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Vinas-Rios JM, Heck VJ, Eysel P, Walter SG, Babasiz T, Kernich N. Perioperative complications associated with fluoroscopy C1 lateral mass screw fixation (Goel technique) versus computed tomography-guided navigation technique: A review of 202 cases from the German Spine Registry (DWG-Register). JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:241-246. [PMID: 38957763 PMCID: PMC11216655 DOI: 10.4103/jcvjs.jcvjs_36_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/08/2024] [Indexed: 07/04/2024] Open
Abstract
Background Overview of the literature - Fractures of the C1 constitute 3%-13% of all cervical spine injuries in adults. Most isolated C1 fractures are stable and can be treated nonoperatively with external immobilization. Traditional surgical options for C1 fracture treatment are occiput-to-C2 fusion or C1 with lateral mass screws (LMSs). Purpose - The aim is to assess the management and perioperative complications of C1 fractures undergoing LMS fusion between fluoroscopy and computed tomography (CT)-guided navigation. Methods This was a retrospective multicenter study of data from the DWG-Register of patients who underwent operative treatment for C1 traumatic fracture with LMSs from January 2017 to September 2022. Inclusion criteria - traumatic injury and age > 18 years old. Results In total, 202 patients with traumatic C1 fracture requiring spinal surgery were identified in the registry; n = 175 (Group 1) were treated conventionally without CT-guided navigation and n = 27 were treated with CT-guided navigation (Group 2). C1-LMS was principally performed by spine surgeons n = 90 (53.4%) and n = 72 (18.5%) by neurosurgeons in both the groups. Intraoperative adverse events were as follows: dural tear in group 1 n = 0 and in group 2 n = 1, vascular injury, with one case in group 1 and no cases in group 2. General complications were: cardiovasculars in group 1 n = 6 (3.4%) and Group 2 n = 4 (14.8%) (P = 0.03), pulmonary complications in group1 n = 2 (1.1%) and n = 9 in group 2 (33.3%) (P < 0.001), stroke n = 1 (0.57%) in group1 and n = 4 in group 2 (14.8%) (P < 0.001), gastrointestinal bleeding n = 1 (0.57%) in group1 and no cases in group 2, renal insufficiency n = 2 (1.1%) in group 1 and n = 3 (11.1%) in group 2 (P = 0.01). One death was recorded in group 2 (3.7%). Conclusion This series of 404 screws placed in 202 patients over 5 years who underwent two types of C1 fracture fixation had a considerably lower incidence of screw malposition and vertebral artery injury than has previously been reported in the literature. C1 screws can be safely placed with a low risk of vertebral artery and neurologic injury with and without CT-guided navigation support.
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Affiliation(s)
| | - Vincent J. Heck
- Department of Faculty of Medicine, University of Cologne, Cologne, Germany
- Department of Spine Surgery, Sana Klinikum Offenbach, Offenbach, Germany
| | - Peer Eysel
- Department of Faculty of Medicine, University of Cologne, Cologne, Germany
| | | | - Tamara Babasiz
- Department of Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Nikolaus Kernich
- Department of Faculty of Medicine, University of Cologne, Cologne, Germany
| | - DWG-Registry Group
- Department of Orthopedics and Traumatology, University of Cologne, Cologne, Germany
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Singh DK, Shankar D, Chand VK, Singh RK, Singh N. C2 Superior Facetal Osteotomy: A Novel Technique in Complex Craniovertebral Junction Surgery for C1 Lateral Mass Screw Placement. Asian Spine J 2023; 17:1125-1131. [PMID: 38105640 PMCID: PMC10764145 DOI: 10.31616/asj.2023.0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/31/2023] [Accepted: 09/25/2023] [Indexed: 12/19/2023] Open
Abstract
Complex craniovertebral junction (CVJ) defects account for a considerable proportion of CVJ diseases. Given the heavily assimilated C1, an unfavorable C1-C2 joint orientation, an overriding C2 superior facet, a low-hanging occiput, and an abnormal vertebral artery course with a high-riding vertebral artery, placement of C1 lateral mass screws might be difficult. To address this, a novel technique for placing C1 lateral mass screws that avoid vertebral artery injury, low-hanging occiput, and overriding C2 superior facet was developed in this study. This approach enables firm fixation of C1-C2 even in difficult situations where the placement of the C1 lateral mass is challenging.
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Affiliation(s)
- Deepak Kumar Singh
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow,
India
| | - Diwakar Shankar
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow,
India
| | - Vipin Kumar Chand
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow,
India
| | - Rakesh Kumar Singh
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow,
India
| | - Neha Singh
- Department of Radiodiagnosis, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow,
India
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Tinner C, Aregger FC, Deml MC. Transoral unilateral lag screw osteosynthesis for coronal split fracture of the lateral mass of the atlas - case report, operative technique and review of the literature. BRAIN & SPINE 2023; 3:101761. [PMID: 38020987 PMCID: PMC10668072 DOI: 10.1016/j.bas.2023.101761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/28/2023] [Accepted: 06/07/2023] [Indexed: 12/01/2023]
Abstract
Introduction Atlas ring fractures, which account for 1.3% of all spinal fractures, are predominantly managed conservatively. However, in certain cases, surgical treatment may be necessary depending on the type of fracture, degree of comminution, fracture location, and associated ligamentous injuries. Surgical stabilization frequently results in a posterior C1-2 or C0-2 fusion, which restricts movement, particularly craniocervical rotation. Coronal split fractures of the lateral mass need to be reduced and fixed due to dislocation, instability and secondary osteoarthritis. The preferred treatment approach involves internal fixation of the reduced fracture fragments, while avoiding restriction of the upper cervical spine's range of motion (ROM). Research question Is unilateral anterior transoral lag screw for treatment of unstable coronal split fracture of lateral mass of the atlas feasible and a safe treatment option? Case Report Material and Methods We report on a 55-year-old female suffering from polytrauma with multiple spinal and extremity injuries. Results A coronal split fracture of the lateral mass of the atlas was treated minimally invasive with a transoral lag screw technique to reduce and fix the fracture that has a tendency for fracture gap widening. Stable fixation and fracture union and thus restoration of function was achieved. Discussion and conclusion Transoral lag screw osteosynthesis for coronal split fracture of the lateral mass of the atlas is a potential treatment option in selected cases to preserve mobility in the upper cervical spine after spinal trauma.
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Affiliation(s)
- Christian Tinner
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Fabian Cedric Aregger
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Moritz Caspar Deml
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Singh DK, Shankar D, Singh N, Singh RK, Chand VK. C2 Screw fixation techniques in atlantoaxial instability: A technical review. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:368-377. [PMID: 36777907 PMCID: PMC9910137 DOI: 10.4103/jcvjs.jcvjs_128_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
Atlantoaxial instability (AAI) is surgically a complex entity due to its proximity to vital neurovascular structures. C1-C2 fusion has been an established standard in its treatment for a considerable time now. Here, we have outlined the most common techniques for C2 screw fixation in practice at present such as C2 pedicle, C2 pars, C2 translaminar, C2 subfacetal, C2-C3 transfacetal, and C2 inferior facet screw. We have discussed in detail the technical as well as biomechanical aspects of each technique of C2 screw fixation in AAI and explored the intricacies of each technique.
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Affiliation(s)
- Deepak Kumar Singh
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Diwakar Shankar
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Neha Singh
- Department of Radiodiagnosis, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rakesh Kumar Singh
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vipin Kumar Chand
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Puneeth S, Karthigeyan M, Salunke P, Panchal C, Kataria MS. C2 Nerve Root Preservation During Posterior Fixation for Instability Secondary to Congenital Craniovertebral Junction Anomalies: Feasibility Factors and Related Outcomes. World Neurosurg 2021; 157:e94-e101. [PMID: 34610446 DOI: 10.1016/j.wneu.2021.09.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Patients with instability because of congenital craniovertebral anomalies often have complex C1-C2 osseovascular anomalies. C2 nerve root sacrifice has been described to address such difficult anatomy during posterior C1-C2 fixation and has its own downsides. Its preservation as a recent alternative poses greater surgical challenge, and the considerations differ from other causes of craniovertebral junctional instability; the pertaining outcomes have been scarcely studied. The objective of this study was to prospectively determine the feasibility and outcomes related to C2 nerve root preservation in patients with congenital atlantoaxial dislocation (CAAD) after posterior C1-C2 fixation. METHODS In this observational study, 63 patients (126 nerve roots) with CAAD after posterior fixation were prospectively assessed. Underlying osseovascular anomalies affecting the feasibility of C2 nerve root preservation, and C2 nerve-related dysfunction at 12 months follow-up were analyzed. RESULTS The overall C2 nerve root preservation rate was 89.7%. Even in the presence of extreme joint obliquity/spondyloptosis and anomalous vertebral artery, it was feasible in about three fourths. After preservation, 28.3% patients developed new-onset C2 nerve root dysfunction: neuralgia in 2, dysesthesia in 6, and hypoesthesia/paresthesia in 9. The symptoms were not disabling in most patients. CONCLUSIONS In most patients with CAAD, C2 nerve root preservation is feasible despite an aberrant bony and vascular anatomy. A few patients after nerve root preservation develop related symptoms that are conservatively manageable, with no significant adverse consequences. Given the controversy in the literature on C2 nerve sacrifice-related outcomes, we favor an attempt at C2 nerve root preservation.
