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Zhou LP, Zhao CH, Zhang ZG, Shang J, Zhang HQ, Ma F, Jia CY, Zhang RJ, Shen CL. Characteristics and evaluation of C1 posterior arch variation for transpedicular screw placement between patients with and without basilar invagination. 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 2023; 32:3547-3560. [PMID: 37530951 DOI: 10.1007/s00586-023-07873-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/24/2023] [Accepted: 07/22/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND C1 transpedicular screw (C1TS) placement provided satisfactory pullout resistance and 3D stability, but its application might be limited in patients with basilar invagination (BI) due to the high incidences of the atlas anomaly and vertebral artery (VA) variation. However, no study has explored the classifications of C1 posterior arch variations and investigated their indications and ideal insertion trajectories for C1TS in BI. PURPOSE To investigate the bony and surrounding arterial characteristics of the atlas, classify posterior arch variations, identify indications for C1TS, evaluate ideal insertion trajectories for C1TS in BI patients without atlas occipitalization (AO), and compare them with those without BI and AO as control. METHODS A total of 130 non-AO patients with and without BI (52 patients and 78 patients, respectively) from two medical centers were included at a 1:1.5 ratio. The posterior arch variations were assessed using a modified C1 morphological classification. Comparisons regarding the bony and surrounding arterial characteristics, morphological classification distributions, and ideal insertion trajectories between BI and control groups were performed. The subgroup analyses based on different morphological classifications were also conducted. In addition, the factors possibly affecting the insertion parameters were investigated using multiple linear regression analyses. RESULTS The BI group was associated with significantly smaller lateral mass height and width, sagittal length of posterior arch, pedicle height, vertical height of posterior arch, and distance between VA and VA groove (VAG) than control group. Four types of posterior arch variations with indications for different screw placement techniques were classified; Classifications I and II were suitable for C1TS. The BI cohort showed a significantly lower rate of Classification I than the control cohort. In the BI group, the subgroup of Classification I had significantly larger distance between the insertion point (IP) and inferior aspect of the posterior arch. In addition, it had the narrowest width along ideal screw trajectory, but a significantly more lateral ideal mediolateral angle than the subgroup of Classification II. Multiple linear regression indicated that the cephalad angle was significantly associated with the diagnosis of BI (B = 3.708, P < 0.001) and sagittal diameter of C1 (B = 3.417, P = 0.027); the ideal mediolateral angle was significantly associated with BMI (B = 0.264, P = 0.031), sagittal diameter of C1 (B = - 4.559, P = 0.002), and pedicle height (B = - 2.317, P < 0.001); the distance between the IP and inferior aspects of posterior arch was significantly associated with age (B = - 0.002, P = 0.035), BMI (B = - 0.007, P = 0.028), sagittal length of posterior arch (B = - 0.187, P = 0.032), pedicle height (B = - 0.392, P < 0.001), and middle and lower parts of posterior arch (B = 0.862, P < 0.001). CONCLUSION The incidence of posterior arch variation in BI patients without AO was remarkably higher than that in control patients. The insertion parameters of posterior screws were different between the morphological classification types in BI and control groups. The distance between VA V3 segments and VAG in BI cohort was substantially smaller than that in control cohort. Preoperative individual 3D computed tomography (CT), CT angiography and intraoperative navigation are recommended for BI patients receiving posterior screw placement.
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Affiliation(s)
- Lu-Ping Zhou
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Chen-Hao Zhao
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Zhi-Gang Zhang
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Jin Shang
- Department of Radiology, The First Affiliated Hospital of University of Science and Technology of China, 107 Huanhudong Road, Hefei, 230031, Anhui, China
| | - Hua-Qing Zhang
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Fang Ma
- Center for Scientific Research, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Chong-Yu Jia
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Ren-Jie Zhang
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China.
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China.
| | - Cai-Liang Shen
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China.
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China.
