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Sharma AK, Acharya N, Camino-Willhuber G, Grace K, Bhatia NN. Unilateral C1-C2 Posterior Fusion in a Patient With Right Vertebral Artery Anomaly With Intracanal Trajectory: A Case Report. JBJS Case Connect 2024; 14:01709767-202409000-00020. [PMID: 39058800 DOI: 10.2106/jbjs.cc.22.00603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
CASE A 59-year-old woman presented with progressively worsening neck pain and radicular symptoms. Cervical radiographs revealed C1-C2 dynamic instability. Magnetic resonance imaging and computed tomographic angiogram revealed an anomalous right vertebral artery with intracanal trajectory at C1. A unilateral left C1-C2 fusion with a C1 lateral mass screw and C2 transarticular screw placement was performed due to the anomalous artery. At 14-month follow-up, the patient's cervical symptoms had resolved. CONCLUSION In this patient with an aberrant vertebral artery who was indicated for C1-C2 fusion, a unilateral contralateral fusion with a C1 lateral mass screw and C2 transarticular screw was a satisfactory treatment option.
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Affiliation(s)
- Abhinav K Sharma
- University of California, Irvine, School of Medicine, Department of Orthopaedic Surgery, Orange, California
| | - Nischal Acharya
- University of California, Irvine, School of Medicine, Department of Neurological Surgery, Orange, California
| | - Gaston Camino-Willhuber
- University of California, Irvine, School of Medicine, Department of Orthopaedic Surgery, Orange, California
| | - Kyrillos Grace
- University of California, Irvine, School of Medicine, Department of Orthopaedic Surgery, Orange, California
| | - Nitin N Bhatia
- University of California, Irvine, School of Medicine, Department of Orthopaedic Surgery, Orange, California
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2
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Cloney MB, Texakalidis P, Roumeliotis AG, Tecle NE, Dahdaleh NS. Atlas fractures with and without simultaneous dens fractures differ with respect to clinical, demographic, and management characteristics. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:418-425. [PMID: 38268695 PMCID: PMC10805171 DOI: 10.4103/jcvjs.jcvjs_126_23] [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: 09/23/2023] [Accepted: 10/16/2023] [Indexed: 01/26/2024] Open
Abstract
Background Patients with simultaneous fractures of the atlas and dens have traditionally been managed according to the dens fracture's morphology, but data supporting this practice are limited. Methods We retrospectively examined all patients with traumatic atlas fractures at our institution between 2008 and 2016. We used multivariable regression and propensity score matching to compare the presentation, management, and outcomes of patients with isolated atlas fractures to patients with simultaneous atlas-dens fractures. Results Ninety-nine patients were identified. Patients with isolated atlas fractures were younger (61 ± 22 vs. 77 ± 14, P = 0.0003), had lower median Charlson Comorbidity Index (3 vs. 5, P = 0.0005), had better presenting Nurick myelopathy scores (0 vs. 3, P < 0.0001), and had different mechanisms of injury (P = 0.0011). Multivariable regression showed that having a simultaneous atlas-dens fracture was independently associated with older age (odds ratio [OR] =1.59 [1.22, 2.07], P = 0.001), worse presenting myelopathy (OR = 3.10 [2.04, 4.16], P < 0.001), and selection for surgery (OR = 4.91 [1.10, 21.97], P = 0.037). Propensity score matching yielded balanced populations (Rubin's B = 23.3, Rubin's R = 1.96) and showed that the risk of atlas fracture nonunion was no different among isolated atlas fractures compared to simultaneous atlas-dens fractures (P = 0.304). Age was the only variable independently associated with atlas fracture nonunion (OR = 2.39 [1.15, 5.00], P = 0.020), having a simultaneous atlas-dens fracture was not significant (P = 0.2829). Conclusions Among patients with atlas fractures, simultaneous fractures of the dens occur in older patients and confer an increased risk of myelopathy and requiring surgical stabilization. Controlling for confounders, the risk of atlas fracture nonunion is equivalent for isolated atlas fractures versus simultaneous atlas-dens fractures.
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Affiliation(s)
- Michael Brendan Cloney
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Pavlos Texakalidis
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Anastasios G Roumeliotis
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Najib El Tecle
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Nader S. Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
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3
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Liu HT, Liang ZH, Song J, Zhang HW, Zhou FC, Zhang QQ, Shao J, Zhang YH. Posterior Atlantoaxial Fusion With C1-2 Pedicle Screw Fixation for Atlantoaxial Dislocation in Pediatric Patients With Mucopolysaccharidosis IVA (Morquio a Syndrome): A Case Series. World Neurosurg 2023; 175:e574-e581. [PMID: 37028486 DOI: 10.1016/j.wneu.2023.03.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE To investigate the efficacy and safety of posterior atlantoaxial fusion (AAF) with C1-2 pedicle screw fixation for atlantoaxial dislocation (AAD) in pediatric patients with mucopolysaccharidosis IVA (MPS IVA). METHODS This study included 21 pediatric patients with MPS IVA who underwent posterior AAF with C1-2 pedicle screw fixation. Anatomical parameters of the C1 and C2 pedicle were measured on preoperative computed tomography (CT). The American Spinal Injury Association (ASIA) scale was used to evaluate the neurological status. The fusion and accuracy of pedicle screw was assessed on postoperative CT. Demographic, radiation dose, bone density, surgical, and clinical data were recorded. RESULTS Patients reviewed included 21 patients younger than 16 years with an average age of 7.4 ± 4.2 years and an average of 20.9 ± 7.7 months follow-up. Fixation of 83 C1 and C2 pedicle screws was performed successfully and 96.3% of them were identified as being safe. One patient developed postoperative transient disturbance of consciousness and one developed fetal airway obstruction and died about 1 month after the surgery. Out of the remaining20 patients, fusion was achieved, symptoms were improved, and no other serious surgical complications were observed at the latest follow-up. CONCLUSIONS Posterior AAF with C1-2 pedicle screw fixation is effective and safe for AAD in pediatric patients with MPS IVA. However, the procedure is technically demanding and should be performed by experienced surgeons with strict multidisciplinary consultations.
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Affiliation(s)
- Hai-Tao Liu
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi-Hui Liang
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Song
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui-Wen Zhang
- Department of Endocrinology and Genetics, Shanghai Institute of Pediatrics, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fu-Chao Zhou
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiu-Qi Zhang
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiang Shao
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue-Hui Zhang
- Spine Center, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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4
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Liu HT, Song J, Zhou FC, Liang ZH, Zhang QQ, Zhang YH, Shao J. Cervical spine involvement in pediatric mucopolysaccharidosis patients: Clinical features, early diagnosis, and surgical management. Front Surg 2023; 9:1059567. [PMID: 36684186 PMCID: PMC9852728 DOI: 10.3389/fsurg.2022.1059567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/22/2022] [Indexed: 01/08/2023] Open
Abstract
Mucopolysaccharidosis (MPS) is a progressive genetic disease that causes a deficiency in lysosomal enzymes, which play an important role in the degradation pathway of glycosaminoglycans. As a result of enzyme defects, mucopolysaccharides cannot be metabolized and thus accumulate. The cervical spine is one of the most commonly involved sites; thus, prompt surgical management before the onset of severe neurological deterioration is critical. However, because of the rarity of the disease, there is no standard treatment. In this review, we characterize the cervical spinal involvement in pediatric patients with MPS, describe the useful imaging technologies for diagnosis, and provide screening procedure for children with MPS. Surgical managements, including indications, surgical methods, possible difficulties, and solutions, are reviewed in detail.
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Affiliation(s)
| | | | | | | | | | | | - Jiang Shao
- Correspondence: Yue-Hui Zhang Jiang Shao
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5
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Chaudhary K, Pennington Z, Rathod AK, Laheri V, Bapat M, Sciubba DM, Suratwala SJ. Application of the Modified Lifeso Radiographic Staging System to the Management and Outcomes for Craniocervical Tuberculosis. Clin Neurol Neurosurg 2022; 222:107453. [DOI: 10.1016/j.clineuro.2022.107453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/18/2022] [Accepted: 09/25/2022] [Indexed: 11/03/2022]
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6
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Byun CW, Lee DH, Park S, Lee CS, Hwang CJ, Cho JH. The association between atlantoaxial instability and anomalies of vertebral artery and axis. Spine J 2022; 22:249-255. [PMID: 34500076 DOI: 10.1016/j.spinee.2021.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/27/2021] [Accepted: 08/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT A screw-rod system is the most widely used technique for atlantoaxial instability (AAI). However, neglecting anomalies of the vertebral artery and axis could lead to fatal complications. Whether or not the presence of AAI is associated with a more complicated anatomy for instrumentation is unclear. PURPOSE To analyze the association between AAI and anomalies of the vertebral artery and axis in patients with and without AAI. STUDY DESIGN A retrospective comparative study. PATIENT SAMPLE One hundred and twenty patients who underwent preoperative 3-dimensional computed tomography with vertebral angiography of the cervical spine at our institution from 2012 to 2020. OUTCOME MEASURES The C2 isthmus height, internal height of the C2 lateral mass, and C2 pedicle width were radiologically assessed. METHODS A case control study with matched cohort analysis was conducted. One hundred and twenty patients were divided into 2 groups according to presence of AAI, and the presence of high-riding vertebral artery (HRVA) and a narrow pedicle for insertion of the C2 pedicle screw was assessed, as was the prevalence of extraosseous vertebral artery anomaly. RESULTS The C2 isthmus height, C2 internal height, and C2 pedicle width were significantly narrower in the AAI group (p<.01, <.01, and <.01, respectively). A significantly greater proportion of patients with AAI had HRVA and a narrow pedicle than those without (p<.01 and < 0.01, respectively). Among patients with AAI, the C2 internal height was significantly narrower in patients with rheumatoid arthritis (p<.01). Five patients (8.3%) with AAI had vertebral artery anomaly (3 fenestration, 2 persistent first intersegmental artery), while there were no vertebral artery anomalies in patients without AAI (p<.01). CONCLUSIONS Vertebral artery anomalies are more common in patients with AAI. Furthermore, posterior instrumentation in patients with AAI has a narrower safe zone compared to that in patients without AAI, which may be caused by a long-lasting deformity rather than a congenital deformity. Therefore, more thorough preoperative evaluation of the anatomy should be performed in these patients.
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Affiliation(s)
- Chan Woong Byun
- Department of Orthopedic Surgery, Seoul Segyero Hospital, Seoul, Republic of Korea
| | - Dong-Ho Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul, Republic of Korea.
| | - Sehan Park
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Choon Sung Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul, Republic of Korea
| | - Chang Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul, Republic of Korea
| | - Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul, Republic of Korea
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Jannelli G, Moiraghi A, Paun L, Cuvinciuc V, Bartoli A, Tessitore E. Atlantoaxial posterior screw fixation using intra-operative spinal navigation with three-dimensional isocentric C-arm fluoroscopy. INTERNATIONAL ORTHOPAEDICS 2022; 46:321-329. [PMID: 34993554 DOI: 10.1007/s00264-021-05276-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/25/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Intra-operative image acquisition coupled with navigation aims to increase screw placement accuracy, and it is particularly helpful in complex spinal procedures. The aim of this study is to analyze the accuracy and reliability of posterior atlanto-axial fixation using spinal navigation combined with intra-operative 3D isocentric C-arm. METHODS We retrospectively reviewed all patients presenting with C1-C2 instability and treated by posterior atlanto-axial fixation in our center between December 2016 and September 2018. Screw positioning was guided by intra-operative navigation, registered with surface matching procedure on a previously obtained CT scan and controlled by intra-operative 3D isocentric C-arm. Age, sex, pre- and post-operative neurological status, duration of surgery, presence/absence of vertebral artery injury, and screw placement were retrospectively collected from patients' records. All patients underwent clinical and radiological follow-up at three months after surgery. Radiological assessment of screw positioning was performed by an independent radiologist using the Gertzbein and Robbins grading. RESULTS N = 11 (7F, 4 M) consecutive patients were included, with a mean age of 72 years (range from 51 to 85). N = 44 navigated screws were inserted and controlled with intra-operative 3D fluoroscopy at the end of the procedure. An acceptable screw positioning (Gertzbein-Robbins grade A and B) was obtained in all cases (100%). No vertebral artery injury was observed. Mean operating time was 123 minutes. At three months, no screw loosening or displacement was observed. CONCLUSION In our experience, spinal navigation coupled with intra-operative 3D fluoroscopy proved to be reliable and safe for C1-C2 screw placement.
