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John AA, Grochmal J, Felton J. Transoral digital reduction of complete anterior odontoid dislocation followed by fiducial-based navigated transcondylar screw fixation: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21576. [PMID: 36130576 PMCID: PMC9379652 DOI: 10.3171/case21576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/08/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Posterior atlantoaxial dislocations (i.e., complete anterior odontoid dislocation) without C1 arch fractures are a rare hyperextension injury most often found in high-velocity trauma patients. Treatment options include either closed or open reduction and optional spinal fusion to address atlantoaxial instability due to ligamentous injury. OBSERVATIONS A 60-year-old male was struck while on his bicycle by a truck and sustained an odontoid dislocation without C1 arch fracture. Imaging findings additionally delineated a high suspicion for craniocervical instability. The patient had neurological issues due to both a head injury and ischemia secondary to an injured vertebral artery. He was stabilized and transferred to our facility for definitive neurosurgical care. LESSONS The patient underwent a successful transoral digital closed reduction and posterior occipital spinal fusion via a fiducial-based transcondylar, C1 lateral mass, C2 pedicle, and C3 lateral mass construct. This unique reduction technique has not been recorded in the literature before and avoided potential complications of overdistraction and the need for odontoidectomy. Furthermore, the use of bone fiducials for navigated screw fixation at the craniocervical junction is a novel technique and recommended particularly for placement of technically demanding transcondylar screws and C2 pedicle screws where pars anatomy is potentially unfavorable.
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Affiliation(s)
| | - Joey Grochmal
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jason Felton
- Division of Neurosurgery, Texas Tech University Health Sciences Center, Lubbock, Texas; and
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Shiraishi D, Nishimura Y, Aguirre-Carreno I, Hara M, Yoshikawa S, Eguchi K, Nagashima Y, Ito H, Haimoto S, Yamamoto Y, Ginsberg HJ, Takayasu M, Saito R. Clinical and Radiological Clues of Traumatic Craniocervical Junction Injuries Requiring Occipitocervical Fusion to Early Diagnosis. Neurospine 2022; 18:741-748. [PMID: 35000327 PMCID: PMC8752707 DOI: 10.14245/ns.2142860.430] [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: 08/09/2021] [Accepted: 10/16/2021] [Indexed: 11/19/2022] Open
Abstract
Objective The purpose of this study is to find the clinical and radiographic characteristics of traumatic craniocervical junction (CCJ) injuries requiring occipitocervical fusion (OC fusion) for early diagnosis and surgical intervention.
Methods We retrospectively reviewed 12 patients with CCJ injuries presenting to St. Michaels Hospital in Toronto who underwent OC fusion and looked into the following variables; (1) initial trauma data on emergency room arrival, (2) associated injuries, (3) imaging characteristics of computed tomography (CT) scan and magnetic resonance imaging (MRI), (4) surgical procedures, surgical complications, and neurological outcome.
Results All patients were treated as acute spinal injuries and underwent OC fusion on an emergency basis. Patients consisted of 10 males and 2 females with an average age of 47 years (range, 18–82 years). All patients sustained high-energy injuries. Three patients out of 6 patients with normal BAI (basion-axial interval) and BDI (basion-dens interval) values showed visible CCJ injuries on CT scans. However, the remaining 3 patients had no clear evidence of occipitoatlantal instability on CT scans. MRI clearly described several findings indicating occipitoatlantal instability. The 8 patients with normal values of ADI (atlantodens interval interval) demonstrated atlantoaxial instability on CT scan, however, all MRI more clearly and reliably demonstrated C1/2 facet injury and/or cruciate ligament injury.
Conclusion We advocate measures to help recognize CCJ injury at an early stage in the present study. Occipitoatlantal instability needs to be carefully investigated on MRI in addition to CT scan with special attention to facet joint and ligament integrity.
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Affiliation(s)
- Daimon Shiraishi
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan.,Department of Neurosurgery, Inazawa Manucipal Hospital, Aichi, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Isaac Aguirre-Carreno
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Masahito Hara
- Department of Neurosurgery, Aichi Medical University Hospital, Aichi, Japan
| | - Satoshi Yoshikawa
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Kaoru Eguchi
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | | | - Hiroshi Ito
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Shoichi Haimoto
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Yu Yamamoto
- Department of Neurosurgery, Inazawa Manucipal Hospital, Aichi, Japan
| | - Howard J Ginsberg
- Department of Neurosurgery, Inazawa Manucipal Hospital, Aichi, Japan
| | - Masakazu Takayasu
- Department of Neurosurgery, Aichi Medical University Hospital, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
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Zileli M, Akıntürk N. Complications of occipitocervical fixation: retrospective review of 128 patients with 5-year mean follow-up. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:311-326. [PMID: 34725722 DOI: 10.1007/s00586-021-07037-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/18/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Occipitocervical fusion is necessary for many pathologies of the craniocervical junction. The anatomy of the region is unique, and fusion can cause significant morbidity. This retrospective review aims to investigate the complication rates and outcomes of occipitocervical fixation. MATERIAL AND METHODS This is a retrospective review of 128 patients with occipitocervical fixation operated between 1994 and 2020. The average follow-up is 63 months. RESULTS The indications of occipitocervical fixation were basilar invagination (53 patients; 41.4%), trauma (25 patients; 19.5%), tumor (23 patients; 18%), instability due to rheumatoid arthritis (13 patients; 10.2%), cervical deformity (7 patients; 5.5%) and os odontoideum (7 patients; 5.5%). There were six early postoperative (1st month) deaths. We observed complications in 67 patients (52%). Most common complication was implant-related (32%), followed by wound problems (23.4%), systemic and other complications (11.7%), neurologic complications (6.2%). Implants are removed in 31 patients (24%) for different reasons: deep wound infection (7), local pain and restriction of head movements (21), respiratory distress and swallowing problems (2), screw fracture and local pain (1). CONCLUSIONS Occipitocervical fixation has quite large number of complications and significantly restricts head movements. With the advent of our biomechanical concepts, indications should be limited, and shorter cervical fixations should be preferred. LEVEL OF EVIDENCE Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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Affiliation(s)
- Mehmet Zileli
- Ege University Neurosurgery Department, Bornova, Izmir, Turkey.
