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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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2
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Yuwakosol P. Morphometric Study for C1 Pedicle Screw Placement in Thai Patients. Asian J Neurosurg 2022; 17:429-434. [PMID: 36398178 PMCID: PMC9665985 DOI: 10.1055/s-0042-1756625] [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: 11/17/2022] Open
Abstract
Background
Traumatic atlantoaxial (upper cervical spine) leads to instability in weightbearing movement and neurological deficit. Presently, C1 (axial) lateral mass or pedicle screws for fixation are the most popular because of excellent mechanical performance for internal fixation. C1 pedicle screw fixation can reduce intraoperative blood loss and postoperative occipital neuralgia more than C1 lateral mass screws. However, screws cannot be inserted completely through the pedicle in some patients due to C1 size.
Objective
We aimed to determine the ideal pedicle screw entry point, angle of screw projection, and pedicle height in the Thai population.
Methods
Patient data were collected and measured using the INFINITT program at Mukdahan Hospital from September 2020 to June 2021. The C1 measurements, i.e., distance from the midline to the medial edge of the posterior arch (DPA) and medial edge transverse foramen (DTF), angle of screw projection, and length and height of the pedicle were recorded. Descriptive statistics and
t
-test were used to analyze the data.
Results
The mean Thai pedicle dimensions were DPA = 14.17 mm (range: 11.19–19.70 mm), DTF = 22.09 mm (range: 18.13–26.44 mm), ideal screw entry point = 18.13 mm (range: 15.19–22.00 mm), ideal angle of screw projection medial angulation = 2.67 degrees (range: 0–7 degrees), and height of posterior arch (pedicle) = 4.77 mm (range: 2.68–7.22 mm). Forty of 167 patients (24.0%) had a pedicle height less than 4.0 mm (bilateral 11 patients and unilateral 29 patients).
Conclusions
The ideal C1 pedicle screw entry point is approximately 18.13 mm from the midline. In the Thai samples with C1 pedicle height less than 4.0 mm, the screws cannot be inserted completely through the pedicle. Therefore, screw insertion should be partially through the pedicle (notching technique).
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Affiliation(s)
- Pakorn Yuwakosol
- Neurosurgical Unit, Department of Surgery, Mukdahan Hospital, Thai Board of Neurological Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand,Address for correspondence Pakorn Yuwakosol, MD Neurosurgical Unit, Department of Surgery, Mukdahan HospitalMukdahan, 49000Thailand
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Sacino AN, Materi J, Davidar AD, Judy B, Liu A, Hwang B, Theodore N. Robot-assisted atlantoaxial fixation: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE22114. [PMID: 35733845 PMCID: PMC9210265 DOI: 10.3171/case22114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Placing screws in the high cervical spine can be challenging because of the vital anatomical structures located in that region. Precision and accuracy with screw placement is needed. The use of robotics in the cervical spine has been described before; however, here the authors describe the use of a new robotic setup. OBSERVATIONS The authors describe 2 cases of robot-assisted placement of C2 pars screws and C1–2 transarticular screws. The operative plans for each patient were as follows: placement of C2 pars screws with C2–4 fusion for hangman’s fracture and placement of C1–2 transarticular screws for degenerative disease. Intraoperative computed tomography (CT) was used to plan and navigate the screws. Postoperative CT showed excellent placement of hardware. Both patients presented for initial postoperative clinic visits with no recurrence of prior symptoms. LESSONS Intraoperative robotic assistance with instrumentation of the high cervical spine, particularly C2 pars and C1–2 transarticular screws, may ensure proper screw placement and help avoid injury.
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Affiliation(s)
- Amanda N. Sacino
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - A. Daniel Davidar
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Brendan Judy
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ann Liu
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Brian Hwang
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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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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Yurube T, Iguchi T, Kinoshita K, Sadamitsu T, Kakutani K. Upper Cervical Compression Myelopathy Caused by the Retro-Odontoid Pseudotumor With Degenerative Osteoarthritis and Calcium Pyrophosphate Dihydrate Disease: A Case Report and Literature Review. Neurospine 2022; 18:903-913. [PMID: 35000348 PMCID: PMC8752696 DOI: 10.14245/ns.2142112.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 06/29/2021] [Indexed: 02/05/2023] Open
Abstract
The retro-odontoid pseudotumor is often concurrent with atlantoaxial subluxation (AAS). Therefore, the pseudotumor is relatively common in rheumatoid arthritis (RA) but rare in primary osteoarthritis (OA). This is a case report of an elderly male patient suffering from neck pain and compression myelopathy caused by the craniocervical pseudotumor with OA but without atlantoaxial instability. He had long-lasting peripheral and spinal pain treated by nonsteroidal anti-inflammatory drugs. Imaging found upper cervical spondylosis without AAS or dynamic instability but with periodontoid calcifications and ossifications, suggesting calcium pyrophosphate dihydrate (CPPD) crystal deposition. Based on a comprehensive literature search and review, CPPD disease around the atlantodental joint is a possible contributor to secondary OA development and retro-odontoid pannus formation through chronic inflammation, which can be enough severe to induce compression myelopathy in non-RA patients without AAS. The global increase in the aged population advises caution regarding more prevalent upper cervical spine disorders associated with OA and CPPD.
