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Su ML, Liu ZH, Tu PH, Huang YC. Dynamic cervical flexion/extension atlantodental interval and functional outcome of the Harms technique for posterior C1/2 fixation: A retrospective analysis of 16 atlantoaxial subluxation cases in a tertiary medical center. Neurochirurgie 2021; 68:168-174. [PMID: 34774580 DOI: 10.1016/j.neuchi.2021.10.003] [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: 08/26/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of this study was to assess the relationship between the atlantodental interval (ADI) on dynamic flexion/extension cervical radiographs and functional outcomes of posterior spinal fixation by the Harms technique for atlantoaxial subluxation (AAS). Dynamic flexion/extension on cervical radiographs is a standard assessment for evaluation of C1/2 instability in AAS patients. Most studies focused on postoperative ADI and functional outcome, including pain and fusion rate; only few studies compared dynamic ADI change pre- to post-operatively. MATERIAL AND METHODS Retrospectively, we reviewed the medical records of 16 patients who underwent posterior spinal fixation in our center from 2018 to 2019. We used dynamic cervical flexion/extension radiographs to assess the pre- to postoperative change at 12 months in ADI of flexion (ADIf), ADI of extension (ADIe), ADI between flexion/extension (ADIΔ), C1/2 fusion rate and functional outcomes measured by the modified Japanese Orthopaedic Association scale (mJOA scale). Postoperative CT at 3∼12 months assessed screw positioning on the Gertzbein and Robbins classification. RESULTS In the 16 patients included in this study, ADIf, ADIe and ADIΔ were significantly reduced, from respectively 8.0mm, 5.0mm and 3.0mm preoperatively to 4.6mm, 3.8mm and 0.8mm at 12 months' follow-up. The fusion rate was 81% and the mJOA score recovery rate was 34.9±14.7%. Although the screw malposition rate was higher than in other studies in C1(10%) and C2(20%), there were no new neurologic deficits or worsening of symptoms at follow-up. CONCLUSIONS The ADIΔ showed significant reduction, showing that the Harms technique of posterior spinal fixation can effective in maintaining the stability of the atlantoaxial joint and improving functional outcome.
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Affiliation(s)
- M-L Su
- Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Z-H Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - P-H Tu
- Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y-C Huang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Ishida W, Ramhmdani S, Xia Y, Kosztowski TA, Xu R, Choi J, De la Garza Ramos R, Elder BD, Theodore N, Gokaslan ZL, Sciubba DM, Witham TF, Bydon A, Wolinsky JP, Lo SFL. Use of Recombinant Human Bone Morphogenetic Protein-2 at the C1-C2 Lateral Articulation without Posterior Structural Bone Graft in Posterior Atlantoaxial Fusion in Adult Patients. World Neurosurg 2018; 123:e69-e76. [PMID: 30448576 DOI: 10.1016/j.wneu.2018.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/07/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Posterior atlantoaxial fusion is an important armamentarium for neurosurgeons to treat several pathologies involving the craniovertebral junction. Although the potential advantages of recombinant human bone morphogenetic protein-2 (rhBMP-2) are well documented in the lumbar spine, its indication for C1-C2 fusion has not been well characterized. In our institution, we apply rhBMP-2 to the C1-C2 joint either alone or with hydroxyapatite, locally harvested autograft chips, and/or morselized allogenic bone graft for selected cases-without conventional posterior structural bone graft. We report the clinical outcomes of the surgical technique to elucidate its feasibility. METHODS We performed a single-center, retrospective review of data from 2008 to 2016 and identified 69 patients who had undergone posterior atlantoaxial fusion with rhBMP-2. The clinical records of these patients were reviewed, and the baseline characteristics, operative data, and postoperative complications were collected and statistically analyzed. RESULTS The average age of the 69 patients was 60.8 ± 4.5 years, and 55.1% were women. With an average follow-up period of 21.1 ± 4.2 months, the C1-C2 fusion rate was 94.3% (65 of 69), and the average time to fusion was 11.4 ± 2.6 months (range, 5-23). The overall reoperation rate was 10.1% (7 of 69), with instrumentation failure in 7 patients (10.1%), adjacent segment disease in 2 (2.9%), and postoperative dysphagia and dyspnea in 2 patients (2.9%). No ectopic bone formation or soft tissue edema developed. CONCLUSIONS Although retrospective and from a single center, our study has shown that rhBMP-2 usage at the C1-C2 joint without posterior structural bone grafting is a safe and reasonable surgical option.