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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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Vaccaro AR, Karamian BA, Levy HA, Canseco JA, Rajasekaran S, Benneker LM, Oner FC, Kandziora F, Schnake KJ, Kepler CK, Schroeder GD. Update on Upper Cervical Injury Classifications: The New AO Upper Cervical Spine Classification System. Clin Spine Surg 2022; 35:249-255. [PMID: 34232156 DOI: 10.1097/bsd.0000000000001215] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/19/2021] [Indexed: 10/20/2022]
Abstract
The upper cervical spine accounts for the largest proportion of cervical range of motion afforded by a complex system of bony morphology and ligamentous stability. Its unique anatomy, however, also makes it particularly vulnerable during both low and high energy trauma. Trauma to this area, referred to as upper cervical spine trauma, can disrupt the stability of the upper cervical spine and result in a wide spectrum of injury. Numerous upper cervical injury classification systems have been proposed, each of which have distinct limitations and drawbacks that have prevented their universal adoption. In this article, we provide an overview of previous classifications, with an emphasis on the development of the new AO Spine Upper Cervical Classification System (AO Spine UCCS).
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Affiliation(s)
- Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Hannah A Levy
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Lorin M Benneker
- Spine Service, Orthopaedic Department, Sonnenhofspital, Bern, Switzerland
| | | | - Frank Kandziora
- Center for Spine Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main, Frankfurt
| | - Klaus J Schnake
- Center for Spinal Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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He H, Hu B, Cai P, Yu R. Computed tomography comparison study of two Axis-based C1 transpedicular screw trajectory designs. Spine J 2021; 21:1763-1771. [PMID: 33757868 DOI: 10.1016/j.spinee.2021.03.013] [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: 04/15/2020] [Revised: 03/07/2021] [Accepted: 03/15/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT To our knowledge, there is no comparison study of two different Axis-based C1 transpedicular screw trajectory (TST) designs. PURPOSE To compare two different Axis-based C1 TST designs. STUDY DESIGN The computed tomography (CT) morphologic analysis of the two different C1 Axis-based TST designs. METHODS Firstly, the design of Axis C/M and related measurements were made on a work station by using neck computed tomography angiography (CTA) data of 62 patients. The central axes (Axis M and Axis C) of C1 TST were designed by multiplanar reconstruction (MPR) technique. Based on Axis M and Axis C, the following parameters were measured: (A, A'), distance between the insertion point (IP) and the midline. (B, B'), distance between IP and the inferior aspect of C1 posterior arch. (C, C'), distance between IP and the C1 anterior cortex of the lateral mass along Axis M/C. (D, D'), insertion angle (IA) based on Axis M/C. (E, E'), the narrowest width of the inner medullary cavity (IMC) along Axis M/C. RESULT The C1 TST can be designed by MPR technique based on CT volume scan. The design of Axis C trajectory was easier to Axis M trajectory. A, A' were 20.7±1.6mm and 20.6±1.9mm. Both B, B' were 2.0±0.6mm. C, C' were 27.2±2.1mm and 27.5±2.1mm. D, D' were 9.9±5.0°and 10.4±7.7°. E, E' were 5.0±1.3mm and 5.4±1.4mm. Among 62 patients (124 sides), Axis C can be achieved by medial inclination, perpendicular, lateral inclination method in 81.5%, 13.7%, 4.8% sides, respectively; Axis M can be achieved by medial inclination, perpendicular, lateral inclination method in 90.3%, 8.9%, 0.8% sides, respectively. CONCLUSION Axis C can be a reliable trajectory for C1 transpedicular screw insertion as long as there is no displaced fracture in the C1 pedicle and lateral mass. Because of the individual differences, the ideal C1 TST can be achieved by medial inclination, perpendicular or even lateral inclination method, although its inclination direction is medial in the majority of patients.