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Affiliation(s)
- Takashi Yurube
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tetsuhiro Iguchi
- Department of Orthopedic Surgery, Saiseikai Hyogo Prefecture Hospital, Kobe, Japan
| | - Keisuke Kinoshita
- Department of Orthopedic Surgery, Saiseikai Hyogo Prefecture Hospital, Kobe, Japan
| | - Takashi Sadamitsu
- Department of Orthopedic Surgery, Saiseikai Hyogo Prefecture Hospital, Kobe, Japan
| | - Kenichiro Kakutani
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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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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Lvov I, Grin A, Talypov A, Barbakadze Z, Abdrafiev R, Krylov V. Fluoroscopic landmarks and trajectories for safe posterior percutaneous transarticular C1-C2 screw insertion: a CT-based simulation 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 2021; 30:1651-1661. [PMID: 33517498 DOI: 10.1007/s00586-021-06744-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/18/2020] [Accepted: 01/19/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine the safe screw trajectory for posterior transarticular fixation of C1-C2 without direct visualisation of C2 lateral masses and by using fluoroscopic landmarks only. METHODS Fluoroscopic models of the craniovertebral region in frontal and sagittal planes were reconstructed using 1-mm interval computed tomography scans of the cervical spine in 30 patients. The imitation model of the screw trajectory was then applied with verification of the exact screw localisation using multiplanar reconstruction. Twenty-seven trajectories for 60 oblique C1-C2 reformations were tested. RESULTS In the frontal plane, all correct trajectories passed through the medial waistline point (WstP) of C3 and through the middle of the lateral mass of C1. In the lateral plane, the posterior spinal process-lateral mass (SpLM) point-middle C1 anterior tuberculum point (ATP), middle SpLM-upper ATP, and lower SpLM-odontoid point (ODP)-had relatively low rates of vertebral artery (VA) injury (2.3%, 4.6%, and 7%, respectively) and other screw malpositions (6.9%, 4.6%, and 4.6%, respectively). In cases of an isthmus height exceeding 8 mm, there were no incidences of VA injury. Patients with an isthmus width greater than 7 mm had a lower risk of screw malposition. CONCLUSION We identified potentially safe trajectories for percutaneous posterior transarticular fixation of C1-C2. Using SpLM, ATP, and ODP landmarks in the lateral plane, and WstP and C1 middle landmarks in the frontal plane, it is possible to achieve an acceptable screw position without direct visualisation of the C2 lateral mass.
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Affiliation(s)
- Ivan Lvov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia.
| | - Andrey Grin
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
- Department of Neurosurgery, Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Aleksandr Talypov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
| | - Zaali Barbakadze
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
| | - Rinat Abdrafiev
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
| | - Vladimir Krylov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
- Department of Neurosurgery, Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Mathkour M, Iwanaga J, Loukas M, Bui CJ, Dumont AS, Tubbs RS. Muscle Sparing C1-C2 Laminoplasty: Cadaveric Feasibility Study. World Neurosurg 2020; 147:e234-e238. [PMID: 33316488 DOI: 10.1016/j.wneu.2020.12.028] [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: 10/22/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Posterior cervical approaches for atlantoaxial and craniovertebral junction pathologies with or without instrumentation are often associated with excessive soft tissue dissection and bleeding consequent with disruption of the venous plexus. A few minimally invasive approaches to this region have been reported from clinical and cadaveric studies in an effort to minimize blood loss, reduce soft tissue dissection, and decrease postoperative pain; however, unilateral minimally invasive approaches have not been described. Here, we describe a minimally invasive atlantoaxial and craniovertebral approach. METHODS Using fresh cadavers, we performed a novel, right-sided, muscle-sparing minimally invasive C1-C2 laminotomy with laminoplasty for access to the atlantoaxial level and craniovertebral junction and used the traditional approach on left sides. RESULTS Using this approach, the atlantoaxial space and craniovertebral junction with wide and generous exposure via unilateral soft tissue dissection and muscle splitting was achieved. After exposure, the musculoosseous unit was easily repositioned, thus allowing for C1-C2 laminoplasty. Grossly, no damage to the vertebral artery or regional nerves was noted. CONCLUSIONS We present a novel, unilateral minimally invasive approach to reach the atlantoaxial and craniovertebral junction. This could allow for faster postoperative recovery, less pain and opioid requirement, and increased maintenance of atlantoaxial stability. Such a technique, after being confirmed in patients, could optimize this surgical technique.
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Affiliation(s)
- Mansour Mathkour
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Neurosurgery Section, Surgery Department, Jazan University School of Medicine, Jazan, Kingdom of Saudi Arabia
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA.
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, Grenada, West Indies; Department of Anatomy, University of Warmia and Mazury, Olsztyn, Poland
| | - C J Bui
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Anatomical Sciences, St. George's University, Grenada, West Indies; Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA
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Yuwakosol P, Oearsakul T, Tunthanathip T. Morphometry of the C2 Pedicle and Lamina in Thai Patients. Asian J Neurosurg 2020; 15:39-44. [PMID: 32181171 PMCID: PMC7057867 DOI: 10.4103/ajns.ajns_312_19] [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: 10/18/2019] [Accepted: 11/13/2019] [Indexed: 11/04/2022] Open
Abstract
Background Traumatic upper cervical spine leads to instability and neurological deficit. At present, C2 (axis) pedicle or lamina screws for fixation are popular because further external immobilization is not needed. However, these techniques demand experience inserting the screws and carry the risk of vertebral artery or spinal cord injury. In some patients, the C2 screws cannot be inserted because of limited C2 size. Objective To determine the width, length, height, and angle in the C2 pedicle and lamina in the Thai population. Materials and Methods Patient data were collected from the Picture Archiving and Communication System at the Faculty of Medicine, Prince of Songkla University from January 2016 to December 2017. The C2 parameters, i.e., width, length, height, and angle of the pedicle and lamina were recorded. Results The CT C-spine scans of 270 patients were enrolled. The mean Thai C2 pedicle dimensions were width 5.51 mm, length 23.78 mm, angle 39.04°, and height 8.64 mm. The mean C2 lamina dimensions were width 5.88 mm, length 32.17 mm, angle 49.46°, and height 12.27 mm. Twenty-four patients from the 270 patients (8.8%) had a pedicle width <3.5 mm but all patients had a lamina width ≥3.5 mm. Conclusion In the Thai samples, 8.8% had a C2 pedicle width <3.5 mm which would not allow insertion of screws; however, they could be replaced with lamina screws since the lamina width was ≥3.5 mm. In this study, all of the patients who could not be inserted pedicle can be replaced with lamina screws inserted.
