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Redlich N, Gelvez D, Dong K, Darlow M, Williams J, Shammassian B, Bhandutia AK. Intraoperative Vertebral Artery Injury: Evaluation, Management, and Prevention. Orthop Clin North Am 2024; 55:139-149. [PMID: 37980099 DOI: 10.1016/j.ocl.2023.06.006] [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] [Indexed: 11/20/2023]
Abstract
Vertebral artery injury (VAI) is a serious and potentially life-threatening injury that is encountered with trauma to the cervical spine and less frequently during surgery. VAI can occur during either anterior or posterior cervical approaches or instrumentation and often involves anomalous courses of the artery. Although the incidence is rare, serious consequences including fistula formation, thrombosis, pseudoaneurysm development, cerebral ischemia, hemorrhage, and death may occur. Management of VAI can be divided into prevention, including review of preoperative imaging with knowledge of the anatomic course, utilization of surgical landmarks intraoperatively, and prompt recognition and management when injury is encountered.
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Affiliation(s)
- Nathan Redlich
- LSUHSC Orthopaedic Surgery Resident, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA.
| | - Daniel Gelvez
- LSUHSC Orthopaedic Surgery Resident, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Katherine Dong
- LSUHSC Orthopaedic Surgery Resident, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Matthew Darlow
- LSUHSC Orthopaedic Surgery Resident, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Jestin Williams
- LSUHSC Orthopaedic Surgery Resident, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Berje Shammassian
- LSUHSC Neurosurgery, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Amit K Bhandutia
- LSUHSC Orthopaedic and Spine Surgery, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
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Xiao H, Huang Z, Xu P, Lin J, Zhu Q, Ji W. Anterior Transarticular Crossing Screw Fixation for Atlantoaxial Joint Instability: A Biomechanical Study. Neurospine 2023; 20:940-946. [PMID: 37798988 PMCID: PMC10562216 DOI: 10.14245/ns.2346472.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/10/2023] [Accepted: 06/20/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE To evaluate the biomechanical stability of anterior transarticular crossing screw (ATCS) and compare it with anterior transarticular screw (ATS) which may provide basic evidence for clinical application. METHODS Eight human fresh cadaveric specimens (occiput-C4) were tested with 5 conditions including the intact status, the injury status (type II odontoid fracture), the injury+ATS fixation status (traditional bilateral ATS fixation); the injury+unilateral ATCS fixation status; and the injury+bilateral ATCS fixation status. Specimens were applied to a pure moment of 1.5 Nm in flexion-extension, lateral bending, and axial rotation, respectively. The range of motions (ROMs) and the neutral zones (NZs) of C1 to C2 segment were calculated and compared between 5 status. RESULTS ATS and ATCS fixations significantly reduced the motions in all directions when compared with the intact and injury statues (p < 0.05). In flexion-extension, the ROMs of ATS, unilateral ATCS, and bilateral ATCS were 4.7° ± 2.5°, 4.1° ± 1.9°, and 3.2° ± 1.2°, respectively. Bilateral ATCS resulted in a significant decrease in ROM in flexion-extension when compared with ATS and unilateral ATCS (p = 0.035 and p = 0.023). In lateral bending and axial rotation, there was no significant difference in ROM between the 3 fixations (p > 0.05). Three fixations resulted in similar NZs in all directions (p > 0.05). CONCLUSION ATCS is a biomechanically effective alternative or supplemental method for atlantoaxial instability.
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Affiliation(s)
- Hang Xiao
- Division of Spinal Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiping Huang
- Division of Spinal Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Panjie Xu
- Division of Spinal Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junyu Lin
- Division of Spinal Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Qingan Zhu
- Division of Spinal Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei Ji
- Division of Spinal Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Orthopaedics, Yunfu People’s Hospital, Yunfu, China
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Kleinstück FS, Fekete TF, Loibl M, Jeszenszky D, Haschtmann D, Porchet F, Mannion AF. Patient-rated outcome after atlantoaxial (C1-C2) fusion: more than a decade of evaluation of 2-year outcomes in 126 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3620-3630. [PMID: 34477947 DOI: 10.1007/s00586-021-06959-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/30/2021] [Accepted: 08/07/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Various surgical techniques have been introduced for atlantoaxial (C1-C2) fusion, the most common being Magerl's (transarticular) or the Harms/Goel screw fixation. Common indications include degenerative osteoarthritis (OA), trauma or rheumatoid arthritis (RA). Only few, small studies have evaluated patient-reported outcomes after C1-C2 fusion. We investigated 2-year outcomes in a large series of consecutive patients undergoing isolated C1-C2 fusion. METHODS We analysed prospectively collected data (2005-2016) from our Spine outcomes database, collected within the framework of EUROSPINE's Spine Tango Registry. It included 126 patients (34 (27%) men, 92 (73%) women; mean (SD) age 67 ± 19 y) who had undergone first-time isolated C1-C2 fusion (61% Magerl, 39% Harms(-Goel)) at least 2 years ago for OA (83 (66%)), RA (20 (16%)), fracture (15 (12%)) or other (8 (6%)). Patients completed the multidimensional Core Outcome Measures Index (COMI; 0-10) and various single item outcomes. RESULTS Questionnaires were returned by 118/126 (94%) patients, 2 years post-operative. Mean COMI scores showed a significant reduction from baseline: 6.9 ± 2.4 to 2.7 ± 2.5 (p < 0.0001). Overall, 75% patients achieved the MCIC of ≥ 2.2 points reduction in COMI and 88% reported a good global outcome. 91% patients were satisfied/very satisfied with their care. Self-reported complications were declared by 16% patients and further surgery at the same segment, by 2.5%. CONCLUSION In this large series with almost complete follow-up, C1-C2 fusion showed extremely good results. Despite the complexity of the intervention, outcomes surpassed those typically reported for simple procedures such as ACDF and lumbar discectomy, suggesting reservations about the procedure should perhaps be reviewed.
