman
- Department of Neurosurgery, Perelman School of Medicine, 3400 Civic Center Blvd, Floor 15, 19104, Philadelphia, PA, USA.
- Medical Scientist Training Program, University of Pennsylvania, Philadelphia, PA, USA.
| | - Ahmed Albayar
- Department of Neurosurgery, Perelman School of Medicine, 3400 Civic Center Blvd, Floor 15, 19104, Philadelphia, PA, USA
| | - Anissa Saylany
- Department of Neurosurgery, Perelman School of Medicine, 3400 Civic Center Blvd, Floor 15, 19104, Philadelphia, PA, USA
| | - Bhargavi R Budihal
- Department of Neurosurgery, Perelman School of Medicine, 3400 Civic Center Blvd, Floor 15, 19104, Philadelphia, PA, USA
| | - Dominic Romeo
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Jason Xu
- Department of Neurosurgery, Perelman School of Medicine, 3400 Civic Center Blvd, Floor 15, 19104, Philadelphia, PA, USA
| | - Joshua Rosenow
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert F Heary
- Division of Neurological Surgery, Mountainside Medical Center, Hackensack Meridian School of Medicine, Montclair, New Jersey, USA
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine, 3400 Civic Center Blvd, Floor 15, 19104, Philadelphia, PA, USA
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Zhou M, Sun P, Du Y, Zeng G, Chen Z, Duan W. Posterior intra-articular distraction technique to treat pediatric atlantoaxial instability. Childs Nerv Syst 2024; 40:2153-2160. [PMID: 38498172 DOI: 10.1007/s00381-024-06358-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/03/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE Surgical treatment for atlantoaxial instability in pediatric patients is challenging. We report our experience with posterior intra-articular distraction technique in treating this disorder. METHODS This is a retrospective descriptive study which included 15 patients of atlantoaxial instability whose age was less than 16 years at the time of clinical presentation. All patients underwent anterior soft tissue released through a posterior-only approach, followed by intra-facet cage implantation, cantilever correction, and instrumentation. Clinical results were measured using the Japanese Orthopedic Association (JOA) scale and radiographic measurements including the atlantodental interval (ADI), posterior atlantodental interval (pADI), the distance of odontoid tip above Chamberlain's line, clivuscanal angle (CCA), and triangular area (TA) of craniovertebral junction. RESULTS The follow-up period ranged from 18 to 72 months, with an average of 41.2 ± 15.2 months. The JOA score increased from 13.6 ± 2.3 to 16.6 ± 0.8. ADI decreased from 4.31 ± 2.37 to 1.85 ± 1.09 mm, and TA decreased from 261.96 ± 107.99 to 197.12 ± 72.37 mm2. pADI increased from 12.89 ± 3.52 to 18.25 ± 3.89 mm, and CCA improved from 132.19 ± 16.34 to 144.35 ± 13.91°. All changes in measurements showed statistically significant. There were no evidence of surgery-related complications or iatrogenic secondary cervical deformity during follow-up. Radiological evaluation showed satisfactory corrections and bony fusions of C1-2 facet joint in all cases. CONCLUSION Posterior intra-articular distraction followed by cage implantation and cantilever correction can be one of the safe and effective ways to solve atlantoaxial instability in pediatric patients.
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Affiliation(s)
- Mading Zhou
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China
- Di Rocco Center of Pediatric Neurosurgery, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Peng Sun
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China
- Di Rocco Center of Pediatric Neurosurgery, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Yueqi Du
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Gao Zeng
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China
- Di Rocco Center of Pediatric Neurosurgery, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Zan Chen
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China.
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China.
| | - Wanru Duan
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China.
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China.
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Leng A, Li J, Meng L, Wang Q. Combined replantation of the posterior arch of the atlas and bilateral axial lamina in the treatment of intradural schwannoma: a case report. Front Surg 2024; 11:1374208. [PMID: 38912398 PMCID: PMC11190363 DOI: 10.3389/fsurg.2024.1374208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 05/27/2024] [Indexed: 06/25/2024] Open
Abstract
Background Laminotomy and laminar replantation have emerged as novel treatment modalities for intraspinal tumors, aiming to minimize postoperative complications and retain spinal mobility. However, existing research predominantly emphasizes their application in the thoracolumbar spine. The unique anatomy of the atlantoaxial segments necessitates surgical techniques that differ from those used in other spinal regions, and the clinical effect of such procedure remains unknown. Case presentation A 61-year-old male patient with intradural schwannoma at the atlantoaxial level was operated on. The patient underwent posterior laminectomy, as well as a combined replantation of the posterior arch of the atlas and bilateral axial laminae. Postoperatively, the patient experienced significant neurological improvement, with no deformities or instability on the radiological assessments during the follow-up. Conclusion Laminotomy with combined replantation of the posterior arch of the atlas and bilateral axial lamina emerges as an effective approach for managing intraspinal tumors at the atlantoaxial level. This technique not only offers ample operating space but also restores the stability of the spinal canal. Moreover, it preserves the mobility of the atlantoaxial segment, minimizes impact on adjacent segments, and mitigates the formation of postoperative fibrosis.
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Affiliation(s)
| | | | | | - Qi Wang
- Department of Orthopaedics, General Hospital of Northern Theater Command, Shenyang, China
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Wang X, Liu H, Wang B, Wu T, He J, Yan L, Ding C. Early Outcomes of Bone Autografting in the Bilateral Atlantoaxial Joints Applied in Posterior Fusion Surgery. Orthop Surg 2024; 16:559-567. [PMID: 38214016 PMCID: PMC10925506 DOI: 10.1111/os.13997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVE Cable-dragged reduction and cantilever beam internal fixation can provide promising results in the treatment of atlantoaxial dislocation or instability. However, bilateral atlantoaxial joints bone autografting has not been conducted in this technique. We aim to evaluate the safety and effectiveness of bilateral atlantoaxial joints bone autografting in posterior cable-dragged reduction and cantilever-beam internal fixation. METHODS In this retrospective study, we included 14 patients with a minimum 24-month follow-up from December 2019 to September 2020. The granular bone harvested from the iliac crest was packed into the bilateral atlantoaxial joints of 14 patients in posterior cable-dragged reduction and cantilever-beam internal fixation. X-ray imaging and cervical computed tomography (CT) were performed during follow-up. The time required for bone fusion was recorded. The clinical outcomes were evaluated using the JOA scores, NDI, and VAS scores. Mann-Whitney U test, the chi-squared test, or the Fisher exact test were used to compare the two groups regarding patient characteristics, clinical outcomes, bone fusion rates, and cervical sagittal alignment. RESULTS The operations were successfully performed in all patients without any intraoperative complications. The mean operation time was (169.64 ± 20.91) minutes, and the intraoperative blood loss was (130.71 ± 33.62) mL. All patients received satisfactory reductions and firm bony fusion at the final follow-up. The fusion rates were 64.29% in the atlantoaxial joints and 21.43% in post bone graft area at 3 months postoperatively, and a significant difference was observed (p = 0.022). Besides, the cervical sagittal alignment in all patients was well maintained in the last follow-up compared to preoperatively. Importantly, a complete bony fusion in the atlantoaxial joints was observed in all patients. Moreover, the JOA, NDI, and VAS scores had improved significantly at the last follow-up. CONCLUSION Bone autografting of the bilateral atlantoaxial joints is a safe and effective technique to increase bone fusion rates, shorten bone fusion time, and reduce complication rates when the cable-dragged reduction and cantilever beam internal fixation approach is used. Therefore, it is a cost-effective surgical procedure for treating patients with atlantoaxial dislocation or instability.
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Affiliation(s)
- Xing‐jin Wang
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Hao Liu
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Bei‐yu Wang
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Ting‐kui Wu
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Jun‐bo He
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Lu Yan
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Chen Ding
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
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Haemmerli J, Ferdowssian K, Wessels L, Mertens R, Hecht N, Woitzik J, Schneider UC, Bayerl SH, Vajkoczy P, Czabanka M. Comparison of intraoperative CT- and cone beam CT-based spinal navigation for the treatment of atlantoaxial instability. Spine J 2023; 23:1799-1807. [PMID: 37619869 DOI: 10.1016/j.spinee.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/18/2023] [Accepted: 08/13/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND CONTEXT Due to the complexity of neurovascular structures in the atlantoaxial region, spinal navigation for posterior C1-C2 instrumentation is nowadays a helpful tool to increase accuracy of surgery and safety of patients. Many available intraoperative navigation devices have proven their reliability in this part of the spine. Two main imaging techniques are used: intraoperative CT (iCT) and cone beam computed tomography (CBCT). PURPOSE Comparison of iCT- and CBCT-based technologies for navigated posterior instrumentation in C1-C2 instability. STUDY DESIGN Retrospective study. PATIENT SAMPLE A total of 81 consecutive patients from July 2014 to April 2020. OUTCOME MEASURES Screw accuracy and operating time. METHODS Patients with C1-C2 instability received posterior instrumentation using C2 pedicle screws, C1 lateral mass or pedicle screws. All screws were inserted using intraoperative imaging either using iCT or CBCT systems and spinal navigation with autoregistration technology. Following navigated screw insertion, a second intraoperative scan was performed to assess the accuracy of screw placement. Accuracy was defined as the percentage of correctly placed screws or with minor cortical breach (<2 mm) as graded by an independent observer compared to misplaced screws. RESULTS A total of 81 patients with C1-C2 instability were retrospectively analyzed. Of these, 34 patients were operated with the use of iCT and 47 with CBCT. No significant demographic difference was found between groups. In the iCT group, 97.7% of the C1-C2 screws were correctly inserted; 2.3% showed a minor cortical breach (<2 mm); no misplacement (>2 mm). In the CBCT group, 98.9% of screws were correctly inserted; no minor pedicle breach; 1.1% showed misplacement >2 mm. Accuracy of screw placement demonstrated no significant difference between groups. Both technologies allowed sufficient identification of screw misplacement intraoperatively leading to two screw revisions in the iCT and three in the CBCT group. Median time of surgery was significantly shorter using CBCT technology (166.5 minutes [iCT] vs 122 minutes [CBCT]; p<.01). CONCLUSIONS Spinal navigation using either iCT- or CBCT-based systems with autoregistration allows safe and reliable screw placement and intraoperative assessment of screw positioning. Using the herein presented procedural protocols, CBCT systems allow shorter operating time.
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Affiliation(s)
- Julien Haemmerli
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Kiarash Ferdowssian
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Lars Wessels
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Robert Mertens
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Ulf C Schneider
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Simon H Bayerl
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany.
| | - Marcus Czabanka
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
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11
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Harel R, Kimchi G, Perry A, Knoller N. C1 lateral mass screw insertion using cannulated, navigated screws: preliminary results of a novel technique. Br J Neurosurg 2023; 37:1624-1627. [PMID: 35341430 DOI: 10.1080/02688697.2022.2054948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/13/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE The upper cervical spine region is densely populated by neural and vascular structures impeding the approach for fusion surgery. Technological advancement simplify the approach to C1-C2 fusion, thus reduce risks. The current paper purpose is to describe initial experience with a novel technique modification for C1 lateral screw insertion that incorporates cannulated-navigated screw system with intra-operative 3D imaging. METHODS A single-center single surgeon database was reviewed to identify all patients who underwent placement of C1 lateral mass screw insertion using the novel technique modification described below, on 2020. This cohort was retrospectively analyzed and compared with a cohort of patients who were operated on by the same surgeon with non-cannulated, navigated screws with intra-operative 3D imaging (O-arm, Medtronic, USA) between 2011 and 2019. Following navigated starting hole and drilling of the C1 lateral mass, a blunt guide-wire is used to palpate the hole and cannulated screw is advanced to the correct position over the wire. After initial purchase, a navigated screw driver is used for final screw depth position. RESULTS Twelve C1 lateral mass screws were inserted in six patients using this novel cannulated-navigated screw placement technique and compared to 24 patients operated using navigated non-cannulated screws. Minimal Estimated Blood Loss (EBL) was recorded in five of six cases undergoing the novel cannulated navigated placement of C1 lateral mass screws. Comparison to non-cannulated cohort demonstrated an EBL of 83CC vs. 354CC (Not significant). Mean surgery time was 97min and 118min for the cannulated-navigated and navigated only procedures (p = 0.03, statistically significant) respectively. In the current cohort, all screws were rated in optimal position and no repositioning procedures were performed. CONCLUSION The new method presented allows for faster and possibly safer and more accurate C1 lateral mass screw insertion.