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Affiliation(s)
- Pakorn Yuwakosol
- Department of Surgery, Neurosurgical Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thakul Oearsakul
- Department of Surgery, Neurosurgical Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thara Tunthanathip
- Department of Surgery, Neurosurgical Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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10
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Safety and Efficacy of Posterior Atlanto-Axial Stabilization Using Intraoperative Navigation System with Preoperative Computed Tomographic Scan. World Neurosurg 2019; 129:110-119. [DOI: 10.1016/j.wneu.2019.05.242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/22/2022]
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Arslan D, Ozer MA, Govsa F, Kitis O. Surgicoanatomical aspect in vascular variations of the V3 segment of vertebral artery as a risk factor for C1 instrumentation. J Clin Neurosci 2019; 68:243-249. [PMID: 31345535 DOI: 10.1016/j.jocn.2019.07.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/07/2019] [Indexed: 11/30/2022]
Abstract
OBJECT Awareness of vascular anomalies in V3 segment of vertebral artery (VA) is crucial to avoid iatrogenic injuries during surgical procedure. This study aimed to analyze the incidence of V3 segment vascular variations and demonstrate the importance of deciding the surgical strategy for C1 screw placement. METHODS Prevalence of vascular variations and morphometric measurements of the VA in the region of the craniocervical junction in 200 cases based on three-dimensional computed tomographic angiography (3D-CTA) scans were studied. RESULTS The VA has a variable course through C2 before it passes above its groove on the posterior arch of C1. Following the vascular variations of V3 segments of VA were persistent including first intersegmental artery (FIA), fenestration (FEN) of the VA, high-riding (HRVA and the posterior inferior cerebellar artery (PICA) branch originating from the C1/2 part of VA. HRVA was observed in 10.1% of patients, FIA in 1.8%, FEN in 1.3%, and PICA in 1.3%. One hundred and twenty-three (24.1%) patients were identified to have HRVA, 6% present on both sides. CONCLUSION The VA with FIA and FEN were rare in this study as many as a 10% the VA present over the starting point for C1 lateral screw. With respect to the vascular anatomy of V3 and more frequent left-sided VA dominancy, standard screw insertion should be started from the right side. Routine preoperative 3D-CTA evaluation is mandatory to prevent the VA injury when C1-C2 instrumentation is planned.
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Affiliation(s)
- Dilek Arslan
- Department of Neurosurgery, Izmir Tepecik Research and Training Hospital, Izmir, Turkey
| | - Mehmet Asim Ozer
- Digital Imaging and 3D Modelling Laboratory, Department of Anatomy, Faculty of Medicine, Izmir, Turkey
| | - Figen Govsa
- Digital Imaging and 3D Modelling Laboratory, Department of Anatomy, Faculty of Medicine, Izmir, Turkey.
| | - Omer Kitis
- Department of Radiology Faculty of Medicine, Ege University, Izmir, Turkey
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Lvov I, Grin A, Kordonskiy A, Sytnik A, Smirnov V, Khushnazarov U, Krylov V. Minimally Invasive Posterior Transarticular Stand-Alone Screw Instrumentation of C1-C2 Using a Transmuscular Approach: Description of Technique, Results and Comparison with Posterior Midline Exposure. World Neurosurg 2019; 128:e796-e805. [PMID: 31078803 DOI: 10.1016/j.wneu.2019.04.259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study was to compare the feasibility, safety, and fusion results of posterior transarticular stand-alone screw (SAS) instrumentation of C1-C2 with a minimally invasive technique to those of a posterior midline exposure. METHODS Between 2008 and 2016, 164 patients underwent surgical treatment for traumatic injuries to the upper cervical vertebrae at our institution. We included 38 patients (27 men and 11 women; age range, 17-81 years) in the study. The posterior midline approach (PMA) group (23 patients) included patients who underwent surgery by means of a conventional midline incision after percutaneous screw insertion. The transmuscular approach (TMA) group (15 patients) included patients who underwent SAS fixation by use of a minimally invasive technique. The mean follow-up period was 58 months (range, 12-118 months). RESULTS Statistical analysis revealed that the operative time, blood loss volume, and severity of postoperative pain were lower in the TMA group. No significant excess of radiation exposure to the surgical team and the patients occurred in TMA group compared with the PMA group. C1-C2 fusion was observed in 37 patients. Stable fibrous fusion between the C1 and C2 vertebrae was found in 1 patient. CONCLUSIONS A minimally invasive technique by use of a paravertebral transmuscular approach provides an alternative to routine posterior transarticular SAS fixation of C1 and C2 through a posterior midline approach. The minimally invasive technique reduces the duration of surgery and the volume of blood loss, decreases the severity of postoperative pain, and does not increase the amount of radiation exposure for the surgical team and the patient.
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Affiliation(s)
- Ivan Lvov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia.
| | - Andrey Grin
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; A. I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Anton Kordonskiy
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | | | - Vladimir Smirnov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | | | - Vladimir Krylov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; A. I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Lvov I, Grin A, Talypov A, Kordonskiy A, Sytnik A, Khushnazarov U, Smirnov V, Krylov V. A Comparison of the Long-Term Results of Posterior Transarticular Stand-Alone Screw Instrumentation and Magerl Technique in Patients with Traumatic Atlantoaxial Instability: Mean 5-Year Follow-Up Study with Radiological and Patient-Rated Outcomes Assessments. World Neurosurg 2019; 125:e1138-e1150. [PMID: 30780035 DOI: 10.1016/j.wneu.2019.01.263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/26/2019] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To perform a radiological analysis of the degeneration of C1-C2 joints after C1-C2 transarticular fixation (TAF) and compare the long-term results of a routine Magerl technique (RMT) to a posterior transarticular C1-C2 stand-alone screw instrumentation (SAS) application. METHODS A total of 40 patients (26 men and 14 women) were included in the present retrospective observational cohort study. The mean follow-up period was 61.7 months (range, 11-118). The mean patient age at the baseline examination was 48.4 years (range, 22-82). Of the 40 patients, 11 were included in the RMT group and 29 in the SAS group. RESULTS The structure of 80 atlantoaxial joints was analyzed, with grade 4 degenerative changes observed in 57 joints (71.3%). Of the 40 analyzed atlanto-odontoid joints, grade 4 degenerative changes were revealed in 18 joints (45%). C1-C2 bone fusion was observed in 38 patients (95%) and stable fibrous fusion in 2 patients (5%). No cases of C1-C2 nonunion were revealed. No statistically significant differences in the frequency of C1-C2 fracture consolidation or C1-C2 fusion were revealed between the RMT and SAS groups. CONCLUSIONS The application of cortical lag screws in TAF might result in stable atlantoaxial joint fusion formation without joint curettage. Atlanto-odontoid joint fusion was also observed after C1-C2 TAF. The application of cortical lag screws for bilateral fixation using the SAS technique resulted in C1-C2 fusion in 93.1% of cases, comparable to the results with the Magerl technique.