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Affiliation(s)
- F S Kleinstück
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - T F Fekete
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland.
| | - M Loibl
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - D Jeszenszky
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - D Haschtmann
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - F Porchet
- Department of Spine Surgery and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - A F Mannion
- Spine Center Division, Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
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Lvov I, Grin A, Talypov A, Barbakadze Z, Abdrafiev R, Krylov V. Fluoroscopic landmarks and trajectories for safe posterior percutaneous transarticular C1-C2 screw insertion: a CT-based simulation study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:1651-1661. [PMID: 33517498 DOI: 10.1007/s00586-021-06744-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/18/2020] [Accepted: 01/19/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine the safe screw trajectory for posterior transarticular fixation of C1-C2 without direct visualisation of C2 lateral masses and by using fluoroscopic landmarks only. METHODS Fluoroscopic models of the craniovertebral region in frontal and sagittal planes were reconstructed using 1-mm interval computed tomography scans of the cervical spine in 30 patients. The imitation model of the screw trajectory was then applied with verification of the exact screw localisation using multiplanar reconstruction. Twenty-seven trajectories for 60 oblique C1-C2 reformations were tested. RESULTS In the frontal plane, all correct trajectories passed through the medial waistline point (WstP) of C3 and through the middle of the lateral mass of C1. In the lateral plane, the posterior spinal process-lateral mass (SpLM) point-middle C1 anterior tuberculum point (ATP), middle SpLM-upper ATP, and lower SpLM-odontoid point (ODP)-had relatively low rates of vertebral artery (VA) injury (2.3%, 4.6%, and 7%, respectively) and other screw malpositions (6.9%, 4.6%, and 4.6%, respectively). In cases of an isthmus height exceeding 8 mm, there were no incidences of VA injury. Patients with an isthmus width greater than 7 mm had a lower risk of screw malposition. CONCLUSION We identified potentially safe trajectories for percutaneous posterior transarticular fixation of C1-C2. Using SpLM, ATP, and ODP landmarks in the lateral plane, and WstP and C1 middle landmarks in the frontal plane, it is possible to achieve an acceptable screw position without direct visualisation of the C2 lateral mass.
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Affiliation(s)
- Ivan Lvov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia.
| | - Andrey Grin
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
- Department of Neurosurgery, Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Aleksandr Talypov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
| | - Zaali Barbakadze
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
| | - Rinat Abdrafiev
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
| | - Vladimir Krylov
- Department of Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine, B. Suharevskaya Pl. 3, Moscow, 107945, Russia
- Department of Neurosurgery, Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Zhou X, Li S, Liu H, Guo Q, Guo X, Chen F, Han Z, Ni B. Comparison of Two Bone Grafting Techniques Applied During Posterior C1-C2 Screw-Rod Fixation and Fusion for Treating Reducible Atlantoaxial Dislocation. World Neurosurg 2020; 143:e253-e260. [PMID: 32711146 DOI: 10.1016/j.wneu.2020.07.110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several bone grafting techniques for posterior atlantoaxial arthrodesis have been reported. The techniques of placing a cancellous morselized bone graft (MBG) on decorticated surfaces of the atlantoaxial complex and securing a structural iliac bone graft (SBG) between C1 and C2 have been used widely. The aim of the present study was to compare the outcomes of these 2 bone grafting techniques for atlantoaxial arthrodesis. METHODS The data from 64 patients with reducible atlantoaxial dislocation treated using posterior C1-C2 screw-rod fixation and fusion were retrospectively reviewed. The MBG technique had been used in 32 patients and the SBG technique in 32 patients. The time required for bone fusion was recorded. The outcomes were evaluated using the Japanese Orthopaedic Association scale score, Neck Disability Index, visual analog scale (VAS) score for neck pain, patient satisfaction, and neck stiffness and compared between the 2 groups. The donor site complications were also compared, and donor site pain was assessed using a VAS. RESULTS At the final follow-up, the bone fusion rate was 100% in both groups. No significant differences were found in the bone fusion time or donor site pain between the 2 groups (P > 0.05). Postoperatively, The Japanese Orthopaedic Association scale scores, Neck Disability Index, and VAS score for neck pain had improved significantly within both groups (P < 0.05), with no statistically significant differences between the 2 groups (P > 0.05). Additionally, no differences were found between the 2 groups in patient satisfaction and neck stiffness postoperatively (P > 0.05). CONCLUSIONS The MBG and SBG techniques were both effective for atlantoaxial arthrodesis, with the advantages of reducing the potential risk of catastrophic bleeding of the epidural venous plexus and C2 nerve root injury.
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Affiliation(s)
- Xin Zhou
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Songkai Li
- Orthopedic Center, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Hua Liu
- Orthopedic Center, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Qunfeng Guo
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Xiang Guo
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Fei Chen
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Zhao Han
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Bin Ni
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China.
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Zhang Y, Li C, Li L, Sun Y, Li Z, Mei Y, Feng X. Design a novel integrated screw for minimally invasive atlantoaxial anterior transarticular screw fixation: a finite element analysis. J Orthop Surg Res 2020; 15:244. [PMID: 32631369 PMCID: PMC7339419 DOI: 10.1186/s13018-020-01764-w] [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: 03/31/2020] [Accepted: 06/26/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To design a new type of screw for minimally invasive atlantoaxial anterior transarticular screw (AATS) fixation with a diameter that is significantly thicker than that of traditional screws, threaded structures at both ends, and a porous metal structure in the middle. The use of a porous metal structure can effectively promote bone fusion and compensate for the disadvantages of traditional AATSs in terms of insufficient fixation strength and difficulty of bone fusion. The biomechanical stability of this screw was verified through finite element analysis. This instrument may provide a new surgical option for the treatment of atlantoaxial disorders. METHODS According to the surgical procedure, the new type of AATS was placed in a three-dimensional atlantoaxial model to determine the setting of relevant parameters such as the diameter, length, and thread to porous metal ratio of the structure. According to the results of measurement, the feasibility and safety of the new AATS were verified, and a representative finite element model of the upper cervical vertebrae was chosen to establish, and the validity of the model was verified. Then, finite element-based biomechanical analysis was performed using three models, i.e., atlantoaxial posterior pedicle screw fixation, traditional atlantoaxial AATS fixation, and atlantoaxial AATS fixation with the new type of screw, and the biomechanical effectiveness of the novel AATS was verified. RESULTS By measuring the atlantoaxial parameters, the atlantoaxial CT data of the representative 30-year-old normal adult male were selected to create a personalized 3D printing AATS screw. In this case, the design parameters of the new screw were determined as follows: diameter, 6 mm; length of the head thread structure, 10 mm; length of the middle porous metal structure, 8 mm (a middle porous structure containing an annular cylinder ); length of the tail thread structure, 8 mm; and total length, 26 mm. Applying the same load conditions to the atlantoaxial complex along different directions in the established finite element models of the three types of atlantoaxial fusion modes, the immediate stability of the new AATS is similar with Atlantoaxial posterior pedicle screw fixation.They are both superior to traditional atlantoaxial anterior screw fixation.The maximum local stress on the screw head in the atlantoaxial anterior surgery was less than those of traditional atlantoaxial anterior surgery. CONCLUSIONS By measuring relevant atlantoaxial data, we found that screws with a larger diameter can be used in AATS surgery, and the new AATS can make full use of the atlantoaxial lateral mass space and increase the stability of fixation. The finite element analysis and verification revealed that the biomechanical stability of the new AATS was superior to the AATS used in traditional atlantoaxial AATS fixation. The porous metal structure of the new AATS may promote fusion between atlantoaxial joints and allow more effective bone fusion in the minimally invasive anterior approach surgery.