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Affiliation(s)
- Ran Harel
- Department of Neurologic Surgery, Sheba Medical Center, Sackler Medical School, Tel-Aviv University, Ramat-Gan, Israel
| | - Gil Kimchi
- Department of Neurologic Surgery, Sheba Medical Center, Sackler Medical School, Tel-Aviv University, Ramat-Gan, Israel
| | - Avital Perry
- Department of Neurologic Surgery, Sheba Medical Center, Sackler Medical School, Tel-Aviv University, Ramat-Gan, Israel
| | - Nachshon Knoller
- Department of Neurologic Surgery, Sheba Medical Center, Sackler Medical School, Tel-Aviv University, Ramat-Gan, Israel
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Calek AK, Widmer J, Fasser MR, Farshad M. Lumbar vertebropexy after unilateral total facetectomy. Spine J 2023; 23:1730-1737. [PMID: 37451550 DOI: 10.1016/j.spinee.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 07/02/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND CONTEXT Posterior decompression with spinal instrumentation and fusion is associated with well-known complications. Alternatives that include decompression and restoration of native stability of the motion segment without fusion continue to be explored, however, an ideal solution has yet to be identified. PURPOSE The aim of this study was to test two different synthetic lumbar vertebral stabilization techniques that can be used after unilateral total facetectomy. STUDY DESIGN Biomechanical cadaveric study. METHODS Twelve spinal segments were biomechanically tested after unilateral total facetectomy and stabilized with a FiberTape cerclage. The cerclage was pulled through the superior and inferior spinous process (interspinous technique) or through the spinous process and around both laminae (spinolaminar technique). The specimens were tested after (1) unilateral total facetectomy, (2) interspinous vertebropexy and (3) spinolaminar vertebropexy. The segments were loaded in flexion-extension (FE), lateral shear (LS), lateral bending (LB), anterior shear (AS) and axial rotation (AR). RESULTS Unilateral facetectomy increased native ROM in FE by 10.6% (7.6%-12.6%), in LS by 25.8% (18.7%-28.4%), in LB 7.5% (4.6%-12.7%), in AS 39.4% (22.6%-49.2%), and in AR by 27.2% (15.8%-38.6%). Interspinous vertebropexy significantly reduced ROM after unilateral facetectomy: in FE by 73% (p=.001), in LS by 23% (p=.001), in LB by 13% (p=.003), in AS by 16% (p=.007), and in AR by 20% (p=.001). In FE and LS the ROM was lower than in the baseline/native condition. In AS and AR, the baseline ROM was not reached by 17% and 1%, respectively. Spinolaminar vertebropexy significantly reduced ROM after unilateral facetectomy: in FE by 74% (p=.001), in LS by 24% (p=.001), in LB by 13% (p=.003), in AS by 28% (p=.004), and in AR by 15 % (p=.001). Baseline ROM was not reached by 9% in AR. CONCLUSION Interspinous vertebropexy seems to sufficiently counteract destabilization after unilateral total facetectomy, and limits range of motion in flexion and extension while avoiding full segmental immobilization. Spinolaminar vertebropexy additionally restores native anteroposterior stability, allowing satisfactory control of shear forces after facetectomy. CLINICAL SIGNIFICANCE Lumbar vertebropexy seems promising to counteract the destabilizating effect of facetectomy by targeted stabilization.
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Affiliation(s)
- Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland; Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Lengghalde 5, CH-8008, Zurich, Switzerland.
| | - Jonas Widmer
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Lengghalde 5, CH-8008, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Lengghalde 5, CH-8008, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland; University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
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13
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Li J, Cao S, Guo D, Lu T, Zang Q. Biomechanical properties of different anterior and posterior techniques for atlantoaxial fixation: a finite element analysis. J Orthop Surg Res 2023; 18:456. [PMID: 37365580 DOI: 10.1186/s13018-023-03905-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/03/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Many techniques for atlantoaxial fixation have been developed. However, the biomechanical differences among various atlantoaxial fixation methods remain unclear. This study aimed to evaluate the biomechanical influence of anterior and posterior atlantoaxial fixation techniques on fixed and nonfixed segments. METHODS An occiput-C7 cervical finite element model was used to construct 6 surgical models including a Harms plate, a transoral atlantoaxial reduction plate (TARP), an anterior transarticular screw (ATS), a Magerl screw, a posterior screw-plate, and a screw-rod system. Range of motion (ROM), facet joint force (FJF), disc stress, screw stress, and bone-screw interface stress were calculated. RESULTS The C1/2 ROMs were relatively small in the ATS and Magerl screw models under all loading directions except for extension (0.1°-1.0°). The posterior screw-plate system and screw-rod system generated greater stresses on the screws (77.6-1018.1 MPa) and bone-screw interfaces (58.3-499.0 MPa). The Harms plate and TARP models had relatively small ROMs (3.2°-17.6°), disc stress (1.3-7.6 MPa), and FJF (3.3-106.8 N) at the nonfixed segments. Changes in disc stress and FJF of the cervical segments were not consistent with changes in ROM. CONCLUSIONS ATS and Magerl screws may provide good atlantoaxial stability. The posterior screw-rod system and screw-plate system may have higher risks of screw loosening and breakage. The Harms plate and TARP model may more effectively relieve nonfixed segment degeneration than other techniques. The C0/1 or C2/3 segment may not be more susceptible to degeneration than other nonfixed segments after C1/2 fixation.
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Affiliation(s)
- Jie Li
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, 157Th West Fifth Road, Xi'an, 710004, Shaanxi Province, China
| | - Shuai Cao
- Department of Orthopedics, Civil Aviation General Hospital, No. 1, Gaojing Stress, Chaoyang District, Beijing, 100123, China
| | - Dong Guo
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, 157Th West Fifth Road, Xi'an, 710004, Shaanxi Province, China
| | - Teng Lu
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, 157Th West Fifth Road, Xi'an, 710004, Shaanxi Province, China.
| | - Quanjin Zang
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, 157Th West Fifth Road, Xi'an, 710004, Shaanxi Province, China.
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Ando M, Funayama T, Sakashita K, Asada T, Yamazaki M. Atlantoaxial Subluxation Associated With Chronic Motor Tics. Cureus 2023; 15:e37543. [PMID: 37193459 PMCID: PMC10182881 DOI: 10.7759/cureus.37543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/18/2023] Open
Abstract
Head jerking is one of the most common symptoms of motor tics, and because of this, patients are at an increased risk of cervical spine disorders. However, there have been no reports of atlantoaxial subluxation in the English literature. To the best of our knowledge, this is the first case of atlantoaxial subluxation associated with chronic motor tics. A 41-year-old man with a history of chronic motor tics since childhood was diagnosed with high cervical myelopathy due to atlantoaxial subluxation. The patient underwent posterior fusion surgery using atlantoaxial instrumentation and an autologous bone graft. Although screw breakage occurred as an early postoperative instrumentation failure, the clinical outcome was excellent after surgery without recurrence of subluxation. Other techniques such as atlantoaxial transarticular fixation and occipitocervical fusion followed by long-term external immobilization might be treatment options at the initial surgery, or in case of postoperative recurrent atlantoaxial subluxation.
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Affiliation(s)
- Miho Ando
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Toru Funayama
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Kotaro Sakashita
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Tomoyuki Asada
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
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15
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Can Axis C be a navigation route - CT comparison study between actual and virtual C1 transpedicular screw insertion. J Clin Neurosci 2023; 111:11-15. [PMID: 36913898 DOI: 10.1016/j.jocn.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/11/2023] [Accepted: 02/24/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Previous studies mainly reported perpendicular and medial inclination insertion methods for C1 transpedicular screw insertion (TSI). Our recent study showed the ideal C1 transpedicular screw trajectory (TST) can be achieved by medial inclination, perpendicular or even lateral inclination insertion, and Axis C can be a reliable trajectory. The purpose of this study is to confirm Axis C is an ideal C1 TST by comparing the cortical perforation differences between actual C1 TSI and virtual C1 transpedicular screw insertion along Axis C (Virtual C1 Axis C TSI). METHODS Firstly, the cortical perforations of the transverse foramen and vertebral canal caused by C1 TSIs in twelve randomly selected patients were evaluated based on their postoperative CT data. Secondly, Virtual C1 Axis C TSIs were performed based on same patients' preoperative CT data. Thirdly, the cortical perforation differences between actual and virtual screws were compared. RESULTS In actual C1 TSI group, there were thirteen locations of cortical perforation in the axial plane, with five sides in transverse foramen and eight sides in vertebral canal, the cortical perforation rate was 54.2%; the degree of perforation was mild in twelve locations and medium in one location. In contrast, there was no cortical perforation in Virtual C1 Axis C TSI group. CONCLUSIONS Axis C is an ideal trajectory for C1 TSI, it can be utilized as a navigation route for computer assisted surgery system.
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Wu C, Deng J, Zeng B, Wang Q, Shen D, Qiu G, Liu X, Wang X, Luo M. A Novel C2 Screw Corridor Parallel to the Sagittal Plane for Transpedicular Fixation - A 3D-CT Study. Clin Spine Surg 2023; 36:E101-E106. [PMID: 36070767 DOI: 10.1097/bsd.0000000000001375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A 3D-CT Study. OBJECTIVE To research the feasibility and advantages of screw corridors parallel to the sagittal plane (SPC) of the C2 for transpedicular fixation. SUMMARY OF BACKGROUND DATA A total of 125 patients were enrolled for analysis, and the 3D model of the C2 for the 125 patients were reconstructed and analyzed. METHODS The SPC screw and the corridor of the general pedicle (GPC) screw of both sides were inserted into these C2 models. The anatomic parameters of the SPC and GPC, including the inner circle diameter, length of the corridors, medial angle and cephalad angle, were measured and compared. The anatomic location of the entry point for the SPC screw was evaluated. RESULTS The diameter of the SPC averaged 5.5±1.8 mm; 81.2% (203/250) were larger than 4 mm. There was no significant difference between the SPC and GPC in diameter or percentage of diameter greater than 4 mm. There was a significant difference between the length of the SPC (25.3±2.4 mm) and the GPC (27.4±2.2 mm). The cephalad angle was 51.6±6.9° for the SPC and 43.3±4.4° for the GPC, and there was a significant difference between the SPC and GPC. The entry point of the SPC screw was located on the cortical crest at the lower 1/4 of the lamina and located to the lower and inner side of the GPC screw entry point. CONCLUSION It is feasible for most patients to accommodate an SPC screw with a diameter of 3.5 mm. All SPC screws crossed the pedicle completely. The optimal entry point of the SPC screw was located on the cortical crest of the axial lamina.
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Affiliation(s)
- Chao Wu
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Jiayan Deng
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Baifang Zeng
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China
| | - Qing Wang
- Department of Orthopedics, Hospital of Southwest Medical University, Luzhou, China
| | - Danwei Shen
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Guigang Qiu
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Xin Liu
- Health Management Center, Zigong Fourth People's Hospital, Zigong, China
| | - Xiangyu Wang
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China
| | - Min Luo
- Radiology department, Zigong Fourth People's Hospital, Zigong, China
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Martins RS, Pereira CS, Lemos C, Rodrigues-Pinto R. Posterior Atlantoaxial Screw Placement in a Portuguese Population: A Morphometric Analysis Based on Computed Tomography Scan Measurements. Rev Bras Ortop 2023; 58:48-57. [PMID: 36969775 PMCID: PMC10038719 DOI: 10.1055/s-0042-1744502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/20/2022] [Indexed: 10/17/2022] Open
Abstract
Objective The present study aims to evaluate the screw length and trajectory angles for posterior atlantoaxial fixation in a Portuguese population, through the study of cervical computed tomography (CT) scans. Methods Cervical CT scans of 50 adults were measured according to predefined screw trajectories of C1-C2 transarticular (C1C2TA), C1 lateral mass (C1LM), C2 pedicle (C2P), C2 pars and C2 laminar (C2L) screws. For each of these trajectories, screw length and angles were measured and compared between males and females. Results For the C1C2TA screw trajectory, the mean length, medial, and cranial angles were 34.12 ± 3.19 mm, 6.24° ± 3.06, and 59.25° ± 5.68, respectively, and for the C1LM screw trajectory, they were 27.12 ± 2.15 mm, 15.82° ± 5.07, and 13.53° ± 4.80, respectively. The mean length, medial, and cranial angles for the C2P screw trajectory were 23.44 ± 2.49 mm, 27.40° ± 4.88, and 30.41° ± 7.27, respectively; and for the C2 pars screw trajectory, they were 16.84 ± 2.08 mm, 20.09° ± 6.83, and 47.53° ± 6,97. The mean length, lateral, and cranial angles for the C2L screw trajectory were 29.10 ± 2.48 mm, 49.80° ± 4.71, and 21.56° ± 7.76, respectively. There were no gender differences except for the lengths of the C1C2TA ( p = 0,020) and C2L ( p = 0,001) screws, which were greater in males than in females. Conclusion The present study provides anatomical references for the posterior atlantoaxial fixation in a Portuguese population. These detailed data are essential to aid spine surgeons to achieve safe and effective screw placement.