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Affiliation(s)
- Gianpaolo Jannelli
- Division of Neurosurgery, Geneva University Hospitals and University of Geneva Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Alessandro Moiraghi
- Division of Neurosurgery, Geneva University Hospitals and University of Geneva Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.,Department of Neurosurgery, GHU Paris-Sainte-Anne Hospital, Université de Paris, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie Et Neurosciences de Paris, Paris, France
| | - Luca Paun
- Division of Neurosurgery, Geneva University Hospitals and University of Geneva Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
| | | | - Andrea Bartoli
- Division of Neurosurgery, Geneva University Hospitals and University of Geneva Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Enrico Tessitore
- Division of Neurosurgery, Geneva University Hospitals and University of Geneva Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
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8
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Raut S, Kundnani VG, Meena MK, Patel JY, Asati S, Patel A. Anthropometric evaluation for surgical feasibility of C1-C2 transarticular screw stabilization in Indian population. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:129-135. [PMID: 34194158 PMCID: PMC8214229 DOI: 10.4103/jcvjs.jcvjs_175_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/18/2021] [Indexed: 11/05/2022] Open
Abstract
Study Design: This study was a radiographic observational study for C1–C2 anthropometry. Purpose: The purpose of the study was to understand the anatomic relationship of C1–C2 in view of transarticular screw (TAS) fixation, to overcome the difficulties related with TAS placement, and to minimize the technique-related complications. Materials and Methods: It was an anthropometric observational study with retrospectively obtained anatomical data of randomly selected 116 patients from a single center. The anatomical measurements such as pars width, pars height, screw trajectory, and length were evaluated on the axial, sagittal, and three-dimensional reconstructed cervical CT scan using the radiant DICOM viewer software by the two fellowship trained spine surgeons which were blind to the study group details. The intra- and interobserver reliability with regard to the measured parameters was statistically analyzed. Results: The mean age of male and female was 28 and 29 years. The average BMI was calculated to be 23.5 and 25 for males and females, respectively. The mean right pars width in males was 5.78 ± 0.93 (range: 3.1–6.5 mm), while in female, it was 5.84 ± 0.95 (range: 3.1–6.5). The mean left pars width in males was 5.95 ± 1.13 (range: 3.8–8.1 mm), while in females, it was 5.70 ± 1.18 (range: 3.7–8.1 mm). Right side mean pars height in males was 5.90 ± 1.2 (range: 3.7–9.4 mm), and in females, it was 6.11 ± 1.04 (range: 3.8–9.3 mm). Left-sided mean pars height in males was 6.0 ± 1.1 (range: 3.2–9.4 mm) as compared to females, in which it was 5.77 ± 1.23 (range: 4.1–9.3 mm). The mean lateral angulation angle in males was 9.99° ± 1.70° (8.1°–15°), while in females, it was 10.15° ± 1.73° (8.1°–15°). The mean sagittal angulation in males was 26.33° ± 3.32° (21.0°–32.80°), while in females, it was 27.18 ± 3.05 (21.0°–32.10°). The average screw length in males was 41.74 ± 5.63 (34–54.8 mm), whereas in females, it was 41.35 ± 4.77 (34–54.8 mm). Conclusion: This study provides a morphometric database which is characteristic of the C1–C2 vertebrae in the normal Indian population with regard to the anatomic feasibility of the TAS fixation for various C1–C2 pathologies. The C2 pars width and height measured in the current study can guide the selection of TAS screws in the Indian population. This study could serve in providing the baseline anatomic parameters assessed in the healthy individuals to design and develop customized screws and related implant assembly which might provide wider clinical applicability.
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Affiliation(s)
- Saijyot Raut
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Vishal G Kundnani
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Mohit Kumar Meena
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Jwalant Y Patel
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Sanjeev Asati
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Ankit Patel
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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9
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Du HG, Phuoc VX, Hoang ND, Dung TT, Van Trung N. Transarticular Screw Fixation in the Treatment of Severe C1-C2 Dislocation: A Case Series Report. Orthop Surg 2020; 12:2031-2040. [PMID: 33185039 PMCID: PMC7767778 DOI: 10.1111/os.12792] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 07/07/2020] [Accepted: 08/04/2020] [Indexed: 01/02/2023] Open
Abstract
Background To aim of the present paper was to evaluate the results of halo traction and transarticular screw fixation combined with bone autoplasty in patients with severe atlantoaxial dislocation. Case presentation This is a retrospective study of severe cases of atlantoaxial dislocation in nine patients (six men and three women) treated with preoperative halo traction and posterior C1–C2 transarticular screw fixation combined with bone autoplasty from June 2006 to June 2011 at the Saint Paul Hospital (Hanoi). The mean age of patients was 37.48 ± 13.753 years (range, 26–50 years). The possibility of fixing dislocation using a halo apparatus was investigated through a series of preoperative halo corrections performed within a span of 1–2 weeks. For transarticular screw fixation, two transarticular screws were used that were positioned according to the Magerl technique. For bone autoplasty, an iliac crest bone graft approximately 3 × 2 cm in size was used. The postoperative assessment of clinical improvement was performed using the neck disability index (NDI), the American Spinal Injury Association (ASIA) impairment scale, and the visual analog scale (VAS) measurement instruments, through the gradation of atlantoaxial dislocation, and via the clivoaxial angle(CAA) index and the space available for cord (SAC) index after 6 months. The image diagnosis demonstrates that all the cases of atlantoaxial dislocations are unstable and correspond to the Fielding and Hawkins type III dislocation. Eight patients underwent complete reduction using the halo fixation device. In one patient, the C1–C2 displacement was manually reduced during surgery. CT scanning revealed that the accuracy of screw placement was 94.4%. The bone fusion rate was 100% after 6 months. Based on the ASIA impairment scale, the preoperative examination of patients revealed grade C injuries in seven patients and grade D injuries in two patients. After surgery, all patients had grade D injuries. Six months after surgery, four patients had moderate self‐reported neck disability (30%–48%) and five patients reported mild disability (10%–28%); that is, the patient perception of the neck problem improved. In the postoperative phase, all patients showed an improvement in VAS pain scores and the SAC score returned to the normal range in all patients. The CAA returned to normal in only seven patients; in the other two patients, the CAA returned to a value that was close to normal (145° and 149°). Conclusion Through halo traction combined with transarticular screw fixation and bone autoplasty, noticeable postoperative improvements were attained based on the clinical scores for NDI, ASIA, and VAS, as well as SAC and CAA.
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Affiliation(s)
- Hoang Gia Du
- Hanoi Medical University, Hanoi, Vietnam.,Department of Orthopedics and Spine, Bachmai University Hospital, Hanoi, Vietnam
| | - Vu Xuan Phuoc
- Hanoi Medical University, Hanoi, Vietnam.,Department of Orthopedics and Spine, Bachmai University Hospital, Hanoi, Vietnam
| | - Nguyen Duc Hoang
- Hanoi Medical University, Hanoi, Vietnam.,Department of Orthopedics and Spine, Bachmai University Hospital, Hanoi, Vietnam
| | - Tran Trung Dung
- Hanoi Medical University, Hanoi, Vietnam.,Saint Paul University Hospital, Hanoi, Vietnam.,Orthopaedic Division, Faculty of Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Nguyen Van Trung
- Hanoi Medical University, Hanoi, Vietnam.,Department of Orthopedics and Spine, Bachmai University Hospital, Hanoi, Vietnam
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10
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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.
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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
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11
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Koffie RM, Larsen AMG, Grannan BL, Hadzipasic M, Yanamadala V, Beaver LV, Shankar GM, Shin JH. Novel Technique for C1-2 Interlaminar Arthrodesis Utilizing a Modified Sonntag Loop-Suture Graft With Posterior C1-2 Fixation. Neurospine 2020; 17:659-665. [PMID: 32054143 PMCID: PMC7538353 DOI: 10.14245/ns.1938344.172] [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: 09/13/2019] [Accepted: 10/18/2019] [Indexed: 11/20/2022] Open
Abstract
Objective Conventional techniques for atlantoaxial fixation and fusion typically pass cables or wires underneath C1 lamina to secure the bone graft between the posterior elements of C1–2, which leads to complications such as cerebrospinal fluid (CSF) leak and neurological injury. With the evolution of fixation hardware, we propose a novel C1–2 fixation technique that avoids the morbidity and complications associated with sublaminar cables and wires.
Methods This technique entails wedging and anchoring a structural iliac crest graft between C1 and C2 for interlaminar arthrodesis and securing it using a 0-Prolene suture at the time of C1 lateral mass and C2 pars interarticularis screw fixation.
Results We identified 32 patients who underwent surgery for atlantoaxial with our technique. A 60% improvement in pain-related disability from preoperative baseline was demonstrated by Neck Disability Index (p<0.001). There were no neurologic deficits. Complications included 2 patients CSF leaks related to presenting trauma, 1 patient with surgical site infection, and 1 patient with transient dysphagia. The rate of radiographic atlantoaxial fusion was 96.8% at 6 months, with no evidence of instrumentation failure, graft dislodgement, or graft related complications.
Conclusion We demonstrate a novel technique for C1–2 arthrodesis that is a safe and effective option for atlantoaxial fusion.
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Affiliation(s)
- Robert M Koffie
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Benjamin L Grannan
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Muhamed Hadzipasic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vijay Yanamadala
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura Van Beaver
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Zhao ZS, Wu GW, Lin J, Zhang YS, Huang YF, Chen ZD, Lin B, Zheng CS. Management of Combined Atlas Fracture with Type II Odontoid Fracture: A Review of 21 Cases. Indian J Orthop 2019; 53:518-524. [PMID: 31303667 PMCID: PMC6590023 DOI: 10.4103/ortho.ijortho_249_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the therapeutic effects of combined atlas fracture with type II (C1-type II) odontoid fractures and to outline a management strategy for it. PATIENTS AND METHODS Twenty three patients with C1-type II odontoid fractures were treated according to our management strategy. Nonoperative external immobilization in the form of cervical collar and halo vest was used in 13 patients with stable atlantoaxial joint. Surgical treatment was early performed in 10 patients whose fractures with traumatic transverse atlantal ligament disruption or atlantoaxial instability. The visual analog scale (VAS), neck disability index (NDI) scale, and American Spinal Injury Association (ASIA) scale at each stage of followup were then collected and compared. RESULTS Compared to pretreatment, the VAS score, NDI score, and ASIA scale were improved among both groups at followup evaluation after treatment. However, in the nonsurgical group, one patient (1/11) developed nonunion which required surgical treatment in later stage and one patient (1/13) with halo vest immobilization had happened pin site infection. Two patients of the surgical group (2/11) had appeared minor complications: occipital cervical pain in one case and cerebrospinal fluid leakage in one case. Two patients (2/23) were excluded from nonsurgical treatment group because their followup period was less than 12 months. Twenty one patients were followed up regularly with an average of 23.9 months (range 15-45 months). CONCLUSIONS We outlined our concluding management principle for the treatment of C1-type II odontoid fractures based on the nature of C1 fracture and atlantoaxial stability. The treatment principle can obtain satisfactory results for the management of C1-type II odontoid fractures.