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Affiliation(s)
- Shivanna Puneeth
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Madhivanan Karthigeyan
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India.
| | - Chirag Panchal
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Mandeep Singh Kataria
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Lenz M, Harland A, Egenolf P, Perera A, Pennig L, Bredow J, Eysel P, Scheyerer MJ. Suggestion of a safe zone for C1 pedicle screws depending on anatomical peculiarities. 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; 30:3614-3619. [PMID: 34559274 DOI: 10.1007/s00586-021-06993-z] [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: 03/13/2021] [Revised: 07/15/2021] [Accepted: 09/13/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE For surgical treatment of instable upper cervical injuries, the Harms technique using lateral mass screws provides rigid fixation and favourable clinical outcomes. The use of the posterior arch of C1 as a "pedicle" allows for screw anchorage, giving improved biomechanical stability. Therefore, the aim of this study was to introduce a bilateral safe zone for C1 pedicle screws, regarding screw angulation and pedicle height. MATERIAL AND METHODS We retrospectively reviewed the CT scans of 500 patients. Three-dimensional reformats were generated for detailed measurements. Centre screw entry point (EP), length of lateral mass as screw trajectory, lateral mass width (LMW), length of screw trajectory (ST), maximal divergence (DI) and maximal convergence (CON) from EP without perforation, and pedicle height (PH) of the posterior arch were measured. RESULTS The 500 cases consisted of 335 males and 165 females, with a mean age of 49.5 years. Measurements did not demonstrate significant side-related differences. The mean screw entry point was 22.8 mm from the midline-axis (left 22.6 mm; right 23.0 mm). From this point, a safe zone between 11.6° of divergence and 19.6° of convergence was detected. Measurements of female patients were generally smaller, with significant differences from male patients (p < 0.05). 158 subjects (31.6%) had a PH < 4 mm. DISCUSSION C1 pedicle screws were feasible in the majority of patients. Proposing a safe zone for screw angulation may provide safety and avoid screw perforation. However, detailed knowledge of the individual C1 anatomy and the preoperative measurement is essential in the operative planning.
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Affiliation(s)
- Maximilian Lenz
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University of Cologne, Joseph-Stelzmann Strasse 24, Kerpener Str. 62, 50931, Cologne, Germany.
| | - Arne Harland
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University of Cologne, Joseph-Stelzmann Strasse 24, Kerpener Str. 62, 50931, Cologne, Germany
| | - Philipp Egenolf
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University of Cologne, Joseph-Stelzmann Strasse 24, Kerpener Str. 62, 50931, Cologne, Germany
| | - Akanksha Perera
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University of Cologne, Joseph-Stelzmann Strasse 24, Kerpener Str. 62, 50931, Cologne, Germany
| | - Lenhard Pennig
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Jan Bredow
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University of Cologne, Joseph-Stelzmann Strasse 24, Kerpener Str. 62, 50931, Cologne, Germany
| | - Peer Eysel
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University of Cologne, Joseph-Stelzmann Strasse 24, Kerpener Str. 62, 50931, Cologne, Germany
| | - Max Joseph Scheyerer
- Department for Orthopaedic and Trauma Surgery, Faculty of Medicine, University of Cologne, Joseph-Stelzmann Strasse 24, Kerpener Str. 62, 50931, Cologne, Germany
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Unni C, Pettakkandy V, P. AJ, Soren SK, K. VK. Atlantoaxial Stabilization by Posterior C1 and C2 Screw-Rod Fixation for Various Pathologies: Case Series and Comprehensive Review of Literature. J Neurosci Rural Pract 2021; 12:228-235. [PMID: 33927515 PMCID: PMC8064858 DOI: 10.1055/s-0041-1722838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
We retrospectively analyzed atlantoaxial dislocation (AAD) of various pathologies, namely, rheumatoid arthritis (RA), os odontoideum, and trauma. Various techniques were discussed in relation to C1-C2 stabilization. The study aims to share our clinical experience in a series of six cases of C1-C2 instability that underwent posterior C1-C2 fusion, with free hand technique and limited fluoroscopy. The clinicoradiological presentation for each patient is described. We reviewed different literatures related to our case vividly and focused on the basic neuroanatomy involved in the atlantoaxial joint. All patients of AAD had evidence of severe canal compromise and chronic compressive spinal cord changes. In our study, the patients age ranged from 28 to 52 years. The study included four males and two females. Out of six patients of AAD, three had history of trauma, two had os odontoideum, and one had chronic inflammatory condition (RA). From our case series, we concluded that the Goel-Harms technique is the most versatile and surgeon friendly technique for C1-C2 fixation. Early recognition and surgical intervention of atlantoaxial joint instability is essential to prevent catastrophic neurological complications.
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Affiliation(s)
- Chandramohan Unni
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| | - Vijayan Pettakkandy
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| | - Abdul Jaleel P.
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| | - Subrat Kumar Soren
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| | - Vineeth K. K.
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
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Paterson A, Byrne S, Hansen M, Kuru R. Modified C1 lateral mass screw insertion using a threaded K-wire. A technical note. J Clin Neurosci 2020; 79:95-99. [PMID: 33070927 DOI: 10.1016/j.jocn.2020.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 05/24/2020] [Accepted: 07/13/2020] [Indexed: 11/20/2022]
Abstract
Instrumented fixation of the C1-C2 motion segment is a standard surgical technique to stabilise that spinal segment. Instability at C1-C2 can arise from a number of conditions. Fixation of the C1 lateral mass usually involves dissection and exposure of the C2 nerve root and the posterior wall of the C2 lateral mass which can result in significant bleeding from the venous plexus. Whilst image guidance is increasing in accessibility, there are few public hospitals in Australia that have access to this technology. The authors describe their technique for insertion of a C1 lateral mass screw over a threaded K-wire to avoid extensive dissection of the C2 nerve root, reducing the risk of significant haemorrhage from the epidural venous plexus during the procedure. A retrospective analysis was undertaken on 18 consecutive patients who underwent C1-C2 instrumented fixation using this technique. Indications for C1-C2 instrumented fixation included traumatic injury (10 patients), failure of non-operative management of odontoid fractures (5 patients), pathological fractures of C2 (2 patients) and inflammatory conditions (1 patient). All patients underwent successful C1-C2 stabilisation using this technique. Blood loss did not exceed 400mls in any patient. There were no vertebral artery injuries and no patient experienced a neurological deterioration. The authors propose that their technique for insertion of a C1 lateral mass screw over a threaded K-wire is safe and effective with a low risk of neurological or vertebral artery injury. The technique may be considered as a slight modification of the Harm's procedure to reduce disturbance of the adjacent venous plexus and thereby reduction in intraoperative bleeding and operative time.
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Affiliation(s)
- Amanda Paterson
- Department of Neurosurgery, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia.
| | - Stephen Byrne
- Department of Neurosurgery, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia; Department of Orthopaedics, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia
| | - Mitchell Hansen
- Department of Neurosurgery, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia
| | - Robert Kuru
- Department of Orthopaedics, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia
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Yang DS, Patel SA, DiSilvestro KJ, Li NY, Daniels AH. Postoperative complication rates and hazards-model survival analysis of revision surgery following occipitocervical and atlanto-axial fusion. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2020; 3:100017. [PMID: 35141587 PMCID: PMC8820023 DOI: 10.1016/j.xnsj.2020.100017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/01/2020] [Accepted: 07/29/2020] [Indexed: 11/16/2022]
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Daniel S. Yang
- Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Shyam A. Patel
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Kevin J. DiSilvestro
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Neill Y. Li
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Alan H. Daniels
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02903, United States
- Corresponding author at: Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Avenue, East Providence, RI 02914, United States.
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Byeon Y, Lee BJ, Park JH. Freehand Placement of the C1 Pedicle Screw Using Direct Visualization of the Pedicle Anatomy and Serial Dilatation. Korean J Neurotrauma 2020; 16:207-215. [PMID: 33163429 PMCID: PMC7607029 DOI: 10.13004/kjnt.2020.16.e15] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 12/02/2022] Open
Abstract
Objective We designed a method for inserting C1 pedicle screws using the direct visualization technique of the pedicle and serial dilatation technique to reduce complications and malposition of screw, and assessed the accuracy of this method. Methods Free-hand C1 pedicle screw insertion using the direct visualization technique of the pedicle and serial dilatation technique was performed on 5 consecutive patients with C1–2 instability at a single institute from March to December 2018. The method involved protecting the vertebral artery (VA) and C1 root using the Penfield No. 1, securing the entry point of the posterior arch screw and the pedicle was visible directly in Trendelenburg position. The hole at the entry point of the C1 posterior arch was serially dilated using a 2.5×3.0 mm drill bit, and the C1 pedicle screw was inserted with the free hand technique. We measured postoperative radiological parameters and recorded intraoperative complications, postoperative neurological deficits and the occurrence of occipital neuralgia. Postoperative computed tomography (CT) was performed to check screw malposition or construction failure. Results Of the 10 C1 pedicle screws on postoperative CT, 20% of screws (grade A) were in the ideal position while 80% of screws (grade B) occupied a safe position. Overall, 100% of screws were safe (grade A or B). There were no iatrogenic neurological deficits, VA injury. Conclusion Freehand placement of the C1 pedicle screw through the direct visualization technique of the pedicle and serial dilatation technique is safe and effective without intraoperative fluoroscopy guidance.
