1
|
Guo Q, Chen F, Zhang M, Wang H, Guo X, Lu X, Ni B. Posterior Reduction and Intra-Articular Cage Fusion With a C2 Nerve Root Preservation Technique for Treating Posterior Atlantoaxial Dislocation Secondary to Os Odontoideum. Oper Neurosurg (Hagerstown) 2023; 25:365-371. [PMID: 37432014 DOI: 10.1227/ons.0000000000000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/16/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Posterior C1-C2 interlaminae compression fusion with iliac bone graft may lead to donor site complications and recurrent C1 posterior dislocation for posterior atlantoaxial dislocation (AAD) secondary to os odontoideum. C1-C2 intra-articular fusion often needs C2 nerve ganglion transection to facilitate exposing and manipulating the facet joint, leading to bleeding from the venous plexus and suboccipital numbness or pain. Therefore, this study was conducted to evaluate the outcomes of posterior C1-C2 intra-articular fusion with a C2 nerve root preservation technique in the treatment of posterior AAD secondary to os odontoideum. METHODS Data of the 11 patients who underwent C1-C2 posterior intra-articular fusion because of posterior AAD secondary to os odontoideum were retrospectively reviewed. Posterior reduction was performed using C1 transarch lateral mass screws and C2 pedicle screws. Intra-articular fusion was performed using a polyetheretherketone cage filled with autologous bone from the caudal edge of the C1 posterior arch and cranial edge of the C2 laminar. Outcomes were evaluated by using the Japanese Orthopaedics Association score, Neck Disability Index, and visual analog scale for neck pain. Bone fusion was evaluated by using computed tomography and 3-dimensional reconstruction. RESULTS The average follow-up duration was 43.9 ± 9.5 months. All patients achieved good reduction and bone fusion, without transection of the C2 nerve roots. The mean bone fusion time was 4.3 ± 1.1 months. There was no complication related to the surgical approach and instrumentation. Function of the spinal cord manifested by the Japanese Orthopaedics Association score significantly improved ( P < .05). The Neck Disability Index score and visual analog scale for neck pain markedly decreased (all P < .05). CONCLUSION Posterior reduction and intra-articular cage fusion with a C2 nerve root preservation technique was a promising treatment of posterior AAD secondary to os odontoideum.
Collapse
Affiliation(s)
- Qunfeng Guo
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, People's Republic of China
| | - Fei Chen
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, People's Republic of China
| | - Mei Zhang
- Department of Traditional Chinese Medicine Rehabilitation, Jing'an Zhabei Central Hospital, Shanghai, People's Republic of China
| | - Haibin Wang
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, People's Republic of China
| | - Xiang Guo
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, People's Republic of China
| | - Xuhua Lu
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, People's Republic of China
| | - Bin Ni
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, People's Republic of China
| |
Collapse
|
2
|
Oh Y, Lee BJ, Lee S, Jeon SR, Roh SW, Park JH. The Results of Interfacetal Fusion Using Local Bone Combined With an Atlantoaxial Instrumentation. Oper Neurosurg (Hagerstown) 2022; 22:284-289. [PMID: 35315815 DOI: 10.1227/ons.0000000000000124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 11/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many studies have described different C1-2 fusion techniques that have evolved over time. We introduced an easy and effective C1-2 fusion technique using local bone chips combined with atlantoaxial instrumentation. OBJECTIVE To identify the efficacy of interfacetal fusion using local bone combined with atlantoaxial instrumentation by assessment of clinical outcomes and fusion rate. METHODS We retrospectively reviewed the data from 25 patients who underwent atlantoaxial stabilization surgery using C1-2 pedicle screws and interfacetal bone fusion by a single surgeon between March 2012 and December 2019. RESULTS The demographics were 15 men and 10 women with a mean age of 57.6 years (range, 27-85 years) at the time of surgery. Three patients underwent surgery for myelopathy due to os odontoideum, 9 for C1-2 instability, 9 for trauma, 3 for rheumatoid arthritis, and 1 for bony spur, C1-2. At 3 months postsurgery, 3 and 21 patients showed 2-point and 1-point improvements in the Nurick grade, respectively. There was no difference in the Nurick score in 1 patient. Seven patients had a computed tomography scan at 1 year after surgery, which revealed a bridging trabecular bone. No movement was observed in the x-ray flexion/extension view at 1 year after surgery in all patients. In addition, no patients complained of postoperative occipital neuralgia. CONCLUSION This study showed that interfacetal fusion with C1-2 pedicle screws using the free-hand technique was efficient and simple.