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Affiliation(s)
- Yingkai Zhang
- Department of Orthopaedic Surgery, Shengjing Hospital of China Medical University, Sanhao Road 36, Shenyang City, 110001, Liaoning Province, People's Republic of China
| | - Cheng Li
- Department of Orthopaedic Surgery, Shengjing Hospital of China Medical University, Sanhao Road 36, Shenyang City, 110001, Liaoning Province, People's Republic of China
| | - Lei Li
- Department of Orthopaedic Surgery, Shengjing Hospital of China Medical University, Sanhao Road 36, Shenyang City, 110001, Liaoning Province, People's Republic of China.
| | - Yanyan Sun
- Shandong Weigao Orthopaedic Device co., Ltd., Weihai, 264300, People's Republic of China
| | - Zeqing Li
- Department of Orthopaedic Surgery, Shengjing Hospital of China Medical University, Sanhao Road 36, Shenyang City, 110001, Liaoning Province, People's Republic of China
| | - Yunli Mei
- Department of Orthopaedic Surgery, Shengjing Hospital of China Medical University, Sanhao Road 36, Shenyang City, 110001, Liaoning Province, People's Republic of China
| | - Xinyuan Feng
- Department of Orthopaedic Surgery, Shengjing Hospital of China Medical University, Sanhao Road 36, Shenyang City, 110001, Liaoning Province, People's Republic of China
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Minimally Invasive Percutaneous C1-C2 Fixation Using an Intraoperative Three-Dimensional Imaging–Based Navigation System for Management of Odontoid Fractures. World Neurosurg 2020; 137:266-271. [DOI: 10.1016/j.wneu.2019.12.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 12/10/2019] [Indexed: 11/23/2022]
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Radiologic Characteristics of Anterior Transarticular Crossing Screw Placement for Atlantoaxial Joint Instability. World Neurosurg 2020; 137:e152-e158. [PMID: 31981786 DOI: 10.1016/j.wneu.2020.01.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/12/2020] [Accepted: 01/13/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The feasibility of anterior transarticular crossing screws (ATCS) was confirmed in cadaveric specimens and it has been used in clinic. However, no study has documented the morphometric characteristics of ATCS. This study seeks to determine the morphometric characteristics of ATCS in C1-C2 fixation. METHODS A total of 100 patients without abnormality of C1-2 were enrolled. The range of screw lateral angles (LAs) and the screw lengths of ATCS on coronal images were measured on multiplanar computed tomography images, as well as the screw incline angles (IAs) in the sagittal plane. The ideal trajectory was designed as toward to the posterosuperior points of the opposite C1 lateral mass, which had the longest screw. RESULTS The LAs were relatively small in men (31.4°-45.3°) compared with women (32.6°-46.0°). In the sagittal plane, the IAs were ranged from 41.0° to 68.4° in men and from 44.4° to 68.1° in women. The overall screw lengths were longer in men (34.7-44.8 mm) than in women (32.2-39.6 mm). In the ideal path, the LA and IA were 38.4° and 41.0° in men and 39.6° and 44.4° in women, and the screw lengths were 44.8 mm in men and 39.6 mm in women. CONCLUSIONS This study provides the range of screw angles and lengths of ATCS, which will help surgeons to perform ATCS safely and accurately.
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Tian W, Liu YJ, Liu B, He D, Wu JY, Han XG, Zhao JW, Fan MX. Guideline for Posterior Atlantoaxial Internal Fixation Assisted by Orthopaedic Surgical Robot. Orthop Surg 2020; 11:160-166. [PMID: 31025810 PMCID: PMC6594511 DOI: 10.1111/os.12454] [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: 03/08/2019] [Accepted: 03/19/2019] [Indexed: 12/01/2022] Open
Abstract
Atlantoaxial transarticular facet screw fixation (Magerl technique) and C1 lateral mass screws combined with C2 pedicle screws fixation (Harms technique) are the most commonly used techniques for posterior internal fixation in the upper cervical spine. Upper cervical spinal surgery is a technically demanding and challenging procedure because of complicated anatomical structures and frequent occurrence of anomalies. Accurate insertion of screws allows for stable and secure internal fixation, which is necessary for both techniques. Traditional methods under fluoroscopic assistance in this region cannot meet the requirements of high levels of accuracy and security during the procedure. Robot-assisted spinal surgery can provide accurate and reliable guidance during the screw insertion, which is evidenced in the literature. As a recently developed technique, robot-assisted surgery is supposed to be performed by skilled surgeons who have received standard training for robotic surgery. The standardized upper cervical spinal surgery assisted by the robot system needs to be introduced to these surgeons. Based on the consensus of consultant specialists, the literature review, and our local experience, this guideline included the introduction of the robotic system, the workflow of robot-assisted procedures, and the precautions to take during procedures. This guideline aims to provide a standardization of the robotic surgery for posterior atlantoaxial internal fixation.