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Affiliation(s)
- Yukyeng Byeon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung-Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Neuroscience & Radiosurgery Hybrid Research Center, Inje University College of Medicine, Goyang, Korea
| | - Jin Hoon Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Lee BJ, Kim M, Jeong SK, Lee S, Jeon SR, Roh SW, Park JH. Comparison of the Accuracy of C1 Pedicle Screw Fixation Using Fluoroscopy and Free-Hand Techniques in Patients With Posterior Arch Thickness of Less Than 4 mm. Oper Neurosurg (Hagerstown) 2020; 19:429-435. [DOI: 10.1093/ons/opaa067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/02/2020] [Indexed: 02/05/2023] Open
Abstract
Abstract
BACKGROUND
C1 pedicle screw insertion is not easy, and more fluoroscopy can be required for safe insertion. Fluoroscopy is time consuming and increases patient radiation exposure. There have been no studies comparing the accuracy of C1 pedicle screw insertion using the fluoroscopy and free-hand techniques.
OBJECTIVE
To describe a free-hand C1 pedicle screw insertion method in patients with the posterior arch thickness of less than 4 mm in the thinnest part of the groove, and to compare the clinical and radiological outcomes of C1 pedicle screw insertion using fluoroscopy vs using the free-hand technique.
METHODS
A total of 25 patients who had atlantoaxial instability with a C1 posterior arch <4 mm and were treated with C1 pedicle screw insertion were included. In 10 patients, fluoroscopy was used for C1 pedicle screw insertion, and 15 patients underwent the free-hand technique. We compared the radiologic and clinical outcomes between the 2 groups.
RESULTS
In patients who underwent the free-hand technique, 96.5% of screws were rated as safe (grade A or B), and 80.0% of screws in the fluoroscopy group were rated as safe. Postoperative occipital neuralgia occurred in one patient in the fluoroscopy group and did not occur in the free-hand technique group. There was no significant difference in the improvement of Nurick grade between the 2 groups.
CONCLUSION
C1 pedicle screw insertion using the free-hand technique is feasible and safe in patients with a C1 posterior arch <4 mm.
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Affiliation(s)
- Byung-Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Neuroscience & Radiosurgery Hybrid Research Center, College of Medicine, Goyang, Republic of Korea
| | - Myeongjong Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong Kyun Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Subum Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang-Ryong Jeon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Woo Roh
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Macki M, Hamilton T, Pawloski J, Chang V. Occipital fixation techniques and complications. JOURNAL OF SPINE SURGERY 2020; 6:145-155. [PMID: 32309653 DOI: 10.21037/jss.2019.12.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Occipitocervical fusions in the adult population are most commonly indicated for neoplastic tumors invading the craniocervical junction (CCJ), rheumatological deformities compromising the foramen magnum, and traumatic dislocations resulting in occiput-C1 instability. Appropriate preoperative imaging will not only assist in identifying the pathology but also determine a treatment regimen for the diseased junction. A treatment algorithm for craniocervical disease is proposed. Lesions must first be identified as irreducible versus reducible: restore extension and/or distraction of the craniovertebral junction without injuring the neural elements. Irreducible lesions require decompression only, while reducible lesions require an added fusion. Techniques in fusion are broadly divided into external immobilization versus internal fixation. The former entails halo rings and tongs for a prolonged duration. Fixation surgeries vary from wiring to screw fixation of the occiput-C1 segment. Details of the operation as well as potential complications are discussed.
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Affiliation(s)
- Mohamed Macki
- Department of Neurosurgery, Henry Ford Hospital, Detroit, MI, USA
| | - Travis Hamilton
- Department of Neurosurgery, Henry Ford Hospital, Detroit, MI, USA
| | - Jacob Pawloski
- Department of Neurosurgery, Henry Ford Hospital, Detroit, MI, USA
| | - Victor Chang
- Department of Neurosurgery, Henry Ford Hospital, Detroit, MI, USA
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C2 Pedicle Screws Combined With C1 Laminar Hooks for Reducible Atlantoaxial Dislocation: An Ideal Salvage Technique for C1-C2 Pedicle Screws. Oper Neurosurg (Hagerstown) 2019; 19:150-156. [DOI: 10.1093/ons/opz332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 09/02/2019] [Indexed: 12/19/2022] Open
Abstract
Abstract
BACKGROUND
A C1 laminar hook can theoretically avoid vertebral artery injury and is less technically demanding. However, only few studies with small samples analyzed the short-term outcomes of C2 pedicle screws combined with C1 laminar hooks (C2PS-C1LH) technique in the treatment of atlantoaxial dislocation. Furthermore, it is not confirmed whether similar clinical outcomes can be achieved with C1-C2 pedicle screw and rod construct (PSRC).
OBJECTIVE
To evaluate the outcomes of C2PS-C1LH and C1-C2 PSRC fixation techniques for treating atlantoaxial dislocation.
METHODS
Data of 52 patients with atlantoaxial dislocation treated by C1-C2 PSRC or C2PS-C1LH fixation were retrospectively reviewed. Outcomes evaluated by visual analog scale score for neck pain (VASSNP), Neck Disability Index (NDI), atlantodental interval (ADI), and the perioperative parameters including blood loss and operation time were analyzed and compared between 2 techniques. Patient satisfaction at final follow-up was also investigated.
RESULTS
There were no complications related to the surgical approach and instrumentation in either group. The mean bone fusion time was 5.06 ± 1.65 mo for the C2PS-C1LH group and 3.93 ± 0.99 mo for the C1-C2 PSRC group (P > .05). Hundred percent of fusion rates were achieved in both groups at month 12 after operation. The ADI, VAS scores, the NDI scores, and the JOA scores were greatly improved in both the groups (P < .05), but there were no significant differences between the 2 groups.
CONCLUSION
C2PS-C1LH fixation technique was comparable to C1-C2 PSRC in the treatment of reducible atlantoaxial dislocation. C2PS-C1LH fixation was an ideal alternative strategy to C1-C2 PSRC fixation.
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Abstract
Odontoid fractures represent one of the most common and controversial injury types affecting the cervical spine, being associated with a high incidence of nonunion, morbidity, and mortality. These complications are especially common and important in elderly patients, for which ideal treatment options are still under debate. Stable fractures in young patients maybe treated conservatively, with immobilization. Although halo-vest has been widely used for their conservative management, studies have shown high rates of complications in the elderly, and therefore current evidence suggests that the conservative management of these fractures should be carried out with a hard cervical collar or cervicothoracic orthosis. Elderly patients with stable fractures have been reported to have better clinical results with surgical treatment. For these and for all patients with unstable fractures, several surgical techniques have been proposed. Anterior odontoid fixation can be used in reducible fractures with ideal fracture patterns, with older patients requiring fixation with 2 screws. In other cases, C1-C2 posterior fixation maybe needed with the best surgical option depending on the reducibility of the fracture and vertebral artery anatomy. In this paper, current evidence on the management of odontoid fractures is discussed, and an algorithm for treatment is proposed.
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Cadena G, Duong HT, Liu JJ, Kim KD. Atlantoaxial fixation using C1 posterior arch screws: feasibility study, morphometric data, and biomechanical analysis. J Neurosurg Spine 2019; 30:314-322. [PMID: 30554179 DOI: 10.3171/2018.8.spine18160] [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: 03/06/2018] [Accepted: 08/15/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVEC1-2 is a highly mobile complex that presents unique surgical challenges to achieving biomechanical rigidity and fusion. Posterior wiring methods have been largely replaced with segmental constructs using the C1 lateral mass, C1 pedicle, C2 pars, and C2 pedicle. Modifications to reduce surgical morbidity led to the development of C2 laminar screws. The C1 posterior arch has been utilized mostly as a salvage technique, but recent data indicate that this method provides significant rigidity in flexion-extension and axial rotation. The authors performed biomechanical testing of a C1 posterior arch screw (PAS)/C2 pars screw construct, collected morphometric data from a population of 150 CT scans, and performed a feasibility study of a freehand C1 PAS technique in 45 cadaveric specimens.METHODSCervical spine CT scans from 150 patients were analyzed to determine the average C1 posterior tubercle thickness and size of C1 posterior arches. Eight cadavers were used to compare biomechanical stability of intact specimens, C1 lateral mass/C2 pars screw, and C1 PAS/C2 pars screw constructs. Paired comparisons were made using repeated-measures ANOVA and Holm-Sidak tests. Forty-five cadaveric specimens were used to demonstrate the feasibility and safety of the C1 PAS freehand technique.RESULTSMorphometric data showed the average craniocaudal thickness of the C1 posterior tubercle was 12.3 ± 1.94 mm. Eight percent (12/150) of cases showed thin posterior tubercles or midline defects. Average posterior arch thickness was 6.1 ± 1.1 mm and right and left average posterior arch length was 28.7 mm ± 2.53 mm and 28.9 ± 2.29 mm, respectively. Biomechanical testing demonstrated C1 lateral mass/C2 pars and C1 PAS/C2 pars constructs significantly reduced motion in flexion-extension and axial rotation compared with intact specimens (p < 0.05). The C1 lateral mass/C2 pars screw construct provided significant rigidity in lateral bending (p < 0.05). There was no statistically significant difference between the two constructs in flexion-extension, lateral bending, or axial rotation. Of the C1 posterior arches, 91.3% were successfully cannulated using a freehand technique with a low incidence of cortical breach (4.4%).CONCLUSIONSThis biomechanical analysis indicates equivalent stability of the C1 PAS/C2 pars screw construct compared with a traditional C1 lateral mass/C2 pars screw construct. Both provide significant rigidity in flexion-extension and axial rotation. Feasibility testing in 45 cadaveric specimens indicates a high degree of accuracy with low incidence of cortical breach. These findings are supported by a separate radiographic morphometric analysis.