Collapse
Affiliation(s)
- Younggyu Oh
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byung-Jou Lee
- Department of Neurological Surgery, Inje University, Ilsan Paik Hospital, College of Medicine, Neuroscience and Radiosurgery Hybrid Research Center, Goyang, Republic of Korea
| | - Subum Lee
- Department of Neurological Surgery, Kyungpook National University School of Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Sang Ryong Jeon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Woo Roh
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Hoon Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Haas P, Hauser TK, Kandilaris K, Schenk S, Tatagiba M, Adib SD. Posterolateral epidural supra-C2-root approach (PESCA) for biopsy of lesions of the odontoid process in same sitting after occipitocervical fixation and decompression-perioperative management and how to avoid vertebral artery injury. Neurosurg Rev 2021; 44:2947-2956. [PMID: 33428076 PMCID: PMC8490265 DOI: 10.1007/s10143-020-01468-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/29/2020] [Accepted: 12/28/2020] [Indexed: 12/02/2022]
Abstract
This study aims to describe the posterolateral epidural supra-C2-root approach (PESCA), which might be a good alternative to the transoral, anterolateral, and other posterolateral approaches for biopsy of lesions of the odontoid process (OP). The preoperative planning of PESCA included computerized tomography (CT), CT-angiography, and three-dimensional reconstruction (if possible, even with three-dimensional print) to analyze the angle of the trajectory and the anatomy of the vertebral artery (VA). For PESCA, the patient is positioned under general anesthesia in prone position. In case of an osteolytic lesion with fracture of the OP, an X-ray is performed after positioning to verify anatomic alignment. In the first step, in case of instability and compression of the spinal cord, a craniocervical fusion and decompression is performed (laminectomy of the middle part of the C1 arc and removal of the lower part of the lateral C1 arc). The trajectory is immediately above the C2 root (and under the upper rest of the lateral part of C1 arc). Even if the trajectory is narrowed, it is possible to perform PESCA without relevant traction of the spinal cord. The vertical segment of V3 of the VA at the level of C2 is protected by the vertebral foramen, and the horizontal part of V3 is protected by the remnant upper lateral part of the C1 arc (in case of normal variants). PESCA might be a good choice for biopsy of selected lesions of the OP in same sitting procedure after craniocervical stabilization and decompression.
Collapse
Affiliation(s)
- Patrick Haas
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Till-Karsten Hauser
- Department of Neuroradiology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Kosmas Kandilaris
- Department of Neuropathology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Sebastian Schenk
- Department of Anesthesiology and Intensive Care Medicine, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| | - Sasan Darius Adib
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany.
| |
Collapse
|
5
|
Chen Q, Brahimaj BC, Khanna R, Kerolus MG, Tan LA, David BT, Fessler RG. Posterior atlantoaxial fusion: a comprehensive review of surgical techniques and relevant vascular anomalies. JOURNAL OF SPINE SURGERY 2020; 6:164-180. [PMID: 32309655 DOI: 10.21037/jss.2020.03.05] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior atlantoaxial fusion is an important surgical technique frequently used to treat various pathologies involving the cervical 1-2 joint. Since the beginning of the 20th century, various fusion techniques have been developed with improved safety profile, higher fusion rates, and superior clinical outcome. Despite the advancement of technology and surgical techniques, posterior C1-2 fusion is still a technically challenging procedure given the complex bony and neurovascular anatomy in the craniovertebral junction (CVJ). In addition, vascular anomalies in this region are not uncommon and can lead to devastating neurovascular complications if unrecognized. Thus, it is important for spine surgeons to be familiar with various posterior atlantoaxial fusion techniques along with a thorough knowledge of various vascular anomalies in the CVJ. Intimate knowledge of the various surgical techniques in combination with an appreciation for anatomical variances, allows the surgeon develop a customized surgical plan tailored to each patient's particular pathology and individual anatomy. In this article, we aim to provide a comprehensive review of existing posterior C1-2 fusion techniques along with a review of common vascular anomalies in the CVJ.
