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Osterhoff G, Scholz M, Disch AC, Katscher S, Spiegl UJA, Schnake KJ, Scheyerer MJ. Geriatric Odontoid Fractures: Treatment Algorithms of the German Society for Orthopaedics and Trauma Based on Expert Consensus and a Systematic Review. Global Spine J 2023; 13:13S-21S. [PMID: 37084350 PMCID: PMC10177304 DOI: 10.1177/21925682231157316] [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] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Systematic review/expert consensus. OBJECTIVES Fractures of the axis represent the most frequent injury of the spine in elderly patients. Both, operative and non-operative treatment are associated with a high rate of complications and mortality. The aim of this article was to summarize the current literature on the management of odontoid fractures in geriatric patients and to weigh it based on an expert consensus process. METHODS In a joint consensus process, members of the Spine Section of the German Orthopaedic and Trauma Society (DGOU) aimed to formulate recommendations for the diagnostic workup and treatment of odontoid fractures in geriatric patients. Based on the previously published recommendations, this article is an updated version with incorporating a systematic review of the recent literature. RESULTS Based on the new data available, the recommendations established in the initial consensus process were adapted. CONCLUSIONS Computed tomography represents the diagnostic standard for patients with suspected injuries of the upper cervical spine. Anderson/D'Alonzo odontoid fractures type 1, non-displaced type 2, and type 3 can be treated conservatively. Even non-unions do not necessarily result in poor clinical outcome. In Anderson/D'Alonzo type 2 fractures, surgical therapy offers the advantage of relatively safe osseous healing with no increased complication rate even in elderly patients and can thus be recommended. In very high aged patients, however, a case-by-case decision should be made. When surgical stabilization of osteoporotic odontoid fractures is indicated, posterior techniques are biomechanically advantageous and can be considered the standard.
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Affiliation(s)
- Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Matti Scholz
- ATOS Orthopaedic Clinic Braunfels, Braunfels, Germany
| | - Alexander C Disch
- University Comprehensive Spine Center (UCSC), University Center for Orthopaedics, Traumatology & Plastic Surgery, University Hospital Carl Gustav Carus at the TU Dresden, Germany
| | - Sebastian Katscher
- Interdisciplinary Center for Spine and Neurotrauma, Sana Klinikum Borna, Borna, Germany
| | - Ulrich J A Spiegl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Waldkrankenhaus Erlangen, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Max J Scheyerer
- Department of Orthopaedics and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Koln, Germany
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Okano I, Salzmann SN, Winter F, Chiapparelli E, Hoshino Y, Shue J, Carrino JA, Sama AA, Cammisa FP, Girardi FP, Hughes AP. The diagnostic accuracy of MRI and nonenhanced CT for high-risk vertebral artery anatomy for subaxial anterior cervical spine surgery safety. J Neurosurg Spine 2022; 36:261-268. [PMID: 34560654 DOI: 10.3171/2021.4.spine21481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Medial migration of the vertebral artery (VA) can be a risk factor for injury during anterior procedures. CT angiography (CTA) has been considered the gold standard for the evaluation of various areas of the arterial anatomy. MRI and nonenhanced CT are more commonly used as routine preoperative imaging studies, but it is unclear if these modalities can safely exclude the anomalous course of the VA. The aims of this cross-sectional observational study were to investigate risk factors for medially migrated VA on CTA and to evaluate the diagnostic accuracy of MRI and nonenhanced CT for high-risk VA anatomy in the subaxial cervical spine. METHODS The records of 248 patients who underwent CTA for any reason at a single academic institution between 2007 and 2018 were reviewed. The authors included MRI and nonenhanced CT taken within 1 year before or after CTA. An axial VA position classification was used to grade VA anomalies in the subaxial cervical spine. The multivariable linear regression analysis with mixed models was performed to identify the risk factors for medialized VA. The sensitivity and specificity of MRI and nonenhanced CT for high-risk VA positions were calculated. RESULTS A total of 175 CTA sequences met the inclusion criteria. The mean age was 63.8 years. Advanced age, disc and pedicle levels, lower cervical levels, and left side were independent risk factors for medially migrated VA. The sensitivities of MRI and nonenhanced CT for the detection of grade 1 or higher VA position were only fair, and the sensitivity of MRI was lower than that of nonenhanced CT (0.31 vs 0.37, p < 0.001), but the specificities were similarly high for both modalities (0.97 vs 0.97). With the combination of MRI and nonenhanced CT, the sensitivity significantly increased to 0.50 (p < 0.001 vs MRI and vs CT alone) with a minimal decrease in specificity. CONCLUSIONS Axial images of MRI and nonenhanced CT demonstrated high specificities but only fair sensitivities. Nonenhanced CT demonstrated better diagnostic value than MRI. When combining both modalities the sensitivity improved, but a substantial proportion of medialized VAs could not be diagnosed.