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Affiliation(s)
- Zhong-Sheng Zhao
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Guang-Wen Wu
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Jie Lin
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Ying-Sheng Zhang
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Yan-Feng Huang
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Zhi-Da Chen
- Department of Orthopedics, The 175th Hospital of PLA, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, Fujian, China
| | - Bin Lin
- Department of Orthopedics, The 175th Hospital of PLA, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, Fujian, China,Address for correspondence: Dr. Chun-Song Zheng, Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, 1 Qiuyang Road, Fuzhou 350122, Fujian, China. E-mail:
Prof. Bin Lin, Department of Orthopedics, the 175th Hospital of PLA, The Affiliated Southeast Hospital of Xiamen University, 269 Zhanghua Road, Zhangzhou 363000, Fujian, China. E-mail:
| | - Chun-Song Zheng
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China,Address for correspondence: Dr. Chun-Song Zheng, Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, 1 Qiuyang Road, Fuzhou 350122, Fujian, China. E-mail:
Prof. Bin Lin, Department of Orthopedics, the 175th Hospital of PLA, The Affiliated Southeast Hospital of Xiamen University, 269 Zhanghua Road, Zhangzhou 363000, Fujian, China. E-mail:
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Potential intraoperative factors of screw-related complications following posterior transarticular C1-C2 fixation: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:400-420. [PMID: 30467736 DOI: 10.1007/s00586-018-5830-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 11/11/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE This study aimed to evaluate the impact of several factors, including patients' intraoperative position, intraoperative visualization technique, fixation method, and type of screws and their parameters, on the frequency of intraoperative screw-associated complications in posterior transarticular C1-C2 fixation. METHODS A systematic review of the PubMed database between January 1986 and March 2018 was performed. The key inclusion criteria comprised detailed descriptions of the surgical technique and post-operative screw-associated complications. RESULTS The initial search resulted in 1041 abstracts, and a total of 54 abstracts were included in the present study. The overall number of operated patients was 2306. In this group, 4439 screws were inserted. The rate of screw-associated complications during the different time periods was estimated upon meta-analysis. Statistical analysis of the screw malposition rate, vertebral artery injury rate, screw breakage rate based on patients' intraoperative position, intraoperative visualization technique, fixation method, and type of implants and their parameters was also performed. CONCLUSIONS The factors that help reduce the rate of screw-associated complications include the intraoperative application of biplanar fluoroscopy or neuronavigation system, the use of 4 mm or thicker lag screws, and screw insertion through contraincisions using cannulated ported instruments. On the other hand, the potential risk factors of screw-associated complications include inadequate intraoperative head fixation using skeletal traction, uniplanar fluoroscopy-guided screw insertion, screw insertion using the posterior midline approach, and the use of 3.5 mm or thinner full-threaded screws. These slides can be retrieved under Electronic Supplementary Material.
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Herzog JP, Zarkadis NJ, Prabhakar G, Kusnezov NA. Biomechanical comparison of a novel C1 posterior U-construct with four other techniques in a C1-C2 fixation model. J Orthop 2018; 15:741-745. [PMID: 29881231 DOI: 10.1016/j.jor.2018.05.010] [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: 02/18/2018] [Accepted: 05/06/2018] [Indexed: 11/16/2022] Open
Abstract
Background Compare the biomechanical stability of a novel "U" posterior cervical fixation construct to four other posterior cervical atlantoaxial fixation constructs. Methods Eight fresh frozen human cadaver spines were tested after a simulated odontoid fracture, and following stabilization with each construct. Results All constructs significantly decreased flexion-extension and axial rotation compared to the destabilized spine. The U construct provided significantly more axial stability than the Brooks wire technique. Conclusion The novel U construct demonstrated comparable biomechanical stability to the existing constructs in all three planes of motion with the exception of axial rotation, in which it was inferior to TAS.
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Affiliation(s)
- Joshua P Herzog
- Orthopaedic Spine Center, Massachusetts General Hospital, Boston, MA, United States
| | - Nicholas J Zarkadis
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, United States
| | - Gautham Prabhakar
- Paul L. Foster School of Medicine at Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Nicholas A Kusnezov
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, United States
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Evaluation of vertebral artery anomaly in basilar invagination and prevention of vascular injury during surgical intervention: CTA features and analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1286-1294. [DOI: 10.1007/s00586-017-5445-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/09/2017] [Accepted: 12/21/2017] [Indexed: 10/18/2022]
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Ghostine SS, Kaloostian PE, Ordookhanian C, Kaloostian S, Zarrini P, Kim T, Scibelli S, Clark-Schoeb SJ, Samudrala S, Lauryssen C, Gill AS, Johnson PJ. Improving C1-C2 Complex Fusion Rates: An Alternate Approach. Cureus 2017; 9:e1887. [PMID: 29392099 PMCID: PMC5788400 DOI: 10.7759/cureus.1887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The surgical repair of atlantoaxial instabilities (AAI) presents complex and unique challenges, originating from abnormalities and/or trauma within the junction regions of the C1-C2 atlas-axis, to surgeons. When this region is destabilized, surgical fusion becomes of key importance in order to prevent spinal cord injury. Several techniques can be utilized to provide for the adequate fusion of the atlantoaxial construct. Nevertheless, many individuals have less than ideal rates of fusion, below 35%-40%, which also involves the C2 nerve root being sacrificed. This suboptimal and unavoidable iatrogenic complication results in the elevated probability of complications typically composed of vertebral artery injury. This review is a retrospective analysis of 87 patients from Cedars Sinai Medical Center in Los Angeles, California, who had the C1-C2 surgical fusion procedure performed within the time frame from 2001 to 2008, with a mean follow-up period of three years. These patients had presented with typical AAI symptoms of fatigability, limited mobility, and clumsiness. Diagnosis of C1-C2 instability was documented via radiographic studies, typically utilizing computed tomography (CT) scans or x-rays. All patients had bilateral C1 lateral masses and C2 pedicle screws. In addition, the C1-C2 joint was accessed by retracting the C2 nerve root superiorly and exposing the joint by utilizing a high-speed burr. The cavity that is developed within the joint is packed with local autologous bone from the cephalad resection of the C2 laminae. Fusion of the C1-C2 joint was achieved in all patients and a final follow-up was conducted approximately three years postoperative. Of the 87 patients, two presented with occipital headaches resulting from the C1 screws impinging on the C2 nerve root. The issue was rectified by removing instrumentation in both patients after documenting complete fusion via radiographic studies, with complete resolution of symptoms. No vertebral artery or spinal cord injuries were reported as a result of the minor complication. Overall, we aim to describe a safe and reliable alternative technique to fuse C1-C2 instability by focusing on intra-articular arthrodesis complementing instrumentation fixation. This methodology is advantageous from a biomechanical standpoint secondary to axial loading, as well as the large surface area available for arthrodesis. Additionally, this technique does not involve the resection of the C2 nerve root, resulting in low risk for vertebral artery or spinal cord injury.
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Affiliation(s)
- Samer S Ghostine
- Neurological Surgery, University of California, Riverside School of Medicine
| | - Paul E Kaloostian
- Neurological Surgery, University of California, Riverside School of Medicine
| | - Christ Ordookhanian
- Neurological Surgery, University of California, Riverside School of Medicine
| | - Sean Kaloostian
- Neurological Surgery, University of California, Irvine School of Medicine
| | | | | | | | | | | | - Carl Lauryssen
- Neurological Surgery, St. David's Round Rock Medical Center
| | - Amandip S Gill
- Neurological Surgery, University of California, Riverside School of Medicine
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Matsumoto Y, Mizutani J, Suzuki N, Otsuka S, Hayakawa K, Fukuoka M, Wada I. Temporary Internal Fixation Using C1 Lateral Mass Screw and C2 Pedicle Screw (Goel-Harms Technique) without Bone Grafting for Chronic Atlantoaxial Rotatory Fixation. World Neurosurg 2017; 102:696.e1-696.e6. [PMID: 28377256 DOI: 10.1016/j.wneu.2017.03.118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 03/24/2017] [Accepted: 03/25/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The primary treatment strategy for chronic atlantoaxial rotatory fixation (chro-AARF) is traction followed by bracing or application of a halo device. However, to complete these conservative therapies, patient cooperation is mandatory. If conservative therapy fails, surgery is required for reduction and prevention of recurrence. It has been considered that surgery for atlantoaxial rotatory fixation necessitates solid bony fusion. However, once bony fusion is achieved, loss of range of motion is problematic. Here, we report a patient with chro-AARF who was successfully treated with temporary internal fixation using a C1 lateral mass screw and C2 pedicle screw (Goel-Harms technique) without any grafting of bone or use of bone substitute materials. CASE DESCRIPTION A 9-year-old boy with chro-AARF was referred to our institution. He had a history of pervasive developmental disorders. He did not cooperate for the completion of conservative therapy and could not tolerate this therapy. Therefore, the orthopedic staff and his parents considered surgery. Under general anesthesia, reduction was easily performed. The Goel-Harms screw-rod construct was completed as a temporary internal fixator without any grafting of bone or use of bone substitute materials. After 6 months, the screw-rod construct was removed. Removal of the screw-rod construct was performed easily without complication. There was no ankylosis of the C1-2 joint, and cervical range of motion was maintained 2.8 years after removal of the construct. CONCLUSIONS When conservative therapy cannot be continued, Goel-Harms surgery as a temporary internal fixator without bone grafting might be a suitable alternative for selected patients with chro-AARF.
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Affiliation(s)
- Yoshihisa Matsumoto
- Department of Orthopaedic Surgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Jun Mizutani
- Department of Rehabilitation Medicine, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan.
| | - Nobuyuki Suzuki
- Department of Orthopaedic Surgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Seiji Otsuka
- Department of Orthopaedic Surgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazuo Hayakawa
- Department of Orthopaedic Surgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Muneyoshi Fukuoka
- Department of Orthopaedic Surgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Ikuo Wada
- Department of Rehabilitation Medicine, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
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Archavlis E, Serrano L, Schwandt E, Nimer A, Molina-Fuentes MF, Rahim T, Ackermann M, Gutenberg A, Kantelhardt SR, Giese A. A novel minimally invasive, dorsolateral, tubular partial odontoidectomy and autologous bone augmentation to treat dens pseudarthrosis: cadaveric, 3D virtual simulation study and technical report. J Neurosurg Spine 2017; 26:190-198. [DOI: 10.3171/2016.7.spine16244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The goal of this study was to demonstrate the clinical and technical nuances of a minimally invasive, dorsolateral, tubular approach for partial odontoidectomy, autologous bone augmentation, and temporary C1–2 fixation to treat dens pseudarthrosis.
METHODS
A cadaveric feasibility study, a 3D virtual reality reconstruction study, and the subsequent application of this approach in 2 clinical cases are reported. Eight procedures were completed in 4 human cadavers. A minimally invasive, dorsolateral, tubular approach for odontoidectomy was performed with the aid of a tubular retraction system, using a posterolateral incision and an oblique approach angle. Fluoroscopy and postprocedural CT, using 3D volumetric averaging software, were used to evaluate the degree of bone removal of C1–2 lateral masses and the C-2 pars interarticularis. Two clinical cases were treated using the approach: a 23-year-old patient with an odontoid fracture and pseudarthrosis, and a 35-year-old patient with a history of failed conservative treatment for odontoid fracture.