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Affiliation(s)
- Wei Tian
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ya-Jun Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Bo Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Da He
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Jing-Ye Wu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Xiao-Guang Han
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Jing-Wei Zhao
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ming-Xing Fan
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
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Lofrese G, Cultrera F, Visani J, Nicassio N, Essayed WI, Donati R, Cavallo MA, De Bonis P. Intraoperative Doppler ultrasound as a means of preventing vertebral artery injury during Goel and Harms C1-C2 posterior arthrodesis: technical note. J Neurosurg Spine 2019; 31:824-830. [PMID: 31419805 DOI: 10.3171/2019.5.spine1959] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 05/28/2019] [Indexed: 11/06/2022]
Abstract
Vertebral artery injury (VAI) is a potential catastrophic complication of Goel and Harms C1-C2 posterior arthrodesis. Meticulous study of preoperative spinal CT angiography together with neuronavigation plays a fundamental role in avoiding VAI. Doppler ultrasonography may be an additional intraoperative tool, providing real-time identification of the vertebral artery (VA) and thus helping its preservation.Thirty-three consecutive patients with unstable odontoid fractures underwent Goel and Harms C1-C2 posterior arthrodesis. Surgery was performed with the aid of lateral fluoroscopic control in 16 cases (control group) that was supplemented by Doppler ultrasonography in 17 cases (Doppler group). Two patients in each group had a C1 ponticulus posticus. In the Doppler group, Doppler probing was performed during lateral subperiosteal muscle dissection, stepwise drilling, and tapping. Blood flow velocity in the V3 segment of the VA was recorded before and after posterior arthrodesis. All patients had a 12-month outpatient follow-up, and outcome was assessed using the Smiley-Webster Pain Scale. Neither VAI nor postoperative neurological impairments were observed in the Doppler group. In the control group, VAIs occurred in the 2 patients with C1 ponticulus posticus. In the Doppler group, 1 patient needed intra- and postoperative blood transfusions, and no difference in terms of Doppler signal or VA blood flow velocity was detected before and after C1-C2 posterior arthrodesis. In the control group, 3 patients needed intra- and postoperative blood transfusions.Useful in supporting fluoroscopy-assisted procedures, intraoperative Doppler may play a significant role even during surgeries in which neuronavigation is used, reducing the chance of a mismatch between the view on the neuronavigation screen and the actual course of the VA in the operative field and supplying the additional data of blood flow velocity.
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Affiliation(s)
| | | | - Jacopo Visani
- 2Neurosurgery Division, University Hospital S. Anna, Cona di Ferrara, Italy; and
| | | | - Walid Ibn Essayed
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Pasquale De Bonis
- 2Neurosurgery Division, University Hospital S. Anna, Cona di Ferrara, Italy; and
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Han IB, Choi UY, Shin DE, Ropper AE, Choi DS, Ahn TK. Symptomatic posterior fossa and supratentorial subdural hygromas as a rare complication following transarticular screw fixation with posterior wiring for atlantoaxial instability: A case report. Medicine (Baltimore) 2019; 98:e14847. [PMID: 31305388 PMCID: PMC6641781 DOI: 10.1097/md.0000000000014847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Atlantoaxial transarticular screw fixation has been an effective and appealing method for inducing fusion of the C1-C2 complex. This technique is usually performed with Gallie fusion. In performing Gallie fusion using sublaminar wiring, a major concern is the risk of dural tear associated with passing sublaminar wires through the epidural space. We present the first report on symptomatic symptomatic subdural hygroma (SDH) due to transarticular screw fixation with posterior wiring. PATIENTS CONCERNS A 50-year-old man had sustained dens fracture 20 years ago and presented with severe neck pain following a recent traffic accident. The images showed atlantoaxial instability due to nonunion of the dens fracture and the patient underwent transarticular screw fixation with posterior sublaminar wiring using Gallie technique. When the U-shaped wire was passed under the arch of C1 from inferior to superior, a dural tear and cerebrospinal fluid (CSF) leak occurred. The site of dural tear was repaired by direct application of sutures. The patient was discharged in good condition. Fifteen day after surgery, the patient was readmitted with a history of a progressive headache associated with vomiting and vertigo. DIAGNONSIS Brain CT and MRI showed bilateral posterior fossa and a right-sided supratentorial SDH. INTERVENTIONS The patient underwent right occipital burr hole and evacuation of posterior fossa SDH due to deteriorating neurological status. OUTCOMES The patient's condition gradually improved after the operation and became asymptomatic at 3-year follow-up. LESSONS Posterior fossa and supratentorial SDH could occur resulting from any intraoperative dural tear and CSF leakage during posterior cervical spinal surgery. Symptomatic SDH after posterior cervical spinal surgery should be cautiously assessed and treated. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- In-Bo Han
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center
| | - Un Yong Choi
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center
| | - Dong-Eun Shin
- Department of Orthopedic Surgery, CHA University School of Medicine, CHA Bundang Medical Center, South Korea
| | | | - Dae-Sung Choi
- Department of Orthopedic Surgery, CHA University School of Medicine, CHA Bundang Medical Center, South Korea
| | - Tae-Keun Ahn
- Department of Neurosurgery, Baylor College of Medicine, TX
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Lvov I, Grin A, Kordonskiy A, Sytnik A, Smirnov V, Khushnazarov U, Krylov V. Minimally Invasive Posterior Transarticular Stand-Alone Screw Instrumentation of C1-C2 Using a Transmuscular Approach: Description of Technique, Results and Comparison with Posterior Midline Exposure. World Neurosurg 2019; 128:e796-e805. [PMID: 31078803 DOI: 10.1016/j.wneu.2019.04.259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study was to compare the feasibility, safety, and fusion results of posterior transarticular stand-alone screw (SAS) instrumentation of C1-C2 with a minimally invasive technique to those of a posterior midline exposure. METHODS Between 2008 and 2016, 164 patients underwent surgical treatment for traumatic injuries to the upper cervical vertebrae at our institution. We included 38 patients (27 men and 11 women; age range, 17-81 years) in the study. The posterior midline approach (PMA) group (23 patients) included patients who underwent surgery by means of a conventional midline incision after percutaneous screw insertion. The transmuscular approach (TMA) group (15 patients) included patients who underwent SAS fixation by use of a minimally invasive technique. The mean follow-up period was 58 months (range, 12-118 months). RESULTS Statistical analysis revealed that the operative time, blood loss volume, and severity of postoperative pain were lower in the TMA group. No significant excess of radiation exposure to the surgical team and the patients occurred in TMA group compared with the PMA group. C1-C2 fusion was observed in 37 patients. Stable fibrous fusion between the C1 and C2 vertebrae was found in 1 patient. CONCLUSIONS A minimally invasive technique by use of a paravertebral transmuscular approach provides an alternative to routine posterior transarticular SAS fixation of C1 and C2 through a posterior midline approach. The minimally invasive technique reduces the duration of surgery and the volume of blood loss, decreases the severity of postoperative pain, and does not increase the amount of radiation exposure for the surgical team and the patient.