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Affiliation(s)
- Ichiro Okano
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 2Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | | | - Fabian Winter
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | | | - Yushi Hoshino
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
- 2Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
- 3Department of Orthopedic Surgery, Asahi University Hospital, Gifu, Japan
| | - Jennifer Shue
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - John A Carrino
- 4Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York
| | - Andrew A Sama
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
| | - Frank P Cammisa
- 1Spine Care Institute, Hospital for Special Surgery, New York, New York
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Yi HJ. Epidemiology and Management of Iatrogenic Vertebral Artery Injury Associated With Cervical Spine Surgery. Korean J Neurotrauma 2022; 18:34-44. [PMID: 35557635 PMCID: PMC9064753 DOI: 10.13004/kjnt.2022.18.e20] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/04/2022] [Accepted: 04/07/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ho Jun Yi
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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Omotoso BR, Harrichandparsad R, Moodley IG, Satyapal KS, Lazarus L. An anatomical investigation of the proximal vertebral arteries (V1, V2) in a select South African population. Surg Radiol Anat 2021; 43:929-941. [PMID: 33689007 PMCID: PMC8164601 DOI: 10.1007/s00276-021-02712-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/09/2021] [Indexed: 11/28/2022]
Abstract
Introduction The most common type of vascular complication during cervical spine surgery is the vertebral artery (VA) injury. The presence of anatomical variation in the artery's morphology has been a significant factor for arterial injury during surgery. Therefore, physicians planning interventions in the craniospinal region need to be aware of the extents of variations. In addition to vascular injury, anatomical variations can predispose to some pathologies in the posterior circulation territory. To provide useful data to interventional radiologists, anatomists, and surgeons, we evaluated the anatomical features of the V1 and V2 segments of the VA in a South African population. Materials and methods The study is an observational, retrospective chart review of 554 consecutive South African patients (Black, Indian and White) who had undergone computed tomography angiography (CTA) from January 2009 to September 2019. Results The VA exhibited morphological variation in its course. We report the incidence of variant origin of the left VA, all from the aortic arch. Variation in the level of entry into the transverse foramen ranged between C7 and C3. A left dominant pattern was observed; we also report on hypoplasia of the VA. In addition, we report incidence of VA tortuosity at V1, V2 to be 76.6% and 32.1%, respectively. Conclusions The baseline data established in this study regarding the diameter, variant origin, and level of entry into the transverse foramen will assist neurosurgeons and interventional radiologists in interpreting, diagnosing, and planning and executing various vascular procedures and treatment of pathology in the vicinity of the VA.
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Affiliation(s)
- B R Omotoso
- Department of Clinical Anatomy, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa
| | - R Harrichandparsad
- Department of Neurosurgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - I G Moodley
- Department of Radiology, Jackpersad and Partners Inc, Specialist Diagnostic Radiologists, Lenmed Ethekwini Hospital and Heart Centre, Durban, South Africa
| | - K S Satyapal
- Department of Clinical Anatomy, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa
| | - L Lazarus
- Department of Clinical Anatomy, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa.
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Anterior Approach to the Subaxial Cervical Spine: Pearls and Pitfalls. J Am Acad Orthop Surg 2021; 29:189-195. [PMID: 33587498 DOI: 10.5435/jaaos-d-17-00891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 10/05/2020] [Indexed: 02/01/2023] Open
Abstract
Since its introduction by Smith and Robinson, the anterior approach to the subaxial cervical spine has become one of the standard procedures for numerous cervical spine pathologies, including, but not limited to degenerative disease, trauma, tumor, deformity, and instability. Along with its increasing popularity and improvements in anterior instrumentation techniques, a comprehensive knowledge of the surgical anatomy during the anterior exposure is critical for trainees and experienced spine surgeons alike to minimize the infrequent but potentially devastating risks associated with this approach. Understanding the anatomy and techniques to minimize damage to relevant structures can reduce the risks of developing notable postoperative complications and morbidity.