| | - Nevhis Akıntürk
- Ege University Neurosurgery Department, Bornova, Izmir, Turkey
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Goparaju PVNR, Rangnekar A, Chigh A, Raut SS, Kundnani V. Safety, efficacy, surgical, and radiological outcomes of short segment occipital plate and C2 transarticular screw construct for occipito-cervical instability. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:381-386. [PMID: 35068820 PMCID: PMC8740813 DOI: 10.4103/jcvjs.jcvjs_113_21] [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: 08/07/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: Our study aims to assess the safety, efficacy, clinicoradiological, functional, neurological outcomes, and complications of posterior occipitocervical fixation using an occipital plate and C1-2 transarticular screw (TAS) construct. Study Design: This was a retrospective analysis of prospectively collected data. Methods: Data of 27 patients who underwent occipital plate and C1-2 TAS construct at a single institute from 2010 to 2015 were collected and analyzed. Demographics, clinical parameters (Visual Analog Score, Oswestry Disability Index, and modified JOA score), radiological parameters – mean atlantodens interval, posterior occipitocervical angle, occipitocervical-2 angle, surgical parameters (operative time, blood loss, hospital stay, and fusion), and complications were evaluated. Results: The mean age of the patients was 54.074 ± 16.52 years (18–81 years), the mean operative time was 116.29 ± 12.23 min, and the mean blood loss was 196.29 ± 38.94 ml. The mean hospital stay was 5.22 ± 1.28 days. The mean ± standard deviation follow-up duration was 62.52 ± 2.27 months. There was a significant improvement in clinical parameters and radiological parameters postoperatively. One patient with implant failure, one patient with pseudoarthrosis, one with neurological deterioration, two wound complications, and two dural tears were noted. Conclusion: Posterior occipitocervical reconstruction with O-C1-2 TAS construct provided excellent clinical outcomes, radiological outcomes, optimal correction of malalignment in the occipitocervical region, and with biomechanically sound fixation. Extending the instrumentation into the subaxial spine will lead to a decrease in the range of motion, increased surgical time, blood loss, more extensive muscle damage, and also increase the costs.
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Affiliation(s)
- Praveen V N R Goparaju
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Ameya Rangnekar
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Amit Chigh
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Saijyot Santosh Raut
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Vishal Kundnani
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Sunshine KS, Elder TA, Tomei KL. Noninvasive evaluation of craniovertebral junction instability in 2 patients following Chiari decompression with rigid C-collar immobilization: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20114. [PMID: 36045931 PMCID: PMC9394172 DOI: 10.3171/case20114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The complex Chiari malformation has been identified in a subset of Chiari patients at higher risk for worsening symptoms following Chiari decompression. Although parameters such as the clivoaxial angle and the perpendicular distance of the dens to the line from the basion to the inferoposterior part of the C2 body (pBC2) have been evaluated to help with the prediction of risk, the decision to pursue an occipitocervical fusion in lower-risk patients does not come without inherent risk. OBSERVATIONS The authors present 2 patients who had symptoms of worsening ventral brainstem compression following Chiari decompression, neither of whom was categorized in the highest risk category for occipitocervical instability. In addition, neither patient had gross instability on radiographic imaging. A trial with rigid C-collar immobilization provided relief of symptoms in both patients and allowed reassurance of the likelihood of success of occipitocervical fusion. LESSONS In patients without clear radiographic instability following Chiari decompression, a C-collar trial may provide a noninvasive option for assessing the potential success of occipitocervical fusion.
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Affiliation(s)
| | - Theresa A. Elder
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Krystal L. Tomei
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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Tian Y, Xu N, Yan M, Passias PG, Segreto FA, Wang S. Atlantoaxial dislocation with congenital "sandwich fusion" in the craniovertebral junction: a retrospective case series of 70 patients. BMC Musculoskelet Disord 2020; 21:821. [PMID: 33287792 PMCID: PMC7722328 DOI: 10.1186/s12891-020-03852-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 12/01/2020] [Indexed: 11/21/2022] Open
Abstract
Background In the setting of congenital C1 occipitalization and C2–3 fusion, significant strain is placed on the atlantoaxial joint. Vertebral fusion both above and below the atlantoaxial joint (i.e., a “sandwich”) creates substantial instability. We retrospectively report on a case series of “sandwich fusion” atlantoaxial dislocation (AAD), describing the associated clinical characteristics and detailing surgical treatment. To the best of our knowledge, the present study is the largest investigation to date of this congenital subgroup of AAD. Methods Seventy consecutive patients with sandwich fusion AAD, from one senior surgeon, were retrospectively reviewed. The clinical features and the surgical treatment results were assessed using descriptive statistics. No funding sources or potential conflict of interest-associated biases exist. Results The mean patient age was 42.2 years (range: 5–77 years); 36 patients were male, and 34 were female. Fifty-eight patients (82.9%) had myelopathy, with Japanese Orthopaedic Association (JOA) scores ranging 4–16 (mean: 12.9). Cranial neuropathy was involved in 10 cases (14.3%). The most common presentation age group was 31 to 40 years (24 cases, 34.3%). Radiological findings revealed brainstem and/or cervical-medullar compression (58 cases, 82.9%), syringomyelia (16 cases, 22.9%), Chiari malformation (12 cases, 17.1%), cervical spinal stenosis (10 cases, 14.3%), high scapula deformity (1 case, 1.4%), os odontoideum (1 case, 1.4%), and dysplasia of the atlas (1 case, 1.4%). Computed tomography angiography was performed in 27 cases, and vertebral artery (VA) anomalies were identified in 14 cases (51.9%). All 70 patients underwent surgical treatment, without spinal cord or VA injury. Four patients (5.7%) suffered complications, including 1 wound infection, 1 screw loosening, and 2 cases of bulbar paralysis. In the 58 patients with myelopathy, the mean JOA score increased from 12.9 to 14.5. The average follow-up time was 50.5 months (range: 24–120 months). All 70 cases achieved solid atlantoaxial fusion at the final follow-up. Conclusions Sandwich fusion AAD, a unique subgroup of AAD, has distinctive clinical features and associated malformations such as cervical-medullar compression, syringomyelia, and VA anomalies. Surgical treatment of AAD was associated with myelopathy improvement and minimal complication occurrence.