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Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Seba Ramhmdani
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Yuanxuan Xia
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Thomas A Kosztowski
- Department of Neurosurgery, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Risheng Xu
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - John Choi
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Rafael De la Garza Ramos
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Benjamin D Elder
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Jean-Paul Wolinsky
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA.
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Robinson LC, Anderson RCE, Brockmeyer DL, Torok MR, Hankinson TC. Comparison of Fusion Rates Based on Graft Material Following Occipitocervical and Atlantoaxial Arthrodesis in Adults and Children. Oper Neurosurg (Hagerstown) 2018; 15:530-537. [PMID: 29554356 DOI: 10.1093/ons/opy013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/17/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Fusion rates following rigid internal instrumentation for occipitocervical and atlantoaxial instability approach 100% in many reports. Based on this success and the morbidity that can be associated with obtaining autograft for fusion, surgeons increasingly select alternative graft materials. OBJECTIVE To examine fusion failure using various graft materials in a retrospective observational study. METHODS Insurance claims databases (Truven Health MarketScan® [Truven Health Analytics, Ann Arbor, Michigan] and IMS Health Lifelink/PHARMetrics [IMS Health, Danbury, Connecticut]) were used to identify patients with CPT codes 22590 and 22595. Patients were divided by age (≥18 yr = adult) and arthrodesis code, establishing 4 populations. Each population was further separated by graft code: group 1 = 20938 (structural autograft); group 2 = 20931 (structural allograft); group 3 = other graft code (nonstructural); group 4 = no graft code. Fusion failure was assigned when ≥1 predetermined codes presented in the record ≥90 d following the last surgical procedure. RESULTS Of 522 patients identified, 419 were adult and 103 were pediatric. Fusion failure occurred in 10.9% (57/522) of the population. There was no statistically significant difference in fusion failure based on graft material. Fusion failure occurred in 18.9% of pediatric occipitocervical fusions, but in 9.2% to 11.1% in the other groups. CONCLUSION Administrative data regarding patients who underwent instrumented occipitocervical or atlantoaxial arthrodesis do not demonstrate differences in fusion rates based on the graft material selected. When compared to many contemporary primary datasets, fusion failure was more frequent; however, several recent studies have shown higher failure rates than previously reported. This may be influenced by broad patient selection and fusion failure criteria that were selected in order to maximize the generalizability of the findings.