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Affiliation(s)
- Rita Santos Martins
- Departamento de Ortopedia, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | | | - Carolina Lemos
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Ricardo Rodrigues-Pinto
- Departamento de Ortopedia, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
- Unidade Vertebro-Medular, Departamento de Ortopedia, Centro Hospitalar Universitário do Porto, Porto, Portugal
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Zou X, Yang H, Deng C, Fu S, Chen J, Ma R, Ma X, Xia H. The use of a novel reduction plate in transoral anterior C1-ring osteosynthesis for unstable atlas fractures. Front Surg 2023; 10:1072894. [PMID: 37206357 PMCID: PMC10188962 DOI: 10.3389/fsurg.2023.1072894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Background Transoral anterior C1-ring osteosynthesis has been reported as an effective treatment for unstable atlas fracture, which aims to preserve important C1-C2 motion. However, previous studies have shown that the anterior fixation plates used in this technique were not suitable for the anterior anatomy of the atlas and lacked an intraoperative reduction mechanism. Objective This study aims to evaluate the clinical effects of a novel reduction plate used in transoral anterior C1-ring osteosynthesis for unstable atlas fractures. Methods 30 patients with unstable atlas fractures treated by this technique from June 2011 to June 2016 were included in this study. The patients' clinical data and radiographs were reviewed, and the reduction of the fracture, internal fixation placement, and bone fusion were assessed using pre- and postoperative images. The patients' neurological function, rotatory range of motion, and pain levels were evaluated clinically during follow-up. Results All 30 surgeries were successfully performed, and the average follow-up duration was 23.5 ± 9.5 months (range 9-48 months). One patient suffered atlantoaxial instability during the follow-up and was treated with posterior atlantoaxial fusion. The remaining 29 patients had satisfactory clinical outcomes, with ideal fracture reduction, good screw and plate placement, well-preserved range of motion, neck pain alleviation and solid bone fusion. There were no vascular or neurological complications during the operation or follow-up. Conclusions The use of this novel reduction plate in transoral anterior C1-ring osteosynthesis is a safe and effective surgical option in the treatment of unstable atlas fractures. This technique offers an immediate intraoperative reduction mechanism, which provides satisfactory fracture reduction, bone fusion, and preservation of C1-C2 motion.
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Affiliation(s)
| | | | | | | | | | | | | | - Hong Xia
- Correspondence: Xiangyang Ma Hong Xia
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The morphological classification and clinical significance of atlas vertebral artery sulcus based on computed tomography three-dimensional reconstruction. Surg Radiol Anat 2023; 45:241-246. [PMID: 36715709 PMCID: PMC9981493 DOI: 10.1007/s00276-023-03079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 01/06/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of this study was to research the morphological classification and clinical significance of vertebral artery sulcus on atlas based on CT three-dimensional reconstruction. METHODS Three-dimensional reconstruction images of 300 adult atlases were collected. A total of 600 atlas vertebral artery sulci were selected in this study. The parameters required for placement of C1 pedicle screw, including depth of grinding drilling (ao), width (cd), length ab), height (H), lateral wall thickness (L1), inner wall thickness (L2), medial angle (∠α), and the cephalad angle to the transverse plane of atlas pedicle (∠β), were measured. RESULTS CT three-dimensional reconstruction images showed that there were five types of atlas vertebral artery sulci: no process type (n = 494 cases, 82.33%), upper process type (n = 29, 4.83%), lower process type (n = 25, 4.17%), double process type (n = 19, 3.17%), and posterior ring type (33, 5.50%). One-way ANOVA tests showed that the five groups differed significantly in the parameter of ao, L2, H, ∠α and ∠β. One-way ANOVA with the LSD post hoc tests showed that the parameter ao of the group of no process type was less than that of the group of upper or lower process type (P < 0.05), and ao of the group of lower process or posterior ring type was less than that of the group of the upper type (P < 0.05). The parameter of ao of the male group was larger than that of the female group. CONCLUSION No process type of the atlas vertebral artery sulcus was the most common, and the medial angle and cephalad angle of the atlas pedicle in this type were the smallest. When pedicle screws are inserted, the above two angles should not be too large. Male's ao was larger than that of female's. All these findings should be considered to avoid the deviation of the nail track.
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Fu SY, Liu H, Wang ZR, Wang B, Li XB, Huang AB. Ideal entry point and trajectory for C2 pedicle screw placement in children: a 3D computed tomography study. 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 2022; 31:3426-3432. [PMID: 36057908 DOI: 10.1007/s00586-022-07374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/13/2022] [Accepted: 08/28/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To identify the ideal entry point for pediatric C2 pedicle screw and to obtain parameters of it for the indication of pediatric atlantoaxial fusion arthrodesis. METHODS The pediatric cervical CT images were reconstructed into the 3D digital models and the C2 vertebrae were separated. The location of ideal entry point and screw placement related linear and angular parameters were assessed on the 3D digital models. RESULTS A total of 214 pedicles from 107 C2 digital models were analyzed. The average entry point for C2 was 3.80 ± 2.78 mm medial to the lateral notch (LN) and 2.57 ± 1.70 mm superior to the LN. The average pedicle diameter (PD) was 6.02 ± 1.31 mm, and the average pedicle screw length (PSL) was 25.63 ± 3.46 mm. Statistical differences were found between different sex for PD and PSL (P < 0.05). As patient age increases, using the most lateral and inferior edge of the lateral mass as a reference marker, the entry point tends to move medial and cephalad, when using the LN as a reference marker, the entry point tends to move medial and slightly caudad. Univariate linear regression analysis suggested that these linear parameters were associated with age (P < 0.01). CONCLUSION In this study, we found that the measurement results of C2 pedicle screw varied based on sex, laterality, and ages for children younger than 18 years. The entry point of the screws facilitating ideal trajectory tends to change in a linear way as a function of age. This information helps the surgeon to establish the specific anatomy related to C2 pedicle screw placement to facilitate fixation in the pediatric patients.
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Affiliation(s)
- Sheng-Yu Fu
- Department of Orthopedics, Taizhou People's Hospital Affiliated to Nanjing Medical University, Taizhou, 225300, Jiangsu, China.,Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Huan Liu
- Department of Orthopedics, Xi'an People's Hospital, Xi'an, 710000, Shaanxi, China
| | - Zhao-Rui Wang
- Department of Orthopedics, Taizhou People's Hospital Affiliated to Nanjing Medical University, Taizhou, 225300, Jiangsu, China.,Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Bang Wang
- Department of Orthopedics, Taizhou People's Hospital Affiliated to Nanjing Medical University, Taizhou, 225300, Jiangsu, China.,Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Xing-Bin Li
- Department of Orthopedics, Taizhou People's Hospital Affiliated to Nanjing Medical University, Taizhou, 225300, Jiangsu, China.,Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Ai-Bing Huang
- Department of Orthopedics, Taizhou People's Hospital Affiliated to Nanjing Medical University, Taizhou, 225300, Jiangsu, China. .,Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China.
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Zhou LP, Shang J, Zhang ZG, Jiang ZF, Zhang HQ, Jia CY, Zhang RJ, Shen CL. Characteristics and Comparisons of Morphometric Measurements and Computed Tomography Hounsfield Unit Values of C2 Laminae for Translaminar Screw Placement Between Patients With and Without Basilar Invagination. Neurospine 2022; 19:899-911. [PMID: 36597627 PMCID: PMC9816593 DOI: 10.14245/ns.2244730.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/24/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Patients with basilar invagination (BI) had high incidences of vertebral variations and high-riding vertebral artery (HRVA) that might restrict the use of pedicle or pars screw and increase the use of translaminar screw on axis. Here, we conducted a radiographic study to investigate the feasibility of translaminar screws and the bone quality of C2 laminae in patients with BI, which were compared with those without BI as control to provide guidelines for safe placement. METHODS In this study, a total of 410 patients (205 consecutive patients with BI and 205 matched patients without BI) and 820 unilateral laminae of the axis were included at a 1:1 ratio. Comparisons with regard to insertion parameters (laminar length, thickness, angle, and height) for C2 translaminar screw placement and Hounsfield unit (HU) values for the assessment of the appropriate bone mineral density of C2 laminae between BI and control groups were performed. Besides, the subgroup analyses based on the Goel A and B classification of BI, HRVA, atlas occipitalization, and C2/3 assimilation were also carried out. Furthermore, the factors that might affect the insertion parameters and HU values were explored through multiple linear regression analyses. RESULTS The BI group showed a significantly smaller laminar length, thickness, height, and HU value than the control group, whereas no significant difference was observed regarding the laminar angle. By contrast, the control group showed significantly higher rates of acceptability for unilateral and bilateral translaminar screw fixations than the BI group. Subgroup analyses showed that the classification of Goel A and B, HRVA, atlas occipitalization, and C2/3 assimilation affected the insertion parameters except the HU values. Multiple linear regression indicated that the laminar length was significantly associated with the male gender (B = 0.190, p < 0.001), diagnoses of HRVA (B = -0.109, p < 0.001), Goel A (B = -0.167, p < 0.001), and C2/3 assimilation (B = -0.079, p = 0.029); the laminar thickness was significantly associated with the male gender (B = 0.353, p < 0.001), diagnoses of HRVA (B = -0.430, p < 0.001), Goel B (B = -0.249, p = 0.026), and distance from the top of odontoid to the Chamberlain line (B = -0.025, p = 0.003); laminar HU values were significantly associated with age (B = -2.517, p < 0.001), Goel A (B = -44.205, p < 0.001), Goel B (B = -25.704, p = 0.014), and laminar thickness (B = -11.706, p = 0.001). CONCLUSION Patients with BI had narrower and smaller laminae with lower HU values and lower unilateral and bilateral acceptability for translaminar screws than patients without BI. Preoperative 3-dimensional computed tomography (CT) and CT angiography were needed for BI patients.
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Affiliation(s)
- Lu-Ping Zhou
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jin Shang
- Department of Radiology, the First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Zhi-Gang Zhang
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Zhen-Fei Jiang
- Department of Orthopedics, the First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Hua-Qing Zhang
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chong-Yu Jia
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ren-Jie Zhang
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China,Co-corresponding Author Ren-Jie Zhang Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui 230022, China
| | - Cai-Liang Shen
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China,Corresponding Author Cai-Liang Shen Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui 230022, China
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Atlas (C1) lateral mass screw placement using the intersection between lateral mass and inferomedial edge of the posterior arch: a cadaveric study. 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 2022; 31:3443-3451. [PMID: 36117232 DOI: 10.1007/s00586-022-07385-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/23/2022] [Accepted: 09/07/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To compare the Atlas (C1) lateral mass screw placement between screw trajectories of 0° and 15° medial angulation while using the intersection between lateral mass and inferomedial edge of the posterior arch. METHODS Forty-eight Atlas lateral masses were prepared and divided into 2 groups: Group 1; screws inserted at 3 mm lateral to the reference point with screw trajectory of 0° angulation(N = 24) and Group 2; those inserted with screw trajectory of 15° medial angulation(N = 24). We evaluated the atlas anatomy, screw purchase and the presence of any breaches using CT scan. RESULTS The radiographic parameters for Groups 1 and 2 were found statistically different (p-value < 0.05): bilateral intraosseous screw lengths (17.92 ± 1.47 mm. vs. 20.71 ± 2.4 mm.), bilateral screw length (29.92 ± 1.72 mm. vs. 33.13 ± 1.78 mm.), left screw medial angulation (x°) (0.67° ± 0.78° vs.14.17° ± 3.51°), right screw medial angulation (y°) (0.83° ± 1.03° vs.14.25° ± 2.53°) and bilateral screw medial angulation (0.75° ± 0.9° vs. 14.21° ± 2.99°). Twenty-two screws (91.67%) using the 0° medial angulation and nineteen screws (79.17%) using the 15° medial angulation had no cortical violations (Grade 0). However, two screws (8.33%) with 0° medial angulation and five screws (20.83%) with 15° medial angulation had breach less than 2 mm (Grade 1). There were no screws with breach between 2 and 4 mm (Grade 2) or greater than 4 mm. (Grade 3). CONCLUSION A starting point of 3-mm lateral to the intersection between lateral mass and inferomedial edge of the Atlas posterior arch can be safely and effectively used to insert C1 lateral mass using both 0° and 15° medial angulation.