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Affiliation(s)
- Yinglun Tian
- Department of Orthopaedics, Peking University Third Hospital, No 49 North Garden Street, HaiDian District, Beijing, 100191, People's Republic of China
| | - Nanfang Xu
- Department of Orthopaedics, Peking University Third Hospital, No 49 North Garden Street, HaiDian District, Beijing, 100191, People's Republic of China
| | - Ming Yan
- Department of Orthopaedics, Peking University Third Hospital, No 49 North Garden Street, HaiDian District, Beijing, 100191, People's Republic of China
| | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Frank A Segreto
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Shenglin Wang
- Department of Orthopaedics, Peking University Third Hospital, No 49 North Garden Street, HaiDian District, Beijing, 100191, People's Republic of China.
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Iwai C, Fushimi K, Nozawa S, Mitsuishi N, Ogawa H, Maeda M, Kuramitsu N, Akiyama H. Spontaneous morphological remodelling of the O-C1 joint after posterior fusion for occipitocervical dislocation. Int J Neurosci 2020; 132:397-402. [PMID: 32883147 DOI: 10.1080/00207454.2020.1818740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Traumatic occipitocervical dislocation (OCD) occurs due to fatal high-energy injury. Modern screw-based constructs enable successful reduction and stabilisation. In view of this, there are no previous reports on the spontaneous remodelling of the O-C1 joint after posterior fusion. We report the first case of postoperative spontaneous remodelling and stabilisation of the O-C1 joint after traumatic OCD.Case description: A 9-year-old girl suffered from traumatic OCD, accompanied by complete rupture of the O-C1-C2 ligamentous complex. Halo-vest fixation, and subsequently posterior fusion surgery from the occipital bone to C2, with autologous iliac crest bone graft and an allograft were performed. However, we could not achieve complete reduction of the O-C1 joint during surgery owing to extremely severe instability.Postoperative X-ray and computed tomography scan showed incomplete reduction of the O-C1 joint. Insufficient congruity of the O-C1 joint persisted. Afterwards, gradual spontaneous remodelling of the O-C1 joint occurred, both anteriorly and posteriorly 3 months postoperatively. Solid union was achieved 6 months postoperatively. Two years later, bilateral O-C1 joints in the patient were completely reformed and restabilised by incredible vigorous remodelling. Insufficient reduction and persisting poor joint congruence after surgery for OCD was probably restabilised by further spontaneous remodelling of articular morphology in such a young patient. CONCLUSIONS Postoperative spontaneous remodelling of the O-C1 joint after posterior reconstruction for OCD may occur in young patients. Incomplete reduction of the O-C1 joint during surgery may be acceptable due to the possibility of postoperative bone remodelling and restabilisation.
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Affiliation(s)
- Chizuo Iwai
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazunari Fushimi
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Satoshi Nozawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Naofumi Mitsuishi
- Department of Orthopaedic Surgery, Takayama Red Cross Hospital, Gifu, Japan
| | - Hiroyasu Ogawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masato Maeda
- Department of Orthopaedic Surgery, Takayama Red Cross Hospital, Gifu, Japan
| | - Norishige Kuramitsu
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Abstract
STUDY DESIGN Narrative literature review. OBJECTIVE To review and present details on the occipitocervical fixation (OCF) technique as well as considerations for planning the procedure. METHODS We present the surgical technique of OCF in a step-by-step didactic and practical manner with surgical tips and tricks, including C1 and C2 screw fixation techniques. Additionally, we discuss complications, the extension of fusion, types of OCF, and how to avoid common side effects associated with OCF. RESULTS The complex and mobile anatomy of the craniocervical junction, when requiring fixation and fusion, warrants rigid instrumentation that can be achieve using a modern screw-plate-rod construct. Indications for OCF are craniocervical instability, and atlantoaxial instability when selective atlantoaxial fusion is not feasible. OCF generally involves occiput-C2 fusion. C1 fixation is generally unnecessary, since it increases the surgical time and is associated with the risk of vascular complications. Selective occiput-C2 fusion is recommended when there is no need for including the cervical subaxial region (eg, when stenosis or fractures coexist in the subaxial spine), and good fixation is achieved at C2. Most instrumentation systems now have occipital plates that are not pre-integrated to rods, making fixation much simpler. Surgical steps, from position to wound closure, are presented in detail, with pearls for practice and discussion of cervical alignment. CONCLUSIONS OCF is a challenging procedure, with potential risk of severe adverse effects. Understanding the surgical indications, as well as the nuances of the surgical technique, is required to improve patient outcomes and avoid complications.
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Affiliation(s)
- Andrei Fernandes Joaquim
- University of Campinas (UNICAMP), Campinas, SP, Brazil,Andrei Fernandes Joaquim, Department of Neurology, Discipline of Neurosurgery, University of Campinas (UNICAMP), Campinas, SP 13083-872, Brazil.