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Affiliation(s)
- Leslie C Robinson
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Richard C E Anderson
- Division of Pediatric Neurosurgery, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Douglas L Brockmeyer
- Division of Pediatric Neurosurgery, Primary Children's Medical Center, Salt Lake City, Utah
| | - Michelle R Torok
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Todd C Hankinson
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Guppy KH, Lee DJ, Harris J, Brara HS. Reoperation for Symptomatic Nonunions in Atlantoaxial (C1-C2) Fusions with and without Bone Morphogenetic Protein: A Cohort of 108 Patients with >2 Years Follow-Up. World Neurosurg 2018; 121:e458-e466. [PMID: 30267948 DOI: 10.1016/j.wneu.2018.09.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine if there is a difference in reoperation rates for symptomatic nonunions in atlantoaxial (C1-C2) fusions with or without bone morphogenetic protein (BMP) using data from a national spine registry and to analyze the different types of bone grafts used in the non-BMP group. METHODS Data from the Kaiser Permanente spine registry were used to identify patients with C1-C2 fusions with >2 years follow-up. Patient characteristics, diagnosis, operative times, length of stay, and reoperations were extracted from the registry. The data set was divided into patients with and without BMP. Further analysis was made of the different types of non-BMP grafts as well as the instrumentation used. RESULTS In our cohort, we found 58 patients (53.7%) with BMP and 50 patients (46.3%) without with an average follow-up time of 5 years (interquartile range, 2.04-8.49). The BMP versus non-BMP groups differed in admitting diagnosis, operative times, length of stay, and follow-up times. There were no reoperations for symptomatic nonunions in both groups. The non-BMP group included iliac crest graft (with or without allograft [+/-] allograft); lamina (+/- allograft); and allograft alone. CONCLUSIONS Using one of the largest retrospective studies on C1-C2 fusions with and without BMP, we found no difference in reoperation rates for symptomatic nonunions. For the non-BMP group, we found that lamina (+/- allograft) or allograft alone may also be just as effective as iliac crest graft (+/- allograft) in having no reoperations for symptomatic nonunions.
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Affiliation(s)
- Kern H Guppy
- Department of Neurosurgery, Kaiser Permanente Medical Group, Sacramento, California, USA.
| | - Darrin J Lee
- Department of Neurological Surgery, University of California, Davis, Sacramento, California, USA
| | - Jessica Harris
- Surgical Outcomes & Analysis Unit of Clinical Analysis, Kaiser Permanente, San Diego, California, USA
| | - Harsimran S Brara
- Department of Neurosurgery, Kaiser Permanente Southern California, Los Angeles, California, USA
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Dusad T, Kundnani V, Dutta S, Patel A, Mehta G, Singh M. Minimally Invasive Microscope-Assisted Stand-Alone Transarticular Screw Fixation without Gallie Supplementation in the Management of Mobile Atlantoaxial Instability. Asian Spine J 2018; 12:710-719. [PMID: 30060381 PMCID: PMC6068403 DOI: 10.31616/asj.2018.12.4.710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/21/2017] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective study. Purpose To evaluate the clinico-radiological efficacy of stand-alone minimally invasive transarticular screw (MIS-TAS) fixation without supplemental Gallie fixation in the management of mobile C1–C2 instability. Overview of Literature Data evaluating the efficacy and feasibility of MIS-TAS in the literature is scanty. Methods Patients with mobile atlantoaxial instability and >2 years follow-up were included and managed by stand-alone TAS fixation using the Magerl technique and morselized allograft without additional fixation. Patient demographics and intra-operative parameters were noted. Clinical parameters (Visual Analog Scale [VAS] and Oswestry Disability Index [ODI]), neurology (modified Japanese Orthopaedic Association [mJOA]), and radiological factors (anterior atlanto-dens interval and space available for cord) were evaluated pre and postoperatively. Computed tomography (CT) was performed in patients who did not show interspinous fusion on X-ray at 1 year, to verify intra-articular fusion. Statistical analysis was performed using IBM SPSS ver. 20.0 (IBM Corp., Armonk, NY, USA); the Student t-test and analysis of variance were used to assess statistical significance (p <0.05). Results A total of 82 consecutive cases (three males, one female; mean age, 36.26±5.78 years) were evaluated. In total, 163 TASs were placed. Significant improvement was noticed in clinical (mean preoperative VAS=7.2±2.19, postoperative VAS=3.3±1.12; mean preoperative ODI=78.3±4.83, postoperative ODI=34.05±3.26) and neurological features (mean preoperative mJOA=14.73±2.68, postoperative mJOA=17.5±2.21). Radiological evidence of fusion was noted in 97.5% cases at final follow-up. Seventeen patients were found to have no interspinous fusions upon X-rays, but CT revealed facet fusion in all patients except in two. Inadvertent vertebral artery injury was noted in three cases. Conclusions Stand-alone TAS fixation with morselized allograft provides excellent radiological and clinical outcomes. The addition of a supplementary tension band and structural graft are not essential. This provides the opportunity to avoid the complications associated with graft harvesting and wiring.