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Erbulut DU, Mumtaz M, Zafarparandeh I, Özer AF. Biomechanical Study on Three Screw-Based Atlantoaxial Fixation Techniques: A Finite Element Study. Asian Spine J 2022; 16:831-838. [PMID: 35378577 PMCID: PMC9827200 DOI: 10.31616/asj.2021.0270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/19/2021] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN This is a finite element study. PURPOSE This study is aimed to compare the biomechanical behaviors of three screw-based atlantoaxial fixation techniques. OVERVIEW OF LITERATURE Screw-based constructs that are widely used to stabilize the atlantoaxial joint come with their own challenges in surgery. Clinical and in vitro studies have compared the effectiveness of screw-based constructs in joint fixation. Nevertheless, there is limited information regarding the biomechanical behavior of these constructs, such as the stresses and strains they experience. METHODS A finite element model of the upper cervical spine was developed. A type II dens fracture was induced in the intact model to produce the injured model. The following three constructs were simulated on the intact and injured models: transarticular screw (C1- C2TA), lateral mass screw in C1 and pedicle screw in C2 (C1LM1-C2PD), and lateral mass screw in C1 and translaminar screw in C2 (C1LM1-C2TL). RESULTS In the intact model, flexion-extension range of motion (ROM) was reduced by up to 99% with C11-C2TA and 98% with C1LM1-C2PD and C1LM1-C2TL. The lateral bending ROM in the intact model was reduced by 100%, 95%, and 75% with C11-C2TA, C1LM1-C2PD, and C1LM1-C2TL, respectively. The axial rotation ROM in the intact model was reduced by 99%, 98%, and 99% with C11-C2TA, C1LM1-C2PD, and C1LM1-C2TL, respectively. The largest maximum von Mises stress was predicted for C1LM1-C2TL (332 MPa) followed by C1LM1-C2PD (307 MPa) and C11-C2TA (133 MPa). Maximum stress was predicted to be at the lateral mass screw head of the C1LM1-C2TL construct. CONCLUSIONS Our model indicates that the biomechanical stability of the atlantoaxial joint in lateral bending with translaminar screws is not as reliable as that with transarticular and pedicle screws. Translaminar screws experience large stresses that may lead to failure of the construct before the required bony fusion occurs.
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Affiliation(s)
- Deniz Ufuk Erbulut
- Herston Biofabrication Institute, Metro North Hospital and Health Service, Brisbane, QLD,
Australia
| | - Muzammil Mumtaz
- Engineering Center for Orthopaedic Research Excellence (ECORE), University of Toledo, Toledo, OH,
USA
| | - Iman Zafarparandeh
- Department of Biomedical Engineering, Istanbul Medipol University, Istanbul,
Turkey
| | - Ali Fahir Özer
- Department of Neurosurgery, Koc University School of Medicine, Istanbul,
Turkey
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González DCN, Ardura Aragón F, Sanjuan JC, Maniega SS, Andrino AL, García Fraile R, Labrador Hernández G, Calabia-Campo J, Caballero-García A, Córdova-Martínez A. C1-C2 Rotatory Subluxation in Adults “A Narrative Review”. Diagnostics (Basel) 2022; 12:diagnostics12071615. [PMID: 35885520 PMCID: PMC9316247 DOI: 10.3390/diagnostics12071615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022] Open
Abstract
The atlantoaxial joint C2 (axis) with the anterior arch of C1 (atlas) allows 50% of cervical lateral rotation. It is responsible for precise and important movements that allow us to perform precise actions, both in normal and working life. Due to low incidence in adults, this condition often goes undiagnosed, or the diagnosis is delayed and the outcome is worse. An early diagnosis and treatment are essential to ensure satisfactory neurological and functional outcomes. The aim of this review is to analyze C1-C2 rotatory subluxation in adults, given its rarity. The time between injury and reduction is key, as it is directly related to prognosis and the severity of the treatment options. Due to low incidence in adults, this condition often goes undiagnosed, or the diagnosis is delayed as a lot of cases are not related to a clear trauma, with a poor prognosis just because of the late diagnosis and the outcome is worse. The correct approach and treatment of atlantoaxial dislocation requires a careful study of the radiological findings to decide the direction and plane of the dislocation, and the search for associated skeletal anomalies.
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Affiliation(s)
- David C. Noriega González
- Department of Surgery, Ophthalmology, Otorhinolaryngology and Physiotherapy, Faculty of Medicine, University of Valladolid, 47005 Valladolid, Spain; (D.C.N.G.); (F.A.A.)
| | - Francisco Ardura Aragón
- Department of Surgery, Ophthalmology, Otorhinolaryngology and Physiotherapy, Faculty of Medicine, University of Valladolid, 47005 Valladolid, Spain; (D.C.N.G.); (F.A.A.)
- Department of Orthopedic, Clinic University Hospital of Valladolid, 47005 Valladolid, Spain; (J.C.S.); (S.S.M.); (A.L.A.); (R.G.F.); (G.L.H.)
| | - Jesús Crespo Sanjuan
- Department of Orthopedic, Clinic University Hospital of Valladolid, 47005 Valladolid, Spain; (J.C.S.); (S.S.M.); (A.L.A.); (R.G.F.); (G.L.H.)
| | - Silvia Santiago Maniega
- Department of Orthopedic, Clinic University Hospital of Valladolid, 47005 Valladolid, Spain; (J.C.S.); (S.S.M.); (A.L.A.); (R.G.F.); (G.L.H.)
| | - Alejandro León Andrino
- Department of Orthopedic, Clinic University Hospital of Valladolid, 47005 Valladolid, Spain; (J.C.S.); (S.S.M.); (A.L.A.); (R.G.F.); (G.L.H.)
| | - Rubén García Fraile
- Department of Orthopedic, Clinic University Hospital of Valladolid, 47005 Valladolid, Spain; (J.C.S.); (S.S.M.); (A.L.A.); (R.G.F.); (G.L.H.)
| | - Gregorio Labrador Hernández
- Department of Orthopedic, Clinic University Hospital of Valladolid, 47005 Valladolid, Spain; (J.C.S.); (S.S.M.); (A.L.A.); (R.G.F.); (G.L.H.)
| | - Juan Calabia-Campo
- Department of Radiology, Clinic University Hospital of Valladolid, 47005 Valladolid, Spain;
| | - Alberto Caballero-García
- Department of Anatomy and Radiology, Health Sciences Faculty, GIR: “Physical Exercise and Aging”, University of Valladolid, Campus Universitario “Los Pajaritos”, 42004 Soria, Spain;
| | - Alfredo Córdova-Martínez
- Department of Biochemistry, Molecular Biology and Physiology, Health Sciences Faculty, GIR: “Physical Exercise and Aging”, University of Valladolid, Campus Universitario “Los Pajaritos”, 42004 Soria, Spain
- Correspondence:
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Cho S, Shlobin NA, Dahdaleh NS. Os odontoideum: A comprehensive review. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:256-264. [PMID: 36263339 PMCID: PMC9574117 DOI: 10.4103/jcvjs.jcvjs_71_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
Os odontoideum (OO) is a rare craniocervical anomaly that is characterized by a round ossicle separated from the C2 vertebral body. With a controversial etiology and unknown prevalence in the population, OO may be asymptomatic or present in patients with myelopathic and neurological symptoms. In this literature review, we aimed to investigate epidemiology, embryology, pathophysiology, clinical presentation, and the role of diagnostic radiography in OO. By providing an overview of different management strategies, surgical complications, and postoperative considerations for OO, our findings may guide neurosurgeons in providing proper diagnosis and treatment for OO patients. A literature review was conducted using the PubMed, EMBASE, and Scopus databases. A search using the query "os odontoideum" yielded 4319 results, of which 112 articles were chosen and analyzed for insights on factors such as etiology, clinical presentation, and management of OO. The presentation of OO varies widely from asymptomatic cases to severe neurological deficits. Asymptomatic patients can be managed either conservatively or surgically, while symptomatic patients should undergo operative stabilization. Although multiple studies show different techniques for surgical management involving posterior fusion, the diversity of such cases illustrates how treatment must be tailored to the individual patient to prevent complications. Conflicting studies and the paucity of current literature on OO highlight poor comprehension of the condition. Further understanding of the natural history of OO is critical to form evidence-based guidelines for the management of OO patients. More large-center studies are thus needed to promote accurate management of OO patients with optimal outcomes.
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Affiliation(s)
- Sia Cho
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nathan A. Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nader S. Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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The medial window technique as a salvage method to insert C2 pedicle screw in the case of a high-riding vertebral artery or narrow pedicle: a technical note and case series. 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 2022; 31:1251-1259. [PMID: 35249142 DOI: 10.1007/s00586-022-07146-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/21/2021] [Accepted: 02/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To describe the safety and feasibility of C2 medial window screw (C2MWS) as an alternative salvage method for C2 pedicle screws in cases of high-riding vertebral artery (HRVA) or narrow pedicle. METHODS The C2MWS technique involves screw insertion by intentionally breaching the medial cortex of the pedicle to avoid vertebral artery injury. Twelve patients who underwent C2 screw insertion via the C2MWS were retrospectively reviewed. C2MWS was indicated in cases of high-riding vertebral artery (HRVA) or narrow pedicle (pedicle width ≤ 4 mm). The width of the canal breach by screw, vertebral artery groove (VAG) breach, solid fusion, neck pain visual analogue scale (VAS) score, and Japanese Orthopedic Association (JOA) score were assessed as outcome measurements. RESULTS C2MWS was indicated due to both HRVA and narrow pedicle for 11 screws, narrow pedicle for one screw, and HRVA for two screws. No screw VAG breach or vertebral artery injury was noted postoperatively. The mean width of canal breach was 2.9 ± 1.3 mm. There were no cases demonstrating neurologic deterioration, and 11 patients (91.7%) demonstrated solid fusion at 1-year follow-up. Furthermore, neck pain VAS and JOA scores significantly improved after the surgery. CONCLUSIONS The C2MWS technique can provide 3-column fixation while reliably avoiding VA injury. C2MWS could be considered as a salvage alternative method when the insertion of C2 pedicle screw is complicated by HRVA or a narrow pedicle, while there is a need to provide firmer fixation strength than that provided by pars or translaminar screws. LEVEL OF EVIDENCE: 4
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Asymmetry of the C2 pars interarticularis: a clinical anatomical study with relevance to screw placement. Surg Radiol Anat 2022; 44:423-429. [PMID: 35217894 DOI: 10.1007/s00276-022-02901-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/28/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Potential asymmetries of the C2 posterior elements pose a problem for the spine surgeon seeking to make the best choice for spinal stabilization while reducing morbidity. METHODS A digital caliper was used to measure the pars interarticularis height and length on left and right sides of 25 adult C2 vertebrae. The pars interarticularis was defined as the bone between the posterior most aspect of the superior articular process and the anterior most aspect of the inferior articular process of C2. Also, the C2 vertebrae from 49 patients were scanned by CT. Parasagittal images were reviewed and using the same definitions as were used for the skeletal specimens, the length and the height of the C2 pars interarticularis from both the left and right sides were measured using CT. The image slices were acquired at 3 mm intervals. The pars interarticularis height was determined on sagittal CT reconstruction, while the pars interarticularis length was calculated on the basis of the axial images. RESULTS The lengths and the heights of the left and right pars interarticularis were compared using CTs of patients and skeletal specimens. No significant differences were found in the length and height measurements of the CT images on both sides. However, in the skeletal specimens, the left and right pars interarticularis did not differ significantly in length but differed significantly in height (p = 0.003). The mean height of the left pars interarticularis was approximately two times larger than the right in the skeletal specimens. Absolute differences were calculated between the side with the greater length and height and the side with the lesser length and height irrespective of their left-right orientations. For CT measurements, most differences in length and height between the greater pars interarticularis and lesser pars interarticularis occurred between 0 and 1 mm with each successive disparity interval yielding lower numbers. Skeletal measurements revealed a similar length disparity distribution to the CT measurements. However, height measurements in the skeletal specimens varied widely. Eight pars interarticularis specimens demonstrated a height difference between 0 and 1 mm. No dry bone pars interarticularis specimens demonstrated a height difference between 1 and 2 mm. The pars interarticularis of nine specimens demonstrated a height difference between 2 and 3 mm. Two demonstrated a height difference between 3 and 4 mm. Four demonstrated a height difference between 4 and 5 mm and two demonstrated a height difference greater than 5 mm. The greater pars interarticularis lengths and heights were combined and compared to their lesser counterparts on CT and skeletal measurements. In all measurements of this type, significant differences were found in the pars interarticularis length and height, whether measured through CT or via digital calipers. CONCLUSION Asymmetry between the left and right C2 pars interarticularis as shown in the present study can alter surgical planning. Therefore, knowledge of this anatomical finding might be useful to spine surgeons.