RESULTS
At 8 cadaveric levels, the mean volumetric bone removal of the C1–2 lateral masses on 1 side was 3% ± 1%, and the mean resection of the pars interarticularis on 1 side was 2% ± 1%. The median angulation of the trajectory was 50°, and the median distance from the midline of the incision entry point on the skin surface was 67 mm. The authors measured the diameter of the working channel in relation to head positioning and assessed a greater working corridor of 12 ± 4 mm in 20° inclination, 15° contralateral rotation, and 5° lateral flexion to the contralateral side. There were no violations of the dura. The reliability of C-2 pedicle screws and C-1 lateral mass screws was 94% (15 of 16 screws) with a single lateral breach. The patients treated experienced excellent clinical outcomes.
CONCLUSIONS
A minimally invasive, dorsolateral, tubular odontoidectomy and autologous bone augmentation combined with C1–2 instrumentation has the ability to provide excellent 1-stage management of an odontoid pseudarthrosis. The procedure can be completed safely and successfully with minimal blood loss and little associated morbidity. This approach has the potential to provide not only a less invasive approach but also a function-preserving option to treat complex C1–2 anterior disease.
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Affiliation(s)
| | | | | | | | | | | | - Maximilian Ackermann
- 4Institute of Anatomy, University Medical Center, Johannes Gutenberg-University Mainz
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Alan N, Cohen JA, Zhou J, Pease M, Kanter AS, Okonkwo DO, Hamilton DK. Top 50 most-cited articles on craniovertebral junction surgery. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:22-32. [PMID: 28250633 PMCID: PMC5324355 DOI: 10.4103/0974-8237.199883] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Craniovertebral junction is a complex anatomical location posing unique challenges to the surgical management of its pathologies. We aimed to identify the fifty most-cited articles that are dedicated to this field. Methods: A keyword search using the Thomson Reuters Web of Knowledge was conducted to identify articles relevant to the field of craniovertebral junction surgery. The articles were reviewed based on title, abstract, and methods, if necessary, and then ranked based on the total number of citations to identify the fifty most-cited articles. Characteristics of the articles were determined and analyzed. Results: The earliest top-cited article was published in 1948. When stratified by decade, 1990s was the most productive with 16 articles. The most-cited article was by Anderson and Dalonzo on a classification of odontoid fractures. By citation rate, the most-cited article was by Herms and Melcher who described Goel's technique of atlantoaxial fixation using C1 lateral mass screws and C2 pedicle screws with rod fixation. Atlantoaxial fixation was the most common topic. The United States, Barrow Neurological Institute, and VH Sonntag were the most represented country, institute, and author, respectively. The significant majority of articles were designed as case series providing level IV evidence. Conclusion: Using citation analysis, we have provided a list of the most-cited articles representing important contributions of various authors from many institutions across the world to the field of craniovertebral junction surgery.
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Affiliation(s)
- Nima Alan
- Department of Neursurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Jonathan Andrew Cohen
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - James Zhou
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Matthew Pease
- Department of Neursurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Adam S Kanter
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - David Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
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Ha MJ, Kim BC, Huh CW, Lee JI, Cho WH, Choi HJ. The Impact of Engorged Vein within Traumatic Posterior Neck Muscle Identified in Preoperative Computed Tomography Angiography to Estimated Blood Loss during Posterior Upper Cervical Spine Surgery. Korean J Neurotrauma 2016; 12:135-139. [PMID: 27857922 PMCID: PMC5110903 DOI: 10.13004/kjnt.2016.12.2.135] [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: 08/09/2016] [Revised: 09/13/2016] [Accepted: 09/20/2016] [Indexed: 11/23/2022] Open
Abstract
Objective Injuries of upper cervical spine are potentially fatal. Thus, appropriate diagnosis and treatment is essential. In our institute, preoperative computed tomography angiography (CTA) has been performed for evaluation of injuries of bony and vascular structure. The authors confirmed the engorged venous plexus within injured posterior neck muscle. We have this research to clarify the relationship between the engorged venous plexus and engorged vein. Methods A retrospective review identified 23 adult patients who underwent 23 posterior cervical spine surgeries for treatment of upper cervical injury between 2013 and 2015. Preoperative CTA was used to identify of venous engorgement within posterior neck muscle. The male to female ratio was 18:5 and the mean age was 53.5 years (range, 25-78 years). Presence of venous engorgement and estimated blood loss (EBL) were analyzed retrospectively. Results The EBL of group with venous engorgement was 454.55 mL. The EBL of group without venous engorgement was 291.67 mL. The EBL of group with venous engorgement was larger than control group in significant. Conclusion The presence of engorged venous plexus is important factor of intraoperative bleeding. Preoperative CTA for identifying of presence of engorged venous plexus and fine operative techniques is important to decrease of blood loss during posterior cervical spine surgery.
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Affiliation(s)
- Mahn Jeong Ha
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung Chul Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Chae Wook Huh
- Department of Neuroradiology, Pusan National University Hospital, Busan, Korea
| | - Jae Il Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Won Ho Cho
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hyuk Jin Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Zhang Z, Wang H, Liu C. Acute Traumatic Cervical Cord Injury in Pediatric Patients with os Odontoideum: A Series of 6 Patients. World Neurosurg 2014; 83:1180.e1-6. [PMID: 25535071 DOI: 10.1016/j.wneu.2014.12.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 12/15/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Os odontoideum can lead to instability of the atlantoaxial joint and places the spinal cord at significant risk for acute traumatic catastrophic events or chronic neurologic change. The purpose of this study was to retrospectively review acute cervical cord injury after minor trauma in 6 pediatric patients with os odontoideum. METHODS Between 2012 and 2013, 6 pediatric patients with os odontoideum who suffered acute traumatic cervical cord injury were reviewed retrospectively. Their clinical history, neurologic symptoms, radiological investigations, follow-up period, American Spinal Injury Association (ASIA) impairment classification, and motor score were reviewed. RESULTS There were 2 male and 4 female subjects ranging in age from 4 to 18 years (mean 11.8 years). Before the traumatic injury, 2 cases were asymptomatic and 4 complained of myelopathic feature with unsteadiness on feet. Falls were the most common injury (n = 5), followed by a minor motor vehicle accident (n = 1). Atlantoaxial instability and cord compression were presented in all cases with dynamic cervical lateral radiographs and magnetic resonance imaging. Most patients presented with spinal cord thinning and hyperintensity on T2-weighted sequences in magnetic resonance imaging. Spinal cord compression was anterior in 2 cases and both anterior and posterior in 4. Two patients was classified as ASIA B, 1 as ASIA C, and 3 as ASIA D category on admission. Two patients presented with respiratory failure with mechanical ventilation for over 2 weeks in perioperative period. Postoperatively, all patients improved neurologically and clinically after underwent posterior atlantoaxial fixation and fusion. CONCLUSIONS Pediatric patients with asymptomatic or myelopathic atlantoaxial instability secondary to os odontoideum are at risk for acute spinal cord injury even after minor traumatic injury. Sufficient fixation and fusion should be undertaken as prophylactic treatment of developing myelopathy and to improve neurologic symptoms with acute traumatic cervical cord injury in pediatric patients with os odontoideum.
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Affiliation(s)
- Zhengfeng Zhang
- Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University, Chongqing, China.
| | - Honggang Wang
- Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Chao Liu
- Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
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Wang L, Liu C, Zhao Q, Tian J. Posterior pedicle screw fixation for complex atlantoaxial fractures with atlanto-dental interval of ≥ 5 mm or C2-C3 angulation of ≥ 11°. J Orthop Surg Res 2014; 9:104. [PMID: 25407360 PMCID: PMC4245791 DOI: 10.1186/s13018-014-0104-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 10/17/2014] [Indexed: 11/18/2022] Open
Abstract
Objective Previous studies have demonstrated that the posterior pedicle screw fixation is an effective and safe method to treat atlantoaxial fractures. However, no report focuses on only the complex atlantoaxial fractures with atlanto-dental interval (ADI) of ≥5 mm or C2-C3 angulation of ≥11°. Methods This study was to retrospectively evaluate the outcome of 15 patients (six females and nine males; age, 27–55 years) who underwent posterior pedicle screw fixation for the above complex atlantoaxial fractures between July 2006 and March 2011. Fracture combinations included three Jefferson-type II odontoid, four anterior ring-type II odontoid, two posterior ring-type II odontoid, one lateral mass-type II odontoid, one Jefferson-hangman’s fracture, three anterior ring-hangman’s fracture, and one lateral mass-hangman’s fracture. Fracture healing and bone fusion were determined on X-ray scan. Upper limbs, lower limbs, and sphincter functions were assessed using the Japanese Orthopaedic Association (JOA) score. The Frankel grading system was used to determine the neurological situation. Results The mean operative time, blood loss, and hospital stays were 108.9 ± 25.8 min, 508.0 ± 209.6 ml, and 13.3 ± 2.0 days. Fracture healing and graft fusion were obtained in all patients within 9 months. The ADI or C2-C3 angulation was reduced to ≤5 mm or ≤11°. The JOA score was significantly improved from 7.27 ± 1.10 preoperatively to 15.7 ± 2.1 postoperatively (P <0.001), with 88.1 ± 18.3% recovery rate and 93.3% excellent and good rate. The neurological situation was improved in all patients by at least 1 grade in the Frankel scale. After a mean of 36.5 months of follow-up (range, 18 to 58 months), no operative complications (spinal cord injury, vertebral artery injury, or cerebrospinal fluid leakage) were observed. Conclusion Posterior pedicle screw fixation is a reliable, effective, and minimally invasive procedure for patients suffering from complex atlantoaxial fractures.
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Affiliation(s)
- Lei Wang
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People's Hospital, 100 Haining Road, Shanghai, 200080, China.
| | - Chao Liu
- Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Qinghua Zhao
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People's Hospital, 100 Haining Road, Shanghai, 200080, China.
| | - Jiwei Tian
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People's Hospital, 100 Haining Road, Shanghai, 200080, China.
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Vertebral artery variations and osseous anomaly at the C1-2 level diagnosed by 3D CT angiography in normal subjects. Neuroradiology 2014; 56:843-9. [DOI: 10.1007/s00234-014-1399-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 06/24/2014] [Indexed: 10/25/2022]
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Bourdillon P, Perrin G, Lucas F, Debarge R, Barrey C. C1-C2 stabilization by Harms arthrodesis: indications, technique, complications and outcomes in a prospective 26-case series. Orthop Traumatol Surg Res 2014; 100:221-7. [PMID: 24629457 DOI: 10.1016/j.otsr.2013.09.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 07/23/2013] [Accepted: 09/27/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION C1-C2 arthrodesis is a surgical challenge due to the proximity of neurovascular structures (vertebral arteries and spinal cord) and the wide range of motion of the joint, hampering bone fusion. A variety of techniques have been successively recommended to reduce anatomic risk and improve results in terms of biomechanical stability and fusion rates. Recently, Harms described a new technique using polyaxial screws in the C1 lateral masses and C2 pedicles. MATERIAL AND METHOD The present study reports our experience in a consecutive series of 26 patients operated on by C1-C2 arthrodesis using the Goel and Harms technique, and details technical aspects step by step. Routine systematic immediate postoperative CT and 6-month CT controlled screw positioning and assessed fusion. Follow-up was at least 1 year, except in 2 cases (10 months). RESULTS Twenty-six patients with a mean age of 57 years were included. Indications comprised: C2 non-union (n=11), C1-C2 fracture and/or dislocation (n=11), inflammatory pathology (n=2) and tumoral pathology (n=2). The results showed the technique to be reliable (no neurovascular complications and 85% of screws with perfect positioning) and an excellent rate of fusion (100% at 6 months). CONCLUSION Anatomic and biomechanical considerations, combined with the present clinical and radiological outcomes, indicate that Goel and Harms fusion is to be considered the first-line attitude of choice for posterior C1-C2 arthrodesis. LEVEL OF EVIDENCE Level IV prospective study.