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Affiliation(s)
- Gilbert Cadena
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Huy T Duong
- 2Department of Neurosurgery, Kaiser Foundation Medical Center, Sacramento, California
| | - Jonathan J Liu
- 3Department of Neurosurgery, Advocate Lutheran General Hospital, Park Ridge, Illinois; and
| | - Kee D Kim
- 4Department of Neurological Surgery, University of California, Davis, Sacramento, California
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Lee DY, Jeong ST, Lee TH, Kim DH. Brown-Sequard syndrome caused by hyperextension in a patient with atlantoaxial subluxation due to an os odontoideum. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:240-243. [PMID: 29174476 PMCID: PMC6136337 DOI: 10.1016/j.aott.2017.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 10/02/2017] [Accepted: 11/12/2017] [Indexed: 11/24/2022]
Abstract
Brown-Sequard syndrome is an uncommon complication of atlantoaxial arthrodesis. A 50-year-old female visited our emergency department after falling from a ladder. Radiologic evaluations revealed chronic C1-2 instability with acute spinal cord injury. The day after atlantoaxial fusion was performed, she developed left-sided motor weakness and the loss of right-sided pain and temperature sensation. Based on physical examination and radiologic findings, we diagnosed her as having Brown-Sequard syndrome. Spine surgeons performing this procedure should therefore consider Brown-Sequard syndrome if a patient displays signs of postoperative hemiplegia.
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Ishak B, Schneider T, Gimmy V, Unterberg AW, Kiening KL. Early Complications, Morbidity, and Mortality in Octogenarians and Nonagenarians Undergoing Posterior Intra-Operative Spinal Navigation-Based C1/2 Fusion for Type II Odontoid Process Fractures. J Neurotrauma 2017. [DOI: 10.1089/neu.2017.4968] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Till Schneider
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Valerie Gimmy
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Karl L. Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Guan Q, Xing F, Long Y, Xiang Z. Postoperative occipital neuralgia in posterior upper cervical spine surgery: a systematic review. Neurosurg Rev 2017; 41:779-785. [PMID: 29116423 DOI: 10.1007/s10143-017-0923-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/17/2017] [Accepted: 10/12/2017] [Indexed: 02/05/2023]
Abstract
Postoperative occipital neuralgia (PON) after upper cervical spine surgery can cause significant morbidity and may be overlooked. The causes, presentation, diagnosis, management, prognosis, and prevention of PON were reviewed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. English-language studies and case reports published from inception to 2017 were retrieved. Data on surgical procedures, incidence, cause of PON, management, outcomes, and preventive technique were extracted. Sixteen articles, including 591 patients, were selected; 93% of the patients with PON underwent C1 lateral mass screw (C1LMS) fixation, with additional 7% who underwent occipitocervical fusion without C1 fixation. PON had an incidence that ranged from 1 to 35% and was transient in 34%, but persistent in 66%. Five articles explained the possible causes. The primary presentation was constant or paroxysmal burning pain located mainly in the occipital and upper neck area and partially extending to the vertical, retroauricular, retromandibular, and forehead zone. Treatment included medications, nerve block, revision surgery, and nerve stimulation. Two prospective studies compared the effect of C2 nerve root transection on PON. PON in upper cervical spine surgery is a debilitating complication and was most commonly encountered by patients undergoing C1LMS fixation. The etiology of PON is partially clear, and the pain could be persistent and hard to cure. Reducing the incidence of PON can be realized by improving technique. More high-quality prospective studies are needed to define the effect of C2 nerve root transection on PON.
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19
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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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Posterior C1-C2 screw-rod fixation and autograft fusion for the treatment of os odontoideum with C1-C2 instability. Clin Neurol Neurosurg 2017; 163:71-75. [PMID: 29078125 DOI: 10.1016/j.clineuro.2017.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/14/2017] [Accepted: 10/19/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To report our experience treating os odontoideum with C1-C2 instability via C1-C2 screw-rod fixation and autograft fusion and to explore the clinical efficacy of such a treatment strategy. PATIENTS AND METHODS We retrospectively reviewed the medical records of patients who were diagnosed with os odontoideum with C1-C2 instability and treated by posterior C1-C2 screw-rod fixation and fusion. Neurological deficits were measured with the Japanese Orthopedic Association (JOA) scoring system and neck pain was assessed using the Visual Analogue Scale (VAS) score. Fusion was determined based on the presence of bridging bone in computed tomography (CT) imaging, whereas stability was determined based on the lack of movement in dynamic radiographs. RESULTS Thirty-two patients (18 males) were included in the study. The surgery was successfully accomplished in all patients. Thirty (93.8%) patients had confirmed C1-C2 bony fusion in CT images and all patients (100%) were stable in dynamic radiographs. The mean preoperative JOA score was 14.3±1.4 (range 11-16); at the final visit, it increased to 16.2±0.8 (range 14-17) (p<0.001). The mean preoperative VAS score was 3.8±0.7 (range 3-5) and decreased at the final visit to 1.0±0.6 (range 0-2) (p<0.001). CONCLUSION Our treatment strategy (C1-C2 screw-rod fixation and autograft fusion) can achieve excellent clinical results with minor complications for patients with os odontoideum with C1-C2 instability.
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21
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Does Transection of the C2 Nerve Roots During C1 Lateral Mass Screw Placement for Atlantoaxial Fixation Result in a Superior Outcome?: A Systematic Review of the Literature and Meta-analysis. Spine (Phila Pa 1976) 2017; 42:E1067-E1076. [PMID: 28098742 DOI: 10.1097/brs.0000000000002069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To evaluate the clinical and functional outcomes of transection of the C2 roots during C1 lateral mass screw placement for atlantoaxial fixation. SUMMARY OF BACKGROUND DATA Transection of the C2 nerve roots has been recommended during atlantoaxial fixation to facilitate C1 lateral mass screw placement and possibly reduce postoperative occipital neuralgia, although this practice remains controversial. METHODS We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library for studies evaluating the outcomes of C1-2 fixation involving sacrifice of the C2 roots. We calculated transformed proportions with 95% confidence intervals (CI) for the outcomes of occipital neuralgia, numbness, bony fusion, and procedural morbidity. For studies comparing C2 transection with nerve sparing surgery, we performed meta-analyses for the outcomes of occipital neuralgia, occipital numbness, blood loss, and operative time. RESULTS Eight observational studies (N = 393) met eligibility criteria. The rate of postoperative occipital neuralgia among included studies was 0% to 25%; occipital numbness, 6.7% to100%; bony fusion, 96.7% to 100%; and procedural morbidity, 0% to 14.3%. Among comparative studies, C2 transection was associated with a higher rate of occipital numbness [odds ratio (OR) 178.6 (95% CI 26.6 to 1198.4)], lower blood loss [mean difference (MD) -195.3 mL (95% CI -317.7 to -72.8 mL)] and shorter operative times [MD -57.5 mins (95% CI -76.9 to -38.2 mins)] than when the C2 roots were spared. We found no difference in rates of occipital neuralgia [OR 1.44 (95% CI 0.45 to 4.68)]. CONCLUSION Transection of the C2 nerve roots appears to be a viable, safe option when undertaking placement of C1 lateral mass screws. The procedure is associated with reduced operative duration and blood loss, increased rate of occipital numbness, and no change in the rate of occipital neuralgia. However, given the relatively low quality of evidence, prospective, controlled studies to evaluate this strategy are recommended. LEVEL OF EVIDENCE N /A.
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Cao L, Yang E, Xu J, Lian X, Cai B, Liu X, Zhang G. "Direct vision" operation of posterior atlantoaxial transpedicular screw fixation for unstable atlantoaxial fractures: A retrospective study. Medicine (Baltimore) 2017; 96:e7054. [PMID: 28640081 PMCID: PMC5484189 DOI: 10.1097/md.0000000000007054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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
BACKGROUND The posterior screw fixation in atlas via posterior arch and lateral mass, also called C1 "pedicle" screw, combined with C2 pedicle screw fixiation has shown better biomechanical stability in unstable atlantoaxial fractures. However, its popularization has to fulfill the limitation imposed by anatomical characteristics. The aim of this study was to explore the manipulation, effect, and safety of the atlantoaxial transpedicular screw fixation under "direct vision" for the treatment of unstable atlantoaxial fracture. METHODS All the patients diagnosed with unstable atlantoaxial fracture, who received surgery treatment of C1,C2 internal fixation from January 2012 to December 2014 were reviewed. Only these patients that were diagnosed with atlantoaxial unstability secondary to trauma and were treated with atlantoaxial transpedicular screw fixation under "direct vision" and iliac autograft were included. The safety of transpedicular screw placement, postoperative outcome, atlantoaxial stability, autograft fusion, and complications was observed and analyzed retrospectively. The pain visual analog scale (VAS) and the Japanese Orthopedic Association (JOA) score were used as surgical curative effect evaluation standards. RESULTS We reviewed a total of 92 patients diagnosed with unstable atlantoaxial fracture, who received surgery treatment of C1,C2 internal fixation from January 2012 to December 2014, and 87 patients were treated with atlantoaxial transpedicular screw fixation under "direct vision" and were included this analysis. A total of 306 transpedicular screws in atlas and axis were placed successfully. All cases were followed-up >12 months. The overall breach rate was 11.36%. None of the breaches resulted in new-onset neurological sequela. The neurological status in cases with bilateral upper extremities numbness and lower extremities weakness had improved after surgery. At the latest follow-up, the neck VAS and JOA scores were significantly improved (P < .01) than those preoperatively. No cases demonstrated implantation failure and bone graft absorption on the postoperative x-ray films and CT scans. CONCLUSION Atlantoaxial transpedicular screw fixation under "direct vision" and iliac autograft for the treatment of unstable atlantoaxial fracture has shown simple manipulation and efficient performance. Thus, the technique of C1-C2 fixation is feasible in treating unstable atlantoaxial fracture.