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Sravani N, Nagarajan K, Venkatesh M, Negi VS, Ramesh AS. Vertebral Artery Loops and Cervicobrachial Pain. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0040-1713057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractVertebral artery loop formation is an uncommon anatomical variation which may be asymptomatic or can cause cervicobrachial pain, radiculopathy, or even bone erosions and enlargement of neural foramina. As this entity is one of the uncommon causes of cervical radiculopathy, this report aims to create awareness among radiologists and clinicians, as vertebral artery loops may be seen incidentally in routine neuroimaging. magnetic resonance imaging (MRI) with magnetic resonance (MR) angiography or multislice computerized tomography (CT) angiography plays an important role in diagnosing as well as creating a roadmap for the surgery.Vertebral artery loop formation as a cause of radiculopathy is an uncommon condition. An abnormal course of vessel can lead to vascular injury during surgery, hence preoperative evaluation with CT or MRI is essential.1
2 Anomalous looping of vertebral artery can cause neurovascular compression apart from bony erosion, widening of vertebral foramen, and even vertebrobasilar insufficiency. Clinical features of vertebral artery loop formation can be radiculopathy, compression over cervical cord leading to sensory and motor deficit, and vertigo when associated with vertebra–basilar insufficiency, which is known as vascular vertigo. It has also been postulated that loop formation of vertebral artery can also lead to posterior circulation infarcts. Left vertebral artery is more prone for loop formation than the right vertebral artery, probably due to increased caliber in greater proportion of individuals. Multilevel and bilateral tortuosity can occur in younger patients rarely where imaging plays an important role.
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Affiliation(s)
- Nichanametla Sravani
- Department of Radio-Diagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Krishnan Nagarajan
- Department of Radio-Diagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Manchikanti Venkatesh
- Department of Radio-Diagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Veer S. Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Andi S. Ramesh
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
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Winter F, Okano I, Salzmann SN, Rentenberger C, Shue J, Sama AA, Girardi FP, Cammisa FP, Hughes AP. A Novel and Reproducible Classification of the Vertebral Artery in the Subaxial Cervical Spine. Oper Neurosurg (Hagerstown) 2020; 18:676-683. [PMID: 31586208 DOI: 10.1093/ons/opz310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/29/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND An injury of the vertebral artery (VA) is one of the most catastrophic complications in the setting of cervical spine surgery. Anatomic variations of the VA can increase the risk of iatrogenic lacerations. OBJECTIVE To propose a novel and reproducible classification system that describes the position of the VA based on a 2-dimensional map on computed tomography angiographs (CTA). METHODS This cross-sectional retrospective study reviewed 248 consecutive CTAs of the cervical spine at a single academic institution between 2007 and 2018. The classification consists of a number that characterizes the location of the VA from the medio-lateral (ML) aspect of the vertebral body. In addition, a letter describes the VA location from the anterior-posterior (AP) aspect. The reliability and reproducibility were assessed by 2 independent raters on 200 VAs. RESULTS The inter- and intrarater reliability values showed the classification's reproducibility. The inter-rater reliability weighted κ-value for the ML aspect was 0.93 (95% CI: 0.93-0.93). The unweighted κ-value was 0.93 (95% CI: 0.86-1.00) for "at-risk" positions (ML grade ≥1), and 0.87 (95% CI: 0.75-1.00) for "high-risk" positions (ML grade ≥2). The weighted κ-value for the intrarater reliability was 0.94 (95% CI: 0.95-0.95). The unweighted κ-values for the intrarater reliability were 0.95 (95% CI: 0.91-0.99) for "at-risk" positions, and 0.87 (95% CI: 0.78-0.96) for "high-risk" positions. CONCLUSION The proposed classification is reliable, reproducible, and independent of individual anatomic size variations. The use of this novel grading system could improve the understanding and interdisciplinary communication about VA anomalies.