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Affiliation(s)
- Ivan Lvov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia.
| | - Andrey Grin
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; A. I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Anton Kordonskiy
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | | | - Vladimir Smirnov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | | | - Vladimir Krylov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; A. I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Lvov I, Grin A, Talypov A, Kordonskiy A, Sytnik A, Khushnazarov U, Smirnov V, Krylov V. A Comparison of the Long-Term Results of Posterior Transarticular Stand-Alone Screw Instrumentation and Magerl Technique in Patients with Traumatic Atlantoaxial Instability: Mean 5-Year Follow-Up Study with Radiological and Patient-Rated Outcomes Assessments. World Neurosurg 2019; 125:e1138-e1150. [PMID: 30780035 DOI: 10.1016/j.wneu.2019.01.263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/26/2019] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To perform a radiological analysis of the degeneration of C1-C2 joints after C1-C2 transarticular fixation (TAF) and compare the long-term results of a routine Magerl technique (RMT) to a posterior transarticular C1-C2 stand-alone screw instrumentation (SAS) application. METHODS A total of 40 patients (26 men and 14 women) were included in the present retrospective observational cohort study. The mean follow-up period was 61.7 months (range, 11-118). The mean patient age at the baseline examination was 48.4 years (range, 22-82). Of the 40 patients, 11 were included in the RMT group and 29 in the SAS group. RESULTS The structure of 80 atlantoaxial joints was analyzed, with grade 4 degenerative changes observed in 57 joints (71.3%). Of the 40 analyzed atlanto-odontoid joints, grade 4 degenerative changes were revealed in 18 joints (45%). C1-C2 bone fusion was observed in 38 patients (95%) and stable fibrous fusion in 2 patients (5%). No cases of C1-C2 nonunion were revealed. No statistically significant differences in the frequency of C1-C2 fracture consolidation or C1-C2 fusion were revealed between the RMT and SAS groups. CONCLUSIONS The application of cortical lag screws in TAF might result in stable atlantoaxial joint fusion formation without joint curettage. Atlanto-odontoid joint fusion was also observed after C1-C2 TAF. The application of cortical lag screws for bilateral fixation using the SAS technique resulted in C1-C2 fusion in 93.1% of cases, comparable to the results with the Magerl technique.
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Affiliation(s)
- Ivan Lvov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia.
| | - Andrey Grin
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; A.I. Evdokimov Moscow Medical University, Moscow, Russia
| | | | - Anton Kordonskiy
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | | | | | - Vladimir Smirnov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | - Vladimir Krylov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia; A.I. Evdokimov Moscow Medical University, Moscow, Russia
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Comparison of Two Posterior Three-Point Fixation Techniques for Treating Reducible Atlantoaxial Dislocation. Spine (Phila Pa 1976) 2019; 44:E60-E66. [PMID: 29939972 DOI: 10.1097/brs.0000000000002754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To compare the outcomes of C1-C2 transarticular screw combined with C1 laminar hook (TAS+C1H) and C1-C2 transarticular screw combined with modified Gallie technique (TAS+G) for treating reducible atlantoaxial dislocation (AAD). SUMMARY OF BACKGROUND DATA Both TAS+C1H and TAS+G fixation were 3-point fixation techniques for AAD. TAS+C1H technique was comparable to TAS+G technique in biomechanics. However, it is unknown whether it can achieve same outcomes as TAS+G technique. METHODS Data of the 63 patients who underwent TAS+C1H or TAS+G fixation and fusion because of AAD were retrospectively reviewed. Bone fusion time was recorded. The outcomes evaluated by visual analog scale score for neck pain (VASSNP), Nurick scale, neck stiffness (none/mild/severe), patient satisfaction, and Neck Disability Index (NDI) were compared between two groups. RESULTS At the final follow-up, bone graft fusion rates were 100% in both groups (P > 0.05). Nurick scales were significantly improved in both groups (P < 0.05), but with no significant differences between groups (P > 0.05). There were no significant differences between two groups in VASSNP, neck stiffness, patient satisfaction, or NDI (all P > 0.05). There were no complications related to the surgical approach and instrumentation in either group. CONCLUSION Both TAS+C1H and TAS+G fixation were effective in the treatment of reducible AAD. TAS+C1H was safer than TAS+G because it could potentially reduce the risk of spinal cord and venous plexus injury associated with sublaminar cables. LEVEL OF EVIDENCE 3.
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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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16
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Ishida W, Ramhmdani S, Xia Y, Kosztowski TA, Xu R, Choi J, De la Garza Ramos R, Elder BD, Theodore N, Gokaslan ZL, Sciubba DM, Witham TF, Bydon A, Wolinsky JP, Lo SFL. Use of Recombinant Human Bone Morphogenetic Protein-2 at the C1-C2 Lateral Articulation without Posterior Structural Bone Graft in Posterior Atlantoaxial Fusion in Adult Patients. World Neurosurg 2018; 123:e69-e76. [PMID: 30448576 DOI: 10.1016/j.wneu.2018.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/07/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Posterior atlantoaxial fusion is an important armamentarium for neurosurgeons to treat several pathologies involving the craniovertebral junction. Although the potential advantages of recombinant human bone morphogenetic protein-2 (rhBMP-2) are well documented in the lumbar spine, its indication for C1-C2 fusion has not been well characterized. In our institution, we apply rhBMP-2 to the C1-C2 joint either alone or with hydroxyapatite, locally harvested autograft chips, and/or morselized allogenic bone graft for selected cases-without conventional posterior structural bone graft. We report the clinical outcomes of the surgical technique to elucidate its feasibility. METHODS We performed a single-center, retrospective review of data from 2008 to 2016 and identified 69 patients who had undergone posterior atlantoaxial fusion with rhBMP-2. The clinical records of these patients were reviewed, and the baseline characteristics, operative data, and postoperative complications were collected and statistically analyzed. RESULTS The average age of the 69 patients was 60.8 ± 4.5 years, and 55.1% were women. With an average follow-up period of 21.1 ± 4.2 months, the C1-C2 fusion rate was 94.3% (65 of 69), and the average time to fusion was 11.4 ± 2.6 months (range, 5-23). The overall reoperation rate was 10.1% (7 of 69), with instrumentation failure in 7 patients (10.1%), adjacent segment disease in 2 (2.9%), and postoperative dysphagia and dyspnea in 2 patients (2.9%). No ectopic bone formation or soft tissue edema developed. CONCLUSIONS Although retrospective and from a single center, our study has shown that rhBMP-2 usage at the C1-C2 joint without posterior structural bone grafting is a safe and reasonable surgical option.