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Byun CW, Lee DH, Park S, Lee CS, Hwang CJ, Cho JH. The association between atlantoaxial instability and anomalies of vertebral artery and axis. Spine J 2022; 22:249-255. [PMID: 34500076 DOI: 10.1016/j.spinee.2021.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/27/2021] [Accepted: 08/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT A screw-rod system is the most widely used technique for atlantoaxial instability (AAI). However, neglecting anomalies of the vertebral artery and axis could lead to fatal complications. Whether or not the presence of AAI is associated with a more complicated anatomy for instrumentation is unclear. PURPOSE To analyze the association between AAI and anomalies of the vertebral artery and axis in patients with and without AAI. STUDY DESIGN A retrospective comparative study. PATIENT SAMPLE One hundred and twenty patients who underwent preoperative 3-dimensional computed tomography with vertebral angiography of the cervical spine at our institution from 2012 to 2020. OUTCOME MEASURES The C2 isthmus height, internal height of the C2 lateral mass, and C2 pedicle width were radiologically assessed. METHODS A case control study with matched cohort analysis was conducted. One hundred and twenty patients were divided into 2 groups according to presence of AAI, and the presence of high-riding vertebral artery (HRVA) and a narrow pedicle for insertion of the C2 pedicle screw was assessed, as was the prevalence of extraosseous vertebral artery anomaly. RESULTS The C2 isthmus height, C2 internal height, and C2 pedicle width were significantly narrower in the AAI group (p<.01, <.01, and <.01, respectively). A significantly greater proportion of patients with AAI had HRVA and a narrow pedicle than those without (p<.01 and < 0.01, respectively). Among patients with AAI, the C2 internal height was significantly narrower in patients with rheumatoid arthritis (p<.01). Five patients (8.3%) with AAI had vertebral artery anomaly (3 fenestration, 2 persistent first intersegmental artery), while there were no vertebral artery anomalies in patients without AAI (p<.01). CONCLUSIONS Vertebral artery anomalies are more common in patients with AAI. Furthermore, posterior instrumentation in patients with AAI has a narrower safe zone compared to that in patients without AAI, which may be caused by a long-lasting deformity rather than a congenital deformity. Therefore, more thorough preoperative evaluation of the anatomy should be performed in these patients.
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Affiliation(s)
- Chan Woong Byun
- Department of Orthopedic Surgery, Seoul Segyero Hospital, Seoul, Republic of Korea
| | - Dong-Ho Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul, Republic of Korea.
| | - Sehan Park
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Choon Sung Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul, Republic of Korea
| | - Chang Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul, Republic of Korea
| | - Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul, Republic of Korea
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Tatter C, Fletcher-Sandersjöö A, Persson O, Burström G, Edström E, Elmi-Terander A. Fluoroscopy-Assisted C1-C2 Posterior Fixation for Atlantoaxial Instability: A Single-Center Case Series of 78 Patients. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010114. [PMID: 35056423 PMCID: PMC8779556 DOI: 10.3390/medicina58010114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 01/10/2022] [Indexed: 04/21/2023]
Abstract
Background and Objectives: Posterior C1-C2 fixation, with trans-articular screws (TAS) or screw-rod-construct (SRC), is the main surgical technique for atlantoaxial instability, and can be performed with a fluoroscopy-assisted free-handed technique or 3D navigation. This study aimed to evaluate complications, radiological and functional outcome in patients treated with a fluoroscopy-assisted technique. Materials and Methods: A single-center consecutive cohort study was conducted of all adult patients who underwent posterior C1-C2 fixation, using TAS or CRS, between 2005-2019. Results: Seventy-eight patients were included, with a median follow-up time of 6.8 years. Trauma was the most common injury mechanism (64%), and cervicalgia the predominant preoperative symptom (88%). TAS was used in 33%, and SRC in 67% of cases. Surgery was associated with a significant reduction in cervicalgia (from 88% to 26%, p < 0.001). The most common complications were vertebral artery injury (n = 2, 2.6%), and screw malposition (n = 5, 6.7%, of which 2 were TAS and 3 were SRC). No patients deteriorated in their functional status following surgery. Conclusions: Fluoroscopy-assisted C1-C2 fixation with TAS or SRC is a safe and effective treatment for atlantoaxial instability, with a low complication rate, few surgical revisions, and pain relief in the majority of the cases.
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Affiliation(s)
- Charles Tatter
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
- Correspondence: ; Tel.: +46-8-517-74-126
| | - Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Oscar Persson
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Gustav Burström
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Erik Edström
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
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Karthigeyan M, Salunke P. Neck Tilt in a Child. J Pediatr 2021; 237:308-309. [PMID: 34126120 DOI: 10.1016/j.jpeds.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/04/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Madhivanan Karthigeyan
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Benomar A, Westwick HJ, Obaid S, Nzokou A, Yuh SJ, Shedid D. Atlantoaxial wiring hardware failure resulting in intracranial hemorrhage and hydrocephalus: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21211. [PMID: 35854788 PMCID: PMC9265237 DOI: 10.3171/case21211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Atlantoaxial sublaminar wiring has many known complications related to hardware failure, but intracranial hemorrhage is a rare complication. OBSERVATIONS A 61-year-old female patient with prior atlantoaxial sublaminar wiring for odontoid fracture nonunion experienced decreased level of consciousness due to a subarachnoid and subdural hemorrhage of the posterior fossa with intraventricular extension and hydrocephalus. Rupture of the sublaminar wire with intramedullary protrusion was the cause of the hemorrhage. The patient was treated with ventriculostomy for hydrocephalus and occipital cervical fusion for spinal instability, along with removal of the broken wire and drainage of a hematoma. LESSONS This uncommon cause of intracranial hemorrhage highlights an additional risk of atlantoaxial sublaminar wiring compared with other atlantoaxial fusion techniques. In addition, this case suggests cervical instrumentation failure as a differential diagnosis of subarachnoid and subdural hemorrhage of the posterior fossa when a history of prior instrumentation is known.
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Affiliation(s)
- Anass Benomar
- Department of Radiology, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Harrison J. Westwick
- Service of Neurosurgery, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Sami Obaid
- Division of Neurosurgery, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada; and
| | - André Nzokou
- Service of Neurosurgery, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Sung-Joo Yuh
- Division of Neurosurgery, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada; and
| | - Daniel Shedid
- Division of Neurosurgery, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada; and
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Zhang L, Wang H. Biomechanical Effects of Lateral Inclination C 1 and C 2 Pedicle Screws on Atlantoaxial Fixation. Orthop Surg 2021; 13:2027-2033. [PMID: 34541829 PMCID: PMC8528989 DOI: 10.1111/os.13137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the biomechanical effect of lateral inclination C1 and C2 pedicle screws on the atlantoaxial fixation through vitro human cadaveric study. Methods From January 2016 to December 2017, fresh‐frozen cadaveric cervical spines with intact ligaments from eight donated cadavers at an average age of 71.5 ± 10.6 years, comprising of six males and two females, were collected. There were no fracture and congenital malformation in all specimens according to the imaging examination. The range of motion (ROM) of the specimens were tested in their intact condition and destabilized condition. Next, the specimens were randomly divided into two groups to ensure no differences in sex and age: Group 1 was medial inclination C1 pedicle screw and C2 pedicle screws (C1MPS‐C2PS) and Group 2 was lateral inclination C1 pedicle screw and C2 pedicle screws (C1LPS‐C2PS). The ROM of the fixation scenarios were recorded. Thereafter, all the specimens with fixation constructs were tested for 1,000 cycles of axial rotation and tensile loading to failure was carried out collinearly to the longitudinal axis of all the screws, the data were documented as screw pullout strength (SPS) in newtons. All the recorded data subjected to quantitative analysis. Results The ROM of specimens was increased significantly in destabilized condition and significantly reduced in fixation condition compared with intact condition. In C1LPS‐C2PS groups, the C1‐C2 cervical segment showed 3.96° ±1.21° and 3.75° ± 1.33° in flexion and extension direction, 2.85° ± 0.91° and 2.96° ± 0.71° in right and left lateral bending, 2.20° ± 0.43° and 2.15° ± 0.40° in right and left axial rotation. In C1MPS‐C2PS groups, it showed 4.24° ±1.31° and 3.98° ± 1.21° in flexion and extension direction, 2.76° ± 1.10° and 3.23° ± 0.62° in right and left lateral bending, 2.20° ± 0.46° and 2.21° ± 0.42° in right and left axial rotation. There was no statistically significant difference on ROM and screw pullout strengths (764.29 ± 129.00 N vs 714.55 ± 164.63 N) between the two groups. However, there was one specimen in the C1MPS‐C2PS group showing rupture the inferior wall of the left screw trajectory owing to the relatively thin posterior arch of the atlas, the screw pullout strength was significantly reduced (left pullout strength value: 430.5 N, right pullout strength value: 748.4 N). Therefore, in the case of the thin posterior arch of the atlas, the C1LPS‐C2PS group had strong long‐term biomechanics. Conclusion The lateral inclination C1 pedicle screw can achieve the same biomechanical strength as the traditional atlas pedicle screw. However, for the case where the posterior arch of the atlas is relatively thin, a lateral inclination C1 pedicle screw is more suitable.
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Affiliation(s)
- Lei Zhang
- Department of Spine Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Huan Wang
- Department of Spine Surgery, Shengjing Hospital of China Medical University, Shenyang, China
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Zhu J, Wu J, Luo K, Wang Z, Jin H, Jin Y, Wang Y, Liu M, Liu P. Intraarticular bone grafting in atlantoaxial facet joints via a posterior approach: nonstructural or structural-a minimum 24-month follow-up. J Orthop Surg Res 2021; 16:524. [PMID: 34425867 PMCID: PMC8381565 DOI: 10.1186/s13018-021-02630-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/24/2021] [Indexed: 11/10/2022] Open
Abstract
Objective To investigate the necessity of nonstructural or structural intraarticular bone grafting in atlantoaxial facet joints via a posterior approach and the influence by the presence of basilar invagination (BI). Methods From November 2016 to October 2018, patients who underwent posterior atlantoaxial or occipitocervical arthrodesis surgery at one institute were retrospectively reviewed. Operation records, preoperative and postoperative clinical status, and radiological films were analyzed. Results Thirty-three patients (19 without BI, 14 with BI) underwent posterior facet joint release followed by intraarticular bone grafting were enrolled finally. Twenty-four nonstructural (15 without BI, 9 with BI) and 9 structural (4 without BI, 5 with BI) grafting were performed. The average follow-up was 32.15±6.73 months (24–47 months). Among them, 1 (3.03%) implant failure occurred, and 32 (96.97%) achieved satisfactory neurological outcomes, including 28 (84.85%) complete and 4 (12.12%) acceptable reductions with complete fusion within 6 months. For patients without BI, structural and nonstructural grafting showed no significant difference in terms of reduction maintenance (100% vs 73.33%, p = 0.530), while for those with BI, structural grafting significantly increased the postoperative height of the joint space (5.67±1.22 mm vs 3.43±1.78 mm, p = 0.002) and maintained it much better than nonstructural grafting (88.89% vs 20.00%, p = 0.023), contributing notably to BI correction. Conclusion Intraarticular structural bone grafting in atlantoaxial facet joints has the advantage of maintaining anterior column height in the case of lateral mass collapse or when BI correction is needed; otherwise, nonstructural bone grafting is enough. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02630-z.