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Affiliation(s)
- Fabian Winter
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Ichiro Okano
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Stephan N Salzmann
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Colleen Rentenberger
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Jennifer Shue
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Andrew A Sama
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Federico P Girardi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Frank P Cammisa
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, New York
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Croci DM, Koetsier E, Maino P, Reinert M, Robert T, Scarone P. Cervical Radiculopathy Caused by a Vertebral Artery Loop: Is a Focused Fluoroscopic-Guided Cervical Epidural Steroid Injection a Possible Treatment Modality? Pain Pract 2020; 20:787-791. [PMID: 32306517 DOI: 10.1111/papr.12903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/08/2020] [Accepted: 04/14/2020] [Indexed: 11/30/2022]
Abstract
We describe a case of a patient suffering with cervical radiculopathy due to vertebral artery loop with nerve root compression, treated with an epidural steroid injection. A 37-year-old man presented with a 2-year history of right-sided radicular pain along the C7 dermatome. Imaging showed a right-sided loop of the vertebral artery at the V1-V2 transition with contact on the C7 nerve root. The pain was resistant to conservative treatment, and the decision was made to perform a focused fluoroscopy-guided translaminar epidural steroid injection near the C7 nerve root. The procedure was uneventful, and the symptoms resolved completely after the procedure. Targeted epidural steroid injection might be a useful and safe diagnostic and therapeutic approach in patients affected by cervical radiculopathy due to a VA loop. To our knowledge, this is the first case of a VA loop associated with cervical radiculopathy treated with this technique.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
| | - Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.,Division of Anaesthesiology, Department of Acute Medicine, Regional Hospital of Lugano, Lugano, Switzerland
| | - Paolo Maino
- Pain Management Center, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.,Division of Anaesthesiology, Department of Acute Medicine, Regional Hospital of Lugano, Lugano, Switzerland
| | - Michael Reinert
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
| | - Pietro Scarone
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
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Kim K, Nariai M, Kawauchi M, Morimoto D, Iwamoto N, Isu T, Morita A. Is the Vertebral Posterior Line a Safety Landmark for Cervical Posterior Screw Insertion? - Radiological Study of the Vertebral Artery in the Cervical Spine. Neurol Med Chir (Tokyo) 2020; 60:223-228. [PMID: 32132344 PMCID: PMC7174243 DOI: 10.2176/nmc.oa.2019-0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
At posterior cervical fixation, iatrogenic injury of the vertebral artery (VA) must be avoided. As the VA is usually located in front of the posterior line of the vertebral body, intraoperative lateral fluoroscopy is used to identify the line. We investigated in how many of 105 patients (210 VAs) this line is a safe marker. We also inspected the original cervical magnetic resonance angiograms (MRA) of 105 consecutive patients who had been treated for other than cervical spine diseases to study some anatomical characteristics of the VA in the cervical spine. The distance from the posterior line of the vertebral body to the posterior VA surface was classified as safe, as requiring attention, and as unsafe. Among the 210 VAs, four hypoplastic vessels were excluded from this study; consequently, 206 VAs were available for assessment. The average distance exceeded 6 mm, it was shorter at the upper cervical level. Although in at least 200 VAs (97.1%) the distance between C4 and C7 was safe, in only 170 VAs (82.5%) was it safe at C3. We observed a total of 31 tortuous loops in 17 VAs; their presence had a significant negative effect on the usefulness of the safety line. Although the posterior line of the vertebral body may be useful for safe screw insertion at the C4-C7 level, it may be less useful at C3. In the presence of tortuous VA loops, close attention must be paid to the reliability of the safety line during cervical spine surgery.
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Affiliation(s)
- Kyongsong Kim
- Department of Neurological Surgery, Chiba Hokuso Hospital, Nippon Medical School.,Department of Neurosurgery, Chiba Shintoshi Rurban Clinic
| | | | | | | | | | - Toyohiko Isu
- Department of Neurosurgery, Kushiro Rosai Hospital
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School
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Tonsbeek AM, Groen JL, Vleggeert-Lankamp CLAM. Surgical Interventions for Cervical Radiculopathy Caused by a Vertebral Artery Loop: A Case Report and Review of the Literature. World Neurosurg 2019; 135:28-34. [PMID: 31809894 DOI: 10.1016/j.wneu.2019.11.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Aberrant vertebral artery loops are a rare clinical condition, with sparse data regarding the optimal treatment guidelines for individual patients. The heterogeneity of treatment options in the literature creates a problem when tailoring treatments to individual patients. In this review of the literature, multiple surgical treatments for cervical vertebral artery loops were analyzed and compared. In addition, this article provides a clinical case of a patient with a vertebral artery loop. METHODS A literature review was conducted to identify studies investigating surgical treatments for a vertebral artery loop. Different surgical techniques were examined and the involved techniques and approaches described. The outcomes were assessed for each study and the effectiveness of the treatment determined. RESULTS Twelve articles met the inclusion criteria for this review. Six types of surgical interventions were found in the literature. Each intervention had similar postoperative results, leading to either a significant improvement or a complete resolution of symptoms. CONCLUSIONS Multiple successful surgical interventions have been described in the medical literature. However, because of the lack of evidence-based studies, no surgical intervention protocol could be determined. Treatment should therefore be tailored to individual patients' characteristics. Because not every radiologically detected vertebral artery loop is the main reason for a patient's symptoms, a thorough multidisciplinary approach is justified and advocated in patients with an atypical presentation, before a neurosurgical intervention takes place. More deliberate clinical decisions can be made once the understanding of the pathogenesis of this rare disease entity has been established and treatment protocols formulated.