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Affiliation(s)
- Liangliang Cao
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Erzhu Yang
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Jianguang Xu
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Xiaofeng Lian
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Bin Cai
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Xiaokang Liu
- Department of Orthopedics, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Guowang Zhang
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
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Al-Habib AF, Al-Rabie A, Aleissa S, Albakr A, Abobotain A. Atlas instrumentation guided by the medial edge of the posterior arch: An anatomic and radiologic study. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:97-102. [PMID: 28694591 PMCID: PMC5490358 DOI: 10.4103/jcvjs.jcvjs_36_17] [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: 11/04/2022] Open
Abstract
STUDY DESIGN This was an interventional human cadaver study and radiological study. OBJECTIVES Atlas instrumentation is frequently involved in fusion procedures involving the craniocervical junction area. Identification of the entry point at the center of atlas lateral mass (ALM) is challenging because of its rounded posterior surface and the surrounding venous plexus. This report examines using the medial edge of atlas posterior arch (MEC1) as a fixed and reliable anatomic reference to guide the entry point of ALM screws. METHODS Fifty, normal, cervical spine computed tomography studies were reviewed. ALM screw trajectories were planned at one point along MEC1 and another point 2 mm lateral to MEC1. Free-hand ALM instrumentation was performed in ten fresh human cadavers using the 2 mm entry point, with a sagittal trajectory parallel to atlas inferior arch (IAC1); three-dimensional imaging was then performed to confirm instrumentation accuracy. RESULTS The average ALM diameter was 12.35 mm. Inserting a screw using the entry point 2 mm lateral to MEC1 was closer to ALM midpoint than using the entry point along MEC1 (P < 0.0001). Twenty ALM screws were successfully inserted in the ten cadavers. No encroachments into the spinal canal or foramen transversarium occurred. However, two screws were superiorly directed and violated the occipitocervical joint; they were not parallel to IAC1. CONCLUSION MEC1 provides a fixed and reliable landmark for ALM instrumentation. An entry point 2 mm point lateral to MEC1 is close to ALM midpoint. IAC1 also provides a guide for the sagittal trajectory. Attention to anatomic landmarks may help reduce complications associated with atlas instrumentation but should be verified in future clinical studies.
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Affiliation(s)
- Amro F Al-Habib
- Department of Surgery, Division of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulkarim Al-Rabie
- Department of Surgery, Division of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sami Aleissa
- Department of Orthopedics, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman Albakr
- Department of Surgery, Division of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Abobotain
- Department of Surgery, Division of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Accuracy Assessment of Using Rapid Prototyping Drill Templates for Atlantoaxial Screw Placement: A Cadaver Study. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5075879. [PMID: 28004004 PMCID: PMC5149599 DOI: 10.1155/2016/5075879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/05/2016] [Indexed: 11/23/2022]
Abstract
Purpose. To preliminarily evaluate the feasibility and accuracy of using rapid prototyping drill templates (RPDTs) for C1 lateral mass screw (C1-LMS) and C2 pedicle screw (C2-PS) placement. Methods. 23 formalin-fixed craniocervical cadaver specimens were randomly divided into two groups. In the conventional method group, intraoperative fluoroscopy was used to assist the screw placement. In the RPDT navigation group, specific RPDTs were constructed for each specimen and were used intraoperatively for screw placement navigation. The screw position, the operating time, and the fluoroscopy time for each screw placement were compared between the 2 groups. Results. Compared with the conventional method, the RPDT technique significantly increased the placement accuracy of the C2-PS (p < 0.05). In the axial plane, using RPDTs also significantly increased C1-LMS placement accuracy (p < 0.05). In the sagittal plane, although using RPDTs had a very high accuracy rate (100%) in C1-LMS placement, it was not statistically significant compared with the conventional method (p > 0.05). Moreover, the RPDT technique significantly decreased the operating and fluoroscopy times. Conclusion. Using RPDTs significantly increases the accuracy of C1-LMS and C2-PS placement while decreasing the screw placement time and the radiation exposure. Due to these advantages, this approach is worth promoting for use in the Harms technique.
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Keskil S, Göksel M, Yüksel U. Unilateral lag-screw technique for an isolated anterior 1/4 atlas fracture. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2016; 7:50-4. [PMID: 27041886 PMCID: PMC4790149 DOI: 10.4103/0974-8237.176625] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
STUDY DESIGN Fractures of the atlas are classified based on the fracture location and associated ligamentous injury. Among patients with atlas fractures treated using external immobilization, nonunion of the fracture could be seen. OBJECTIVE Ideally, treatment strategy for an unstable atlas fracture would involve limited fixation to maintain the fracture fragments in a reduced position without restricting the range of motion (ROM) of the atlantoaxial and atlantooccipital joints. SUMMARY OF BACKGROUND DATA Such a result can be established using either transoral limited internal fixation or limited posterior lateral mass fixation. However, due to high infection risk and technical difficulty, posterior approaches are preferred but none of these techniques can fully address anterior 1/4 atlas fractures such as in this case. MATERIALS AND METHODS A novel open and direct technique in which a unilateral lag screw was placed to reduce and stabilize a progressively widening isolated right-sided anterior 1/4 single fracture of C1 that was initially treated with a rigid cervical collar is described. RESULTS Radiological studies made after the surgery showed no implant failure, good cervical alignment, and good reduction with fusion of C1. CONCLUSIONS It is suggested that isolated C1 fractures can be surgically reduced and immobilized using a lateral compression screw to allow union and maintain both C1-0 and C1-2 motions, and in our knowledge this is the first description of the use of a lag screw to achieve reduction of distracted anterior 1/4 fracture fragments of the C1 from a posterior approach. This technique has the potential to become a valuable adjunct to the surgeon's armamentarium, in our opinion, only for fractures with distracted or comminuted fragments whose alignment would not be expected to significantly change with classical lateral mass screw reduction.
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Affiliation(s)
- Semih Keskil
- Department of Neurosurgery, Medical School, Kırıkkale University, Kırıkkale, Turkey
| | - Murat Göksel
- Department of Neurosurgery, Medical School, Kırıkkale University, Kırıkkale, Turkey
| | - Ulaş Yüksel
- Department of Neurosurgery, Medical School, Kırıkkale University, Kırıkkale, Turkey
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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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Huang DG, Hao DJ, Li GL, Guo H, Zhang YC, He BR. C2 nerve dysfunction associated with C1 lateral mass screw fixation. Orthop Surg 2015; 6:269-73. [PMID: 25430709 DOI: 10.1111/os.12136] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 08/03/2014] [Indexed: 11/29/2022] Open
Abstract
The C1 lateral mass screw technique is widely used for atlantoaxial fixation. However, C2 nerve dysfunction may occur as a complication of this procedure, compromising the quality of life of affected patients. This is a review of the topic of C2 nerve dysfunction associated with C1 lateral mass screw fixation and related research developments. The C2 nerve root is located in the space bordered superiorly by the posterior arch of C1 , inferiorly by the C2 lamina, anteriorly by the lateral atlantoaxial joint capsule, and posteriorly by the anterior edge of the ligamentum flavum. Some surgeons suggest cutting the C2 nerve root during C1 lateral mass screw placement, whereas others prefer to preserve it. The incidence, clinical manifestations, causes, management, and prevention of C2 nerve dysfunction associated with C(1) lateral mass screw fixation are reviewed. Sacrifice of the C2 nerve root carries a high risk of postoperative numbness, whereas postoperative nerve dysfunction can occur when it has been preserved. Many surgeons have been working hard on minimizing the risk of postoperative C2 nerve dysfunction associated with C1 lateral mass screw fixation.