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Affiliation(s)
- Tarun Dusad
- Department of Orthopaedics, Bombay Hospital & Medical Research Centre, Mumbai, India
| | - Vishal Kundnani
- Department of Orthopaedics, Bombay Hospital & Medical Research Centre, Mumbai, India
| | - Shumayou Dutta
- Department of Orthopaedics, Bombay Hospital & Medical Research Centre, Mumbai, India
| | - Ankit Patel
- Department of Orthopaedics, Bombay Hospital & Medical Research Centre, Mumbai, India
| | - Gaurav Mehta
- Department of Orthopaedics, Bombay Hospital & Medical Research Centre, Mumbai, India
| | - Mahendra Singh
- Department of Orthopaedics, Bombay Hospital & Medical Research Centre, Mumbai, India
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Turel MK, Kerolus MG, Traynelis VC. Machined cervical interfacet allograft spacers for the management of atlantoaxial instability. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 8:332-337. [PMID: 29403245 PMCID: PMC5763590 DOI: 10.4103/jcvjs.jcvjs_87_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: The use of cervical interfacet spacers (CISs) to augment stability and provide solid arthrodesis at the atlantoaxial joint has not been studied in detail. The aim of this work is to report the outcomes with the use of machined allograft CISs at C1-2. Methods: A retrospective review of 19 patients who underwent an atlantoaxial fusion with the use of CISs was performed. All patients had instability documented with flexion and extension lateral radiographs. This instability was due to trauma, degenerative stenosis, symptomatic C1-2 arthropathy, and os odontoideum. Clinical and radiological outcomes were assessed. Fusion was determined based on a lack of hardware failure, absence of motion on flexion and extension plain X-ray films, and presence of bridging trabecular bone which was most often demonstrated by a computed tomography. Results: The mean age was 69.1 ± 12.9 years. Eight patients had traumatic fractures, six patients had degenerative stenosis, two patients had C2 neuralgia due to C1-2 arthropathy, two patients had C1-2 ligamentous subluxation, and one patient had an unstable os odontoideum. The occiput or subaxial spine was included in the arthrodesis in 10 patients. Rib autograft was utilized in most patients. No patient had postoperative neurological worsening, malposition of hardware, or vertebral artery injury and there were no mortalities. The fusion rate was 95%. The mean follow-up was 12.1 ± 5.5 months. Conclusions: CIS is a promising adjuvant for the treatment of atlantoaxial instability.
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Affiliation(s)
- Mazda K Turel
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Mena G Kerolus
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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7
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Ghostine SS, Kaloostian PE, Ordookhanian C, Kaloostian S, Zarrini P, Kim T, Scibelli S, Clark-Schoeb SJ, Samudrala S, Lauryssen C, Gill AS, Johnson PJ. Improving C1-C2 Complex Fusion Rates: An Alternate Approach. Cureus 2017; 9:e1887. [PMID: 29392099 PMCID: PMC5788400 DOI: 10.7759/cureus.1887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The surgical repair of atlantoaxial instabilities (AAI) presents complex and unique challenges, originating from abnormalities and/or trauma within the junction regions of the C1-C2 atlas-axis, to surgeons. When this region is destabilized, surgical fusion becomes of key importance in order to prevent spinal cord injury. Several techniques can be utilized to provide for the adequate fusion of the atlantoaxial construct. Nevertheless, many individuals have less than ideal rates of fusion, below 35%-40%, which also involves the C2 nerve root being sacrificed. This suboptimal and unavoidable iatrogenic complication results in the elevated probability of complications typically composed of vertebral artery injury. This review is a retrospective analysis of 87 patients from Cedars Sinai Medical Center in Los Angeles, California, who had the C1-C2 surgical fusion procedure performed within the time frame from 2001 to 2008, with a mean follow-up period of three years. These patients had presented with typical AAI symptoms of fatigability, limited mobility, and clumsiness. Diagnosis of C1-C2 instability was documented via radiographic studies, typically