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Affiliation(s)
- Jun Zhu
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Jian Wu
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Keyu Luo
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Zhong Wang
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Huaijian Jin
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Yufei Jin
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Yingbo Wang
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Mingyong Liu
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, 400042, China.
| | - Peng Liu
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, 400042, China. .,State Key Laboratory of Trauma: Burns & Combined Wound, Institute for Traffic Medicine of Army Medical University, No. 10, Changjiangzhilu, Daping Street, Yuzhong District, Chongqing, 400042, China.
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Lasswell TL, Medley JB, Callaghan JP, Cronin DS, McKinnon CD, Singh S, Rasoulinejad P. Biomechanical comparison of a C1 posterior arch clamp with C1 lateral mass screws in constructs for C1-C2 fusion. Proc Inst Mech Eng H 2021; 235:1463-1470. [PMID: 34278841 PMCID: PMC8573685 DOI: 10.1177/09544119211032479] [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: 11/18/2022]
Abstract
The aim of this experimental study was to assess the biomechanical performance of a novel C1 posterior arch (C1PA) clamp compared with C1 lateral mass (C1LM) screws in constructs used to treat atlantoaxial instability. These constructs had either C2 pedicle (C2P) screws or C2 translaminar (C2TL) screws. Eight fresh-frozen human cadaveric ligamentous spine specimens (C0-C3) were tested under six conditions: the intact state, the destabilized state after a simulated odontoid fracture, and when instrumented with four constructs (C1LM-C2P, C1LM-C2TL, C1PA-C2P, C1PA-C2TL). Each specimen was tested in a spinal loading simulator that separately applied axial rotation, flexion-extension and lateral bending. In each test condition, displacement controlled angular motion was applied in both directions at a speed of 2 deg/s until a resulting moment of 1.5 Nm was achieved. The measured ranges of motion (ROM) of the C1-C2 segments were compared for each test condition using nonparametric Friedman tests. The destabilized state had significantly more C1-C2 motion (p < 0.05) than the intact state in all cases, and all constructs greatly reduced this motion. C2 pedicle screw constructs that used the C1PA clamp had significantly less C1-C2 motion (p < 0.05) than those with C1LM screws in flexion-extension as well as axial rotation and no statistically significant difference was detected in lateral bending. C2 translaminar screw constructs that used the C1PA clamp had significantly less C1-C2 motion (p < 0.05) than those with C1LM screws in flexion-extension and no statistically significant difference was detected in axial rotation or in lateral bending. Data from the current study suggested that constructs using the novel C1PA clamp would provide as good, or improved, biomechanical stability to the C1-C2 segment compared with constructs using C1LM screws.
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Affiliation(s)
- Timothy L Lasswell
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, Canada
| | - John B Medley
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Jack P Callaghan
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
| | - Duane S Cronin
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Colin D McKinnon
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
| | - Supriya Singh
- Division of Orthpaedic Surgery, Department of Surgery, Western University and Victoria Hospital, London Health Sciences Centre, London, ON, Canada
| | - Parham Rasoulinejad
- Division of Orthpaedic Surgery, Department of Surgery, Western University and Victoria Hospital, London Health Sciences Centre, London, ON, Canada
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Zhang L, Wang H. A novel segmentation method for cervical vertebrae based on PointNet++ and converge segmentation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 200:105798. [PMID: 33545639 DOI: 10.1016/j.cmpb.2020.105798] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/10/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Cervical spine instability is the key pathogenic factor for cervical spondylosis, which may easily cause cervical spinal cord nerve compression, numbness, weakness, and even paralysis of the limbs. The reconstruction of the internal fixation of the cervical spine is of great therapeutic significance, but is a high-risk and difficult procedure that requires precise planning. The high similarities between vertebrae may interfere with automatic operation planning; therefore, the segmentation of vertebrae is of great significance. METHODS Our segmentation algorithm has 3 parts. Firstly, an adaptive threshold filter to segment the cervical vertebra tissue structure form CT images. Secondly, segmentation of single vertebrae based on PointNet++ is introduced to segmentation cervical spine. Finally, converge segmentation which is based on edge information is utilized to clearly distinguish the edges of the two vertebrae to enhance the accuracy segmentation result. RESULTS Our approach improved the accuracy of the system up to 96.15%, and achieved the highest reported average score based on this dataset. We compared the results of the CNN and PointNet methods on a separate dataset of 240 CT scans with 18 classes and achieved a significantly higher performance for any given vertebra. Our experiments illustrated the promise and robustness of recent PointNet++-based segmentation of medical images. CONCLUSION The proposed method has better classification performance for segmentation cervical spine images, which segment a three-dimensional vertebral body directly and effectively. Furthermore, the precise segmentation of a single vertebral body can be used in automatic biomechanical analysis, computer-aided diagnosis and other aspects, so as to improve the level of automation in the treatment of cervical spondylosis.
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Affiliation(s)
- Lei Zhang
- Spine Surgery Unit, Shengjing Hospital of China Medical University, Shenyang, 110004 P.R.China
| | - Huan Wang
- Spine Surgery Unit, Shengjing Hospital of China Medical University; Address: No.36 Sanhao Street, Heping District, Shenyang, 110004, Liaoning Province, P.R.China.
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Occipital bone erosion induced by C1 pedicle screw as a late complication of atlantoaxial fixation: a case report and literature review. Spine Deform 2021; 9:621-625. [PMID: 33030699 DOI: 10.1007/s43390-020-00222-1] [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: 04/28/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The objective of this case report is to highlight occipital bone erosion as an unusual late complication of C1-C2 instrumented fixation. CASE PRESENTATION A 60-year-old man of a displaced Anderson type II odontoid fracture was surgically treated by C1-C2 pedicle screw fixation. Occipital bone erosions, caused by a repeat irritation of the end of rod to the occipital bone, were detected on multiplane reconstructed computed tomography at 3 months after surgery. The lesion progressed over time with increasing the C2 anteversion on radiological evaluations. Eventually, the bony shell had been reactively formed around the protruded screw-rod construct and the Oc-C1 segment had been spontaneously stabilized. Fortunately, he had experienced no symptoms caused by the lesion at 5-year follow-up. CONCLUSION The occipital bone erosion is an unusual late complication in C1-C2 posterior fixation using C1 pedicle screw. The increasing occipital-C1 lordosis compensating for the great C2 anteversion (high C2 slope) was related to the progression of the lesion. In C1-C2 pedicle screw fixation, surgeons should recognize a possibility of this complication and realize a relation between the occurrence of the lesion and the sagittal alignment of the cervical spine to take measures to avoid the complication.
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Chen Z, Yu H, Song C, Zhang L, Wu J, Xiao L, Lin B. Clinical outcomes of posterior laminectomy and pedicle screw fixation for upper cervical intraspinal tumors: a case series. J Int Med Res 2020; 48:300060520960318. [PMID: 33050748 PMCID: PMC7570786 DOI: 10.1177/0300060520960318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective This study was performed to introduce posterior laminectomy and pedicle screw fixation for the treatment of upper cervical spinal cord tumors and investigate the curative effects. Methods Eighteen patients (11 men, 7 women) who underwent surgical treatment of an upper cervical intraspinal tumor from January 2008 to June 2013 were reviewed. Clinical parameters including age, sex, affected spinal levels, lesion location, duration and type of symptoms, and pathological features were retrospectively investigated. Results The mean operation time was 181.9 ± 25.5 minutes (range, 135–240 minutes), and the mean blood loss volume was 1038.9 ± 284.2 mL (range, 750–1530 mL). The Frankel grade, Japanese Orthopaedic Association score, and Karnofsky performance status score were significantly better postoperatively than preoperatively. The radiographic examination revealed good bone graft fusion. Two patients developed tumor recurrence, while four patients developed intraoperative or postoperative complications. Conclusions Management of upper cervical intraspinal tumors by posterior laminectomy and pedicle screw fixation can relieve compression of the cervical cord and nerve root, thoroughly remove the tumor lesion, reconstruct the stability of the upper cervical spine, and improve patients’ quality of life.
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Affiliation(s)
- Zhida Chen
- Department of Orthopaedics, the Affiliated Southeast Hospital of Xiamen University, the 909th Hospital of PLA, Orthopaedic Center of People's Liberation Army, Zhangzhou, China
| | - Hui Yu
- Department of Orthopedic and Trauma Surgery, University Hospital Bonn, Germany
| | - Chao Song
- Department of Orthopaedics, the Affiliated Southeast Hospital of Xiamen University, the 909th Hospital of PLA, Orthopaedic Center of People's Liberation Army, Zhangzhou, China
| | - Li Zhang
- Department of Orthopaedics, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Jin Wu
- Department of Orthopaedics, the Affiliated Southeast Hospital of Xiamen University, the 909th Hospital of PLA, Orthopaedic Center of People's Liberation Army, Zhangzhou, China
| | - Lili Xiao
- Department of Ultrasound, the Affiliated Southeast Hospital of Xiamen University, the 909th Hospital of PLA, Zhangzhou, China
| | - Bin Lin
- Department of Orthopaedics, the Affiliated Southeast Hospital of Xiamen University, the 909th Hospital of PLA, Orthopaedic Center of People's Liberation Army, Zhangzhou, China
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Zou X, Ouyang B, Wang B, Yang H, Ge S, Chen Y, Ni L, Zhang S, Xia H, Wu Z, Ma X. Motion-preserving treatment of unstable atlas fracture: transoral anterior C1-ring osteosynthesis using a laminoplasty plate. BMC Musculoskelet Disord 2020; 21:538. [PMID: 32787814 PMCID: PMC7425063 DOI: 10.1186/s12891-020-03575-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/06/2020] [Indexed: 11/26/2022] Open
Abstract
Background C1-ring osteosynthesis is a valid alternative to posterior C1–C2 or C0–C2 fusion to preserve important C1–C2 motion in the treatment of unstable atlas fractures. Nevertheless, the fixation instruments used in current studies for transoral anterior C1-ring osteosynthesis were not suitable for anterior anatomy of the atlas or did not have reduction mechanism. We therefore present this report to investigate preliminary clinical effects of transoral anterior C1-ring osteosynthesis using a laminoplasty plate in unstable atlas fractures. Methods From January 2014 to December 2017, 13 patients with unstable atlas fractures were retrospectively reviewed. All patients were treated with transoral anterior C1-ring osteosynthesis using a laminoplasty plate. Pre- and postoperative images were obtained to assess reduction of the fracture, internal fixation placement, and bone union. Neurological function, range of motion, and pain levels were evaluated clinically on follow-up. Results The surgeries were successfully performed in all cases. The average follow-up duration was 16.6 ± 4.4 months (range 12–24 months). One patient suffered screw loosening after operation and underwent replacement operation subsequently. Satisfactory clinical outcomes were achieved in all patients with ideal fracture reduction, reliable plate placement, well-preserved range of motion, and neck pain alleviation. All patients achieved bone union of fractures without loss of reduction or implant failure or C1–C2 instability during the follow-up. No vascular or neurological complication was noted during the operation and follow-up. Conclusions Transoral anterior C1-ring osteosynthesis using a laminoplasty plate is a effective surgical treatment for unstable atlas fractures. This technique has a ingenious reduction mechanism, and can provide satisfactory bone union and preservation of C1–C2 motion.
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Affiliation(s)
- Xiaobao Zou
- The First School of Clinical Medicine, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China.,Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Beiping Ouyang
- The First School of Clinical Medicine, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China.,Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Binbin Wang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Haozhi Yang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Su Ge
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Yuyue Chen
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Ling Ni
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Shuang Zhang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Hong Xia
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Zenghui Wu
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Xiangyang Ma
- The First School of Clinical Medicine, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China. .,Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China.