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Posterior Occipitocervical Fusion for Unstable Upper Cervical Trauma in Old and Elderly Population, Although Decreases Upper Cervical Rotation, Does Not Significantly Increase Neck Disability Index. Adv Orthop 2020; 2020:7906985. [PMID: 32802518 PMCID: PMC7416230 DOI: 10.1155/2020/7906985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/10/2020] [Indexed: 11/18/2022] Open
Abstract
Background Despite the research progress in the thoraco-lumbo-pelvic balance, cervical spine balance has only recently gained increasing interest. To our knowledge, there is a lack of research regarding sagittal occipitocervical spine balance restoration following posterior occipitocervical fusion (POCF). Purpose The primary outcome measure is the evaluation of sagittal cervical alignment roentgenographic parameters and the secondary is the functional outcome (NDI), following POCF for upper (C1 & C2) cervical trauma (UCT) in coexistence with upper cervical spine degeneration. Patients and Methods. Twenty old and elderly patients aged 62 ± 12 years with evident upper cervical degeneration, who received POCF for upper C1 & C2 unstable cervical spine injuries, were included. C2-C7 lordosis, C2-C7 SVA, spinocranial angle (SCA), T1-slope, neck tilt (NT), thorax inlet angle (TIA), cervical tilt (CT), cranial tilt (CrT), and C0-C1 angle were measured. The subfusion angle was used to study the behavior of the unfused cervical segments below fusion. The Neck Disability Index (NDI) was used for the functional outcome evaluation. 29 age-matched individuals were used as controls for radiographic analysis and self-reported functional status comparison. Results The roentgenographic data were measured 3 and 39 ± 12 months postoperatively. Twelve patients showed no disability, and eight showed mild disability. Postoperatively, the patients stood with less C2-C7 lordosis, SCA, and CT (P < 0.02) but with higher NT (P < 0.02) in comparison to the controls. The patient's neck disability (NDI) was increasing as TIA increases (P=0.023). Subfusion angle seems to adapt to C2-C7 lordosis (P < 0.0033) and C0-C2 angle (P < 0.003) without any changes till the last evaluation. Conclusions POCF sufficiently restored occipitocervical sagittal balance along with functional outcome similar to controls in adult and elderly individuals with evident upper cervical degeneration. We do not recommend POCF for young active individuals without occipitocervical pathology, but in contrary, we recommend the removal of the spinocranial connection hardware after cervical fusion is completed.
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Bodeliwala S, Nagar V, Singh H, Singh D, Jagetia A, Pandey S, Ruttala R, Kumar P. Pattern of Pulmonary Dysfunctions in Craniovertebral Junction Anomaly and Its Persistence after Rigid Occipitocervical Fixation. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0040-1712064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Abstract
Introduction Despite a significant advancement in operative techniques of occipitocervical fixation, there is a poor postoperative patient outcome. This can be attributed to restrictive lung pattern in craniovertebral junction anomalies (CVJAs) patients resulting from repeated trauma to cervicomedullary junction by the pincer action of the bony anomalies and compression of the brainstem. We evaluate the changes in pulmonary function tests (PFTs) following rigid occipitocervical fixation in CVJA.
Methods PFTs of 20 CVJA patients were measured pre and postoperatively using spirometry. Measurements included forced vital capacity (FVC), forced expiratory volume in one second (FEV1), maximum forced mid-expiratory flow rate (FEF25–75%), and ratio of FEV1 and FVC (FEV1%). The parameters were compared with the predicted normal values based on their age and sex. PFTs were repeated on the seventh postoperative day. McCormick grading was used to assess neurological function.
Results The values of PFTs in the preoperative period were significantly lower than predicted normal values. The mean values of FVC, FEV1, FEF25–75% were 72, 68, and 71% of their mean predicted values, with FEV1% in the range of 70 to 95% with a mean of 81.4%. Postoperatively there was further significant reduction in the mean values of FVC, FEV1, FEF25–75%, and FEV1% compared with the preoperative values. There was neurological improvement in McCormick grades of patients postoperatively (from grade III and IV to grade II).
Conclusion A significant restrictive lung disease is present in patients of CVJA, even though not clinically apparent, and it persists in the early postoperative period. However, a long-term follow-up is required to assess whether pulmonary function parameters improve subsequently.
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Affiliation(s)
- Shaam Bodeliwala
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, Delhi, India
| | - Vikas Nagar
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, Delhi, India
| | - Hukum Singh
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, Delhi, India
| | - Daljit Singh
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, Delhi, India
| | - Anita Jagetia
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, Delhi, India
| | - Sharad Pandey
- Department of Neurosurgery, Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, Delhi, India
| | - Rajesh Ruttala
- Department of Medicine, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Pankaj Kumar
- Department of Neurosurgery, Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, Delhi, India
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Wenning KE, Hoffmann MF. Does isolated atlantoaxial fusion result in better clinical outcome compared to occipitocervical fusion? J Orthop Surg Res 2020; 15:8. [PMID: 31918713 PMCID: PMC6953136 DOI: 10.1186/s13018-019-1525-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 12/18/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The C0 to C2 region is the keystone for range of motion in the upper cervical spine. Posterior procedures usually include a fusion of at least one segment. Atlantoaxial fusion (AAF) only inhibits any motion in the C1/C2 segment whereas occipitocervical fusion (OCF) additionally interferes with the C0/C1 segment. The purpose of our study was to investigate clinical outcome of patients that underwent OCF or AAF for upper cervical spine injuries. METHODS Over a 5-year period (2010-2015), consecutive patients with upper cervical spine disorders were retrospectively identified as having been treated with OCF or AAF. The Numeric Pain Rating Scale (NPRS) and the Neck Disability Index (NDI) were used to evaluate postoperative neck pain and health restrictions. Demographics, follow-up, and clinical outcome parameters were evaluated. Infection, hematoma, screw malpositioning, and deaths were used as complication variables. Follow-up was at least 6 months postoperatively. RESULTS Ninety-six patients (male = 42, female = 54) underwent stabilization of the upper cervical spine. OCF was performed in 44 patients (45.8%), and 52 patients (54.2%) were treated with AAF. Patients with OCF were diagnosed with more comorbidities (p = 0.01). Follow-up was shorter in the OCF group compared to the AAF group (6.3 months and 14.3 months; p = 0.01). No differences were found related to infection (OCF 4.5%; AAF 7.7%) and revision rate (OCF 13.6%; AAF 17.3%; p > 0.05). Regarding bother and disability, no differences were discovered utilizing the NDI score (AAF 21.4%; OCF 37.4%; p > 0.05). A reduction of disability measured by the NDI was observed with greater follow-up for all patients (p = 0.01). CONCLUSION Theoretically, AAF provides greater range of motion by preserving the C0/C1 motion segment resulting in less disability. The current study did not show any significant differences regarding clinical outcome measured by the NDI compared to OCF. No differences were found regarding complication and infection rates in both groups. Both techniques provide a stable treatment with comparable clinical outcome.