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Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Seba Ramhmdani
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Yuanxuan Xia
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Thomas A Kosztowski
- Department of Neurosurgery, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Risheng Xu
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - John Choi
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Rafael De la Garza Ramos
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Benjamin D Elder
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Jean-Paul Wolinsky
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA.
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Bhimani AD, Chiu RG, Esfahani DR, Patel AS, Denyer S, Hobbs JG, Mehta AI. C1–C2 Fusion Versus Occipito-Cervical Fusion for High Cervical Fractures: A Multi-Institutional Database Analysis and Review of the Literature. World Neurosurg 2018; 119:e459-e466. [DOI: 10.1016/j.wneu.2018.07.182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
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Biomechanical Comparison of Four Different Atlantoaxial Posterior Fixation Constructs in Adults: A Finite Element Study. Spine (Phila Pa 1976) 2018; 43:E891-E897. [PMID: 29462065 DOI: 10.1097/brs.0000000000002584] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Finite element analysis. OBJECTIVE To compare the biomechanical stability imparted to the C1 and C2 vertebrae by the transarticular (TA), C1 lateral mass (LM)-C2 pedicle (PS), C1LM-C2 pars, and C1LM-C2 translaminar (TL) screw fixation techniques. SUMMARY OF BACKGROUND DATA Cadaveric biomechanical studies of several atlantoaxial posterior fixation techniques have been performed, showing significant heterogeneity in biomechanical properties among the studies. METHODS From computed tomography images, a nonlinear intact three-dimensional C1-2 finite element model was developed and validated. Four finite element models were reconstructed from different C1-2 fixation techniques. The range of motion (ROM) and maximum von Misses stresses for the four screw techniques were compared under flexion, extension, lateral bending, and axial rotation. RESULTS C1LM-C2PS showed the greatest decrease in ROM with flexion/extension and lateral bending. C1-2TA and C1LM-C2 pars showed less ROM reduction than the other techniques, in flexion/extension. C1LM-C2TL showed the least decrease in ROM during axial rotation. For C1-2TA, the maximum stress was in the C1-2 joint region. In the C1LM-C2PS, the C1 rod head, C2 pars screw, and C2TL screw were stressed at the C2 rod head. The maximal von Mises stress on the C1-2TA at the C1-2 joint site was the highest at flexion/extension, whereas the C1LM-C2PS had the lowest stress on the screw at flexion/extension and lateral bending. The C1LM-C2TL showed the highest stress in axial rotation and lateral bending. CONCLUSION In this study, C1LM-C2PS fixation was the most stable technique. If surgeons have to use other fixation methods besides the C2 pedicle screw, they need to be aware that additional fixation or postoperative immobilization may be required to achieve ROM restriction. Careful observation at the maximum stress site on the screw including screw loosening, screw-bone interface disruption or screw fracture will be necessary during follow-up imaging examinations (x-ray and computed tomography scan) after atlantoaxial fixation. LEVEL OF EVIDENCE N/A.
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Pruthi N, Nehete L, Maity T, Dawn R, Ravindranath Y, Ravindranath R, Philips M. Can the position of the vertebral artery be predicted on a lateral view X-ray of the craniovertebral junction? A radiological anatomy study. Surg Neurol Int 2018; 9:124. [PMID: 30034915 PMCID: PMC6034355 DOI: 10.4103/sni.sni_109_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/11/2018] [Indexed: 11/04/2022] Open
Abstract
Background The most feared complication while inserting C2 screws is vertebral artery injury. This article proposes predicting the position of the vertebral artery on a true lateral X-ray of the axis vertebra from the background information acquired from the computed tomography (CT) scan utilizing fluoroscopy. Methods Spiral CT scans of 33 C2 vertebrae were performed utilizing a 16-slice CT scanner lateral X-rays of C2 were then obtained before and after painting the vertebral artery grooves with barium. The space available for transarticular and C2 pedicle screw insertion above the vertebral artery groove in the isthmus was then calculated as a ratio for both X-rays and CT scans. Results There was no statistically significant difference between the (mean) ratios calculated by CT scan and X-rays regarding the space available for transarticular and C2 pedicle screw insertion (left side: 0.3894 vs 0.3897; right side: 0.3892 vs 0.3925; P > 0.05). The Kappa test revealed that CT scan and X-ray findings were in agreement in majority of the bones (left side: n = 24, 72.7%, right side: n = 22, 73.3%; P < 0.05). Conclusion A thorough understanding of a true lateral view X-ray based on background information extracted from three dimensional CT scans helps predict the highest point of the vertebral artery groove. This proves useful for placement of C2 transarticular and pedicle screws during regular "open" and "minimally invasive" spine surgery.
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Affiliation(s)
- Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Lokesh Nehete
- Department of Neurosurgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Tanmoy Maity
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Rose Dawn
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Yogita Ravindranath
- Department of Human Anatomy, St. Johns Medical College, Bengaluru, Karnataka, India
| | - Roopa Ravindranath
- Department of Human Anatomy, St. Johns Medical College, Bengaluru, Karnataka, India
| | - Mariamma Philips
- Department of Biostatistics, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
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Richard SA, Lan ZG, Yang X, Huang S. An infantile alantoaxial dislocation with patent foramen ovale managed with titanium cabling and allogenic bone grafts. Pediatr Rep 2018; 10:7339. [PMID: 29721245 PMCID: PMC5907727 DOI: 10.4081/pr.2018.7339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 02/05/2023] Open
Abstract
Atlantoaxial dislocation is a disorder that is characterized with loss of stability of the atlas and axis (C1-C2) with consequential loss of usual articulation. Although this condition is very common, no one has reported a case as young as our patients. We present a 7-month infant with bilateral paralysis of the lower limbs for four (4) months with no history of trauma. Computer tomographic (CT-scan) imaging revealed alantoaxial dislocation with severe cervical spinal cord compression. The odontoid process is displaced outwardly with no bone destruction. Doppler echocardiogram done revealed patent foramen ovale. Thorough physical examination as well as radiological evaluation revealed no feather malformations. Electrophysio - logical studies reveal normal compound muscle action potentials (CMAP) and sensory nerve action potentials (SNAPs) in all the limbs. Electromyography (EMG) also revealed normal nerves in the limbs and the trunk. We attained a stable fusion and anatomical reduction using a posterior titanium wire and an iliac bone graft harvested from his mother. This is the youngest patient reported in literature. Infantile alantoaxial dislocation should be managed at early stage to prevent long-term neurologic disorders.