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Affiliation(s)
- P Bourdillon
- Service de Neurochirurgie C et Chirurgie du Rachis, Hôpital Pierre-Wertheimer, GHE, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, 59, boulevard Pinel, 69500 Bron, France
| | - G Perrin
- Service de Neurochirurgie C et Chirurgie du Rachis, Hôpital Pierre-Wertheimer, GHE, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, 59, boulevard Pinel, 69500 Bron, France.
| | - F Lucas
- Service de Neurochirurgie C et Chirurgie du Rachis, Hôpital Pierre-Wertheimer, GHE, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, 59, boulevard Pinel, 69500 Bron, France
| | - R Debarge
- Service de Neurochirurgie C et Chirurgie du Rachis, Hôpital Pierre-Wertheimer, GHE, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, 59, boulevard Pinel, 69500 Bron, France
| | - C Barrey
- Service de Neurochirurgie C et Chirurgie du Rachis, Hôpital Pierre-Wertheimer, GHE, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, 59, boulevard Pinel, 69500 Bron, France; Laboratoire de Biomécanique, Art et Métiers Paristech, ESNAM, 151, boulevard de l'Hôpital, 75013 Paris, France
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Mick TJ. Congenital Diseases. Clin Imaging 2014. [DOI: 10.1016/b978-0-323-08495-6.00008-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Cai XH, Liu ZC, Yu Y, Zhang MC, Huang WB. Evaluation of biomechanical properties of anterior atlantoaxial transarticular locking plate system using three-dimensional finite element analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:2686-94. [PMID: 23821221 DOI: 10.1007/s00586-013-2887-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 06/21/2013] [Accepted: 06/25/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate a new anterior atlantoaxial transarticular locking plate system using finite element analysis. METHODS Thin-section spiral computed tomography was performed from occiput to C2 region. A finite element model of an unstable atlantoaxial joint, treated with an anterior atlantoaxial transarticular locking plate system, was compared with the simple anterior atlantoaxial transarticular screw system. Flexion, extension, lateral bending, and axial rotation were imposed on the model. Displacement of the atlantoaxial transarticular screw and stress at the screw-bone interface were observed for the two internal fixation systems. RESULTS Screw displacement was less using the anterior atlantoaxial transarticular locking plate system compared to simple anterior atlantoaxial transarticular screw fixation under various conditions, and stability increased especially during flexion and extension. CONCLUSIONS The anterior atlantoaxial transarticular locking plate system not only provided stronger fixation, but also decreased screw-bearing stress and screw-bone interface stress compared to simple anterior atlantoaxial transarticular screw fixation.
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Affiliation(s)
- Xian-hua Cai
- Department of Orthopedics, Wuhan General Hospital of Guangzhou Command, 627 Wuluo Road, Wuhan, 430070, China,
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Abstract
BACKGROUND Rotatory atlantoaxial subluxation (RAS) is a rare condition that is often misdiagnosed and therefore incorrectly managed. We describe our experience and propose an algorithm for treating neglected RAS nonoperatively. METHODS All consecutive children with neglected (>6 wk) RAS were treated in our department between 2005 and 2010 by cervical traction using a Gleason traction device and nonsteroidal anti-inflammatory drugs and muscle relaxants. When reduction was not achieved, the Gleason device was replaced by a halo device without manipulative reduction, and weight was added as necessary until reduction was successful. Fixation of reduction was either by a sternooccipital mandibular immobilizer or a halo vest for 3 to 4 months. RESULTS All 5 children (4 boys and 1 girl, aged 4 to 11 y) were successfully treated for neglected RAS. The mean duration from symptom onset (eg, limited neck range of motion, discomfort) to treatment initiation was 11.6 weeks (range, 6 to 16 wk). Closed reduction was achieved by a Gleason or a noninvasive halo device within 1 to 2 weeks in 4 cases. The fifth case was reduced after 5 weeks of traction using a halo with a 5 kg weight. All children had symmetrical full range of motion, normal neurological examination, and were fully engaged in educational and sports activities without recurrent dislocations at final follow-up (mean, 30 mo; range, 18 to 49 mo). CONCLUSIONS Conservative treatment by gradual and prolonged traction without manipulative reduction in neglected RAS might be a successful method. Reduction can often be achieved within 2 weeks of treatment onset. LEVEL OF EVIDENCE Level IV (retrospective case series).
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Minimally invasive anterior transarticular screw fixation and microendoscopic bone graft 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 2013; 21:1568-74. [PMID: 22315033 DOI: 10.1007/s00586-012-2153-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 01/03/2012] [Accepted: 01/08/2012] [Indexed: 10/14/2022]
Abstract
PURPOSE Even though transarticular screw (TAS) fixation has been commonly used for posterior C1-C2 arthrodesis in both traumatic and non-traumatic lesions, anterior TAS fixation C1-2 is a less invasive technique as compared with posterior TAS which produces significant soft tissue injury, and there were few reports on percutaneous anterior TAS fixation and microendoscopic bone graft for atlantoaxial instability. The goals of our study were to describe and evaluate a new technique for anterior TAS fixation of the atlantoaxial joints for traumatic atlantoaxial instability by analyzing radiographic and clinical outcomes. METHODS This was a retrospective study of seven consecutive patients with C1-C2 instability due to upper cervical injury treated by a minimally invasive procedure from May 2007 to August 2009. Bilateral anterior TAS were inserted by the percutaneous approach under Iso-C3D fluoroscopic control. The atlantoaxial joint space was prepared for morselized autogenous bone graft under microendoscopy. The data for analysis included time after the injuries, operating time, intraoperative blood loss, X-ray exposure time, clinical results, and complications. Radiographic evaluation included the assessment of atlantoaxial fusion rate and placement of TAS. Bone fusion of the atlantoaxial joints was assessed by flexion extension lateral radiographs and 1-mm thin-slice computed tomography images as radiographic results. Clinical assessment was done by analyzing the recovery state of clinical presentation from the preoperative period to the last follow-up and by evaluating complications. RESULTS A total of 14 screws were placed correctly. The atlantoaxial solid fusion without screw failure was confirmed by CT scan in seven cases after a mean follow-up of 27.5 months (range 18-45 months). All patients with associated clinical presentation made a recovery without neurologic sequelae. Postoperative dysphagia occurred and disappeared in two cases within 5 days after surgery. There were no other complications during the follow-up period. CONCLUSIONS Percutaneous anterior TAS fixation and microendoscopic bone graft could be an option for achieving C1-C2 stabilization with several potential advantages such as less tissue trauma and better accuracy. Bilateral TAS fixation and morselized autograft affords effective fixation and solid fusion by a minimally invasive approach.
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Vergara P, Bal JS, Hickman Casey AT, Crockard HA, Choi D. C1-C2 posterior fixation: are 4 screws better than 2? Neurosurgery 2012; 71:86-95. [PMID: 22113242 DOI: 10.1227/neu.0b013e318243180a] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Several types of C1-C2 fixation techniques have been described over the years in order to treat atlantoaxial instability. OBJECTIVE To compare the pros and cons of the most popular C1-C2 posterior fixation used today: C1 lateral mass-C2 pedicle screw and rods (Harms) and transarticular screw (Magerl) fixations. METHODS Retrospective review of 122 patients who underwent Harms or Magerl fixation for atlantoaxial instability. Surgical, clinical, and radiological outcomes were compared in the 2 groups. RESULTS 123 operations were performed, of which 47 were by the Harms technique (group H) and 76 by the Magerl technique (group M). No significant differences were found in duration of surgery, blood loss, postoperative pain, and length of hospitalization. Postoperatively, neck pain, C2-radiculopathy, and hand function improved in both groups, with better, but not statistically significant, results for group H. The intraoperative complication rate was 2.1% in group H and 21% in group M (P < .05); postoperative complication rate was 10.6% in group H and 21% in group M (P > .05). The major complications were vertebral artery injury (2.1% in group H, 13.1% in group M, P = .05) and screw fracture (2.1% in group H, 9.2% in group M, P > .05). Fusion rate at the end of follow-up was not significantly higher in group H. C1-C2 range of movements in flexion/extension at the end of follow-up was lower in group H (P = .017). CONCLUSION Magerl with posterior wiring and Harms techniques are both effective options for stabilizing the atlantoaxial complex. However, the Harms technique appears to be safer, to have fewer complications, and to demonstrate a more robust long-term fixation.
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Affiliation(s)
- Pierluigi Vergara
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom.
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Werle S, Ezzati A, ElSaghir H, Boehm H. Is inclusion of the occiput necessary in fusion for C1-2 instability in rheumatoid arthritis? J Neurosurg Spine 2012; 18:50-6. [PMID: 23157277 DOI: 10.3171/2012.10.spine12710] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The atlantoaxial joint is the location most and earliest affected in patients with rheumatoid arthritis (RA). In longstanding disease, ligamentous and osseous destruction can progress and involve all cervical segments. If surgical intervention is necessary, some prefer, to be safe, undertaking fusion to the occiput, whereas others advocate 1-level fusion of C1-2. Sparing the occiput (Oc)-C1 segment would allow retention of a considerable amount of physiological range of motion and seems beneficial against subaxial overload. Previous clinical studies on this topic have provided only nonspecific data after short-term follow-up, rendering a segment-sparing approach questionable. The purpose of the present investigation was to assess long-term progression of inflammatory or degenerative destruction in the Oc-C1 segment after isolated C1-2 fusion for RA. METHODS In a series of 113 consecutive patients with RA-related destruction restricted to the craniocervical junction, 14 individuals underwent Oc-C2 fusion and 99 underwent surgery exclusively at the C1-2 level. After a mean follow-up period of 9.4 years (range 4.9-14.7 years), 46 patients were available for clinical and radiographic examination, including CT imaging. RESULTS None of the 46 patients needed additional surgery to extend the fusion to the occiput. Despite marked deterioration in the subaxial cervical spine, in general there were little or no changes in the atlantooccipital region. All but one patient presented with bony fusion of the fixed C1-2 level at follow-up. CONCLUSIONS The results of this investigation suggest that if the Oc-C1 joint is free of osseous destructions on conventional radiographs and free of abnormalities on MRI scans at the time of surgery (for transarticular fixation and fusion of C1-2), there is a very low risk for relevant destruction in the following 5-14 years. Thus, no prophylactic oligosegmental approach, but rather a segment-sparing monosegmental approach, is preferred, even in patients with high inflammatory levels.
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Affiliation(s)
- Stephan Werle
- Department of Spinal Surgery and Paraplegiology, Zentralklinik Bad Berka, Bad Berka, Germany.
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Kim DG, Eun JP, Park JS. Posterior cervical fixation with a nitinol shape memory loop for primary surgical stabilization of atlantoaxial instability: a preliminary report. J Korean Neurosurg Soc 2012; 52:21-6. [PMID: 22993673 PMCID: PMC3440498 DOI: 10.3340/jkns.2012.52.1.21] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 04/24/2012] [Accepted: 07/06/2012] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate a new posterior atlantoaxial fixation technique using a nitinol shape memory loop as a simple method that avoids the risk of vertebral artery or nerve injury. Methods We retrospectively evaluated 14 patients with atlantoaxial instability who had undergone posterior C1-2 fusion using a nitinol shape memory loop. The success of fusion was determined clinically and radiologically. We reviewed patients' neurologic outcomes, neck disability index (NDI), solid bone fusion on cervical spine films, changes in posterior atlantodental interval (PADI), and surgical complications. Results Solid bone fusion was documented radiologically in all cases, and PADI increased after surgery (p<0.05). All patients remained neurologically intact and showed improvement in NDI score (p<0.05). There were no surgical complications such as neural tissue or vertebral artery injury or instrument failure in the follow-up period. Conclusion Posterior C1-2 fixation with a nitinol shape memory loop is a simple, less technically demanding method compared to the conventional technique and may avoid the instrument-related complications of posterior C1-2 screw and rod fixation. We introduce this technique as one of the treatment options for atlantoaxial instability.