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Affiliation(s)
- Ivan Lvov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia.
| | - Andrey Grin
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; A.I. Evdokimov Moscow Medical University, Moscow, Russia
| | | | - Anton Kordonskiy
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | | | | | - Vladimir Smirnov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | - Vladimir Krylov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; A.I. Evdokimov Moscow Medical University, Moscow, Russia
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Potential intraoperative factors of screw-related complications following posterior transarticular C1-C2 fixation: a systematic review and meta-analysis. 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 2018; 28:400-420. [PMID: 30467736 DOI: 10.1007/s00586-018-5830-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 11/11/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE This study aimed to evaluate the impact of several factors, including patients' intraoperative position, intraoperative visualization technique, fixation method, and type of screws and their parameters, on the frequency of intraoperative screw-associated complications in posterior transarticular C1-C2 fixation. METHODS A systematic review of the PubMed database between January 1986 and March 2018 was performed. The key inclusion criteria comprised detailed descriptions of the surgical technique and post-operative screw-associated complications. RESULTS The initial search resulted in 1041 abstracts, and a total of 54 abstracts were included in the present study. The overall number of operated patients was 2306. In this group, 4439 screws were inserted. The rate of screw-associated complications during the different time periods was estimated upon meta-analysis. Statistical analysis of the screw malposition rate, vertebral artery injury rate, screw breakage rate based on patients' intraoperative position, intraoperative visualization technique, fixation method, and type of implants and their parameters was also performed. CONCLUSIONS The factors that help reduce the rate of screw-associated complications include the intraoperative application of biplanar fluoroscopy or neuronavigation system, the use of 4 mm or thicker lag screws, and screw insertion through contraincisions using cannulated ported instruments. On the other hand, the potential risk factors of screw-associated complications include inadequate intraoperative head fixation using skeletal traction, uniplanar fluoroscopy-guided screw insertion, screw insertion using the posterior midline approach, and the use of 3.5 mm or thinner full-threaded screws. These slides can be retrieved under Electronic Supplementary Material.
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Schunemann V, Kim J, Dornbos D, Nimjee SM. C2-C3 Anterior Cervical Arthrodesis in the Treatment of Bow Hunter's Syndrome: Case Report and Review of the Literature. World Neurosurg 2018; 118:284-289. [DOI: 10.1016/j.wneu.2018.07.129] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 02/06/2023]
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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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A Modified Posterior C1/C2 Fusion Technique for the Management of Traumatic Odontoid Type II Fractures by Using Intraoperative Spinal Navigation: Midterm Results. J Orthop Trauma 2018; 32:e366-e371. [PMID: 29905624 DOI: 10.1097/bot.0000000000001241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess midterm safety and efficacy of a modified Goel-Harms technique for the treatment of odontoid instabilities. DESIGN Longitudinal prospective cohort study. SETTING Urban Level 1 Trauma Center in Southwest Germany. PATIENTS/PARTICIPANTS Orthopaedic and neurosurgical trauma patients older than 18 years admitted for ≤24 hours. MAIN OUTCOME MEASUREMENTS The outcome was evaluated with respect to neurological outcome, radiological outcome and surgical complications. For the functional assessment, the EQ-5D questionnaire was used. Furthermore, the Neck Disability Index and visual analog scale for neck pain were determined. A median follow-up of 39 months (range: 6-97 months) was given. RESULTS Of the total sample (n = 56), 26 patients with an acute traumatic odontoid fracture type II underwent posterior atlantoaxial instrumentation using spinal navigation. Neck pain evaluated with visual analog scale and Neck Disability Index showed a significant decrease at final follow-up compared to preoperative values (P < 0.05). According to the EQ-5D, the valuation of quality of life after C1/C2 fusion showed an excellent outcome with complete recovery in most cases (0.7-1). CONCLUSIONS Our results demonstrate satisfactory and maintained midterm clinical and radiological results after a median follow-up of 39 months. With the use of intraoperative spinal navigation, we demonstrate a modified C1/C2 posterior fusion technique, rendering accuracy, feasibility, and overall safety. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Creation of 3-Dimensional Life Size: Patient-Specific C1 Fracture Models for Screw Fixation. World Neurosurg 2018; 114:e173-e181. [DOI: 10.1016/j.wneu.2018.02.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/20/2018] [Accepted: 02/22/2018] [Indexed: 02/07/2023]
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Abstract
Lateral atlantoaxial osteoarthritis (AAOA), or C1-C2 lateral mass arthritis (LMA), is an unfamiliar degenerative cervical disease with a clinical presentation that markedly differs from subaxial spondylosis. The prevalence of LMA in the nonsurgical outpatient setting is 4%. Risk factors include age and occupation. The typical patient is between 50 and 90 years old, presents with upper cervical or occipital pain, has limited rotation, and has pain provocation during passive rotation to the affected side. Pain stems from degeneration of the lateral C1-C2 articulation and may be referred or radicular, through the greater occipital nerve. Although there is no consensus on diagnostic work-up, the disease is classically seen on the open-mouth odontoid radiograph. Computerized tomography, magnetic resonance imaging, bone scan, and diagnostic injections are also useful. Initial treatment is conservative, and upwards of two-thirds of LMA patients obtain lasting relief with noninvasive measures and injections. In patients with severe, recalcitrant pain, limited C1-C2 fusion offers satisfactory and reliable relief. The goals of this review article are to provide a synthesis of the literature on LMA, to offer a treatment approach to LMA, and to identify problems with the current state of knowledge on LMA.