Collapse
Affiliation(s)
- Qi Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Bledi C Brahimaj
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Ryan Khanna
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Mena G Kerolus
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Lee A Tan
- Department of Neurosurgery, UCSF Medical Center, San Francisco, CA, USA
| | - Brian T David
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Richard G Fessler
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
6
|
Florman JE, Cushing DA, England EC, White E. How to Transect the C2 Root for C1 Lateral Mass Screw Placement: Case Series and Review of an Underappreciated Variable in Outcome. World Neurosurg 2019; 127:e1210-e1214. [PMID: 31004854 DOI: 10.1016/j.wneu.2019.04.100] [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: 02/14/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The techniques for atlantoaxial arthrodesis have been modified over the years, and placing C1 lateral mass screws is a modern approach. C2 neuropathy is a complication of concern; however, sacrifice of the C2 nerve is an accepted and often favored adjunct. The impact of the technique for cutting the C2 nerve is not adequately addressed in the literature. The aim of this study was to evaluate the clinical outcomes from a series of roots sacrificed during C1-2 fusion with attention to the C2 transection method. METHODS Clinical data were collected from trauma patients who underwent C1 screw fixation for atlantoaxial fusion. Chart review was performed and outcome assessed through telephone surveys to patients who were at least 6 months postoperative. Quality of life, C2 nerve function, neck pain, and head pain were assessed. RESULTS Sixty-six roots were divided in 35 patients. There were no cases of occipital neuralgia at routine 3-month follow-up. Delayed telephone surveys were completed in 17 patients and exposed 4 cases of severe head/neck pain but none consistent with occipital neuralgia. CONCLUSIONS C2 neuralgia is rare when sharply dividing the C2 root with the aid of bipolar electrocautery at the midportion of the ganglion where it overlies the C1-2 joint. A literature review suggests the impact of the root sacrifice method is an underappreciated modifiable factor in outcome. In future reports, description of the root transection technique is imperative and trials comparing ganglionectomy versus transection proximal to the ganglion or through the ganglion should be considered.
Collapse
Affiliation(s)
- Jeffrey E Florman
- Department of Neurosurgery, Maine Medical Center, Portland, Maine, USA.
| | - Deborah A Cushing
- Department of Neurosurgery, Maine Medical Center, Portland, Maine, USA
| | - Emma C England
- Department of Neurosurgery, Maine Medical Center, Portland, Maine, USA
| | - Elbert White
- Department of Neurosurgery, Maine Medical Center, Portland, Maine, USA
| |
Collapse
|
7
|
Clifton W, Edwards S, Dove C, Damon A, Simon L, Rosenbush K, Nottmeier E, Quinones-Hinojosa A, Pichelmann M. Finding the "Sweet Spot" for C2 Root Transection in C1 Lateral Mass Exposure. World Neurosurg 2019; 127:e738-e744. [PMID: 30951909 DOI: 10.1016/j.wneu.2019.03.256] [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: 02/24/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Atlantoaxial fusion often requires C2 nerve transection for complete C1 lateral mass exposure. Nerve transection is made ideally at the preganglionic segment proximal to the dorsal root ganglion to minimize the risk of postoperative dysesthesias. If the nerve is transected too proximally, cerebrospinal fluid leak may be encountered by violation of the dura and arachnoid where the sensory and motor nerve rootlets exit the subarachnoid space. In this study we aimed to quantify the length of the C2 nerve preganglionic segment using cadaveric specimens and develop a method for reliable intraoperative localization for sectioning during C1-2 arthrodesis. METHODS Using microsurgical techniques, 16 C2 nerves from 8 frozen and injected cadaveric cervical spine specimens were dissected. Two key measurements were taken to establish a reliable method of preganglionic segment identification. The "sweet spot" for nerve transection was based on the approximate location of the midpoint of the preganglionic segment. RESULTS The final determination of the ideal spot for C2 nerve transection using these calculations was 3 mm lateral to the medial border of the lateral mass. CONCLUSIONS This anatomic study found remarkable consistency in the preganglionic segment length. The medial border of the lateral mass appeared to be a consistently reliable landmark for identification of the preganglionic segment of the C2 nerve root. By using relationships between known anatomic structures intraoperatively, safety of atlantoaxial fixation can be optimized to maximize complication avoidance and satisfactory patient outcomes.
Collapse
Affiliation(s)
- William Clifton
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA.
| | - Steve Edwards
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Conrad Dove
- College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Aaron Damon
- College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Leslie Simon
- Department of Emergency Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Kristin Rosenbush
- College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Eric Nottmeier
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | - Mark Pichelmann
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| |
Collapse
|
8
|
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.
Collapse
|