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Sharma JK, Kalidindi KKV, Sangondimath G, Mallepally AR, Marathe N, Chhabra HS. Clinicoradiological outcomes of Goel and Harms fixation for atlantoaxial instability: An institutional experience. Surg Neurol Int 2020; 11:189. [PMID: 32754360 PMCID: PMC7395524 DOI: 10.25259/sni_350_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/22/2020] [Indexed: 11/04/2022] Open
Abstract
Background Few studies have reported on the long-term outcomes of Goel and Harms C1-C2 fusions in the Asian population. Methods This was a retrospective analysis of 53 patients undergoing Goel and Harms fixation (2010 -2018). Clinical outcomes were assessed utilizing the neck disability index (NDI), Japanese Orthopedic Association (JOA) score, and visual analog scale (VAS). Outcomes were then correlated with fusion rates (using dynamic X-rays), atlanto-dens interval (ADI), and space available for cord (SAC) data. Results The study's 53 patients averaged 49.98 years of age and included 42 males and 11 females. The mean preoperative versus postoperative scores on multiple outcome measures showed NDI 31.62 ± 11.05 versus decreased to 8.68 ± 3.76 post, mean JOA score (e.g., in 41 patients with myelopathy) improved from 13.20 ± 3.96 to 15.2 ± 2.17, and the mean VAS decreased from 4.85 ± 1.03 to 1.02 ± 0.87 and showed restoration of the ADI (1.96 ± 0.35 mm) and SAC (20.42 ± 0.35 mm). A 98.13% rate of C1-C2 fusion was achieved at 12 postoperative months. Conclusion Goel and Harms technique for C1-C2 fusion resulted in both good clinical and radiological outcomes.
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Affiliation(s)
- Jeevan Kumar Sharma
- Department of Spine Service, Indian Spinal Injuries Center, New Delhi, India
| | | | | | | | - Nandan Marathe
- Department of Spine Service, Indian Spinal Injuries Center, New Delhi, India
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The internal carotid artery and the atlas: anatomical relationship and implications for C1 lateral mass fixation. Surg Radiol Anat 2020; 43:87-92. [PMID: 32734343 DOI: 10.1007/s00276-020-02537-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The internal carotid artery (ICA) is potentially at risk during posterior fixation of C1. In this study, we performed a CT-based anatomical analysis of the relationship between the internal carotid artery and the lateral mass of the atlas. METHODS We analysed 30 CT angiography of the cervical spine, and we measured on both sides the distance of the carotid artery from the midline, distance of the ICA from the anterior cortex of C1 and from the ideal C1 screw entry point. We measured the angle between the sagittal plane passing through the entry point and the tangent line of the vessel. Separated statistical analysis between left and right sides, between male and female patients, and differentiation by age were also performed. RESULTS Sixty ICAs were studied. The mean distance of the ICA from the midline was 23.3 ± 4.3 mm, with a minimum of 15 mm. The distance between the ICA and the anterior cortical layer of C1 was 4.8 ± 2.7 mm, with a minimum of 1.1 mm. The distance between the screw entry point and the arterial wall was 22.6 ± 2.8 mm, with a minimum of 17.5 mm. The mean angle was 10.4°, with a minimum of 11°. CONCLUSIONS Although rare, intraoperative lesion of the ICA is reported and the spine surgeon must be aware of this risk. Careful preoperative planning is mandatory and the position of the ICA in relation to C1 must be assessed. The anatomical parameters presented in this paper can be useful to reduce the risk of ICA injury.
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de Lacerda Schickert S, van den Beucken JJ, Leeuwenburgh SC, Jansen JA. Pre-Clinical Evaluation of Biological Bone Substitute Materials for Application in Highly Loaded Skeletal Sites. Biomolecules 2020; 10:E883. [PMID: 32526829 PMCID: PMC7356650 DOI: 10.3390/biom10060883] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/31/2020] [Accepted: 06/02/2020] [Indexed: 12/27/2022] Open
Abstract
The development of bone substitute materials (BSMs) intended for load-bearing bone defects is highly complicated, as biological and mechanical requirements are often contradictory. In recent years, biological BSMs have been developed which allow for a more efficient integration of the material with the surrounding osseous environment and, hence, a higher mechanical stability of the treated defect. However, while these materials are promising, they are still far from ideal. Consequently, extensive preclinical experimentation is still required. The current review provides a comprehensive overview of biomechanical considerations relevant for the design of biological BSMs. Further, the preclinical evaluation of biological BSMs intended for application in highly loaded skeletal sites is discussed. The selected animal models and implantation site should mimic the pathophysiology and biomechanical loading patterns of human bone as closely as possible. In general, sheep are among the most frequently selected animal models for the evaluation of biomaterials intended for highly loaded skeletal sites. Regarding the anatomical sites, segmental bone defects created in the limbs and spinal column are suggested as the most suitable. Furthermore, the outcome measurements used to assess biological BSMs for regeneration of defects in heavily loaded bone should be relevant and straightforward. The quantitative evaluation of bone defect healing through ex vivo biomechanical tests is a valuable addition to conventional in vivo tests, as it determines the functional efficacy of BSM-induced bone healing. Finally, we conclude that further standardization of preclinical studies is essential for reliable evaluation of biological BSMs in highly loaded skeletal sites.
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Affiliation(s)
| | | | | | - John A. Jansen
- Department of Dentistry—Regenerative Biomaterials, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Philips van Leydenlaan 25, 6525EX Nijmegen, The Netherlands; (S.d.L.S.); (J.J.J.P.v.d.B.); (S.C.G.L.)
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Du YQ, Li T, Ma C, Qiao GY, Yin YH, Yu XG. Biomechanical evaluation of two alternative techniques to the Goel-Harms technique for atlantoaxial fixation: C1 lateral mass-C2 bicortical translaminar screw fixation and C1 lateral mass-C2/3 transarticular screw fixation. J Neurosurg Spine 2020; 32:682-688. [PMID: 31952043 DOI: 10.3171/2019.11.spine191178] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors conducted a study to investigate the biomechanical feasibility and stability of C1 lateral mass-C2 bicortical translaminar screw (C1LM-C2TL) fixation, C1 lateral mass-C2/3 transarticular screw (C1LM-C2/3TA) fixation, and C1LM-C2/3TA fixation with transverse cross-links (C1LM-C2/3TACL) as alternative techniques to the Goel-Harms technique (C1 lateral mass-C2 pedicle screw [C1LM-C2PS] fixation) for atlantoaxial fixation. METHODS Eight human cadaveric cervical spines (occiput-C7) were tested using an industrial robot. Pure moments that were a maximum of 1.5 Nm were applied in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). The specimens were first tested in the intact state and followed by destabilization (a type II odontoid fracture) and fixation as follows: C1LM-C2PS, C1LM-C2TL, C1LM-C2/3TA, and C1LM-C2/3TACL. For each condition, the authors evaluated the range of motion and neutral zone across C1 and C2 in all directions. RESULTS Compared with the intact spine, each instrumented spine significantly increased in stability at the C1-2 segment. C1LM-C2TL fixation demonstrated similar stability in FE and LB and greater stability in AR than C1LM-C2PS fixation. C1LM-C2/3TA fixation was equivalent in LB and superior in FE to those of C1LM-C2PS and C1LM-C2TL fixation. During AR, the C1LM-C2/3TA-instrumented spine failed to maintain segmental stability. After adding a cross-link, the rotational stability was significantly increased in the C1LM-C2/3TACL-instrumented spine compared with the C1LM-C2/3TA-instrumented spine. Although inferior to C1LM-C2TL fixation, the C1LM-C2/3TACL-instrumented spine showed equivalent rotational stability to the C1LM-C2PS-instrumented spine. CONCLUSIONS On the basis of our biomechanical study, C1LM-C2TL and C1LM-C2/3TACL fixation resulted in satisfactory atlantoaxial stabilization compared with C1LM-C2PS. Therefore, the authors believe that the C1LM-C2TL and C1LM-C2/3TACL fixation may serve as alternative procedures when the Goel-Harms technique (C1LM-C2PS) is not feasible due to anatomical constraints.
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Affiliation(s)
- Yue-Qi Du
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
| | - Teng Li
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
| | - Chao Ma
- 2Key Laboratory of Modern Measurement and Control Technology, Ministry of Education, Beijing Information Science and Technology University, Beijing, China
| | - Guang-Yu Qiao
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
| | - Yi-Heng Yin
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
| | - Xin-Guang Yu
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
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Huang PJ, Lin JH, Chiang YH. Miniplate-Augmented Interlaminar Fusion in C1-C2 Screwing. World Neurosurg 2020; 138:e634-e641. [PMID: 32173550 DOI: 10.1016/j.wneu.2020.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The interlaminar fusion combination involving C1-C2 screwing fixation is one of the most effective techniques for atlantoaxial dislocation or subluxation, and the bone graft is usually stabilized by wiring constructs. However, some adverse events were reported during the insertion of sublaminar wiring, such as accidentally damaging the spinal cord or dura. Thus we used the miniplate to stabilize the harvest bone graft on the C1-C2 laminar, which led to a shorter operation time and prevented spinal canal violation. This study investigated the safety and efficacy of the novel surgical technique, namely miniplate-augmented interlaminar fusion. METHODS We retrospectively reviewed 43 patients who underwent posterior atlantoaxial fusion with the miniplate-augmented iliac crest autograft at our institute. Complications related to surgery were recorded and calculated. After operation, patients were followed up through routine radiography to examine whether the fusion of the atlantoaxial segment was achieved. Success of fusion was defined as follows: 1) the presence of bone bridging between the bone graft and both the atlas and axis; and 2) the absence of movement of the atlantoaxial spinous process on flexion-extension radiography, which meant that the variation of length measured in 2 views, respectively, was <1 mm. The first time when radiography showed successful fusion after surgery was termed as fusion time and was recorded individually. In addition, overall fusion rates and mean fusion times were analyzed. RESULTS Of 43 patients, long-term follow-up data were available for 31 patients, whereas the remaining 12 patients had dropped out (mean follow-up duration, 24.91 months; range, 6-72 months). Among 31 patients, 22 (70.96%) were women and 9 (29.03%) were men. The mean age was 63.33 years. Regarding the etiology, atlantoaxial dislocations or subluxations were caused due to degeneration, rheumatoid arthritis, odontoid fracture, trauma, and os odontoideum in 14 (45%), 3 (10%), 5 (16%), 8 (26%), and 1 (3%) patient(s), respectively. Successful fusion was achieved in 30 (96.77%) patients, with a mean fusion time of 6.23 months, whereas only 1 (3.23%) patient did not meet the fusion criteria. No complications related to the miniplate occurred. We noted vertebral artery rupture not requiring blood transfusion in 1 patient, aspiration pneumonia in 1 patient, urinary tract infection in 1 patient, anemia requiring transfusion in 1 patient, and leg dysesthesia in 1 patient. No neurologic deficit was found. CONCLUSIONS Miniplate-augmented interlaminar fusion with C1-C2 screwing resulted in excellent fusion rates with a considerably low probability of complications. Hence this novel technique for bone graft fixation with atlantoaxial screwing has a good efficacy and safety and can serve as an alternative for bone graft fixation during C1-C2 fusion.
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Affiliation(s)
- Po-Jen Huang
- Department of Neurosurgery, Taipei Medical University, Taipei, Taiwan
| | - Jiann-Her Lin
- Department of Neurosurgery, Taipei Medical University, Taipei, Taiwan; Department of Surgery, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.
| | - Yung-Hsiao Chiang
- Department of Neurosurgery, Taipei Medical University, Taipei, Taiwan; Department of Surgery, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
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Zou X, Yang H, Ge S, Chen Y, Ni L, Zhang S, Xia H, Wu Z, Ma XY. Anterior Transoral Débridement Combined with Posterior Fixation and Fusion for Atlantoaxial Tuberculosis. World Neurosurg 2020; 138:e275-e281. [PMID: 32105878 DOI: 10.1016/j.wneu.2020.02.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Atlantoaxial tuberculosis (TB) is rare in clinical practice, accounting for only about 0.3%-1% of spinal TB. An anterior-only surgical approach cannot provide strong fixation, whereas a posterior approach cannot achieve complete removal of lesions. A method combining anterior and posterior approaches to treat atlantoaxial TB is advisable. The aim of this study was to evaluate the effectiveness of anterior transoral débridement combined with posterior fixation and fusion for atlantoaxial TB. METHODS Clinical data of 20 patients with atlantoaxial TB who underwent anterior transoral débridement combined with posterior fixation and fusion in our hospital were retrospectively analyzed. Antituberculosis drugs were administered for 18 months after surgery. Neurologic status, clinical symptoms, fusion, reduction, and complications were evaluated. RESULTS Surgeries were performed successfully in all 20 cases with no injuries to spinal cord, nerves, or blood vessels. Clinical symptoms were relieved in all 20 patients (100%). Postoperative Japanese Orthopaedic Association score, occipitocervical visual analog scale score, and atlantodental interval were significantly improved (P < 0.05). Average follow-up duration was 33 months (range, 24-48 months). Bony fusion was achieved in all 20 cases. No serious complications were documented during follow-up. CONCLUSIONS Anterior transoral débridement combined with posterior fixation and fusion is an effective treatment for atlantoaxial TB, achieving removal of lesions and stability.