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Affiliation(s)
- Katharina E Wenning
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789, Bochum, Germany.
| | - Martin F Hoffmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789, Bochum, Germany
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Clifton W, Edwards S, Dove C, Damon A, Simon L, Rosenbush K, Nottmeier E, Quinones-Hinojosa A, Pichelmann M. Finding the "Sweet Spot" for C2 Root Transection in C1 Lateral Mass Exposure. World Neurosurg 2019; 127:e738-e744. [PMID: 30951909 DOI: 10.1016/j.wneu.2019.03.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Atlantoaxial fusion often requires C2 nerve transection for complete C1 lateral mass exposure. Nerve transection is made ideally at the preganglionic segment proximal to the dorsal root ganglion to minimize the risk of postoperative dysesthesias. If the nerve is transected too proximally, cerebrospinal fluid leak may be encountered by violation of the dura and arachnoid where the sensory and motor nerve rootlets exit the subarachnoid space. In this study we aimed to quantify the length of the C2 nerve preganglionic segment using cadaveric specimens and develop a method for reliable intraoperative localization for sectioning during C1-2 arthrodesis. METHODS Using microsurgical techniques, 16 C2 nerves from 8 frozen and injected cadaveric cervical spine specimens were dissected. Two key measurements were taken to establish a reliable method of preganglionic segment identification. The "sweet spot" for nerve transection was based on the approximate location of the midpoint of the preganglionic segment. RESULTS The final determination of the ideal spot for C2 nerve transection using these calculations was 3 mm lateral to the medial border of the lateral mass. CONCLUSIONS This anatomic study found remarkable consistency in the preganglionic segment length. The medial border of the lateral mass appeared to be a consistently reliable landmark for identification of the preganglionic segment of the C2 nerve root. By using relationships between known anatomic structures intraoperatively, safety of atlantoaxial fixation can be optimized to maximize complication avoidance and satisfactory patient outcomes.
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Affiliation(s)
- William Clifton
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA.
| | - Steve Edwards
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Conrad Dove
- College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Aaron Damon
- College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Leslie Simon
- Department of Emergency Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Kristin Rosenbush
- College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Eric Nottmeier
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | - Mark Pichelmann
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
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Morphometric Measurements of the C1 Lateral Mass with Congenital Occipitalization of the Atlas. World Neurosurg 2019; 121:e1-e7. [DOI: 10.1016/j.wneu.2018.08.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 11/22/2022]
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14
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Abstract
Occipitocervical fusion (OCF) is indicated for instability at the craniocervical junction (CCJ). Numerous surgical techniques, which evolved over 90 years, as well as unique anatomic and kinematic relationships of this region present a challenge to the neurosurgeon. The current standard involves internal rigid fixation by polyaxial screws in cervical spine, contoured rods and occipital plate. Such approach precludes the need of postoperative external stabilization, lesser number of involved spinal segments, and provides 95-100% fusion rates. New surgical techniques such as occipital condyle screw or transarticular occipito-condylar screws address limitations of occipital fixation such as variable lateral occipital bone thickness and dural sinus anatomy. As the C0-C1-C2 complex is the most mobile portion of the cervical spine (40% of flexion-extension, 60% of rotation and 10% of lateral bending) stabilization leads to substantial reduction of neck movements. Preoperative assessment of vertebral artery anatomical variations and feasibility of screw insertion as well as visualization with intraoperative fluoroscopy are necessary. Placement of structural and supplemental bone graft around the decorticated bony elements is an essential step of every OCF procedure as the ultimate goal of stabilization with implants is to provide immobilization until bony fusion can develop.
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15
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Kasliwal MK, Fontes RB, Traynelis VC. Occipitocervical dissociation-incidence, evaluation, and treatment. Curr Rev Musculoskelet Med 2016; 9:247-54. [PMID: 27255101 PMCID: PMC4958379 DOI: 10.1007/s12178-016-9347-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Traumatic occipitocervical dissociation (OCD) results from ligamentous injury to the craniocervical junction and is associated with a high rate of mortality and significant neurologic morbidity. The diagnosis is frequently missed on initial lateral cervical spinal radiographs mainly due to inadequate visualization of radiological landmarks and low degree of suspicion. Widespread availability of multidetector computed tomography (MDCT) of the spine and development of better diagnostic radiological criteria has allowed timely diagnosis and good clinical outcome following posterior occipitocervical fusion and instrumentation for a pathology that was once considered uniformly fatal. The present paper reviews the clinical features, diagnosis, and management of OCD in light of most recent literature.
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Affiliation(s)
- Manish K Kasliwal
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St., Chicago, IL, 60612, USA
| | - Ricardo B Fontes
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St., Chicago, IL, 60612, USA
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St., Chicago, IL, 60612, USA.