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Affiliation(s)
- Duk-Gyu Kim
- Department of Neurosurgery, Research Institute of Clinical Medicine, Institute for Medical Sciences, Chonbuk National University Medical School and Hospital, Jeonju, Korea
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Reis MT, Nottmeier EW, Reyes PM, Baek S, Crawford NR. Biomechanical analysis of a novel hook-screw technique for C1–2 stabilization. J Neurosurg Spine 2012; 17:220-6. [DOI: 10.3171/2012.5.spine1242] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Food and Drug Administration has not cleared the following medical devices for the use described in this study. The following medical devices are being discussed for an off-label use: cervical lateral mass screws.
Object
As an alternative for cases in which the anatomy and spatial relationship between C-2 and a vertebral artery precludes insertion of C-2 pedicle/pars or C1–2 transarticular screws, a technique that includes opposing laminar hooks (claw) at C-2 combined with C-1 lateral mass screws may be used. The biomechanical stability of this alternate technique was compared with that of a standard screw-rod technique in vitro.
Methods
Flexibility tests were performed in 7 specimens (occiput to C-3) in the following 6 different conditions: 1) intact; 2) after creating instability and attaching a posterior cable/graft at C1–2; 3) after removing the graft and attaching a construct comprising C-1 lateral mass screws and C-2 laminar claws; 4) after reattaching the posterior cable-graft at C1–2 (posterior hardware still in place); 5) after removing the posterior cable-graft and laminar hooks and placing C-2 pedicle screws interconnected to C-1 lateral mass screws via rod; and 6) after reattaching the posterior cable-graft at C1–2 (screw-rod construct still in place).
Results
All types of stabilization significantly reduced the range of motion, lax zone, and stiff zone compared with the intact condition. There was no significant biomechanical difference in terms of range of motion or lax zone between the screw-rod construct and the screw-claw-rod construct in any direction of loading.
Conclusions
The screw-claw-rod technique restricts motion much like the standard Harms technique, making it an acceptable alternative technique when aberrant arterial anatomy precludes the placement of C-2 pars/pedicle screws or C1–2 transarticular screws.
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Affiliation(s)
- Marco Túlio Reis
- 1Spinal Biomechanics Laboratory, Department of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | | | - Phillip M. Reyes
- 1Spinal Biomechanics Laboratory, Department of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Seungwon Baek
- 1Spinal Biomechanics Laboratory, Department of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Neil R. Crawford
- 1Spinal Biomechanics Laboratory, Department of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Elliott RE, Tanweer O, Boah A, Morsi A, Ma T, Frempong-Boadu A, Smith ML. Is external cervical orthotic bracing necessary after posterior atlantoaxial fusion with modern instrumentation: meta-analysis and review of literature. World Neurosurg 2012; 79:369-74.e1-12. [PMID: 22484066 DOI: 10.1016/j.wneu.2012.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 12/10/2011] [Accepted: 03/29/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND No guidelines exist regarding external cervical orthoses (ECO) after atlantoaxial fusion. We reviewed published series describing C1-2 posterior instrumented fusions with screw-rod constructs (SRC) or transarticular screws (TAS) and compared rates of fusion with and without postoperative ECO. METHODS Online databases were searched for English-language articles between 1986 and April 2011 describing ECO use after posterior atlantoaxial instrumentation with SRC or TAS. Eighteen studies describing 947 patients who had SRC (± ECO: 254 of 693 patients), and 33 studies describing 1424 patients with TAS (± ECO: 525 of 899 patients) met inclusion criteria. Meta-analysis techniques were applied to estimate rates of fusion with and without ECO use. RESULTS All studies provided class III evidence, and no studies directly compared outcomes with or without ECO use. There was no significant difference in the proportion of patients who achieved successful fusion between patients treated with ECO and without ECO for SRC or TAS patients. Point estimates and 95% confidence intervals (CI) for rates of fusion ± ECO were 97.4% (CI: 95.2% to 98.6%) versus 97.9% (CI: 93.6% to 99.3%) for SRC and 93.6% (CI: 90.7% to 95.6%) versus 95.3% (CI: 90.8% to 97.7%) for TAS. There was no correlation between duration of ECO treatment and fusion (dose effect). CONCLUSIONS After C1-2 fusion with modern instrumentation, ECO may be unnecessary (class III). Some centers recommend ECO use with patients with softer bone quality (class IV). Prospective, randomized studies with validated radiographic and clinical outcome metrics are necessary to determine the utility of ECO after C1-2 fusion and its impact on patient comfort and cost.
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Elliott RE, Tanweer O, Boah A, Morsi A, Ma T, Frempong-Boadu A, Smith ML. Atlantoaxial fusion with transarticular screws: meta-analysis and review of the literature. World Neurosurg 2012; 80:627-41. [PMID: 22469527 DOI: 10.1016/j.wneu.2012.03.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 03/28/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To review published series describing C1-2 posterior instrumented fusions and summarize clinical and radiographic outcomes of patients treated with transarticular screw (TAS) fixation. METHODS Online databases were searched for English-language articles published between 1986 and April 2011 describing posterior atlantoaxial instrumentation with C1-2 TAS fixation. There were 45 studies including 2073 patients treated with TAS that fulfilled inclusion criteria. Meta-analysis techniques were used to calculate outcomes. RESULTS All studies provided class III evidence. The 30-day perioperative mortality rate was 0.8%, and the incidence of neurologic injury was 0.2%. The incidence of clinically significant malpositioned screws was 7.1% (confidence interval [CI], 5.7%-8.8%), the incidence of vertebral artery injury was 3.1% (CI, 2.3%-4.3%), and the rate of fusion with the TAS technique was 94.6% (CI, 92.6%-96.1%). CONCLUSIONS TAS fixation is a safe and effective treatment option for C1-2 instability with high rates of fusion (approximately 95%). Screw malposition and vertebral artery injury occurred in approximately 5% of patients. The successful insertion of TAS requires a thorough knowledge of atlantoaxial anatomy.
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Leone A, Costantini A, Visocchi M, Vestito A, Colelli P, Magarelli N, Colosimo C, Bonomo L. The role of imaging in the pre- and postoperative evaluation of posterior occipito-cervical fusion. Radiol Med 2011; 117:636-53. [DOI: 10.1007/s11547-011-0746-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 03/01/2011] [Indexed: 11/28/2022]
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Lee KH, Kang DH, Lee CH, Hwang SH, Park IS, Jung JM. Inferolateral entry point for c2 pedicle screw fixation in high cervical lesions. J Korean Neurosurg Soc 2011; 50:341-7. [PMID: 22200017 DOI: 10.3340/jkns.2011.50.4.341] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 08/12/2011] [Accepted: 10/17/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this retrospective study was to evaluate the efficacy and safety of atlantoaxial stabilization using a new entry point for C2 pedicle screw fixation. METHODS Data were collected from 44 patients undergoing posterior C1 lateral mass screw and C2 screw fixation. The 20 cases were approached by the Harms entry point, 21 by the inferolateral point, and three by pars screw. The new inferolateral entry point of the C2 pedicle was located about 3-5 mm medial to the lateral border of the C2 lateral mass and 5-7 mm superior to the inferior border of the C2-3 facet joint. The screw was inserted at an angle 30° to 45° toward the midline in the transverse plane and 40° to 50° cephalad in the sagittal plane. Patients received followed-up with clinical examinations, radiographs and/or CT scans. RESULTS There were 28 males and 16 females. No neurological deterioration or vertebral artery injuries were observed. Five cases showed malpositioned screws (2.84%), with four of the screws showing cortical breaches of the transverse foramen. There were no clinical consequences for these five patients. One screw in the C1 lateral mass had a medial cortical breach. None of the screws were malpositioned in patients treated using the new entry point. There was a significant relationship between two group (p=0.036). CONCLUSION Posterior C1-2 screw fixation can be performed safely using the new inferolateral entry point for C2 pedicle screw fixation for the treatment of high cervical lesions.
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Affiliation(s)
- Kwang Ho Lee
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
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Surgical treatment of chronic C1-C2 dislocation with absence of odontoid process using C1 hooks with C2 pedicle screws: a case report and review of literature. Spine (Phila Pa 1976) 2011; 36:E1245-9. [PMID: 21358484 DOI: 10.1097/brs.0b013e318205620a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case report. OBJECTIVE.: A rare case of chronic C1-C2 dislocation with absence of odontoid process that underwent posterior C1-C2 arthrodesis using C1 hooks and C2 pedicle screws. SUMMARY OF BACKGROUND DATA C1-C2 dislocation is a rare but fatal upper cervical injury. To date, there have been many reports about C1-C2 dislocation of traumatic origin. However, very few C1-C2 dislocation cases of congenital odontoid deformities had been presented. This was particularly the case when the odontoid process was absent. METHODS Plain radiograph of his cervical spine revealed a C1-C2 dislocation, and subsequent computed tomographic scan as well as magnetic resonance imaging (MRI) detected absence of odontoid process and cord compression. Upon admission, the patient was placed on skull traction and the weight increased from 3.5 to 5.5 kg. After 10 days of traction, reduction was achieved radiographically and the posterior C1-C2 arthrodesis by C1 hooks with C2 pedicle screws was performed. RESULTS After surgery, the patient showed significant improvement in gait function despite slightly raised muscle tone in his lower extremities. Four-month postoperative radiographs indicated restoration of C1-C2 alignment and bony fusion. No residual cord compression was present. CONCLUSION In clinical evaluation of patients who present with neck pain and limited cervical motion with or without neurologic deficits, C1-C2 dislocation should be considered. If the patient has no history of trauma or infection, congenital C1-C2 deformity, especially odontoid malformation, has to be included as a possible factor. Once the diagnosis is confirmed, posterior C1-C2 arthrodesis may become necessary for stabilizing C1-C2 and preventing it from deterioration or new development of neurologic symptoms.
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Lalanne LB, OcampoII GA. Artrodesis C1C2 con tornillos transarticulares en artritis reumatoidea: experiencia y revisión de la literatura. COLUNA/COLUMNA 2011. [DOI: 10.1590/s1808-18512011000400007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Describir los resultados clínicos e imagenológicos utilizando la técnica de fijación C1 C2 con tornillos transarticulares y asas de alambre en pacientes portadores de AR en un seguimiento a largo plazo y revisar la literatura actual. MÉTODO: Entre los años 2002 y 2006, 11 pacientes (9 mujeres y 2 hombres) con inestabilidad C1 C2 secundaria a AR fueron intervenidos quirúrgicamente. Se realizó fijación C1 C2 con tornillos transarticulares por vía posterior más asas de alambre y aplicación de injerto óseo autólogo de cresta ilíaca. Se registró Índice de Ranawat pre y posoperatorio, Distancia Anterior Atlas Odontoides (DAAO) pre y posoperatorio, tiempo operatorio, días de hospitalización, complicaciones intra y posoperatorias y tiempo de consolidación radiológica, con un seguimiento promedio de 34 meses. RESULTADOS: Todos los pacientes presentaron mejoría del Índice de Ranawat en el postoperatorio. La DAAO preoperatoria promedio fue de 11,9 mm (DS ± 2,57), rango 7 a 16, y la DAAO postoperatoria promedio fue de 3 mm (DS ± 1,20), rango 2 a 6. El tiempo quirúrgico fue de 94 minutos en promedio y el promedio de días de hospitalización fue de 7 días. No se presentaron complicaciones intraoperatorias. Un caso presentó seroma de herida operatoria que requirió tratamiento quirúrgico. El tiempo de consolidación fue en promedio 14 semanas. CONCLUSIÓN: La artrodesis atlantoaxial con tornillos y amarras es una buena alternativa para el manejo de la inestabilidad C1-C2 en pacientes portadores de AR, consiguiendo buenos resultados clínicos e imagenológicos en un seguimiento a largo plazo.