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Ishak B, Schneider T, Tubbs RS, Gimmy V, Younsi A, Unterberg AW, Kiening KL. Modified Posterior C1 Lateral Mass Screw Insertion for Type II Odontoid Process Fractures Using Intraoperative Computed Tomography–Based Spinal Navigation to Minimize Postoperative Occipital Neuralgia. World Neurosurg 2017; 107:194-201. [DOI: 10.1016/j.wneu.2017.07.159] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/16/2022]
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Morphometric Study of C1 Pedicle and Feasibility Evaluation of C1 Pedicle Screw Placement with a Novel Clinically Relevant Radiological Classification in an Indian Population. Asian Spine J 2017; 11:679-685. [PMID: 29093775 PMCID: PMC5662848 DOI: 10.4184/asj.2017.11.5.679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 01/14/2017] [Accepted: 02/13/2017] [Indexed: 02/05/2023] Open
Abstract
Study Design A retrospective computed tomography (CT)-based morphometric study of 84 C1pedicles in an Indian population focusing on critical morphometric dimensions vis-a-vis C1 pedicle screw placement. Purpose To determine the feasibility of C1 pedicle screw placement in an Indian population and propose a novel classification system for the same. Overview of Literature At present, C1 pedicle screws are rarely used, and very few studies have focused on the feasibility of pedicle screw placement in terms of racial, gender, and ethnic variations in anatomical structures. There are no CT-based data on C1 pedicles that assess the feasibility of pedicle screw placement in the Indian population. Methods We measured C1 pedicle diameter on CT coronal scan images of 42 adult patients. Extramedullary height (EMH) and intramedullary height (IMH) were measured. We examined the differences between the right and left atlas pedicles and compared measures between males and females. These data were analyzed using significance tests. Based on the results, we propose a novel classification system, which we believe will help in determining the feasibility of C1 pedicle screw placement. Results Forty-two adult patients (84 pedicles) were examined. Average EMH and IMH were 4.48±0.91 and 0.86±0.77, respectively. Approximately, 32% of the C1 pedicles had bone thicknesses of <4 mm, 49% had IMH of <1 mm, and 38% had no pedicles. The average thickness in women was 4.21±0.93 mm, which was significantly thinner than that in men (4.73±0.81 mm, p=0.004). Right and left pedicles were not significantly different. Conclusions Our data indicate that approximately one-third of the Indian population may not be suitable candidates for C1 pedicle screw placement. Caution should be exercised while placing type 1B and type 2 pedicles based on our proposed classification system.
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Huang KY, Lin RM, Fang JJ. A novel method of C1-C2 transarticular screw insertion for symptomatic atlantoaxial instability using a customized guiding block: A case report and a technical note. Medicine (Baltimore) 2016; 95:e5100. [PMID: 27787362 PMCID: PMC5089091 DOI: 10.1097/md.0000000000005100] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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
Atlantoaxial instability treated with the C1-2 transarticular screw fixation is biomechanically more stable; however, the technique demanding and the potential risk of neurovascular injury create difficulties for clinical usage, and there is still lack of clinical experience till now.We reported an adult female patient with symptomatic atlantoaxial instability due to rheumatoid arthritis that was successfully treated with a bilateral C1-C2 transarticular screw fixation using a customized guiding block. We preoperatively determined the trajectories for bilateral C1-C2 transarticular screws on a 3-dimensional reconstruction model from the computed tomography (CT) and self-developed computer software, and designed a rapid prototyping customized guiding block in order to offer a guide for the entry point and insertion angle of the C1-C2 transarticular screws.The clinical outcome was good, and the follow-up period was >3 years. The accuracy of the screws is good in comparison with preoperative and postoperative CT findings, and no neurovascular injury occurred.The patient was accurately and successfully treated with a bilateral C1-C2 transarticular screw fixation using a customized guiding block.
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Affiliation(s)
- Kuo-Yuan Huang
- Department of Orthopedics, College of Medicine, National Cheng Kung University
| | - Ruey-Mo Lin
- Department of Orthopedics, China Medical University, Tainan Municipal An-Nan Hospital
| | - Jing-Jing Fang
- Department of Mechanical Engineering, National Cheng Kung University, Tainan, Taiwan
- Correspondence: Jing-Jing Fang, Department of Mechanical Engineering, National Cheng Kung University, Tainan, Taiwan (e-mail: )
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Zheng Y, Hao D, Wang B, He B, Hu H, Zhang H. Clinical outcome of posterior C1–C2 pedicle screw fixation and fusion for atlantoaxial instability: A retrospective study of 86 patients. J Clin Neurosci 2016; 32:47-50. [DOI: 10.1016/j.jocn.2015.12.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/21/2015] [Accepted: 12/27/2015] [Indexed: 11/16/2022]
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Dolati P, Eichberg DG, Thomas A, Ogilvy CS. Application of Pipeline Embolization Device for Iatrogenic Pseudoaneurysms of the Extracranial Vertebral Artery: A Case Report and Systematic Review of the Literature. Cureus 2015; 7:e356. [PMID: 26623211 PMCID: PMC4658329 DOI: 10.7759/cureus.356] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Traumatic pseudoaneurysms of the vertebral artery (VA) are uncommon vascular lesions and definitive management is often challenging. Between 0% and 8% of craniocervical fusions are complicated by VA injury. In these cases, preserving the vertebral artery while treating the pseudoaneurysm is the goal of any treatment option. We describe the second known case of a patient with and iatrogenic extracranial vertebral artery pseudoaneurysm treated effectively using the Pipeline Embolization Device (PED) (Ev3 Neurovascular, Irvine, CA). Although there have been only two cases reported, the use of flow-diverting stents appears to be efficacious for the treatment of non-actively bleeding traumatic pseudoaneurysms.