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Affiliation(s)
- Anthony M Tonsbeek
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Justus L Groen
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
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Osterhoff G, Schnake K, Scheyerer MJ, Ullrich BW, Hartmann F, Franck A, Koepp H, Reinhold M, Schmeiser G, Sprengel K, Zimmermann V, Siekmann H, Badke A, Gebhard H, Täubel KC, Grüninger S, Verheyden AP, Schleicher P, Spiegl UJA. Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:647-656. [PMID: 31634954 DOI: 10.1055/a-0989-2791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Odontoid fractures in geriatric patients represent an entity of increasing incidence with a high rate of morbidity and mortality. The optimal diagnostic and therapeutic management is being controversially discussed in the literature. METHODS In a consensus process and based on the current literature, the members of the working groups "Osteoporotic Fractures" and "Upper Cervical Spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) defined recommendations for the diagnostics and treatment of odontoid fractures in geriatric patients. RESULTS For the diagnosis of odontoid fractures in symptomatic patients, computed tomography represents the gold standard, along with conventional radiographs. Magnetic resonance and dynamic imaging can be used as ancillary imaging modalities. With regard to fracture classification, the systems described by Anderson/D'Alonzo and by Eysel/Roosen have proved to be of value. A treatment algorithm was developed based on these classifications. Anderson/D'Alonzo type 1, type 3, and non-displaced type 2 fractures usually can be treated non-operatively. However, a close clinical and radiological follow-up is essential. In Anderson/D'Alonzo type 2 fractures, operative treatment is associated with better fracture healing. Displaced type 2 and type 3 fractures should be stabilized operatively. Type 2 fractures with suitable fracture patterns (Eysel/Roosen 2A/B) can be stabilized anteriorly. Posterior C I/II-stabilization procedures are well established and suitable for all fracture patterns.
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Affiliation(s)
- Georg Osterhoff
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig
| | - Klaus Schnake
- Zentrum für Wirbelsäulen- und Skoliosetherapie, Schön Klinik Nürnberg/Fürth, Fürth
| | - Max J Scheyerer
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln
| | - Bernhard W Ullrich
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost GgmbH Halle/Saale
| | - Frank Hartmann
- Zentrum für Unfallchirurgie und Orthopädie, Ev. Stift St. Martin, Gemeinschaftsklinikum Mittelrhein, Koblenz
| | - Alexander Franck
- Klinik für Orthopädie und Unfallchirurgie, Regiomed Klinikum Coburg
| | - Holger Koepp
- Wirbelsäulenzentrum, St. Josefs-Hospital, Wiesbaden
| | - Maximilian Reinhold
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Südstadt Rostock
| | | | - Kai Sprengel
- Klinik für Traumatologie, UniversitätsSpital Zürich, Schweiz
| | - Volker Zimmermann
- Abt. Unfallchirurgie und Orthopädische Chirurgie, Klinikum Traunstein
| | - Holger Siekmann
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle
| | - Andreas Badke
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Unfallklinik Tübingen
| | | | - Kai C Täubel
- Orthopädisch-Unfallchirurgisches Zentrum, ALB FILS KLINIKEN, Standort Klinik am Eichert, Göppingen
| | - Sebastian Grüninger
- Universitätsklinik für Orthopädie und Unfallchirurgie, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg
| | - Akhil P Verheyden
- Klinik für Unfall-, Orthopädische und Wirbelsäulenchirurgie, Ortenau Klinikum Lahr-Ettenheim