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16
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Guzik G. "Quality of life of patients after surgical treatment of cervical spine metastases". BMC Musculoskelet Disord 2016; 17:315. [PMID: 27461418 PMCID: PMC4962512 DOI: 10.1186/s12891-016-1175-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/20/2016] [Indexed: 11/18/2022] Open
Abstract
Background Metastases of malignant neoplasms to the cervical spine are relatively rare. The most common symptom of metastatic disease is pain. Symptoms associated with roots damage or spinal cord compression indicate locally advanced disease. In a large number of patients, surgical treatment brings benefits such as pain reduction and improvement of the quality of life. Pain intensity, neurological status, and quality of patients’ lives are measured with the VAS, Frankel, and Karnofsky scales. Methods Symptoms of the disease, morphology of the metastasis and treatment outcomes were evaluated in 57 patients treated surgically because of metastases to the cervical spine over the period 2010–2014 in Brzozów. The morphology of the metastases was assessed on the basis of CT and MR examinations. Pre- and postoperative functional status of the patients was evaluated using Karnofsky scale. The intensity of pain was assessed with VAS and the neurological status was evaluated by using Frankel’s grades. Anterior approach was employed in 16 patients, posterior approach in 30 patients, and postero-anterior approach in 11 patients. The inter-group differences were evaluated using the U Mann–Whitney and Wilcoxon Matched Pairs test. All statistical analyses were performed by using Statistica 10. A value of P < 0.05 was considered statistically significant. Results The majority of patients suffered from pain associated with instability of the spine. Multi-level metastases were noted in 40 patients, while in 17 patients 1 vertebra was involved. In 51 patients the metastases caused pathological fractures of the vertebrae. The most common neurological complications was observed in patients with multi-level tumors and with pedicles involvement. After surgery patients functional status improved and pain intensity decreased. The best results (statistically significant) were observed in patients operated with anterolateral approach. Complications were scarce. Two patients required reoperation due to infection. Conclusions Surgical treatment of metastases to the cervical spine gives good outcomes and it ought to be a treatment of choice. Proper and multifaceted qualification of the patients for different treatments is of vital importance.
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Affiliation(s)
- Grzegorz Guzik
- Department of Orthopaedic Oncology, Specialist Hospital in Brzozów- Podkarpacie Oncology Centre, Bielawskiego 18, 36-200, Brzozów, Poland.
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17
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Occipitocervical Fusions in Elderly Patients: Mortality and Reoperation Rates From a National Spine Registry. World Neurosurg 2016; 86:161-7. [DOI: 10.1016/j.wneu.2015.09.077] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 09/20/2015] [Accepted: 09/23/2015] [Indexed: 11/21/2022]
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18
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Chang PY, Yen YS, Wu JC, Chang HK, Fay LY, Tu TH, Wu CL, Huang WC, Cheng H. The importance of atlantoaxial fixation after odontoidectomy. J Neurosurg Spine 2016; 24:300-308. [DOI: 10.3171/2015.5.spine141249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Although anterior odontoidectomy has been widely accepted as a procedure for decompression of the craniovertebral junction (CVJ), postoperative biomechanical instability has not been well addressed. There is a paucity of data on the necessity for and choice of fixation.
METHODS
The authors conducted a retrospective review of consecutively treated patients with basilar invagination who underwent anterior odontoidectomy and various types of posterior fixation. Posterior fixation included 1 of 3 kinds of constructs: occipitocervical (OC) fusion with atlantoaxial (AA) fixation, OC fusion without AA fixation, or AA-only (without OC) fixation. On the basis of the use or nonuse of AA fixation, these patients were assigned to either the AA group, in which the posterior fixation surgery involved both the atlas and axis simultaneously, regardless of whether the patient underwent OC fusion, or the non-AA group, in which the OC fusion construct spared the atlas, axis, or both. Clinical outcomes and neurological function were compared. Radiological results at each time point (i.e., before and after odontoidectomy and after fixation) were assessed by calculating the triangular area causing ventral indentation of the brainstem in the CVJ.
RESULTS
Data obtained in 14 consecutively treated patients with basilar invagination were analyzed in this series; the mean follow-up time was 5.75 years. The mean age was 53.58 years; there were 7 males and 7 females. The AA and non-AA groups consisted of 7 patients each. The demographic data of both groups were similar. Overall, there was significant improvement in neurological function after the operation (p = 0.03), and there were no differences in the postoperative Nurick grades between the 2 groups (p = 1.00). According to radiological measurements, significant decompression of the ventral brainstem was achieved stepwise in both groups by anterior odontoidectomy and posterior fixation; the mean ventral triangular area improved from 3.00 ± 0.86 cm2 to 2.08 ± 0.51 cm2 to 1.68 ± 0.59 cm2 (before and after odontoidectomy and after fixation, respectively; p < 0.05). The decompression gained by odontoidectomy (i.e., reduction of the ventral triangular area) was similar in the AA and non-AA groups (0.66 ± 0.42 cm2 vs 1.17 ± 1.42 cm2, respectively; p = 0.38). However, the decompression achieved by posterior fixation was significantly greater in the AA group than in the non-AA group (0.64 ± 0.39 cm2 vs 0.17 ± 0.16 cm2, respectively; p = 0.01).
CONCLUSIONS
Anterior odontoidectomy alone provides significant decompression at the CVJ. Adjuvant posterior fixation further enhances the extent of decompression after the odontoidectomy. Moreover, posterior fixation that involves AA fixation yields significantly more decompression of the ventral brainstem than OC fusion that spares AA fixation.