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Huang DG, Hao DJ, He BR, Wu QN, Liu TJ, Wang XD, Guo H, Fang XY. Posterior atlantoaxial fixation: a review of all techniques. Spine J 2015; 15:2271-81. [PMID: 26165477 DOI: 10.1016/j.spinee.2015.07.008] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 04/24/2015] [Accepted: 07/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Posterior atlantoaxial fixation is an effective treatment for atlantoaxial instability. Great advancements on posterior atlantoaxial fixation techniques have been made in the past decades. However, there is no article reviewing all the posterior atlantoaxial fixation techniques yet. PURPOSE The aim was to review the evolution and advancements of posterior atlantoaxial fixation. STUDY DESIGN This was a literature review. METHODS The application of all posterior fixation techniques in atlantoaxial stabilization, including wiring techniques, interlaminar clamp fixation, transarticular fixation, screw-plate systems, screw-rod systems, and hook-screw systems, are reviewed and discussed. Recent advancements on the novel technique of atlantoaxial fixation are described. The combination of the C1 and C2 screws in screw-rod systems are described in detail. RESULTS All fixation techniques are useful. The screw-rod system appears to be the most popular approach. However, many novel or modified fixation methods have been introduced in recent years. CONCLUSIONS Great advancements on posterior atlantoaxial fixation techniques have been made in the past decades. The wiring technique and interlaminar clamps technique have fallen out of favor because of the development of newer and superior fixation techniques. The C1-C2 transarticular screw technique may remain the gold standard for atlantoaxial fusion, whereas screw-rod systems, especially the C1 pedicle screw combined with C2 pedicle/pars screw fixation, have become the most popular fixation techniques. Hook-screw systems are alternatives for atlantoaxial fixation.
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Affiliation(s)
- Da-Geng Huang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Ding-Jun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China.
| | - Bao-Rong He
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Qi-Ning Wu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Tuan-Jiang Liu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Xiao-Dong Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Hua Guo
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Xiang-Yi Fang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
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Riedinger B, Bürki A, Stahl C, Howard J, Forterre F. Biomechanical Evaluation of the Stabilizing Function of Three Atlantoaxial Implants Under Shear Loading: A Canine Cadaveric Study. Vet Surg 2015; 44:957-63. [PMID: 26413939 DOI: 10.1111/vsu.12402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the biomechanical properties of a ventral transarticular lag screw fixation technique, a new dorsal atlantoaxial instability (AAI) clamp, and a new ventral AAI hook plate under sagittal shear loading after transection of the ligaments of the atlantoaxial joint. STUDY DESIGN Cadaveric biomechanical study. ANIMALS Canine cadavers (n = 10). MATERIALS AND METHODS The occipitoatlantoaxial region of Beagles euthanatized for reasons unrelated to the study was prepared leaving only ligamentous structures and the joint capsules between the first 2 cervical vertebrae (C1 and C2). The atlanto-occipital joints were stabilized with 2 transarticular diverging positive threaded K-wires. The occipital bone and the caudal end of C2 were embedded in polymethylmethacrylate and loaded in shear to a force of 50 Newtons. The range of motion (ROM) and neutral zone (NZ) of the atlantoaxial joint were determined after 3 loading cycles with atlantoaxial ligaments intact, after ligament transection, and after fixation with each implant. The testing order of implants was randomly assigned. The implants tested last were subjected to failure testing. RESULTS All stabilization procedures decreased the ROM and NZ of the atlantoaxial joint compared to transected ligament specimens. Only stabilization with transarticular lag screws and ventral plates produced a significant reduction of ROM compare to intact specimens. CONCLUSION Fixation with transarticular lag screws and a ventral hook plate was biomechanically similar and provided more rigidity compared to dorsal clamp fixation. Further load cycling to failure tests and clinical studies are required before making clinical recommendations.
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Affiliation(s)
- Benoit Riedinger
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Alexander Bürki
- Institute for Surgical Technology and Biomechanics, University of Berne, Berne, Switzerland
| | - Christina Stahl
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Judith Howard
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Berne, Switzerland
| | - Franck Forterre
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Berne, Switzerland
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Yin Q, Wang J. Current Trends in Management of Atlantoaxial Dislocation. Orthop Surg 2015; 7:189-99. [PMID: 26311092 PMCID: PMC6583745 DOI: 10.1111/os.12196] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 06/26/2015] [Indexed: 01/26/2023] Open
Abstract
Atlantoaxial dislocation (AAD), often caused by trauma, tumors or congenital malformations, is a challenging disorder of the craniocervical junction. Because of its deep location and intricate anatomic structure, the craniocervical junction is always a difficult region for spine surgery. With recent developments in medical science, great progress has been made in the diagnosis and treatment of AAD such that more instructive clinical classifications and efficacious treatment strategies, various novel operation techniques including innovative posterior or transoral anterior reduction, and novel fixation instruments are now widely used in clinical practice for managing AAD. However, surgeons continue to face more special characteristics and difficulty in carrying out upper cervical surgery than they encounter in other regions of the spine. Consequently, this high risk surgery should only be performed by extremely skilled and experienced surgeons and only when stringent indications have been met. Therefore, the aim of this course is to assist surgeons who are dealing with AAD by providing comprehensive information about AAD, including related anatomy, classification, clinical manifestations and diagnosis, imaging examinations and surgical techniques, thus decreasing the occurrence of complications and improving the level of diagnosis and treatment.