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Affiliation(s)
- Da-geng Huang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
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Impact of Starting Point and C2 Nerve Status on the Safety and Accuracy of C1 Lateral Mass Screws. ACTA ACUST UNITED AC 2015; 28:171-85. [PMID: 23429321 DOI: 10.1097/bsd.0b013e3182898aa9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sattarov K, Skoch J, Abbasifard S, Patel AS, Avila MJ, Walter CM, Baaj AA. Posterior atlantoaxial fixation: A cadaveric and fluoroscopic step-by-step technical guide. Surg Neurol Int 2015; 6:S244-7. [PMID: 26005587 PMCID: PMC4431047 DOI: 10.4103/2152-7806.156611] [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] [Received: 01/22/2015] [Accepted: 02/23/2015] [Indexed: 11/21/2022] Open
Abstract
Background: Atlantoaxial surgical fixation is widely employed treatment strategy for a myriad of pathologies affecting the stability of the atlantoaxial joint. The most common technique used in adults, and in certain cases in children, involves a posterior construct with C1 lateral mass screws, and C2 pars or pedicle screws. This technical note aims to provide a step-by-step guide to this procedure using cadaveric and fluoroscopic images. Methods: An embalmed, human, cadaveric, specimen was used for this study. The subject did not have obvious occipital-cervical pathology. Dissections and techniques were performed to mimic actual surgical technique. Photographs were taken during each step, and the critical aspects of each step were highlighted. Fluoroscopic images from a real patient undergoing C1/C2 fixation were also utilized to further highlight the anatomic-radiographic relationships. This study was performed without external or industry funding. Results: Photographic and radiographic pictures and drawings are presented to illustrate the pertinent anatomy and technical aspects of this technique. The nuances of each step, including complication avoidance strategies are also highlighted. Conclusions: Given the widespread utilization of this technique, described step-by-step guide is timely for surgeons and trainees alike.
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Affiliation(s)
- Kamran Sattarov
- Department of Surgery, Division of Neurosurgery, University of Arizona Medical Center, 1501 N. Campbell Ave. Tucson, Arizona, 85724, USA
| | - Jesse Skoch
- Department of Surgery, Division of Neurosurgery, University of Arizona Medical Center, 1501 N. Campbell Ave. Tucson, Arizona, 85724, USA
| | - Salman Abbasifard
- Department of Surgery, Division of Neurosurgery, University of Arizona Medical Center, 1501 N. Campbell Ave. Tucson, Arizona, 85724, USA
| | - Apar S Patel
- Department of Surgery, Division of Neurosurgery, University of Arizona Medical Center, 1501 N. Campbell Ave. Tucson, Arizona, 85724, USA
| | - Mauricio J Avila
- Department of Surgery, Division of Neurosurgery, University of Arizona Medical Center, 1501 N. Campbell Ave. Tucson, Arizona, 85724, USA
| | - Christina M Walter
- Department of Surgery, Division of Neurosurgery, University of Arizona Medical Center, 1501 N. Campbell Ave. Tucson, Arizona, 85724, USA
| | - Ali A Baaj
- Department of Surgery, Division of Neurosurgery, University of Arizona Medical Center, 1501 N. Campbell Ave. Tucson, Arizona, 85724, USA
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An anatomic study to determine the optimal entry point, medial angles, and effective length for safe fixation using posterior C1 lateral mass screws. Spine (Phila Pa 1976) 2015; 40:E191-8. [PMID: 25398038 DOI: 10.1097/brs.0000000000000715] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Anatomic study of the C1 lateral mass using fine-cut computed tomographic scans and Mimics software. OBJECTIVE To investigate the optimal entry point, medial angles, and effective length for safe fixation using posterior C1 lateral mass screws. SUMMARY OF BACKGROUND DATA Placing posterior C1 lateral mass screws is technically demanding, and a misplaced screw can result in injury to the vertebral artery, spinal cord, or internal carotid artery. Although various insertion angles have been proposed for posterior C1 lateral mass screw, no clear consensus has been reached on the ideal medial angle of the C1 lateral mass. METHODS The C1 lateral masses were evaluated using computed tomographic scans and Mimics software in 70 patients. The effective width and effective screw length of posterior C1 lateral mass screws were measured at different medial angulations relative to the midline sagittal plane. The height (H) for screw entry point on the posterior surface of C1 lateral mass and the distance (D) between screw entry point and the intersection of the midline sagittal plane and the posterior arch of the atlas were also measured. RESULTS The mean height (H) for screw entry on the posterior surface of the lateral mass was 4.25 mm, the mean distance (D) between screw entry point and the intersection of the midsagittal plane and the posterior arch of the atlas was 27.62 mm. The optimal medial angle was 20.86° with a corresponding effective width of 10.56 mm and effective screw length of 21.87 mm. CONCLUSION This study helps to define the specific anatomy related to C1 posterior lateral mass screw placement in an effort to facilitate instrumentation. However, variation is seen in lateral mass anatomy, and this study must be combined with customized surgical planning that includes advanced imaging for safe and effective instrumentation. LEVEL OF EVIDENCE 1.
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Clinical Application of the “Pedicle Exposure Technique” for Atlantoaxial Instability Patients With a Narrow C1 Posterior Arch. ACTA ACUST UNITED AC 2015; 28:25-30. [DOI: 10.1097/bsd.0000000000000078] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dewan MC, Godil SS, Mendenhall SK, Devin CJ, McGirt MJ. C2 nerve root transection during C1 lateral mass screw fixation: does it affect functionality and quality of life? Neurosurgery 2014; 74:475-80; discussion 480-1. [PMID: 24476905 DOI: 10.1227/neu.0000000000000306] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Sectioning of the C2 nerve root allows for direct visualization of the C1-2 joint and may facilitate arthrodesis. OBJECTIVE To determine the clinical and functional consequences of C2 nerve root sectioning during placement of C1 lateral mass screws. METHODS All patients undergoing C1 lateral mass screw fixation were included in this prospective study. A standard questionnaire was used to determine the severity of occipital numbness/pain and its effect on quality of life (QOL). Domains of the neck disability index were used to assess the disability related to C2 symptoms. RESULTS A total of 28 patients were included (C2 transection, 8; C2 preservation, 20). A trend of decreased blood loss and length of surgery was observed in the C2 transection cohort. Occipital numbness was reported by 4 (50.0%) patients after C2 transection. Occipital neuralgia was reported by 7 (35.0%) patients with C2 preservation. None of the patients with numbness after C2 transection reported being "bothered" by it. All patients with occipital neuralgia after C2 sparing reported being "bothered" by it, and 57.1% reported a moderate to severe effect on QOL. The use of medication was reported by 5 (71.4%) patients with neuralgia vs none with numbness. Mean disability was significantly higher with neuralgia vs numbness (P = .016). CONCLUSION C2 nerve root transection is associated with increased occipital numbness but this has no effect on patient-reported outcomes and QOL. C2 nerve root preservation can be associated with occipital neuralgia, which has a negative impact on patient disability and QOL. C2 nerve root transection has no negative consequences during C1-2 stabilization.
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Affiliation(s)
- Michael C Dewan
- *Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee; ‡Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina; §Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Yang JS, Choi HJ, Cho YJ, Kang SH. Sensory complications in patients after scalp mass excision and its anatomical considerations. J Korean Neurosurg Soc 2014; 55:200-4. [PMID: 25024823 PMCID: PMC4094744 DOI: 10.3340/jkns.2014.55.4.200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/02/2014] [Accepted: 04/23/2014] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the incidence of postsurgical sensory complications in patients with scalp masses and classify the locations of them from a surgical standpoint according to anatomical considerations. METHODS A total of 121 patients who underwent surgery for scalp mass were included in this study. The authors reviewed medical records and preoperative radiologic images. We investigated the complications related to sensory changes after procedure. Enrolled patients have been divided into three groups. Group A included patients with tumors above the superior nuchal line (SNL), Group B with tumors within the trapezius muscle area and patients who had tumors on the lateral trapezius muscle area were assigned to Group C. We compared the incidence related to postoperative sensory complications and summarized their additional treatments for these with clinical outcome. RESULTS There were 12 patients (10%) with sensory complications related on the mass excision site (Group A: 1 patient, Group B: 2 patients, Group C: 9 patients). Six patients were affected with lesser occipital nerve (LON), 2 patients on greater occipital nerve (GON) and 4 patients on GON and LON. Over 6 months after surgery, two of the twelve patients with sensory complications did not have complete recovered pain in spite of proper medications and local chemical neurolysis with 1.0% lidocaine and dexamethasone. CONCLUSION Occipital neuropathy should be considered as a complication related excision of scalp mass. The sensory complications are more frequent in Group C because of the anatomical characteristics of the occipital nerves and there were no statistical difference for other variables.
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Affiliation(s)
- Jin Seo Yang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Yong Jun Cho
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Suk Hyung Kang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
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Carrier CS, Sama AA, Girardi FP, Lebl DR. Anterior transarticular screw fixation for atlantoaxial arthrodesis: A report of two cases. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2014; 4:85-9. [PMID: 24737928 PMCID: PMC3980563 DOI: 10.4103/0974-8237.128540] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The sequelae of atlantoaxial instability (AAI) range from axial neck pain to life-threatening neurologic injury. Instrumentation and fusion of the C1-2 joint is often indicated in the setting of clinical or biomechanical instability. This is the first clinical report of anterior Smith-Robinson C1-2 transarticular screw (TAS) fixation for AAI. The first patient presented with ischemic brain tissue secondary to post-traumatic C1-2 segment instability from a MVC 7 years prior to presentation. The second patient presented with a 3 year history of persistent right-sided neck and upper scalp pain. Both were treated with transarticular C1-2 fusion through decortication of the atlantoaxial facet joints and TAS fixation via the anterior Smith-Robinson approach. At 16 months follow-up, the first patient maintained painless range of motion of the cervical spine and denied sensorimotor deficits. The second patient reported 90% improvement in her pre-operative symptoms of neck pain and paresthesia. Anterior Smith-Robinson C1-2 TAS fixation provides a useful alternative to the posterior Goel and Magerl techniques for C1-2 stabilization and fusion.