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Bahadur R, Goyal T, Dhatt SS, Tripathy SK. Transarticular screw fixation for atlantoaxial instability - modified Magerl's technique in 38 patients. J Orthop Surg Res 2010; 5:87. [PMID: 21092173 PMCID: PMC2995783 DOI: 10.1186/1749-799x-5-87] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Accepted: 11/22/2010] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Symptomatic atlantoaxial instability needs stabilization of the atlantoaxial joint. Among the various techniques described in literature for the fixation of atlantoaxial joint, Magerl's technique of transarticular screw fixation remains the gold standard. Traditionally this technique combines placement of transarticular screws and posterior wiring construct. The aim of this study is to evaluate clinical and radiological outcomes in subjects of atlantoaxial instability who were operated using transarticular screws and iliac crest bone graft, without the use of sublaminar wiring (a modification of Magerl's technique). METHODS We evaluated retrospectively 38 subjects with atlantoaxial instability who were operated at our institute using transarticular screw fixation. The subjects were followed up for pain, fusion rates, neurological status and radiographic outcomes. Final outcome was graded both subjectively and objectively, using the scoring system given by Grob et al. RESULTS Instability in 34 subjects was secondary to trauma, in 3 due to rheumatoid arthritis and 1 had tuberculosis. Neurological deficit was present in 17 subjects. Most common presenting symptom was neck pain, present in 35 of the 38 subjects.Postoperatively residual neck and occipital pain was present in 8 subjects. Neurological deficit persisted in only 7 subjects. Vertebral artery injury was seen in 3 subjects. None of these subjects had any sign of neurological deficit or vertebral insufficiency. Three cases had nonunion. At the latest follow up, subjectively, 24 subjects had good result, 6 had fair and 8 had bad result. On objective grading, 24 had good result, 11 had fair and 3 had bad result. The mean follow up duration was 41 months. CONCLUSIONS Transarticular screw fixation is an excellent technique for fusion of the atlantoaxial complex. It provides highest fusion rates, and is particularly important in subjects at risk for nonunion. Omitting the posterior wiring construct that has been used along with the bone graft in the traditional Magerl' s technique achieves equally good fusion rates and is an important modification, thereby avoiding the complications of sublaminar wire passage.
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Affiliation(s)
- Raj Bahadur
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Government Medical College and Hospital, Chandigarh, India
| | - Tarun Goyal
- Dept of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Saravdeep S Dhatt
- Dept of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sujit K Tripathy
- Dept of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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C1 lateral mass screw insertion with protection of C1-C2 venous sinus: technical note and review of the literature. Spine (Phila Pa 1976) 2010; 35:E1133-6. [PMID: 20885280 DOI: 10.1097/brs.0b013e3181e215ff] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a technical note and review of the literature. OBJECTIVE We propose to describe a revised surgical technique of C1 lateral mass screw insertion with protection of C1-C2 venous sinus surrounding the C2 nerve root. SUMMARY OF BACKGROUND DATA During C1 lateral mass screw insertion and in posterior C1-C2 fixation, iatrogenic injury of C1-C2 venous sinus results in bleeding, which is troublesome. Appropriate management of the venous sinus in this region is critical to successful surgery in this complex anatomic region. METHODS We reviewed 48 patients who underwent posterior C1-C2 fixation at our institution between September 2001 and October 2008. Twenty-four atlas screws were inserted by the originally described C1 lateral mass screw technique (group A), and 28 through a revised posterior arch and lateral mass screw technique (C1 transpedicular screw) (group B). The final group of 44 atlas screws was placed with our newly revised technique (group C). RESULTS Bleeding of venous sinus was encountered in 3 group A, 2 group B, and 1 group C atlas screw insertions. The incidence rate was 12.50% (A), 7.14% (B), and 2.27% (C). Statistical comparison showed no significant difference between the groups. All the cases were followed for a mean period of 28.1 month. Four patients in group A complained of postoperative numbness in occipitocervical region. No patients in group B or group C voiced this complaint. A high fusion rate was found in all 3 groups with no signs of implant failure. CONCLUSION Bleeding of C1-C2 venous sinus is vigorous and frustrating. The revised technique we describe provides theoretical and practical protection of venous sinus. In addition, the firm bony purchase of screws afforded by this technique contributes to achieving stabilization of the upper cervical spine and a high fusion rate.
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Zhang Z, Zhou Y, Wang J, Chu T, Li C, Ren X, Wang W. Acute traumatic cervical cord injury in patients with os odontoideum. J Clin Neurosci 2010; 17:1289-93. [DOI: 10.1016/j.jocn.2010.01.051] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 01/05/2010] [Accepted: 01/17/2010] [Indexed: 11/27/2022]
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Ventral Cancellous Bone Augmentation of the Dens and Temporary Instrumentation C1/C2 as a Function-preserving Option in the Treatment of Dens Pseudarthrosis. ACTA ACUST UNITED AC 2010; 23:285-92. [DOI: 10.1097/bsd.0b013e3181aac6ff] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Guo X, Ni B, Zhao W, Wang M, Zhou F, Li S, Ren Z. Biomechanical assessment of bilateral C1 laminar hook and C1-2 transarticular screws and bone graft for atlantoaxial instability. ACTA ACUST UNITED AC 2010; 22:578-85. [PMID: 19956032 DOI: 10.1097/bsd.0b013e31818da3fe] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED STUDYDESIGN: In vitro biomechanical test was conducted to compare the stability of 5 different atlantoaxial posterior fusion techniques. OBJECTIVE To evaluate the biomechanical stability of an atlas laminar hook combined with transarticular (TA) screws relative to 4 different conventional fusion techniques. SUMMARY OF BACKGROUND DATA The atlantoaxial instability caused by fractures, rheumatoid arthritis, congenital deformity, or traumatic lesions of the transverse ligament often result in acute or chronic spinal cord compression, a possible threat to a patient's life. Posterior atlantoaxial fixations are used to reconstruct the stability of atlantoaxial articulation. Conventional posterior atlantoaxial fixations are associated with high rates of pseudoarthrosis and carry the potential risk of neurologic complication. TA screw fixation can provide an excellent biomechanical stability. As a modified 3-point fixation technique, the bilateral C1-2 TA screws have been combined with C1 laminar hook and bone grafts. This modified technique had carried good clinical outcomes. METHODS Eight human specimens (C0-C4) were loaded nondestructively with pure moments and the range of motion at the level of C1-C2 was measured. Eight specimens were implanted with each of the following techniques, respectively: Gallie fixation, C1-2 TA screw fixation combined with Gallie fixation, C1-2 TA screw fixation, C1 laminar hook combined with C1-2 TA screw fixation plus bone grafts, and the C1 lateral mass screws in the atlas combined with C2 isthmic screws in axis. RESULTS Although the C1-2 TA screws best restricted lateral bending and axial rotation, the modified 3-point fixation technique additionally restricted flexion-extension and provided the excellent stability. Differences in axial rotation and lateral bending (with + or - 1.5 Nm load) were observed when the 3-point fixation techniques (TA + Gallie and TA + hook) were compared with atlas lateral mass screws in the atlas combined with isthmic screws in axis. CONCLUSIONS The modified C1 laminar hook combined with C1-2 TA screws and bone graft fixation provided the best biomechanical stability. The C1 lateral mass screws in the atlas combined with isthmic screws in axis fixation is a sound alternative when the C1-2 TA screw fixation is not feasible.
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Affiliation(s)
- Xiang Guo
- Department of Orthopedics, The Second Affiliated Hospital, The Second Military Medical University, Shanghai, People's Republic of China
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Elgafy H, Potluri T, Goel VK, Foster S, Faizan A, Kulkarni N. Biomechanical analysis comparing three C1-C2 transarticular screw salvaging fixation techniques. Spine (Phila Pa 1976) 2010; 35:378-85. [PMID: 20081561 DOI: 10.1097/brs.0b013e3181bc9cb5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN This is an in vitro biomechanical study. OBJECTIVE To compare the biomechanical stability of the 3 C1-C2 transarticular screw salvaging fixation techniques. SUMMARY AND BACKGROUND DATA Stabilization of the atlantoaxial complex is a challenging procedure because of its complicated anatomy. Many posterior stabilization techniques of the atlantoaxial complex have been developed with C1-C2 transarticular screw fixation been the current gold standard. The drawback of using the transarticular screws is that it has a potential risk of vertebral artery injury due to a high riding transverse foramen of C2 vertebra, and screw malposition. In such cases, it is not recommended to proceed with inserting the contralateral transarticular screw and the surgeon should find an alternative to fix the contralateral side. Many studies are available comparing different atlantoaxial stabilization techniques, but none of them compared the techniques to fix the contralateral side while using the transarticular screw on one side. The current options are C1 lateral mass screw and short C2 pedicle screw or C1 lateral mass screw and C2 intralaminar screw, or C1-C2 sublaminar wire. METHODS Nine fresh human cervical spines with intact ligaments (C0-C4) were subjected to pure moments in the 6 loading directions. The resulting spatial orientations of the vertebrae were recorded using an Optotrak 3-dimensional Motion Measurement System. Measurements were made sequentially for the intact spine after creating type II odontoid fracture and after stabilization with unilateral transarticular screw placement across C1-C2 (TS) supplemented with 1 of the 3 transarticular salvaging techniques on the contralateral side; C1 lateral mass screw and C2 pedicle screw (TS+C1LMS+C2PS), C1 lateral mass and C2 intralaminar screw (TS+C1LMS+C2ILS), or sublaminar wire (TS + wire). RESULTS The data indicated that all the 3 stabilization techniques significantly decreased motion when compared to intact in all the loading cases (left/right lateral bending, left/right axial rotation, flexion) except extension. All the 3 instrumented specimens were equally stable in extension/flexion and lateral bending modes. TS+C1LMS+C2PS was equivalent to TS+C1LMS+C2ILS (P > 0.05) and superior to TS + wire in axial rotation (P < 0.05). Also, TS+C1LMS+C2ILS was superior to TS + wire in axial rotation (P < 0.05). CONCLUSION Fixation of atlantoaxial complex using unilateral transarticular screw supplemented with contralateral C1 lateral mass and C2 intralaminar screws is biomechanically equivalent to C1 lateral mass and C2 pedicle screws and both are biomechanically superior to C1-C2 sublaminar wire in axial rotation.
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Affiliation(s)
- Hossein Elgafy
- Engineering Center for Orthopaedic Research Excellence, Department of Bioengineering, College of Engineering, University of Toledo, Toledo, OH, USA.