utilizing computed tomography (CT) scans or x-rays. All patients had bilateral C1 lateral masses and C2 pedicle screws. In addition, the C1-C2 joint was accessed by retracting the C2 nerve root superiorly and exposing the joint by utilizing a high-speed burr. The cavity that is developed within the joint is packed with local autologous bone from the cephalad resection of the C2 laminae. Fusion of the C1-C2 joint was achieved in all patients and a final follow-up was conducted approximately three years postoperative. Of the 87 patients, two presented with occipital headaches resulting from the C1 screws impinging on the C2 nerve root. The issue was rectified by removing instrumentation in both patients after documenting complete fusion via radiographic studies, with complete resolution of symptoms. No vertebral artery or spinal cord injuries were reported as a result of the minor complication. Overall, we aim to describe a safe and reliable alternative technique to fuse C1-C2 instability by focusing on intra-articular arthrodesis complementing instrumentation fixation. This methodology is advantageous from a biomechanical standpoint secondary to axial loading, as well as the large surface area available for arthrodesis. Additionally, this technique does not involve the resection of the C2 nerve root, resulting in low risk for vertebral artery or spinal cord injury.
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Affiliation(s)
- Samer S Ghostine
- Neurological Surgery, University of California, Riverside School of Medicine
| | - Paul E Kaloostian
- Neurological Surgery, University of California, Riverside School of Medicine
| | - Christ Ordookhanian
- Neurological Surgery, University of California, Riverside School of Medicine
| | - Sean Kaloostian
- Neurological Surgery, University of California, Irvine School of Medicine
| | | | | | | | | | | | - Carl Lauryssen
- Neurological Surgery, St. David's Round Rock Medical Center
| | - Amandip S Gill
- Neurological Surgery, University of California, Riverside School of Medicine
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Huang DG, Zhang XL, Hao DJ, Yu CC, Mi BB, Yuan QL, He BR, Liu TJ, Guo H, Wang XD. Posterior atlantoaxial fusion with a screw-rod system: Allograft versus iliac crest autograft. Clin Neurol Neurosurg 2017; 162:95-100. [DOI: 10.1016/j.clineuro.2017.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/26/2017] [Accepted: 10/01/2017] [Indexed: 10/18/2022]
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Intraoperative Navigation Is Associated with Reduced Blood Loss During C1-C2 Posterior Cervical Fixation. World Neurosurg 2017; 107:574-578. [PMID: 28842229 DOI: 10.1016/j.wneu.2017.08.051] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Traumatic injuries, degenerative/rheumatologic conditions, tumors, or infections of the upper cervical spine may in certain circumstances require surgical stabilization. C1 lateral mass screws (Harms technique) in combination with C2 instrumentation (pars, pedicle, translaminar screws) have become a mainstay of surgical treatment. The surgical anatomy of the C1 lateral mass can be challenging especially with the robust venous plexus that often causes significant bleeding with exposure of the C1-C2 articular complex. The purpose of this study was to examine whether the use of navigation reduced intraoperative blood loss during atlantoaxial fixation. METHODS We reviewed our institutional experience with atlantoaxial instrumentation with and without navigation from 2007 to 2016. We limited our cases to those requiring C1-C2 stabilization in traumatic and degenerative cases and not as part of more extensive surgical stabilizations. We identified 45 consecutive patients and compared intraoperative blood loss, need for transfusion, and time of procedure with and without the use of navigation. RESULTS There was a significant reduction in the amount of intraoperative blood loss in the navigated (n = 20) versus non-navigated cases (n = 25). In addition, although the navigated cases initially were longer, currently there is no significant difference in the length of the cases. CONCLUSIONS In our series, surgical navigation significantly reduced blood loss compared with non-navigated cases without increasing surgical time or risk of complication. Furthermore, navigation has the potential to reduce operative times due to a reduction in blood loss.