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Affiliation(s)
| | - Zhi Gang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiao Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Siqing Huang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
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Comparison of Outcomes Between C1-C2 Screw-Hook Fixation and C1-C2 Screw-Rod Fixation for Treating Reducible Atlantoaxial Dislocation. Spine (Phila Pa 1976) 2017; 42:1587-1593. [PMID: 28296813 DOI: 10.1097/brs.0000000000002152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To compare the outcomes of C1-C2 transarticular screw with C1 laminar hook (TAS + C1H) fixation and C1 trans-arch lateral mass screw with C2 pedicle screw (C1TLMS + C2PS) fixation in the treatment of reducible atlantoaxial dislocation (AAD). SUMMARY OF BACKGROUND DATA TAS + C1H is comparable to TAS with posterior wiring techniques and superior to C1 lateral mass screw combined with C2 pedicle screw (C1LMS + C2PS) in biomechanics. There were, however, few studies analyzing the differences in outcomes between TAS + C1H technique and modified C1LMS + C2PS technique (C1TLMS + C2PS) for treating AAD. METHODS Data of 30 patients with reducible AAD treated by TAS + C1H fixation and another 30 cases treated by C1TLMS + C2PS fixation were retrospectively analyzed. Bone fusion time was recorded. The outcomes evaluated by American Spinal Injury Association impairment scale, visual analog scale score for neck pain, neck stiffness (none/mild/severe), patient satisfaction, and Neck Disability Index (NDI) were compared between two groups. RESULTS There were no complications related to the surgical approach and instrumentation in either group. At the final follow-up, bone graft fusion rates were 100% in both the TAS + C1H fixation group and the C1TLMS + C2PS fixation group (P > 0.05). The neurological status evaluated by American Spinal Injury Association impairment scale were greatly improved in both screw-hook group (P < 0.001) and screw-rod group (P < 0.001), but with no significant differences between groups (P > 0.05). There were no significant differences between two groups in visual analog scale score for neck pain, neck stiffness, patient satisfaction, or Neck Disability Index (all P > 0.05). CONCLUSION C1TLMS + C2PS fixation was comparable to TAS + C1H fixation in fusion rate and functional outcomes for treating reducible AAD. To reduce the risk of vertebral artery injury, computed tomography scan, and reconstruction should be done to analyze vertebral artery course and C1-C2 anatomic structures before operation. LEVEL OF EVIDENCE 3.
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Comparison of outcomes after atlantoaxial fusion with C1 lateral mass–C2 pedicle screws and C1–C2 transarticular 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 2016; 26:1064-1072. [DOI: 10.1007/s00586-016-4829-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 09/09/2016] [Accepted: 10/16/2016] [Indexed: 11/25/2022]
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Huang KY, Lin RM, Fang JJ. A novel method of C1-C2 transarticular screw insertion for symptomatic atlantoaxial instability using a customized guiding block: A case report and a technical note. Medicine (Baltimore) 2016; 95:e5100. [PMID: 27787362 PMCID: PMC5089091 DOI: 10.1097/md.0000000000005100] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Atlantoaxial instability treated with the C1-2 transarticular screw fixation is biomechanically more stable; however, the technique demanding and the potential risk of neurovascular injury create difficulties for clinical usage, and there is still lack of clinical experience till now.We reported an adult female patient with symptomatic atlantoaxial instability due to rheumatoid arthritis that was successfully treated with a bilateral C1-C2 transarticular screw fixation using a customized guiding block. We preoperatively determined the trajectories for bilateral C1-C2 transarticular screws on a 3-dimensional reconstruction model from the computed tomography (CT) and self-developed computer software, and designed a rapid prototyping customized guiding block in order to offer a guide for the entry point and insertion angle of the C1-C2 transarticular screws.The clinical outcome was good, and the follow-up period was >3 years. The accuracy of the screws is good in comparison with preoperative and postoperative CT findings, and no neurovascular injury occurred.The patient was accurately and successfully treated with a bilateral C1-C2 transarticular screw fixation using a customized guiding block.
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Affiliation(s)
- Kuo-Yuan Huang
- Department of Orthopedics, College of Medicine, National Cheng Kung University
| | - Ruey-Mo Lin
- Department of Orthopedics, China Medical University, Tainan Municipal An-Nan Hospital
| | - Jing-Jing Fang
- Department of Mechanical Engineering, National Cheng Kung University, Tainan, Taiwan
- Correspondence: Jing-Jing Fang, Department of Mechanical Engineering, National Cheng Kung University, Tainan, Taiwan (e-mail: )
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Akinduro OO, Baum GR, Howard BM, Pradilla G, Grossberg JA, Rodts GE, Ahmad FU. Neurological outcomes following iatrogenic vascular injury during posterior atlanto-axial instrumentation. Clin Neurol Neurosurg 2016; 150:110-116. [PMID: 27618782 DOI: 10.1016/j.clineuro.2016.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/10/2016] [Accepted: 08/13/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Iatrogenic vascular injury is a feared complication of posterior atlanto-axial instrumentation. A better understanding of clinical outcome and management options following this injury will allow surgeons to better care for these patients. The object of the study was to systematically review the neurologic outcomes after iatrogenic vascular injury during atlanto-axial posterior instrumentation. METHODS We performed a systematic review of the Medline database following PRISMA guidelines. In our analysis, we included any retrospective cohort studies, prospective cohort studies, case reports, cases series, or systematic reviews with patients who had undergone posterior atlanto-axial fusion via screw rod constructs (SRC) or transarticular screws (TAS) that reported a patient with an injury to an arterial vessel directly attributable to the surgical procedure. RESULTS Sixty cases of vascular injury were reported in 2078 (2.9%) patients over 27 publications. The average age for this patient population was 55.7+/-17.9. Vascular injury following posterior C1/2 instrumentation resulted in ipsilateral stroke in 10.0% (n=6/60) and non-persistent neurologic deficit in 6.7% (n=4/60) of cases with the deficit being permanent (not including death) in 1.7% (n=1/60) of cases. Four patients (6.7%) died. Arteriovenous fistula or pseudoaneurysm occurred in 8.3% (n=5/60) and 3.3% (n=2/60) of cases, respectively. Eight patients (13.3%) underwent endovascular repair of the injury with no permanent deficit. CONCLUSION Neurological morbidity after iatrogenic vascular injury during posterior C1/2 fixation is higher than previously reported in literature. Some patients may benefit from endovascular treatment. Surgeons should be aware of normal and anomalous vertebral artery anatomy to avoid this potentially catastrophic complication.