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Affiliation(s)
- Peng-Yuan Chang
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Yu-Shu Yen
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Jau-Ching Wu
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Hsuan-Kan Chang
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Li-Yu Fay
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
- 4Institute of Pharmacology, National Yang-Ming University; and
| | - Tsung-Hsi Tu
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
- 5Molecular Medicine Program, Taiwan International Graduate Program, Academia Sinica, Taipei, Taiwan
| | - Ching-Lan Wu
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine and
| | - Wen-Cheng Huang
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Henrich Cheng
- 1Department of Neurosurgery, Neurological Institute, and
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine and
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Godzik J, Ravindra VM, Ray WZ, Schmidt MH, Bisson EF, Dailey AT. Comparison of structural allograft and traditional autograft technique in occipitocervical fusion: radiological and clinical outcomes from a single institution. J Neurosurg Spine 2015; 23:144-52. [PMID: 25955801 DOI: 10.3171/2014.12.spine14535] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors' objectives were to compare the rate of fusion after occipitoatlantoaxial arthrodesis using structural allograft with the fusion rate from using autograft, to evaluate correction of radiographic parameters, and to describe symptom relief with each graft technique. METHODS The authors assessed radiological fusion at 6 and 12 months after surgery and obtained radiographic measurements of C1-2 and C2-7 lordotic angles, C2-7 sagittal vertical alignments, and posterior occipitocervical angles at preoperative, postoperative, and final follow-up examinations. Demographic data, intraoperative details, adverse events, and functional outcomes were collected from hospitalization records. Radiological fusion was defined as the presence of bone trabeculation and no movement between the graft and the occiput or C-2 on routine flexion-extension cervical radiographs. Radiographic measurements were obtained from lateral standing radiographs with patients in the neutral position. RESULTS At the University of Utah, 28 adult patients underwent occipitoatlantoaxial arthrodesis between 2003 and 2010 using bicortical allograft, and 11 patients were treated using iliac crest autograft. Mean follow-up for all patients was 20 months (range 1-108 months). Of the 27 patients with a minimum of 12 months of follow-up, 18 (95%) of 19 in the allograft group and 8 (100%) of 8 in the autograft group demonstrated evidence of bony fusion shown by imaging. Patients in both groups demonstrated minimal deterioration of sagittal vertical alignment at final follow-up. Operative times were comparable, but patients undergoing occipitocervical fusion with autograft demonstrated greater blood loss (316 ml vs 195 ml). One (9%) of 11 patients suffered a significant complication related to autograft harvesting. CONCLUSIONS The use of allograft in occipitocervical fusion allows a high rate of successful arthrodesis yet avoids the potentially significant morbidity and pain associated with autograft harvesting. The safety and effectiveness profile is comparable with previously published rates for posterior C1-2 fusion using allograft.
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Affiliation(s)
- Jakub Godzik
- Department of Neurosurgery, Washington University, St. Louis, Missouri; and
| | - Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Wilson Z Ray
- Department of Neurosurgery, Washington University, St. Louis, Missouri; and
| | - Meic H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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20
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Kukreja S, Ambekar S, Sin AH, Nanda A. Occipitocervical Fusion Surgery: Review of Operative Techniques and Results. J Neurol Surg B Skull Base 2015; 76:331-9. [PMID: 26401473 DOI: 10.1055/s-0034-1543967] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 10/29/2014] [Indexed: 02/03/2023] Open
Abstract
Objective Varying types of clinicoradiologic presentations at the craniovertebral junction (CVJ) influence the decision process for occipitocervical fusion (OCF) surgery. We discuss the operative techniques and decision-making process in OCF surgery based on our clinical experience and a literature review. Material and Methods A total of 49 consecutive patients who underwent OCF participated in the study. Sagittal computed tomography images were used to illustrate and measure radiologic parameters. We measured Wackenheim clivus baseline (WCB), clivus-canal angle (CCA), atlantodental distance (ADD), and Powers ratio (PR) in all the patients. Results Clinical improvement on Nurick grading was recorded in 36 patients. Patients with better preoperative status (Nurick grades 1-3) had better functional outcomes after the surgery (p = 0.077). Restoration of WCB, CCA, ADD, and PR parameters following the surgery was noted in 39.2%, 34.6%, 77.4%, and 63.3% of the patients, respectively. Complications included deep wound infections (n = 2), pseudoarthrosis (n = 2), and deaths (n = 4). Conclusion Conventional wire-based constructs are superseded by more rigid screw-based designs. Odontoidectomy is associated with a high incidence of perioperative complications. The advent of newer implants and reduction techniques around the CVJ has obviated the need for this procedure in most patients.
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Affiliation(s)
- Sunil Kukreja
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
| | - Sudheer Ambekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
| | - Anthony H Sin
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
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21
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Felbaum D, Spitz S, Sandhu FA. Correction of clivoaxial angle deformity in the setting of suboccipital craniectomy: technical note. J Neurosurg Spine 2015; 23:8-15. [PMID: 25860518 DOI: 10.3171/2014.11.spine14484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A subset of patients with Chiari Type I malformation may develop neurological dysfunction secondary to an abnormally obtuse clivoaxial angle (CXA) and clivoaxial deformity causing deformative stress injury to the neural axis. Clivoaxial deformity can occur after initial standard suboccipital craniectomy, duraplasty, and C-1 laminectomy for brainstem compression, or severe clivoaxial deformity may be present in conjunction with a Chiari malformation. Clivoaxial deformity and abnormal CXA can be treated with an occipitocervical fusion (OCF). Performing OCF in the setting of a cranial defect can be challenging with currently available instrumentation. The authors describe their recent experience and outcomes in 3 consecutive pediatric patients using the "inside-out" technique for treating clivoaxial deformity and abnormal CXA in the setting of a craniectomy defect to restore stability to the craniocervical junction, while correcting the CXA.
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Affiliation(s)
- Daniel Felbaum
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington DC
| | - Steven Spitz
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington DC
| | - Faheem A Sandhu
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington DC
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22
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Mendes GAC, Dickman CA, Rodriguez-Martinez NG, Kalb S, Crawford NR, Sonntag VKH, Preul MC, Little AS. Endoscopic endonasal atlantoaxial transarticular screw fixation technique: an anatomical feasibility and biomechanical study. J Neurosurg Spine 2015; 22:470-7. [PMID: 25679235 DOI: 10.3171/2014.10.spine14374] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The primary disadvantage of the posterior cervical approach for atlantoaxial stabilization after odontoidectomy is that it is conducted as a second-stage procedure. The goal of the current study is to assess the surgical feasibility and biomechanical performance of an endoscopic endonasal surgical technique for C1-2 fixation that may eliminate the need for posterior fixation after odontoidectomy. METHODS The first step of the study was to perform endoscopic endonasal anatomical dissections of the craniovertebral junction in 10 silicone-injected fixed cadaveric heads to identify relevant anatomical landmarks. The second step was to perform a quantitative analysis using customized software in 10 reconstructed adult cervical spine CT scans to identify the optimal screw entry point and trajectory. The third step was biomechanical flexibility testing of the construct and comparison with the posterior C1-2 transarticular fixation in 14 human cadaveric specimens. RESULTS Adequate surgical exposure and identification of the key anatomical landmarks, such as C1-2 lateral masses, the C-1 anterior arch, and the odontoid process, were provided by the endonasal endoscopic approach in all specimens. Radiological analysis of anatomical detail suggested that the optimal screw entry point was on the anterior aspect of the C-1 lateral mass near the midpoint, and the screw trajectory was inferiorly and slightly laterally directed. The custommade angled instrumentation was crucial for screw placement. Biomechanical analysis suggested that anterior C1-2 fixation compared favorably to posterior fixation by limiting flexion-extension, axial rotation, and lateral bending (p > 0.3). CONCLUSIONS This is the first study that demonstrates the feasibility of an endoscopic endonasal technique for C1-2 fusion. This novel technique may have clinical utility by eliminating the need for a second-stage posterior fixation operation in certain patients undergoing odontoidectomy.