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Van Cleynenbreugel J, Schutyser F, Goffin J, Van Brussel K, Suetens P. Image-Based Planning and Validation of C1-C2 Transarticular Screw Fixation Using Personalized Drill Guides. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/10929080209146015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Behari S, Jaiswal A, Srivastava A, Rajput D, Jain VK. Os odontoideum with "free-floating" atlantal arch causing C1-2 anterolisthesis and retrolisthesis with cervicomedullary compression. Indian J Orthop 2010; 44:417-23. [PMID: 20924483 PMCID: PMC2947729 DOI: 10.4103/0019-5413.69316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Os odontoideum (OO) with C1-2 anterolisthesis and retrolisthesis may cause cervicomedullary injury both from anterior and posterior aspects. We analyzed fourteen such patients for biomechanical issues, radiological features and management of OO with free-floating atlantal arch and review pertinent literature. MATERIALS AND METHODS Fourteen patients having nonsyndromic, reducible atlantoaxial dislocation (AAD) with orthotopic OO were analyzed. During neck flexion, their C1 anterior arch-os complex displaced anteriorly relative to remnant odontoid-C2 body. The posteriorly directed hypoplastic remnant odontoid sliding below the atlas and forward translation of the C1 posterior arch caused concomitant cervicomedullary compression. During neck extension, there was retrolisthesis of the "free-floating" C1 arch-os complex into spinal canal. Spinal stenosis and lateral C1-2 facet dislocation; Klippel-Feil anomaly; and posterior circulation infarcts were also present in one patient each, respectively. Posterior C1-2 (n=10) or occipitocervical fusion (n=3) was performed in neutral position to stabilize atlantoaxial movements. RESULTS Follow-up (mean, 3.9 years) assessment revealed improvement in spasticity and weakness in 13 patients. One patient had neurological deterioration following C1-2 posterior sublaminar fusion, requiring its conversion to occipitocervical contoured rod fusion. One patient with posterior circulation stroke died prior to any operative intervention. Follow-up lateral view radiographs showed a bony union or a stable construct in these 13 patients. CONCLUSIONS OO with free-floating atlantal arch may precipitate cord injury both during neck flexion and extension. This condition may be overlooked unless lateral radiographs of craniovertebral junction are undertaken in neck extension, along with the usual ones in neutral and flexed positions. Etiological factors include C1 ring-OO unrestrained movements above the hypoplastic odontoid; upward pull on OO by alar and apical ligaments; lax C1-2 facet joint ligaments; and congenital presence of horizontal facet joint surfaces that facilitates C1-2 translation.
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Affiliation(s)
- Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow – 226 014, India,Address for correspondence: Dr. Sanjay Behari, Additional Professor, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow - 226 014, India. E-mail: ,
| | - Awadhesh Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow – 226 014, India
| | - Arun Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow – 226 014, India
| | - Dinesh Rajput
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow – 226 014, India
| | - Vijendra K Jain
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow – 226 014, India
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C1-C2 transarticular screw fixation for atlantoaxial instability due to rheumatoid arthritis: a seven-year analysis of outcome. Spine (Phila Pa 1976) 2009; 34:2880-5. [PMID: 20010395 DOI: 10.1097/brs.0b013e3181b4e218] [Citation(s) in RCA: 24] [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.: Observational study. Retrospective analysis of prospectively collected data. OBJECTIVE.: The purpose of this article was to report long-term (minimum 7 years) clinical and radiologic outcome of our series of patients with Rheumatoid Arthritis who underwent transarticular screw fixation to treat atlantoaxial subluxation. SUMMARY OF BACKGROUND DATA.: The indications for intervention in patients with atlantoaxial instability are pain, myelopathy, and progressive neurologic deficit. The various treatment options available for these patients are isolated C1-C2 fusion, occipitocervical fusion with or without transoral surgery. Review of current literature suggests that C1-C2 transarticular screw fixation has significant functional benefits, although there is discrepancy in this literature regarding improvement in function following surgery. METHODS.: Myelopathy was assessed using Ranawat myelopathy score and Myelopathy Disability Index. Pain scores were assessed using Visual Analogue Scale. The radiologic imaging was assessed and the following data were extracted; atlanto-dens interval, space available for cord, presence of signal change on T2 weighted image, and fusion rates. RESULTS.: Thirty-seven patients, median age 56, were included in the study. Average duration of neck symptoms was 15.8 months. Average duration of rheumatoid arthritis before surgery was 20.6 years. Preoperative symptoms: suboccipital pain in 26 patients; neck pain, 32; myelopathy, 22; and 5 were asymptomatic. After surgery: suboccipital pain, 2; neck pain, 3; and myelopathy, 10. Ninety percent patients with neck and suboccipital pain improved after surgery in their Visual Analogue pain scores, with all of them having >50% improvement in VAS scores (6.94-2.12 [P < 0.05]).Preoperative Ranawat grade was as follows: grade 1 in 15 patients, grade 2 in 7, and grade 3a in 14, grade 3b in 1.After surgery: grade 1 in 27 patients, grade 2 in 7, grade 3a in 1, and grade 3b in 2. The mean myelopathy score improved after surgery (59.62-32.75, P < 0.05).The space available for the cord was improved in 63%, unchanged in 33%, and worse in 4%.Twenty-seven percent had T2 signal change and 18% had cervicomedullary compression; 97% had bony fusion. BILATERAL SCREWS WERE USED IN 33 PATIENTS AND UNILATERAL SCREWS IN 4 PATIENTS (ABERRANT VERTEBRAL ARTERY).: Computer image guidance was used in 73%. CONCLUSION.: C1-C2 transarticular screw fixation is a safe technique for atlantoaxial subluxation for patients with rheumatoid arthritis. This study clearly demonstrates improvement in Visual Analogue Scale, Ranawat grading and the Myelopathy Disability Index even at long-term follow up.
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Guo X, Ni B, Wang M, Wang J, Li S, Zhou F. Bilateral atlas laminar hook combined with transarticular screw fixation for an unstable bursting atlantal fracture. Arch Orthop Trauma Surg 2009; 129:1203-9. [PMID: 18661139 DOI: 10.1007/s00402-008-0706-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The unstable atlas burst fracture ("Jefferson fracture") is a fracture of the anterior and posterior atlantal arch with rupture of the transverse atlantal ligament and an incongruence of the atlanto-occipital and the atlanto-axial joint facets. The posterior atlantoaxial fusion is frequently used to reconstruct the stability of atlantoaxial joint. Conventional posterior atlantoaxial fixations are associated with high rates of pseudoarthrosis and chronic atlantoaxial instability. As a modified three-point fixation the bilateral C1-2 transarticular screws combined with C1 laminar hook and bone grafts can provide best biomechanical stability, but no standard protocol has been reported for the use of this fusion technique. A retrospective review of clinical series should be conducted to evaluate the clinical outcome of bilateral atlas laminar hook combined with transarticular screw fixation for unstable bursting atlantal fracture. MATERIALS AND METHODS From March 2002 to March 2006, there were total 12 cases of unstable atlantal bursting fractures, 10 males and 2 females, age ranging 18-54, with mean of 36 years old. All patients were operated on posterior atlantoaxial fusion using bilateral atlas laminar hook combined with transarticular screw fixation after atlantoaxial joint were reduced and followed up for 12-24 months. The medical records and radiographs of the 12 patients were reviewed. Each patient underwent a complete cervical radiograph series including lateral flexion-extension view and a computed topographic scan. The Frankel grades and ASIA scores were applied to assess the neurologic status. RESULTS In all patients, a good bony fusion of the atlanto-axial segment was achieved. All patients showed significant improvement of the neurologic defect and no instability on their follow-up plain radiographs and computerized tomography in follow-up interval. CONCLUSIONS For the patients who suffer from the unstable bursting atlantal fracture, the nonoperative methods could carry some clinical complications including infection, nerve injury, etc. and is frequently failure, Posterior atlantoaxial fusion using bilateral atlas laminar hook combined with transarticular screw fixation is an effective treatment.
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Affiliation(s)
- Xiang Guo
- Department of Orthopaedics, Changzheng Hospital, 415 Fengyang Road, Huangpu District, Shanghai, People's Republic of China
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Sciubba DM, Noggle JC, Vellimana AK, Alosh H, McGirt MJ, Gokaslan ZL, Wolinsky JP. Radiographic and clinical evaluation of free-hand placement of C-2 pedicle screws. J Neurosurg Spine 2009; 11:15-22. [DOI: 10.3171/2009.3.spine08166] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Stabilization of the cervical spine can be challenging when instrumentation involves the axis. Fixation with C1–2 transarticular screws combined with posterior wiring and bone graft placement has yielded excellent fusion rates, but the technique is technically demanding and places the vertebral arteries (VAs) at risk. Placement of screws in the pars interarticularis of C-2 as described by Harms and Melcher has allowed rigid fixation with greater ease and theoretically decreases the risk to the VA. However, fluoroscopy is suggested to avoid penetration laterally, medially, and superiorly to avoid damage to the VA, spinal cord, and C1–2 joint, respectively. The authors describe how, after meticulous dissection of the C-2 pars interarticularis, such screws can be placed accurately and safely without the use of fluoroscopy.
Methods
Prospective follow-up was performed in 55 consecutive patients who underwent instrumented fusion of C-2 by a single surgeon. The causes of spinal instability and type and extent of instrumentation were documented. All patients underwent preoperative CT or MR imaging scans to determine the suitability of C-2 screw placement. Intraoperatively, screws were placed following dissection of the posterior pars interarticularis. Postoperative CT scans were performed to determine the extent of cortical breach. Patients underwent clinical follow-up, and complications were recorded as vascular or neurological. A CT-based grading system was created to characterize such breaches objectively by location and magnitude via percentage of screw diameter beyond the cortical edge (0 = none; I = < 25% of screw diameter; II = 26–50%; III = 51–75%; IV = 76–100%).
Results
One-hundred consecutive screws were placed in the pedicle of the axis by a single surgeon using external landmarks only. In 10 cases, only 1 screw was placed because of a preexisting VA anatomy or bone abnormality noted preoperatively. In no case was screw placement aborted because of complications noted during drilling. Early complications occurred in 2 patients and were limited to 1 wound infection and 1 transient C-2 radiculopathy. There were 15 total breaches (15%), 2 of which occurred in the same patient. Twelve breaches were lateral (80%), and 3 were superior (20%). There were no medial breaches. The magnitude of the breach was classified as I in 10 cases (66.7% of breaches), II in 3 cases (20% of breaches), III in 1 case (6.7%), and IV in 1 case (6.7%).
Conclusions
Free-hand placement of screws in the C-2 pedicle can be done safely and effectively without the use of intraoperative fluoroscopy or navigation when the pars interarticularis/pedicle is assessed preoperatively with CT or MR imaging and found to be suitable for screw placement. When breaches do occur, they are overwhelmingly lateral in location, breach < 50% of the screw diameter, and in the authors' experience, are not clinically significant.
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A novel computer-assisted drill guide template for placement of C2 laminar screws. 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 2009; 18:1379-85. [PMID: 19517142 DOI: 10.1007/s00586-009-1051-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 04/09/2009] [Accepted: 05/17/2009] [Indexed: 10/20/2022]
Abstract
The present method of C2 laminar screw placement relies on anatomical landmarks for screw placement. Placement of C2 laminar screws using drill template has not been described in the literature. The authors reported on their experience with placement of C2 laminar screws using a novel computer-assisted drill guide template in nine patients undergoing posterior occipito-cervical fusion. CT scan of C2 vertebrae was performed. 3D model of C2 vertebrae was reconstructed by software MIMICS 10.01. The 3D vertebral model was then exported in STL format, and opened in a workstation running software UG imageware12.0 for determining the optimal laminar screw size and orientation. A virtual navigational template was established according to the laminar anatomic trait. The physical vertebrae and navigational template were manufactured using rapid prototyping. The navigational template was sterilized and used intraoperative to assist the placement of laminar screw. Overall, 19 C2 laminar screws were placed and the accuracy of screw placement was confirmed with postoperative X-ray and CT scanning. There were not complications of related screws insertion. Average follow-up was 9 months (range 4-13 months), 77.8% of the patients exhibited improvement in their myelopathic symptoms; in 22.2% the symptoms were unchanged. Postoperative computed tomographic (CT) scanning was available for allowing the evaluation of placement of thirteen C2 laminar screws, all of which were in good position with no spinal canal violation. This study shows a patient-specific template technique that is easy to use, can simplify the surgical act and generates highly accurate C2 laminar screw placement. Advantages of this technology over traditional techniques include planning of the screw trajectory is done completely in the presurgical period as well as the ability to size the screw to the patient's anatomy.
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