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Affiliation(s)
- Qing‐shui Yin
- Orthopaedic HospitalGeneral Hospital of Guangzhou Military Command of People's Liberation ArmyGuangzhouChina
| | - Jian‐hua Wang
- Orthopaedic HospitalGeneral Hospital of Guangzhou Military Command of People's Liberation ArmyGuangzhouChina
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Ohya J, Chikuda H, Kato S, Horiguchi H, Takeshita K, Tanaka S, Yasunaga H. Risks of In-Hospital Death and Complications After Fusion Surgery in Patients with Atlantoaxial Subluxation: Analysis of 1090 Patients Using the Japanese Diagnosis Procedure Combination Database. World Neurosurg 2015; 83:603-7. [DOI: 10.1016/j.wneu.2014.12.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 09/06/2014] [Accepted: 12/10/2014] [Indexed: 11/25/2022]
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Mallory GW, Halasz SR, Clarke MJ. Advances in the treatment of cervical rheumatoid: Less surgery and less morbidity. World J Orthop 2014; 5:292-303. [PMID: 25035832 PMCID: PMC4095022 DOI: 10.5312/wjo.v5.i3.292] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 03/08/2014] [Accepted: 04/17/2014] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis is a chronic systemic inflammatory disease that often affects the cervical spine. While it was initially thought that cervical involvement was innocuous, natural history studies have substantiated the progressive nature of untreated disease. Over the past 50 years, there has been further elucidation in the pathophysiology of the disease, as well as significant advancements in medical and surgical therapy. The introduction of disease modifying drugs and biologic agents has reduced the amount of patients with advanced stages of the disease needing surgery. Advancement in instrumentation techniques has improved patient outcomes and fusion rates. The introduction of endoscopic approaches for ventral decompression may further lower surgical morbidity. In this review, we give a brief overview of the pertinent positives of the disease. A discussion of historical techniques and the evolution of surgical therapy into the modern era is provided. With improved medical therapies and less invasive approaches, we will likely continue to see less advanced cases of disease and less surgical morbidity. Nonetheless, a thorough understanding of the disease is crucial, as its systemic involvement and need for continued medical therapy have tremendous impact on overall complications and outcomes even in patients being seen for standard degenerative disease with comorbid rheumatoid.
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Gautschi OP, Payer M, Corniola MV, Smoll NR, Schaller K, Tessitore E. Clinically relevant complications related to posterior atlanto-axial fixation in atlanto-axial instability and their management. Clin Neurol Neurosurg 2014; 123:131-5. [PMID: 25012025 DOI: 10.1016/j.clineuro.2014.05.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 05/22/2014] [Accepted: 05/26/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Magerl transarticular technique and the Harms-Goel C1 lateral mass-C2 isthmic screw technique are the two most commonly used surgical procedures to achieve fusion at C1-C2 level for atlanto-axial instability. Despite recent technological advances with an increased safety, several complications may still occur, including vascular lesions, neurological injuries, pain at the harvested bone graft site, infections, and metallic device failure. METHODS We retrospectively analyzed all patients (n=42 cases) undergoing a Harms-Goel C1-C2 fixation surgery with polyaxial C1 lateral mass screws and C2 isthmic screws at two different institutions between 2003 and 2012 and report clinical and radiological complications. One patient was lost to follow-up. The mean follow-up of the remaining 41 patients was 18.7 months (range 12-90). A clinically relevant complication was defined as a complication determining the onset of a new neurological deficit or requiring the need for a revision surgery. RESULTS A total of 14 complications occurred in 10 patients (24.4% of 41 patients). Greater occipital nerve neuralgia was evident in 4 patients (9.8%). All but one completely resolved at the end of the follow-up. Persistent neck pain was reported by 3 patients (7.3%), hypoesthesia by 1 patient (2.4%), and anesthesia in the C2 area on both sides in 1 patient (2.4%). Furthermore, a superficial, a deep, and a combined superficial and deep wound infection occurred in 1 patient each (2.4%). One patient (2.4%) had pain at the iliac bone graft donor site for several weeks with spontaneous resolution. A posterior progressive intestinal herniation through the iliac scar was seen in 1 case (2.4%), which required surgical repair. No vascular damages occurred. Altogether, 5/41 patients (12.2%) had a clinically relevant complication including 4 patients necessitating a revision surgery at the C1-C2 level (9.8%). CONCLUSIONS Atlanto-axial fixation surgery remains a challenging procedure because of the proximity of important neurovascular structures. Nevertheless, on the basis of our current experience, the C1 lateral mass-C2 isthmic screw technique appears to be safe with a low incidence of clinically relevant complications. Postoperative C2 neuralgia, as the most frequent problem, is due to surgical manipulation during preparation of the C1 screw entry point.
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Affiliation(s)
- O P Gautschi
- Department of Neurosurgery, Geneva University Medical Center, Faculty of Medicine, University of Geneva, Switzerland.