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Filis AK, Aghayev KV, Doulgeris JJ, Gonzalez-Blohm SA, Vrionis FD. Spinal neoplastic instability: biomechanics and current management options. Cancer Control 2015; 21:144-50. [PMID: 24667401 DOI: 10.1177/107327481402100207] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Often the spine is afflicted from primary or metastatic neoplastic disease, which can lead to instability. Instability can cause deformity, pain, and spinal cord compression and is an indication for surgery. Although overt instability is uniformly agreed upon, it is sometimes difficult for specialists to agree on subtle degrees of instability due to lack of objective criteria. METHODS In this article, treatment options and the spine instability neoplastic system are discussed and the neoplastic instability literature is reviewed. RESULTS The Spinal Instability Neoplastic Score helps specialists determine whether instability is present and when surgery may be indicated. However, other parameters such as spinal cord compression and extent of disease dictate whether surgery is the most appropriate option. A wide range of fusion techniques exists, each one tailored to the location of the lesion and goals for surgery. CONCLUSIONS To optimize results, expert knowledge on the techniques and patient selection is of importance. Furthermore, a multidisciplinary approach is required because treatment of neoplastic disease is multimodal.
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Pseudotumor retroodontoideo en un paciente con hiperostosis esquelética idiopática difusa. Neurocirugia (Astur) 2014; 25:25-8. [DOI: 10.1016/j.neucir.2013.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 11/19/2012] [Accepted: 01/08/2013] [Indexed: 02/04/2023]
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25
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Cappuccio M, De Iure F, Amendola L, Paderni S, Bosco G. Occipito-cervical fusion in post-traumatic instability of the upper cervical spine and cranio-cervical junction. 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 Suppl 6:S900-4. [PMID: 24043340 DOI: 10.1007/s00586-013-3015-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 09/08/2013] [Accepted: 09/08/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Surgical management of upper cervical spine (UCS) unstable injuries may be challenging as the number of cases requiring this surgery collected in every single center is small. This retrospective study was conducted to analyze the radiographic and clinical results in 12 patients undergoing a posterior occipito-cervical fusion by a polyaxial screws-rod-plate system. METHODS There were eight male and four female patients with a mean age of 73.7 years (range 32-89 years). Six patients presented neurologic deficits at admission. Six patients had sustained major trauma. The remaining six patients had suffered a minor trauma. RESULTS Two patients died postoperatively in Intensive Care Unit. All surviving patients achieved solid fusion at 6 months. No surviving patient had neurological deterioration postoperatively. There were no instrumentation failures or revision required. Two patients suffered from superficial occipital wound infection. CONCLUSIONS Although the indication to occipito-cervical fusion decreased since the new C1-C2 posterior fixation techniques were described, it remains a valid and reliable option in UCS post-traumatic instability to be applied even in emergency especially in the elderly.
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Ahmed R, Menezes AH. Management of operative complications related to occipitocervical instrumentation. Neurosurgery 2013; 72:ons214-28; discussion ons228. [PMID: 23313976 DOI: 10.1227/neu.0b013e31827bf512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The continued evolution of instrumentation techniques for fusions at the craniovertebral junction has enabled surgical treatment of a wide range of developmental, neoplastic, traumatic, and degenerative conditions. There has been an increased recognition of the morbidity associated with the complications secondary to occipitocervical instrumentation. OBJECTIVE To present representative complications secondary to occipitocervical instrumentation in patients who presented to our institution and to emphasize underlying principles in diagnosis and management of craniovertebral disease conditions through illustrative examples of their presentation, management, and follow-up. METHODS Clinical records for patients referred to the senior author (A.H.M.) between 2005 and 2010 for evaluation and management of their symptoms arising as a consequence of surgical intervention by a different primary neurosurgeon were reviewed. RESULTS Eight patients were identified with representative complications secondary to occipitocervical instrumentation. These complications included incorrect surgical technique, persistent instability, hardware misplacement with potential for vascular injury, associated neural injury, and secondary complications of wound healing resulting from methyl methacrylate use. Surgical revision was required in 2 patients. The remaining patients improved with removal of the offending hardware and acrylic cement. All patients reported symptom resolution, and dynamic imaging studies on follow-up indicated stable alignment and bony fusion. CONCLUSION These cases serve as illustrative examples of the spectrum of neural, vascular, biomechanical, and instrument-related complications associated with occipitocervical arthrodesis. Basic principles of occipitocervical instrumentation that enable safe and successful treatment of craniovertebral junction disease conditions have been highlighted. Potential complications and management strategies are discussed.
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Affiliation(s)
- Raheel Ahmed
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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27
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Techniques of Atlantoaxial Fixation and the Resection of C2 Nerve Root. World Neurosurg 2012; 78:603-4. [PMID: 22381287 DOI: 10.1016/j.wneu.2011.12.070] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 12/09/2011] [Indexed: 11/22/2022]
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28
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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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