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Affiliation(s)
- C S Carrier
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - A A Sama
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York 10021, USA
| | - F P Girardi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York 10021, USA
| | - D R Lebl
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York 10021, USA
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Huang DG, Hao DJ, Jiang YH, Cheng Y, Pan JW, Qiang YQ, He BR, Qian LX. The height for screw index (HSI) predicts the development of C2 nerve dysfunction associated with C1 lateral mass screw fixation for atlantoaxial instability. 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 2014; 23:1092-8. [PMID: 24570123 DOI: 10.1007/s00586-013-3160-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 12/27/2013] [Accepted: 12/27/2013] [Indexed: 10/25/2022]
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Yeom JS, Buchowski JM, Kim HJ, Chang BS, Lee CK, Riew KD. Postoperative occipital neuralgia with and without C2 nerve root transection during atlantoaxial screw fixation: a post-hoc comparative outcome study of prospectively collected data. Spine J 2013; 13:786-95. [PMID: 23711959 DOI: 10.1016/j.spinee.2013.04.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 02/10/2013] [Accepted: 04/03/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although routine transection of the C2 nerve root during atlantoaxial segmental screw fixation has been recommended by some surgeons, it remains controversial and to our knowledge no comparative studies have been performed to determine whether transection or preservation of the C2 nerve root affects patient-derived sensory outcomes. PURPOSE The purpose of this study is to specifically analyze patient-derived sensory outcomes over time in patients with intentional C2 nerve root transection during atlantoaxial segmental screw fixation compared with those without transection. STUDY DESIGN This is a post-hoc comparative analysis of prospectively collected patient-derived outcome data. PATIENT SAMPLE The sample consists of 24 consecutive patients who underwent intentional bilateral transection of the C2 nerve root during posterior atlantoaxial segmental screw fixation (transection group) and subsequent 41 consecutive patients without transection (preservation group). OUTCOME MEASURES A visual analog scale (VAS) score was used for occipital neuralgia as the primary outcome measure and VAS score for neck pain, neck disability index score and Japanese Orthopedic Association score for cervical myelopathy and recovery rate, with bone union rate as the secondary outcome measure. METHODS Patient-derived outcomes including change in VAS score for occipital neuralgia over time were statistically compared between the two groups. This study was not supported by any financial sources and there is no topic-specific conflict of interest related to the authors of this study. RESULTS Seven (29%) of the 24 patients in the transection group experienced increased neuralgic pain at 1 month after surgery either because of newly developed occipital neuralgia or aggravation of preexisting occipital neuralgia. Four of the seven patients required almost daily medication even at the final follow-up (44 and 80 months). On the other hand, only four (10%) of 41 patients in the preservation group had increased neuralgic pain at 1 month after surgery, and at ≥ 1 year, no patients had increased neuralgic pain. The difference in the prevalence of increased neuralgic pain between the two groups was statistically significant at all time points (3, 6, 12, and 24 months postoperatively) except at 1 month postoperatively. The intensity of neuralgic pain, which preoperatively had not been significantly different between the two groups, was significantly higher in the transection group at the final follow-up. CONCLUSIONS C2 nerve root transection is not a benign procedure and, in our experience, more than a quarter of the patients experience increased neuralgic pain following C2 nerve root transection. Because the prevalence and intensity of postoperative neuralgia was significantly higher with C2 nerve root transection than with its preservation, we recommend against routine C2 nerve root transection when performing atlantoaxial segmental screw fixation.
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Affiliation(s)
- Jin S Yeom
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-ku, Sungnam 463-707, Republic of Korea
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Hu Y, Kepler CK, Albert TJ, Yuan ZS, Ma WH, Gu YJ, Xu RM. Accuracy and complications associated with the freehand C-1 lateral mass screw fixation technique: a radiographic and clinical assessment. J Neurosurg Spine 2013; 18:372-7. [PMID: 23373564 DOI: 10.3171/2013.1.spine12724] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aims of this study were to evaluate a large series of posterior C-1 lateral mass screws (LMSs) to determine accuracy based on CT scanning findings and to assess the perioperative complication rate related to errant screw placement.
Methods
Accuracy of screw placement was evaluated using postoperative CT scans obtained in 196 patients with atlantoaxial instability. Radiographic analysis included measurement of preoperative and postoperative CT scans to evaluate relevant anatomy and classify accuracy of instrumentation placement. Screws were graded using the following definitions: Type I, screw threads completely within the bone (ideal); Type II, less than half the diameter of the screw violates the surrounding cortex (safe); and Type III, clear violation of transverse foramen or spinal canal (unacceptable).
Results
A total of 390 C-1 LMSs were placed, but 32 screws (8.2%) were excluded from accuracy measurements because of a lack of postoperative CT scans; patients in these cases were still included in the assessment of potential clinical complications based on clinical records. Of the 358 evaluable screws with postoperative CT scanning, 85.5% of screws (Type I) were rated as being in the ideal position, 11.7% of screws (Type II) were rated as occupying a safe position, and 10 screws (2.8%) were unacceptable (Type III). Overall, 97.2% of screws were rated Type I or II. Of the 10 screws that were unacceptable on postoperative CT scans, there were no known associated neurological or vertebral artery (VA) injuries. Seven unacceptable screws erred medially into the spinal canal, and 2 patients underwent revision surgery for medial screws. In 2 patients, unilateral C-1 LMSs penetrated the C-1 anterior cortex by approximately 4 mm. Neither patient with anterior C-1 penetration had evidence of internal carotid artery or hypoglossal nerve injury. Computed tomography scanning showed partial entry of C-1 LMSs into the VA foramen of C-1 in 10 cases; no occlusion, associated aneurysm, or fistula of the VA was found. Two patients complained of postoperative occipital neuralgia. This was transient in one patient and resolved by 2 months after surgery. The second patient developed persistent neuralgia, which remained 2 years after surgery, necessitating referral to the pain service.
Conclusions
The technique for freehand C-1 LMS fixation appears to be safe and effective without intraoperative fluoroscopy guidance. Preoperative planning and determination of the ideal screw insertion point, the ideal trajectory, and screw length are the most important considerations. In addition, fewer malpositioned screws were inserted as the study progressed, suggesting a learning curve to the technique.
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Affiliation(s)
- Yong Hu
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
| | - Christopher K. Kepler
- 2Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, Pennsylvania
| | - Todd J. Albert
- 2Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, Pennsylvania
| | - Zhen-shan Yuan
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
| | - Wei-hu Ma
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
| | - Yong-jie Gu
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
| | - Rong-ming Xu
- 1Department of Spinal Surgery, Ningbo No. 6 Hospital, Zhejiang Province, China; and
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Solanki GA, Martin KW, Theroux MC, Lampe C, White KK, Shediac R, Lampe CG, Beck M, Mackenzie WG, Hendriksz CJ, Harmatz PR. Spinal involvement in mucopolysaccharidosis IVA (Morquio-Brailsford or Morquio A syndrome): presentation, diagnosis and management. J Inherit Metab Dis 2013; 36:339-55. [PMID: 23385297 PMCID: PMC3590412 DOI: 10.1007/s10545-013-9586-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 12/29/2012] [Accepted: 01/07/2013] [Indexed: 11/30/2022]
Abstract
Mucopolysaccharidosis IVA (MPS IVA), also known as Morquio-Brailsford or Morquio A syndrome, is a lysosomal storage disorder caused by a deficiency of the enzyme N-acetyl-galactosamine-6-sulphate sulphatase (GALNS). MPS IVA is multisystemic but manifests primarily as a progressive skeletal dysplasia. Spinal involvement is a major cause of morbidity and mortality in MPS IVA. Early diagnosis and timely treatment of problems involving the spine are critical in preventing or arresting neurological deterioration and loss of function. This review details the spinal manifestations of MPS IVA and describes the tools used to diagnose and monitor spinal involvement. The relative utility of radiography, computed tomography (CT) and magnetic resonance imaging (MRI) for the evaluation of cervical spine instability, stenosis, and cord compression is discussed. Surgical interventions, anaesthetic considerations, and the use of neurophysiological monitoring during procedures performed under general anaesthesia are reviewed. Recommendations for regular radiological imaging and neurologic assessments are presented, and the need for a more standardized approach for evaluating and managing spinal involvement in MPS IVA is addressed.
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Affiliation(s)
- Guirish A Solanki
- Department of Paediatric Neurosurgery, Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, UK.
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Yi P, Dong L, Tan M, Wang W, Tang X, Yang F, Zhang G. Clinical application of a revised screw technique via the C1 posterior arch and lateral mass in the pediatric population. Pediatr Neurosurg 2013; 49:159-65. [PMID: 24603124 DOI: 10.1159/000358807] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 01/16/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Pediatric patients with insufficient height (≤4 mm) of the C1 posterior arch may restrict atlas screw placement via the posterior arch and lateral mass (PALM). For these patients, we modified this technique, called the 'pedicle exposure technique' (PET). We aimed to analyze the clinical feasibility and safety of the PET in the pediatric population. METHODS Twenty pediatric patients with atlantoaxial instability (AAI) were enrolled in this study. The average C1 posterior arch was 3.1 (2.5-3.9) mm on CT scan. All patients underwent the C1 PET and C2 pedicle screw fixation. The imaging was performed to evaluate the accuracy of screw placement and bony fusion. RESULTS Forty screws were inserted via C1 PALM using the PET. Venous plexus bleeding occurred in 1 patient and the internal wall of the C1 lateral mass was perforated in 1 patient. There were no perioperative neurological deficits or vertebral artery injury. Follow-up was performed in all 20 cases over a period ranging from 6 to 80 months. Bony union was seen within 3-6 months. At the final follow-up visit, 14 patients had experienced an improvement, while 6 had complete resolution of their neck pain. Myelopathy symptoms were improved in 9 patients with spinal compression. CONCLUSION The PET is an effective alternative for pediatric AAI when the height of the C1 posterior arch is <4 mm. Because of the higher screw entry point through the C1 posterior arch, there is effective biomechanical stability and less irritation of the venous plexus and C2 nerve root.