| | | | - Ulrich J A Spiegl
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig
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Igoumenou VG, Mavrogenis AF, Angelini A, Baracco R, Benzakour A, Benzakour T, Bork M, Vazifehdan F, Nena U, Ruggieri P. Complications of spine surgery for metastasis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:37-56. [DOI: 10.1007/s00590-019-02541-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
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Lee CH, Hong JT, Kang DH, Kim KJ, Kim SW, Kim SW, Kim YJ, Chung CK, Shin JJ, Oh JK, Yi S, Lee JK, Lee JH, Lee HJ, Chun HJ, Cho DC, Jin YJ, Choi KC, Han IH, Hyun SJ, Hur JW, Song GS. Epidemiology of Iatrogenic Vertebral Artery Injury in Cervical Spine Surgery: 21 Multicenter Studies. World Neurosurg 2019; 126:e1050-e1054. [DOI: 10.1016/j.wneu.2019.03.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/26/2022]
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14
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Nazemi AK, Bickley SR, Behrend CJ, Carmouche JJ. C1-2 Fixation Approach for Patients With Vascular Irregularities: A Case Report. Geriatr Orthop Surg Rehabil 2018; 8:263-267. [PMID: 29318090 PMCID: PMC5755840 DOI: 10.1177/2151458517733158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 07/26/2017] [Accepted: 08/30/2017] [Indexed: 11/16/2022] Open
Abstract
In posterior spinal fusion (PSF), the vertebral artery is most vulnerable to injury at C1-2. C2 pedicle screws are often placed into the dorsomedial isthmus of C2. Alternative techniques include C2 laminar screws and wiring techniques. A 67-year-old male underwent PSF for persistent severe intractable neck pain and degeneration at C1-2. The patient had an enlarged left vertebral artery with midline migration into the C2 body. This pattern was within one standard deviation of normal; however, it rendered typical placement of a C2 pedicle screw unsafe. As a salvage, a C2 laminar screw was placed on the left to avoid risk of vertebral artery injury. The operation and recovery were without complication. C2 laminar screws can be viable alternatives to C2 pedicle screws in cases of midline vertebral artery migration or other vascular anomalies preventing normal safe placement of C2 pedicle screws.
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Affiliation(s)
- Alireza K Nazemi
- Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Stetson R Bickley
- Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Carilion Clinic Radiology, Roanoke, VA, USA
| | - Caleb J Behrend
- Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Institute for Orthopaedics and Neurosciences, Carilion Clinic, Roanoke, VA, USA
| | - Jonathan J Carmouche
- Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Institute for Orthopaedics and Neurosciences, Carilion Clinic, Roanoke, VA, USA
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15
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Scholz M, Kandziora F, Hildebrand F, Kobbe P. [Injuries of the upper cervical spine : Update on diagnostics and management]. Unfallchirurg 2017; 120:683-700. [PMID: 28776221 DOI: 10.1007/s00113-017-0380-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Injuries to the upper cervical spine represent a diagnostic and therapeutic challenge to the treating surgeon due to the complex anatomical relationships and biomechanical features. In this further education article the diagnostic principles, established classifications and therapeutic recommendations as well as injury-specific characteristics of bony and ligamentous injuries to the upper cervical spine (C0-C2) are presented.