| | - M Payer
- Department of Neurosurgery, Geneva University Medical Center, Faculty of Medicine, University of Geneva, Switzerland; Neurosurgical Spine Unit, Hirslanden Klinik, Zurich, Switzerland
| | - M V Corniola
- Department of Neurosurgery, Geneva University Medical Center, Faculty of Medicine, University of Geneva, Switzerland
| | - N R Smoll
- Department of Neurosurgery, Geneva University Medical Center, Faculty of Medicine, University of Geneva, Switzerland; Gippsland Medical School, Monash University, Victoria, Australia
| | - K Schaller
- Department of Neurosurgery, Geneva University Medical Center, Faculty of Medicine, University of Geneva, Switzerland
| | - E Tessitore
- Department of Neurosurgery, Geneva University Medical Center, Faculty of Medicine, University of Geneva, Switzerland
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Guo X, Ni B, Xie N, Lu X, Guo Q, Lu M. Bilateral C1-C2 transarticular screw and C1 laminar hook fixation and bone graft fusion for reducible atlantoaxial dislocation: a seven-year analysis of outcome. PLoS One 2014; 9:e87676. [PMID: 24498163 PMCID: PMC3909196 DOI: 10.1371/journal.pone.0087676] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 12/28/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bilateral C1-2 transarticular screw and C1 laminar hook fixation was developed on the basis of transarticular screws fixation. The modified technique has showed a better biomechanical stability than established techniques in previous study. However, long-term (minimum follow-up 7 years) outcomes of patients with reducible atlantoaxial dislocation who underwent this modified fixation technique have not still been reported. METHODS A retrospective study was conducted to evaluate the outcome of 36 patients who underwent this modified technique. Myelopathy was assessed using the Ranawat myelopathy score and Myelopathy Disability Index. Pain scores were assessed using Visual Analogue Scale. Radiological imaging was assessed and the following data were extracted: the atlantodental intervals, the space available for cord, presence of spinal cord signal change on T2 weighted image, C1-C2 angle, C2-C7 angle and fusion rates. FINDINGS All patients achieved a minimum seven-year follow up. 95% patients with neck and suboccipital pain improved after surgery; in their Visual Analogue pain scores, there was a greater than 50% improvement in their VAS scores with a drop of 5 points on the VAS (P<0.05). 92% of patients improved in the Ranawat myelopathy grade; the Myelopathy Disability Index assessment showed a preoperative mean score of 35.62 with postoperative mean 12.75(P<0.05). There was not any significant atlantoaxial instability at each follow-up time. The space available for cord increased in all patients. Postoperative sagittal kyphosis of the subaxial spine was not observed. After six months after surgery, bone grafts of all patients were fused. No complications related to surgery were found in the period of follow-up. CONCLUSIONS The long-term outcomes of this case series demonstrate that under the condition of thorough preoperative preparations, bilateral C1-C2 transarticular screw and C1 laminar hook fixation and bone graft fusion is a reliable posterior atlantoaxial fusion technique for reducible atlantoaxial dislocation.
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Affiliation(s)
- Xiang Guo
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, P.R. China
| | - Bin Ni
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, P.R. China
- * E-mail:
| | - Ning Xie
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, P.R. China
| | - Xuhua Lu
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, P.R. China
| | - Qunfeng Guo
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, P.R. China
| | - Ming Lu
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, P.R. China
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Atlantoaxial transarticular screw fixation and posterior fusion using polyester cable: a 10-year experience. 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 2013; 22:1564-9. [PMID: 23608934 DOI: 10.1007/s00586-013-2789-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 03/19/2013] [Accepted: 04/14/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To retrospective review the clinical outcomes of the modified operative technique using a polyester suture material (Ethibond* Excel) for atlantoaxial transarticular screw fixation and posterior fusion. METHODS The retrospective reviews were conducted from 2002 to 2012. The patient's medical record reviews included demographic data, cause of atlantoaxial instability, orthopedic and surgical history, clinical presentation, radiographic finding including plain radiography, complications, operative detail, and outcome of treatment. Fusion of C1-C2 was defined as either graft consolidation or absence of C1-C2 movement on lateral flexion-extension radiograph. RESULTS Twenty-three patients demonstrated clinical and radiographic evidence of atlantoaxial instability (13 men and 10 women, with a mean age of 42 years). Majority of atlantoaxial instability was caused by trauma. Most common clinical symptom was neck pain with or without cervical myelopathy. Bilateral screws were placed in 18 of the 23 patients. Five patients underwent placement of unilateral screws. The 13 patients were inserted by screws with diameter 4.0 mm. The means screw length was 40.33 mm. The means of operative time and estimated blood loss were 3.6 h and 234 ml, respectively. The mean of follow-up duration was 18 months. All 41 screws were positioned satisfactorily in C1 lateral mass. All 23 patients achieved fusion (100% fusion rate). After a period of follow-up, 9 of the 10 neurological deficit patients had completely recovered. CONCLUSIONS We concluded that the atlantoaxial transarticular screw fixation and posterior fusion using polyester cable can be used for C1-2 fusion with a high fusion rate and less complications in various cases.
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Ling JM, Tiruchelvarayan R, Seow WT, Ng HB. Surgical treatment of adult and pediatric C1/C2 subluxation with intraoperative computed tomography guidance. Surg Neurol Int 2013; 4:S109-17. [PMID: 23646272 PMCID: PMC3642753 DOI: 10.4103/2152-7806.109454] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 01/28/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical treatment of C1/C2 subluxation has evolved significantly over the past 2 decades, from the relatively simpler posterior wiring to more technically demanding instrumentations such as C1 lateral mass screws - C2 pedicle screws, C1/C2 transarticular screws, and occipital cervical fusion. Navigation with fluoroscopy is currently the standard of practice in most centers. However, fluoroscopy at this level carries several major drawbacks, such as blockage by the mandible and inability to produce axial images for assessment of the reduction of rotatory subluxation. METHODS The authors report a series of 21 patients with C1/C2 subluxation treated surgically with intraoperative computed tomography (ICT) guidance. RESULTS There were 7 children and 14 adults. Eight patients underwent C1/C2 fixation with a Harm's construct, and 13 patients underwent occipital cervical fusion. One out of 17 (6%) C1 lateral mass screws has breached the medial wall of lateral mass by 1 mm. Two out of 20 (10%) C2 pedicle screws have breached the foramen transversarium by 1 mm (Neo classification grade 1). The position of all subaxial screws (49 lateral mass screws and 13 pedicle screws) and occipital screws (50 screws) appeared satisfactory. No neurovascular damage occurred in all the patients. CONCLUSIONS Ninety eight percent of the screws were placed in ideal position with the aid of ICT. Only 2% of the screws deviated from the planned position, but the breaches were not clinically significant and hence no revision was required. This showed that ICT guidance can help to achieve a high accuracy of surgical instrumentation for the treatment of C1/C2 subluxation.
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Affiliation(s)
- Ji Min Ling
- Department of Neurosurgery, National Neuroscience Institute of Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore
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