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Tanaka M, Askar AEKA, Kumawat C, Arataki S, Komatsubara T, Taoka T, Uotani K, Oda Y. A Novel Technique for Basilar Invagination Treatment in a Patient with Klippel-Feil Syndrome: A Clinical Example and Brief Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:616. [PMID: 38674263 PMCID: PMC11051808 DOI: 10.3390/medicina60040616] [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: 02/11/2024] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024]
Abstract
Objectives and Background: To present a novel technique of treatment for a patient with basilar invagination. Basilar invagination (BI) is a congenital condition that can compress the cervicomedullary junction, leading to neurological deficits. Severe cases require surgical intervention, but there is debate over the choice of approach. The anterior approach allows direct decompression but carries high complication rates, while the posterior approach provides indirect decompression and offers good stability with fewer complications. Materials and Methods: A 15-year-old boy with severe myelopathy presented to our hospital with neck pain, bilateral upper limb muscle weakness, and hand numbness persisting for 4 years. Additionally, he experienced increased numbness and gait disturbance three months before his visit. On examination, he exhibited hyperreflexia in both upper and lower limbs, muscle weakness in the bilateral upper limbs (MMT 4), bilateral hypoesthesia below the elbow and in both legs, mild urinary and bowel incontinence, and a spastic gait. Radiographs revealed severe basilar invagination (BI). Preoperative images showed severe BI and that the spinal cord was severely compressed with odontoid process. Results: The patient underwent posterior surgery with the C-arm free technique. All screws including occipital screws were inserted into the adequate position under navigation guidance. Reduction was achieved with skull rotation and distraction. A follow-up at one year showed the following results: Manual muscle testing results and sensory function tests showed almost full recovery, with bilateral arm recovery (MMT 5) and smooth walking. The cervical Japanese Orthopedic Association score of the patient improved from 9/17 to 16/17. Postoperative images showed excellent spinal cord decompression, and no major or severe complications had occurred. Conclusions: Basilar invagination alongside Klippel-Feil syndrome represents a relatively uncommon condition. Utilizing a posterior approach for treating reducible BI with a C-arm-free technique proved to be a safe method in addressing severe myelopathy. This novel navigation technique yields excellent outcomes for patients with BI.
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Affiliation(s)
- Masato Tanaka
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (A.E.K.A.A.); (C.K.); (S.A.); (T.K.); (T.T.)
| | - Abd El Kader Al Askar
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (A.E.K.A.A.); (C.K.); (S.A.); (T.K.); (T.T.)
| | - Chetan Kumawat
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (A.E.K.A.A.); (C.K.); (S.A.); (T.K.); (T.T.)
| | - Shinya Arataki
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (A.E.K.A.A.); (C.K.); (S.A.); (T.K.); (T.T.)
| | - Tadashi Komatsubara
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (A.E.K.A.A.); (C.K.); (S.A.); (T.K.); (T.T.)
| | - Takuya Taoka
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (A.E.K.A.A.); (C.K.); (S.A.); (T.K.); (T.T.)
| | - Koji Uotani
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama 700-8558, Japan; (K.U.); (Y.O.)
| | - Yoshiaki Oda
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama 700-8558, Japan; (K.U.); (Y.O.)
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Zhou LP, Zhang RJ, Shen CL. Letter to the Editor Concerning "Feasibility of C2 Pedicle Screw Fixation with the "in-out-in" Technique for Patients with Basilar Invagination". Spine (Phila Pa 1976) 2024; 49:E58-E59. [PMID: 37737672 DOI: 10.1097/brs.0000000000004834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Lu-Ping Zhou
- Department of Orthopedics and Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ren-Jie Zhang
- Department of Orthopedics and Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Cai-Liang Shen
- Department of Orthopedics and Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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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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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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