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Iyer RR, Tuite GF, Meoded A, Carey CC, Rodriguez LF. A Modified Technique for Occipitocervical Fusion Using Compressed Iliac Crest Allograft Results in a High Rate of Fusion in the Pediatric Population. World Neurosurg 2017; 107:342-350. [PMID: 28790003 DOI: 10.1016/j.wneu.2017.07.172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/26/2017] [Accepted: 07/29/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND In children, high rates of occipitocervical (OC) fusion have been demonstrated with the use of rigid instrumentation in combination with harvested autograft, with or without bone morphogenetic protein (BMP). Historically, the use of allograft materials demonstrated inferior OC fusion outcomes compared with autograft. However, autograft harvest harbors an increased risk of patient morbidity, and the use of BMP is costly and controversial in children. Thus, there remains a need for safer, less costly, yet efficacious techniques for OC fusion in the pediatric population. METHODS We retrospectively reviewed the charts of patients younger than 21 years of age who underwent OC fusion with structural allograft placement at our institution from 2010 to 2015. Data collected included age, sex, follow-up duration, fusion outcomes, and postoperative complications. RESULTS A total of 19 patients (8 female and 11 male) underwent OC fusion with our surgical technique. Mean age was 8.5 ± 4.3 years. Radiographic follow up data were available for 18 of 19 patients. One patient was lost to clinical follow up but had radiographic confirmation of fusion. Thus, 18 of 18 (100%) of patients with radiographic follow-up achieved successful arthrodesis as determined by computed tomography. Median duration to documented fusion was 4.5 months. Clinical follow-up was available for 17 of 19 patients and was on average 18.8 ± 13.5 months. One patient required reoperation for graft fracture 8 months after radiographic confirmation of successful fusion. There were no vertebral artery injuries or other postoperative complications. CONCLUSIONS We demonstrate a modified technique for OC fusion in children with unique structural allograft shaping and affixation, leading to excellent fusion outcomes at follow up. This technique obviates the need for autograft harvest or BMP, and may decrease postoperative morbidity.
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Affiliation(s)
- Rajiv R Iyer
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Gerald F Tuite
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Avner Meoded
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Carolyn C Carey
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Luis F Rodriguez
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.
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11
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Zhang YH, Shen L, Shao J, Chou D, Song J, Zhang J. Structural Allograft versus Autograft for Instrumented Atlantoaxial Fusions in Pediatric Patients: Radiologic and Clinical Outcomes in Series of 32 Patients. World Neurosurg 2017. [PMID: 28624564 DOI: 10.1016/j.wneu.2017.06.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Allograft with wire techniques showed a low fusion rate in pediatric atlantoaxial fusions (AAFs) in early studies. Using allograft in pediatric AAFs with screw/rod constructs has not been reported. Thus we compared the fusion rate and clinical outcomes in pediatric patients who underwent AAFs with screw/rod constructs using either a structural autograft or allograft. METHODS Pediatric patients (aged ≤12 years) who underwent AAFs between 2007 and 2015 were retrospectively evaluated. Patients were divided into 2 groups (allograft or autograft). Clinical and radiographic results were collected from hospital records and compared. RESULTS A total of 32 patients were included (18 allograft, 14 autograft). There were no significant group differences in age, sex, weight, diagnosis, or duration of follow-up. A similar fusion rate was achieved (allograft: 94%, 17/18; autograft: 100%, 14/14); however, the average fusion time was 3 months longer in the allograft group. Blood loss was significantly lower in the allograft group (68 ± 8.5 mL) than the autograft group (116 ± 12.5 mL). Operating time and length of hospitalization were slightly (nonsignificantly) shorter for the allograft group. A significantly higher overall incidence of surgery-related complications was seen in the autograft group, including a 16.7% (2/14) rate of donor-site-related complications. CONCLUSIONS The use of allograft for AAF was safe and efficacious when combined with rigid screw/rod constructs in pediatric patients, with a similar fusion rate to autografts and an acceptable complication rate. Furthermore, blood loss was less when using allograft and donor-site morbidity was eliminated; however, the fusion time was increased.