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Affiliation(s)
- Xiaobao Zou
- First School of Clinical Medicine, Southern Medical University, Guangzhou, China; Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Haozhi Yang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Su Ge
- Graduate School, Guangzhou University of Traditional Chinese Medicine, Guangzhou, China; Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Yuyue Chen
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Ling Ni
- Graduate School, Guangzhou University of Traditional Chinese Medicine, Guangzhou, China; Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Shuang Zhang
- First School of Clinical Medicine, Southern Medical University, Guangzhou, China; Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Hong Xia
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Zenghui Wu
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Xiang-Yang Ma
- First School of Clinical Medicine, Southern Medical University, Guangzhou, China; Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China.
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Chen ZD, Wu J, Lu CW, Zeng WR, Huang ZZ, Lin B. C1-C2 Pedicle Screw Fixation for Pediatric Atlantoaxial Dislocation: Initial Results and Long-term Follow-up. J Pediatr Orthop 2020; 40:65-70. [PMID: 31923165 DOI: 10.1097/bpo.0000000000001111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are few studies reporting the use of atlantoaxial pedicle screws and the long-term effects of C1-C2 posterior fusion in children. Our study is to investigate the initial results of C1-C2 pedicle screw fixation for pediatric atlantoaxial dislocation (AAD) and assessed spontaneous change of postoperative radiography after a long-term follow-up period. METHODS Posterior pedicle screw fixations were performed in 21 pediatric patients with AAD. All the patients underwent implant removal 1 year after their initial surgery and had regular follow-up with an average duration of 76.4 months (range, 52 to 117 mo). Clinical and radiographic data were then collected and compared. RESULTS Frankel Grade was significantly improved at 3 months follow-up compared with pretreatment values. All patients had good bony fusion at a mean of 4.2±0.9 months (range, 3 to 6 mo) after treatment. None of the patients experienced worsening neurological symptoms or injury to the vertebral artery. However, 2 cases experienced minor complications. Following removal of the implants, no spinal deformities or subaxial instabilities were found. The mean angle of sagittal curvature increased from 12.1±2.4 degrees (range, 0 to 22 degrees) immediately postoperatively to 19.1±2.7 degrees (range, 6 to 31 degrees) at the final follow-up (P>0.05). CONCLUSIONS The results demonstrated that C1-C2 pedicle screw fixation could achieve satisfactory initial results for the management of the pediatric AAD. Moreover, removal of the metal implant after bony fusion did not increase the risk of spinal deformity or subaxial instability at long-term follow-up.
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Affiliation(s)
- Zhi-Da Chen
- Department of Orthopaedics, The Affiliated Southeast Hospital of Xiamen University, Orthopaedic Center of People's Liberation Army, Zhangzhou, People's Republic of China
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Tian W, Liu YJ, Liu B, He D, Wu JY, Han XG, Zhao JW, Fan MX. Guideline for Posterior Atlantoaxial Internal Fixation Assisted by Orthopaedic Surgical Robot. Orthop Surg 2020; 11:160-166. [PMID: 31025810 PMCID: PMC6594511 DOI: 10.1111/os.12454] [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: 03/08/2019] [Accepted: 03/19/2019] [Indexed: 12/01/2022] Open
Abstract
Atlantoaxial transarticular facet screw fixation (Magerl technique) and C1 lateral mass screws combined with C2 pedicle screws fixation (Harms technique) are the most commonly used techniques for posterior internal fixation in the upper cervical spine. Upper cervical spinal surgery is a technically demanding and challenging procedure because of complicated anatomical structures and frequent occurrence of anomalies. Accurate insertion of screws allows for stable and secure internal fixation, which is necessary for both techniques. Traditional methods under fluoroscopic assistance in this region cannot meet the requirements of high levels of accuracy and security during the procedure. Robot-assisted spinal surgery can provide accurate and reliable guidance during the screw insertion, which is evidenced in the literature. As a recently developed technique, robot-assisted surgery is supposed to be performed by skilled surgeons who have received standard training for robotic surgery. The standardized upper cervical spinal surgery assisted by the robot system needs to be introduced to these surgeons. Based on the consensus of consultant specialists, the literature review, and our local experience, this guideline included the introduction of the robotic system, the workflow of robot-assisted procedures, and the precautions to take during procedures. This guideline aims to provide a standardization of the robotic surgery for posterior atlantoaxial internal fixation.
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Affiliation(s)
- Wei Tian
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ya-Jun Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Bo Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Da He
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Jing-Ye Wu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Xiao-Guang Han
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Jing-Wei Zhao
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ming-Xing Fan
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
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Sangondimath G, Mallepally AR, Salimath S. Computed Tomography-Based Feasibility Study of C1 Posterior Arch Crisscrossing Screw Fixation. Asian Spine J 2020; 14:298-304. [PMID: 31906612 PMCID: PMC7280928 DOI: 10.31616/asj.2019.0199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/19/2019] [Indexed: 12/02/2022] Open
Abstract
Study Design Retrospective radiographic analysis. Purpose Posterior fixation of C1 using screws is the most popular technique among the various methods for C1 stabilization, but it places the surrounding neurovascular structures at risk. Approximately 20% of the population has an anomalous groove for the vertebral artery; therefore, salvage methods are necessary. Therefore, we analyzed the feasibility of a newer C1 posterior arch crisscrossing screw fixation technique and studied its feasibility in the Indian population on the basis of the anatomy of the C1 posterior arch. Overview of Literature Multiple techniques have been described for C1–C2 fixation, such as wiring techniques, interlaminar clamps, transarticular screws, screw-plate/screw-rod system fixation, and hook-screw system fixation techniques, to provide rigid C1–C2 stability. However, although C1 fixation has evolved with time, it is not complication-free. Methods A 100 computed tomography (CT) scans of cervical spines with 1 mm slice thickness in the axial and sagittal sections obtained were randomly selected for the evaluation. Atlantoaxial anomalies due to trauma, deformities, infections, and tumors were excluded. All the images were measured for height of the posterior tubercle, width of the posterior arch, and length of the screw, and the screw projection angle was calculated. Demographic data were collected for all the subjects. Results Out of the 88 CT scans analyzed, the mean height of the posterior tubercle was 7.4 mm, wherein 84.09% exceeded 7 mm, and the width of the posterior tubercle was 5.4 mm, wherein 88.6% (n=78) had posterior arch width >3.5 mm. A total of 13.6% (n=12) vertebrae were not suitable for screw placement, whereas 75% (n=66) vertebrae could accommodate 3.5×15 mm or longer screws. The screw projection angles ranged from 11.2° to 35° on the right and from 15.6° to 38.2° on the left. Conclusions C1 posterior arch screw fixation is a feasible and safe method because it poses little risk of injury to the surrounding neurovascular structures.
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Affiliation(s)
| | | | - Suman Salimath
- Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India
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Buchmann N, Schweizer C, Kirschke JS, Rienmüller A, Gempt J, Ringel F, Meyer B, Ryang YM. C1–C2 posterior screw fixation in atlantoaxial fractures revisited: technical update based on 127 cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:1036-1042. [DOI: 10.1007/s00586-019-06244-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 10/13/2019] [Accepted: 11/28/2019] [Indexed: 11/28/2022]
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Wang HW, Yin YH, Li T, Yu XG, Qiao GY. Effects of transverse connector on reduction and fixation of atlantoaxial dislocation and basilar invagination using posterior C1-C2 screw-rod technique. Spine J 2019; 19:1995-2002. [PMID: 31254651 DOI: 10.1016/j.spinee.2019.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The mechanical strength provided by internal fixation is crucial for maintaining reduction and facilitating bony fusion. Though satisfactory results with the C1-C2 technique have been acquired in most clinical reports, the related problems of fusion delay and pseudarthrosis still exist. To increase the chance of bony fusion, a transverse connector (TC) is frequently used to augment torsional stiffness of thoracolumbar screw/rod constructs. Nevertheless, the clinical implication of TC in the management of atlantoaxial dislocation (AAD) and basilar invagination (BI) remains largely unknown. PURPOSE To evaluate the effects of TC application on C1-C2 screw-rod constructs based on consecutive adult patients with AAD and BI in a single institution over a 10-year period. STUDY DESIGN A retrospective study. PATIENT SAMPLE Patients with AAD and BI, who were treated with posterior C1-C2 screw-rod technique with or without TC usage from June 2007 to June 2017 at a single institution. OUTCOME MEASURES The radiological measurements included the anterior atlantodental interval (AADI), posterior atlantodental interval (PADI), height of odontoid process above Chamberlain line, and cervicomedullary angle (CMA). Patients' neurologic status was evaluated with the Japanese Orthopaedic Association (JOA) score. Fusion status was evaluated at different follow-up periods. METHODS We compared the difference of clinical, radiological, and surgical outcomes between the TC and NTC groups postoperatively. RESULTS In total, there were 149 consecutive patients in the TC group and 168 patients in the NTC group. On average, 1.2 TCs per patient were used in the TC group. No significant differences were identified for operative time and blood loss between groups. There was also no statistical difference in the radiological measurements of AADI, PADI, Chamberlain line, and CMA between the TC and NTC groups preoperatively and postoperatively. A significantly higher JOA score was obtained in the TC group than that in the NTC group postoperatively. The fusion rates were higher in the TC group than those in the NCT group at the early stage postoperatively (3 and 6 months; p<.01). CONCLUSIONS Use of TCs seems to improve bony fusion and neurologic outcomes in the treatment of AAD and BI with C1-C2 screw-rod technique.
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Affiliation(s)
- Hua-Wei Wang
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China
| | - Yi-Heng Yin
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China
| | - Teng Li
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China
| | - Xin-Guang Yu
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China.
| | - Guang-Yu Qiao
- Department of Neurosurgery, PLA General Hospital, 28 Fuxing Rd, Haidian District, Beijing 100853, China
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Han IB, Choi UY, Shin DE, Ropper AE, Choi DS, Ahn TK. Symptomatic posterior fossa and supratentorial subdural hygromas as a rare complication following transarticular screw fixation with posterior wiring for atlantoaxial instability: A case report. Medicine (Baltimore) 2019; 98:e14847. [PMID: 31305388 PMCID: PMC6641781 DOI: 10.1097/md.0000000000014847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Atlantoaxial transarticular screw fixation has been an effective and appealing method for inducing fusion of the C1-C2 complex. This technique is usually performed with Gallie fusion. In performing Gallie fusion using sublaminar wiring, a major concern is the risk of dural tear associated with passing sublaminar wires through the epidural space. We present the first report on symptomatic symptomatic subdural hygroma (SDH) due to transarticular screw fixation with posterior wiring. PATIENTS CONCERNS A 50-year-old man had sustained dens fracture 20 years ago and presented with severe neck pain following a recent traffic accident. The images showed atlantoaxial instability due to nonunion of the dens fracture and the patient underwent transarticular screw fixation with posterior sublaminar wiring using Gallie technique. When the U-shaped wire was passed under the arch of C1 from inferior to superior, a dural tear and cerebrospinal fluid (CSF) leak occurred. The site of dural tear was repaired by direct application of sutures. The patient was discharged in good condition. Fifteen day after surgery, the patient was readmitted with a history of a progressive headache associated with vomiting and vertigo. DIAGNONSIS Brain CT and MRI showed bilateral posterior fossa and a right-sided supratentorial SDH. INTERVENTIONS The patient underwent right occipital burr hole and evacuation of posterior fossa SDH due to deteriorating neurological status. OUTCOMES The patient's condition gradually improved after the operation and became asymptomatic at 3-year follow-up. LESSONS Posterior fossa and supratentorial SDH could occur resulting from any intraoperative dural tear and CSF leakage during posterior cervical spinal surgery. Symptomatic SDH after posterior cervical spinal surgery should be cautiously assessed and treated. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- In-Bo Han
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center
| | - Un Yong Choi
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center
| | - Dong-Eun Shin
- Department of Orthopedic Surgery, CHA University School of Medicine, CHA Bundang Medical Center, South Korea
| | | | - Dae-Sung Choi
- Department of Orthopedic Surgery, CHA University School of Medicine, CHA Bundang Medical Center, South Korea
| | - Tae-Keun Ahn
- Department of Neurosurgery, Baylor College of Medicine, TX
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