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Affiliation(s)
- Ping Yi
- Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, People's Republic of China
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Modified C1 lateral mass screw insertion using a high entry point to avoid postoperative occipital neuralgia. J Clin Neurosci 2013; 20:162-7. [PMID: 23117140 DOI: 10.1016/j.jocn.2012.01.045] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 10/11/2011] [Accepted: 01/07/2012] [Indexed: 11/22/2022]
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Elliott RE, Kang MM, Smith ML, Frempong-Boadu A. C2 Nerve Root Sectioning in Posterior Atlantoaxial Instrumented Fusions: A Structured Review of Literature. World Neurosurg 2012; 78:697-708. [PMID: 22120564 DOI: 10.1016/j.wneu.2011.10.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 08/20/2011] [Accepted: 10/21/2011] [Indexed: 11/26/2022]
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Kang MM, Anderer EG, Elliott RE, Kalhorn SP, Frempong-Boadu A. C2 Nerve Root Sectioning in Posterior C1-2 Instrumented Fusions. World Neurosurg 2012; 78:170-7. [PMID: 22120333 DOI: 10.1016/j.wneu.2011.07.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 05/20/2011] [Accepted: 07/08/2011] [Indexed: 10/15/2022]
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Jian FZ, Su CH, Chen Z, Wang XW, Ling F. Feasibility and limitations of C1 lateral mass screw placement in patients of atlas assimilation. Clin Neurol Neurosurg 2012; 114:590-6. [DOI: 10.1016/j.clineuro.2011.12.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 11/24/2011] [Accepted: 12/11/2011] [Indexed: 10/14/2022]
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Ducati A. Nerves are not made to be cut. World Neurosurg 2012; 78:601-2. [PMID: 22381281 DOI: 10.1016/j.wneu.2011.12.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 12/10/2011] [Indexed: 11/26/2022]
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Herzog JP, Groff MW. Does sacrifice of the C2 root benefit C1-2 arthrodesis? World Neurosurg 2012; 78:598-600. [PMID: 22381215 DOI: 10.1016/j.wneu.2012.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 01/12/2012] [Indexed: 11/18/2022]
Affiliation(s)
- Joshua P Herzog
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Bransford RJ, Freeborn MA, Russo AJ, Nguyen QT, Lee MJ, Chapman JR, Bellabarba C. Accuracy and complications associated with posterior C1 screw fixation techniques: a radiographic and clinical assessment. Spine J 2012; 12:231-8. [PMID: 22386958 DOI: 10.1016/j.spinee.2012.02.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 09/15/2011] [Accepted: 02/07/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The variable C1 anatomy can make instrumentation challenging and prone to potentially severe complications. New techniques have expanded available options. PURPOSE The aims of this study were to evaluate a large series of posterior C1 screws to determine accuracy by computed tomography (CT) scan; assess dimensions of "safe bony windows" with CT; and assess perioperative complication rate related to errant screw placement. STUDY DESIGN Retrospective review of a single tertiary care spine database to identify patients with C1 instrumentation between December 2002 and September 2008. PATIENT SAMPLE The sample comprised 176 patients with 344 C1 screws. All 176 patients were assessed for perioperative complications related to their C1 screws. Twenty-nine patients did not have postoperative CT scans, leaving 147 patients with 286 screws for analysis of screw accuracy. OUTCOME MEASURES The outcome measures consisted of a radiographic assessment of accuracy of placement of C1 instrumentation and a clinical assessment of perioperative complications related to C1 instrumentation focusing on neurologic and vascular injuries. METHODS Clinical data were obtained from the medical record. Radiographic analyses included preoperative and postoperative CT scans to quantify the patients' bone and classify accuracy of instrumentation. Screws were graded using the following definitions: Type I, screw threads completely within the bone; Type II, less than half the diameter of the screw violates the surrounding cortex; and Type III, clear violation of transverse foramen or spinal canal. RESULTS One hundred seventy-six patients (97 males and 79 females) underwent posterior C1 screw (lateral mass [LM] or transarticular [TA]) fixation. A total of 344 screws were placed with 216 LM screws and 128 TA screws. Twenty-nine patients (58 screws) did not have postoperative CT scans and were not included for analysis of radiographic accuracy but were included in assessment of complications based on medical records. Ninety-six percent of screws (Type I or II) were rated as "safe," and 86% of screws were rated as being ideal (Type I). Twelve screws (4%) were unacceptably placed (Type III). There were no known neurologic or vertebral artery injuries. One patient underwent revision surgery for a medially placed screw. Mean C1 LM width was 10.5 mm across all patients. Estimated blood loss averaged 331 mL. CONCLUSIONS Our findings demonstrate a low incidence of complications associated with posterior screw instrumentation of the C1 LM.
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Affiliation(s)
- Richard J Bransford
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104, USA.
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Posterior C1-2 fusion with C1 lateral mass and C2 isthmic screws: accuracy of screw position, alignment and patient outcome. Acta Neurochir (Wien) 2012; 154:305-12. [PMID: 22200812 DOI: 10.1007/s00701-011-1224-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 11/01/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Transarticular screw fixation is seen as the "gold standard" in instrumented fusion of C1 and C2. However, drawbacks are the necessity of a reduction before instrumentation and a risk of vertebral artery injury. Therefore, C1 lateral mass and C2 isthmic screws are an alternative. The present study assessed the feasibility of C1-2 stabilization with C1 lateral mass and C2 isthmic screws and evaluated quality of life. METHOD All data of 35 consecutive patients treated from May 2006 to September 2009 were collected. Patients had C1 lateral mass and C2 isthmic screws. RESULTS Twenty patients were operated on for traumatic instabilities, six for neoplastic instabilities, five for infectious instabilities and two each for degenerative and congenital instabilities. Sixty-six of 70 C1 screws had an ideal position, while four were placed suboptimal without the need for revision. Twelve of 68 C2 screws were not ideal but acceptable; one screw needed a surgical revision. There was one non-surgery related case of neurological deterioration after multilevel instrumentation. No vascular injuries occurred. Realignment was correct in all patients. After a median follow-up of 12 months, patients showed a reduction of pain, disability and improvements in EQ-5D items. SF36 data compared with a normative population and a historical cohort showed lower levels of function in all domains. CONCLUSION C1-C2 instrumented fusion with lateral mass and isthmic screws is a safe procedure. Sufficient screw position and alignment was possible in all cases. Therefore, at our institution transarticular screws were abandoned in favor of C1 lateral mass and C2 isthmic screws.
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Estillore RP, Buchowski JM, Minh DV, Park KW, Chang BS, Lee CK, Riew KD, Yeom JS. Risk of internal carotid artery injury during C1 screw placement: analysis of 160 computed tomography angiograms. Spine J 2011; 11:316-23. [PMID: 21474083 DOI: 10.1016/j.spinee.2011.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 03/08/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Injury to the internal carotid artery (ICA) is a potentially catastrophic complication of C1-lateral mass (C1-LM) or C1-C2 transarticular screw insertion. PURPOSE This study was designed to determine the risk of injury to the ICA during placement of these screws using computed tomography angiography (CTA). STUDY DESIGN Radiographic analysis using CTA. PATIENT SAMPLE One hundred sixty CTAs were examined, for a total of 320 ICAs. OUTCOME MEASURES Not applicable. METHODS Fine-cut intravenous CTAs with multiplanar and three-dimensional reconstruction were reviewed. The position of the ICA in relation to the anterior cortex (AC) of C1, anterior end of the anterior tubercle (AT), and medial margin of the transverse foramen (TF) was measured bilaterally in three ascending and equidistant levels of the C1-AT. RESULTS The position of the ICA in relation to C1 was variable. The average distance between the ICA and the AC of C1 was only 3.7 mm. Furthermore, 96% of the time the posterior margin of the ICA was located posterior to the anteriormost aspect of the anterior C1 tubercle (average distance, 5.4 mm), making the ICA vulnerable to damage if a drill, tap, or screw was inserted to the depth of the anteriormost portion of the AT as seen on a lateral fluoroscopic or radiographic view. The medial margin of the ICA was located medial to the TF (a location potentially vulnerable to injury with bicortical screw placement) less often at the caudal aspect of the C1-AT (54%) than at its middle or cranial aspect (74% and 75%, respectively). No ICAs were located anterior to the medial 30% of the C1-LM or more medially. CONCLUSIONS Bicortical C1-LM or C1-C2 transarticular screw placement carries a potential risk of ICA injury. Given the wide variation in ICA location relative to C1, if bicortical C1 fixation is required, preoperative CTA should be considered to determine the optimal screw trajectory. In general, inferomedially angulated C1-LM screws appear to be safer with respect to the ICA injury than other potential trajectories.
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Affiliation(s)
- Romel P Estillore
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-ku, Sungnam 463-707, Republic of Korea
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