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Affiliation(s)
- Hongwei He
- Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Medical Imaging Department, Ningbo First Hospital, Ningbo, China.
| | - Baiwen Hu
- Department of Orthopedics, Ningbo First Hospital, Ningbo, China
| | - Pengchao Cai
- Department of Radiology, Ningbo Ninth Hospital, Ningbo, China
| | - Risheng Yu
- Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Xing XH, Zhang AM, Adu IK, Huang MH, Cui G. Arterial Vascular Structures Running Through Retrotransverse Foramen and Retrotransverse Groove of the Atlas Vertebrae. World Neurosurg 2021; 154:e416-e420. [PMID: 34293524 DOI: 10.1016/j.wneu.2021.07.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Retrotransverse foramen (RTF) and retrotransverse groove (RTG) are anatomic variations of the atlas (C1) vertebrae. RTF contains an anastomotic vein connecting atlanto-occipital and atlanto-axodian venous sinuses. The purpose of this study was to analyze the arterial vascular structures running though the RTF and RTG. METHODS Three-dimensional volume rendered computed tomography angiography (3D VR CTA) images of 427 patients (264 men, 163 women; age 17-87 years) were reviewed and evaluated using the RadiAnt DICOM Viewer (version 5.0.2; Medixant, Poznan, Poland). The incidence of RTF or RTG, the incidence of the V3 segment of vertebral artery variants, and the artery vascular structures inside the RTF and RTG anatomic variation of C1 were analyzed. RESULTS Fifty (11.7%) atlases presented RTF anatomical variant; 113 (26.5%) atlases presented RTG anatomical variants. The incidence of the V3 segment of vertebral artery variants was 0.94% (4 of 427). Three (0.7%) were persistent first intersegmental artery and 1 (0.2%) was the fenestration of the vertebral artery on left side. In 4 cases of C1 vertebral artery V3 segmental variants, there were no RTF and RTG. No artery vascular structure was found in RTF or RTG. CONCLUSIONS The RTF or RTG of C1 was a common anatomical variant. No arterial vascular structure runs though the RTF or RTG. The presence of C1 RTF and RTG variants had no effect on the V3 segmental course of the vertebral artery. Preoperative understanding of these variations using 3D CTA are helpful for the safe execution of the upper cervical posterior approach surgeries.
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Affiliation(s)
- Xi-Hong Xing
- Department of Neurosurgery, First Affiliated Hospital of Soochow University, Suzhou, China; Department of Neurosurgery, Second Hospital of Jingzhou, Affiliated Hospital of Hubei College of Chinese Medicine, Jingzhou, China
| | - Ai-Ming Zhang
- Department of Neurosurgery, Second Hospital of Jingzhou, Affiliated Hospital of Hubei College of Chinese Medicine, Jingzhou, China
| | - Isaac Kumi Adu
- Department of Neurosurgery, Second Hospital of Jingzhou, Affiliated Hospital of Hubei College of Chinese Medicine, Jingzhou, China; Health Science Center, Yangtze University, Jingzhou, China
| | - Man-Hua Huang
- Department of Radiology, First People's Hospital of Jingzhou City, Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Gang Cui
- Department of Neurosurgery, First Affiliated Hospital of Soochow University, Suzhou, China.