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Affiliation(s)
- Yue-Hui Zhang
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Shen
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiang Shao
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Jia Song
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Zhang
- Department of Orthopedic Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Reintjes SL, Amankwah EK, Rodriguez LF, Carey CC, Tuite GF. Allograft versus autograft for pediatric posterior cervical and occipito-cervical fusion: a systematic review of factors affecting fusion rates. J Neurosurg Pediatr 2016; 17:187-202. [PMID: 26496632 DOI: 10.3171/2015.6.peds1562] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fusion rates are high for children undergoing posterior cervical fusion (PCF) and occipito-cervical fusion (OCF). Autologous bone has been widely used as the graft material of choice, despite the risk of donor-site morbidity associated with harvesting the bone, possibly because very low fusion rates were reported with posterior allograft cervical fusions in children several decades ago. Higher overall fusion rates using allograft in adults, associated with improvements in internal fixation techniques and the availability of osteoinductive substances such as bone morphogenetic protein (BMP), have led to heightened enthusiasm for the use of bank bone during pediatric PCF. A systematic review was performed to study factors associated with successful bone fusion, including the type of bone graft used. METHODS The authors performed a comprehensive PubMed search of English-language articles pertaining to PCF and OCF in patients less than 18 years old. Of the 561 abstracts selected, 148 articles were reviewed, resulting in 60 articles that had sufficient detail to be included in the analysis. A meta-regression analysis was performed to determine if and how age, fusion technique, levels fused, fusion substrate, BMP use, postoperative bracing, and radiographic fusion criteria were related to the pooled prevalence estimates. A systematic review of the literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. RESULTS A total of 604 patients met the specific inclusion and exclusion criteria. The overall fusion rate was 93%, with a mean age of 9.3 years and mean follow-up of 38.7 months. A total of 539 patients had fusion with autograft (94% fusion rate) and 65 patients with allograft (80% fusion rate). Multivariate meta-regression analysis showed that higher fusion rates were associated with OCF compared with fusions that excluded the occiput (p < 0.001), with the use of autograft instead of allograft (p < 0.001), and with the use of CT to define fusion instead of plain radiography alone. The type of internal fixation, the use of BMP, patient age, and the duration of follow-up were not found to be associated with fusion rates in the multivariate analysis. CONCLUSIONS Fusion rates for PCF are high, with higher rates of fusion seen when autograft is used as the bone substrate and when the occiput is included in the fusion construct. Further study of the use of allograft as a viable alternative to autograft bone fusion is warranted because limited data are available regarding the use of allograft in combination with more rigid internal fixation techniques and osteoinductive substances, both of which may enhance fusion rates with allograft.
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Affiliation(s)
- Stephen L Reintjes
- Neuroscience Institute, and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida; and
| | - Ernest K Amankwah
- Department of Clinical and Translational Research, All Children's Hospital/Johns Hopkins Medicine, St. Petersburg
| | - Luis F Rodriguez
- Neuroscience Institute, and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida; and
| | - Carolyn C Carey
- Neuroscience Institute, and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida; and
| | - Gerald F Tuite
- Neuroscience Institute, and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida; and.,Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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C1-C2 Fusion: Promoting Stability, Reducing Morbidity. World Neurosurg 2014; 82:1052-4. [DOI: 10.1016/j.wneu.2013.02.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 02/22/2013] [Indexed: 11/23/2022]
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