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Affiliation(s)
- Matti Scholz
- BG Unfallklink Frankfurt am Main gGmbH, Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt, Deutschland
| | - Frank Kandziora
- BG Unfallklink Frankfurt am Main gGmbH, Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt, Deutschland
| | - Frank Hildebrand
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Philipp Kobbe
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
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16
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Guan Q, Chen L, Long Y, Xiang Z. Iatrogenic Vertebral Artery Injury During Anterior Cervical Spine Surgery: A Systematic Review. World Neurosurg 2017; 106:715-722. [PMID: 28712898 DOI: 10.1016/j.wneu.2017.07.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Iatrogenic vertebral artery injury (VAI) during anterior cervical surgery is rare but potentially catastrophic. METHODS Causes, presentation, diagnosis, management, prognosis, and prevention of VAI were reviewed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. English language studies and case reports published from 1980 to 2017 were retrieved. Data on diagnosis, surgical procedures and approach, site and cause of VAI, management, outcomes, and vertebral artery (VA) status were extracted. RESULTS In 25 articles including 54 patients, VAI was diagnosed during or after surgery commonly indicated for cervical degenerative diseases (64%), tumors (14%), and trauma (9%). The incidence of VAI for each side was similar regardless of approach. Common presentations were unexpected copious surgical bleeding, delayed hemorrhage of pseudoaneurysm with neck swelling, dyspnea, hypotension, and cervical bruits caused by arteriovenous fistula. Causes included drilling (61%), instrumentation (16%), and soft tissue retraction (8%). Direct exposure or angiography confirmed VAI. Ten patients had VA anomalies; collateral status was verified in 9 before definitive treatment. Tamponade was adopted for urgent hemostasis in most cases but with a high incidence of pseudoaneurysm (48%). Unknown VA status increased occlusion risk and neurologic sequelae (41%). VA repair and stent placement had excellent outcomes. CONCLUSIONS Extensive lateral decompression, loss of landmarks, and anatomic variations or pathologic status of VA increased VAI risk. Evaluation of collateral vessels before definitive treatment helped determine appropriate management and avoid neurologic sequelae. Tamponade was not recommended as definitive treatment. Meticulous preoperative evaluation, cautious intraoperative manipulation, and real-time radiographic guidance reduced VAI risk.
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Affiliation(s)
- Qing Guan
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Long Chen
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ye Long
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhou Xiang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Ekşi MŞ, Toktaş ZO, Yılmaz B, Demir MK, Özcan-Ekşi EE, Bayoumi AB, Yener Y, Akakın A, Konya D. Vertebral artery loops in surgical perspective. 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 2016; 25:4171-4180. [PMID: 27388018 DOI: 10.1007/s00586-016-4691-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/16/2016] [Accepted: 07/03/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Vertebral artery loop is a congenital or acquired anomaly. Vertebral artery loops are incidentally diagnosed during evaluation of neck problems and trauma. We aimed to present the incidence of VA loops using magnetic resonance angiography in consecutive patients and discuss epidemiological data including the gender, age, location, signs and symptoms, treatment approaches and outcomes of VA loops via analyzing literature. METHODS In the first leg of our two-legged study, consecutive patients were evaluated using magnetic resonance angiography to detect any medial loop of vertebral arteries. The study period was from October 2015 to March 2016. In the second leg, academic databases about medial loop of vertebral artery were screened. Case reports, case series, abstracts and references of relevant literature were searched manually to avoid any missing cases. RESULTS We evaluated 239 consecutive patients using magnetic resonance angiography. Twenty-one patients were excluded from the study due to inadequate image acquisition, aplastic vertebral artery and/or concomitant vertebral artery stenosis. Medial loop of V2 vertebral artery was observed in 13 patients (5.9 %): 9 with left, 2 with right and 2 with bilateral medial V2 loop. Patients with medial V2 loop were significantly older than patients with straight vertebral arteries (70.30 vs. 62.36, p = 0.028). In the literature analysis, VA loops were more commonly observed at V2 segment (90.5 %). Vertebral artery loops were mostly diagnosed at the 5th and 6th decades of life predominantly in females. The most common signs and symptoms were radiculopathy and/or neck pain, and signs and symptoms of vertebrobasilar insufficiency. CONCLUSIONS Concise pre-operative evaluation of the vertebral arteries is essential to avoid the injury of undiagnosed VA loops during surgery, which might result in catastrophic circumstances. Further evaluation of the vertebral arteries using MR angiography is required, especially in elder age, before cervical spine surgeries.
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Affiliation(s)
- Murat Şakir Ekşi
- Department of Orthopedic Surgery-Spine Center, University of California at San Francisco, Medical Center, 500 Parnassus Avenue MU320 West, San Francisco, CA, 94143-0728, USA.
| | - Zafer Orkun Toktaş
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Baran Yılmaz
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Mustafa Kemal Demir
- Department of Radiology, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Emel Ece Özcan-Ekşi
- Department of Physical Medicine and Rehabilitation, Antalya Ataturk State Hospital, Antalya, Turkey
| | - Ahmed B Bayoumi
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Yasin Yener
- Department of Anesthesiology, Medical Park Göztepe Hospital, Istanbul, Turkey
| | - Akın Akakın
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Deniz Konya
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
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