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Burtsev AV, Sergeenko OM, Gubin AV. An alternative way of C1 screwing: Supralaminar C1 lateral mass screws. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:191-196. [PMID: 34194167 PMCID: PMC8214239 DOI: 10.4103/jcvjs.jcvjs_45_21] [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: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/18/2022] Open
Abstract
Study Design: This study involves literature review, technical note, and case series. Objectives: The objectives were to analyze indications and contraindications, advantages, and disadvantages for C1 lateral mass screw (LMS) insertion above or partially above the arch, to descript technical features, and to give examples of the practical application of this technique and investigated its safety. Methods: A literature review was carried out in English and Russian in PubMed, Google Scholar, and eLibrary databases. We selected four patients, treated in our clinic, which was carried out partially supralaminar C1 LMS. Results: Only three descriptions of supralaminar C1 LMS were found in the literature. Four adult patients underwent posterior C1–C2 screw fixation with C1 LMS along the superior edge of the C1 arch at our clinic. Partially supralaminar C1 screws were inserted on one of the sides due to the difficulties of using classical techniques. The main reasons for supralaminar screw fixation were narrow C1 lamina, hypertrophied venous plexus, and intraoperative failures of classic techniques application (broken screw trajectory, profuse venous bleeding from the plexus). The average follow-up time for the patients was 2.7 years, no complications were noted, and all had a satisfactory spinal fusion. Conclusions: The proposed types of C1 LMS above or partially above the C1 arch can be useful alternative method of C1 screwing in selected patients. Indications for the use of the supralaminar C1 LMS method can be narrow C1 posterior arch and pedicle, pronounced C1-C2 venous plexus, some V3 segment anomalies at C1 level, small arthritic inferior part of lateral mass, and intraoperative failures of classic techniques application.
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Affiliation(s)
| | | | - Alexander V Gubin
- National Medical Research Center for Traumatology and Orthopedics named after N.N. Priorov, Moscow, Russia
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Xing XH, Huang MH, Adu IK, Wang JC, Cui G. Retrotransverse Foramen and Retrotransverse Groove Anatomic Variations of the Atlas Vertebra in the Chinese Population. World Neurosurg 2021; 152:e193-e200. [PMID: 34052448 DOI: 10.1016/j.wneu.2021.05.065] [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: 02/28/2021] [Revised: 05/15/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyze the prevalence of retrotransverse foramen (RTF) or retrotransverse groove (RTG) anatomic variations in Chinese atlas vertebra (C1). METHODS Three-dimensional volume-rendered computed tomography angiography images of 427 subjects (264 males, 163 females; 17-87 years old) were reviewed and evaluated using dedicated software. The prevalence of RTF and RTG anatomic variation of C1 was analyzed. RESULTS RTF anatomic variants were present in 50 (11.7%) atlases. Bilateral RTF, unilateral left RTF, and unilateral right RTF were present in 16 (3.8%), 20 (4.9%), and 14 (3.3%) vertebrae. Comparison between males and females revealed differences in bilateral RTF (P = 0.010) and unilateral left RTF (P = 0.008). RTG anatomic variants were present in 113 (26.5%) atlases. Bilateral RTG, unilateral left RTG, and unilateral right RTG were present in 39 (9.1%), 30 (7.0%), and 44 (10.3%) vertebrae. Comparison between males and females revealed differences in RTG (P = 0.000), bilateral RTG (P = 0.006), and unilateral left RTG (P = 0.034). RTF was detected in 36 cases on the left and 30 cases on the right. RTG was detected in 69 cases on the left and 79 cases on the right. There were no side differences in the prevalence of RTF and RTG. CONCLUSIONS The incidence of RTG is higher than the incidence of RTF. Incidence of bilateral RTF, bilateral RTG, unilateral left RTF, unilateral left RTG, and RTG differed between males and females. Preoperative understanding of these variations using three-dimensional computed tomography angiography is helpful for safe execution of upper cervical posterior approach surgery.
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Affiliation(s)
- Xi-Hong Xing
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, China; Department of Neurosurgery, the Second Hospital of Jingzhou & the Affiliated Hospital of Hubei College of Chinese Medicine, Jingzhou, China
| | - Man-Hua Huang
- Department of Radiology, the First Hospital of Jingzhou, Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Isaac Kumi Adu
- Department of Neurosurgery, the Second Hospital of Jingzhou & the Affiliated Hospital of Hubei College of Chinese Medicine, Jingzhou, China; Health Science Center, Yangtze University, Jingzhou, China
| | - Jian-Cheng Wang
- Department of Radiology, the Second Hospital of Jingzhou & the Affiliated Hospital of Hubei College of Chinese Medicine, Jingzhou, China
| | - Gang Cui
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, China.
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