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Affiliation(s)
- Oluwaseun O Akinduro
- Department of Neurological Surgery, Mayo Clinic Florida, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA
| | - Griffin R Baum
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite 2200, Atlanta, GA 30322, USA
| | - Brian M Howard
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite 2200, Atlanta, GA 30322, USA
| | - Gustavo Pradilla
- Department of Neurological Surgery, Emory University School of Medicine, Grady Memorial Hospital, 49 Jesse Hill Drive SE, Room 341, Atlanta GA 30303, USA
| | - Jonathan A Grossberg
- Department of Neurological Surgery, Emory University School of Medicine, Grady Memorial Hospital, 49 Jesse Hill Drive SE, Room 341, Atlanta GA 30303, USA
| | - Gerald E Rodts
- Emory Orthopedics and Spine Center, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, 30329 USA
| | - Faiz U Ahmad
- Department of Neurological Surgery, Emory University School of Medicine, Grady Memorial Hospital, 49 Jesse Hill Drive SE, Room 341, Atlanta GA 30303, USA.
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Tanenbaum JE, Lubelski D, Rosenbaum BP, Thompson NR, Benzel EC, Mroz TE. Predictors of outcomes and hospital charges following atlantoaxial fusion. Spine J 2016; 16:608-18. [PMID: 26792199 PMCID: PMC5506776 DOI: 10.1016/j.spinee.2015.12.090] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 11/27/2015] [Accepted: 12/21/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Atlantoaxial fusion is used to correct atlantoaxial instability that is often secondary to traumatic fractures, Down syndrome, or rheumatoid arthritis. The effect of age and comorbidities on outcomes following atlantoaxial fusion is unknown. PURPOSE This study aimed to better understand trends and predictors of outcomes and charges following atlantoaxial fusion and to identify confounding variables that should be included in future prospective studies. STUDY DESIGN A retrospective analysis of data from the Nationwide Inpatient Sample (NIS), a nationally representative, all-payer database of inpatient diagnoses and procedures in the United States. PATIENT SAMPLE We included all patients who underwent atlantoaxial fusion (International Classification of Disease, Ninth Revision, Clinical Modification code 81.01) between 1998 and 2011 who were 18 years or older at the time of admission. OUTCOME MEASURES Outcome measures included in-hospital charges, hospital length of stay (LOS), in-hospital mortality, and discharge disposition. METHODS Predictors of outcome following atlantoaxial fusion were assessed using a series of univariable analyses. Those predictors with a p-value of less than .2 were included in the final multivariable models. Independent predictors of outcome were those that were significant at an alpha level of 0.05 following inclusion in the final multivariable models. Logistic regression was used to determine predictors of in-hospital mortality and discharge disposition whereas linear regression was used to determine predictors of hospital charges and LOS. Discharge weights were used to produce generalizable results. RESULTS From 1998 to 2011, there were 8,914 hospitalizations recorded wherein atlantoaxial fusion was performed during the inpatient hospital stay. Of these hospitalizations, 8,189 (91.9%) met inclusion criteria. Of the study sample, 62% was white, and the majority of patients were either insured by Medicare (47.2%) or had private health insurance (35.6%). The most common comorbidity as defined by the NIS and the Elixhauser comorbidity index was hypertension (43.2%). The in-hospital mortality rate for the study population was 2.7%, and the median LOS was 6.0 days. The median total charge (inflation adjusted) per hospitalization was $73,561. Of the patients, 48.9% were discharged to home. Significant predictors of in-hospital mortality included increased age, emergent or urgent admissions, weekend admissions, congestive heart failure, coagulopathy, depression, electrolyte disorder, metastatic cancer, neurologic disorder, paralysis, and non-bleeding peptic ulcer. Many of these variables were also found to be predictors of LOS, hospital charges, and discharge disposition. CONCLUSION This study found that older patients and those with greater comorbidity burden had greater odds of postoperative mortality and were being discharged to another care facility, had longer hospital LOS, and incurred greater hospital charges following atlantoaxial fusion.
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Affiliation(s)
- Joseph E Tanenbaum
- Center for Spine Health, Cleveland Clinic, Cleveland, OH, USA; School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA.
| | - Daniel Lubelski
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA,Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin P Rosenbaum
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicolas R Thompson
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Edward C Benzel
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Thomas E Mroz
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Tok S, Neidert MC, Bloemberg G, Sürücü O. Aggregatibacter aphrophilus ventriculitis following C1-C2 transarticular screw fixation. Neurol Neurochir Pol 2016; 50:63-8. [PMID: 26851694 DOI: 10.1016/j.pjnns.2015.11.005] [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: 06/02/2015] [Revised: 10/22/2015] [Accepted: 11/13/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Central nervous system (CNS) infections after cervical spine surgery are a rare but serious complication and may be caused by uncommon pathogens. We report the case of a 57-year-old male who developed slowly progressive mental confusion with headaches, increased daytime sleepiness and mild gait disturbance within the last 3 weeks. Six weeks prior to admission to our department, he underwent an atlantoaxial fusion by C1-C2 transarticular screw fixation for rheumatoid arthritis related C1-C2 multidirectional instability. METHODS We analyzed clinical and neuroradiological findings. RESULTS The findings were consistent with communicating hydrocephalus secondary to ventriculitis and the left C1-C2 screw was found to be misplaced with perforation of the dura. The situation was interpreted as implant related surgical site infection of the cerebrospinal fluid followed by ventriculitis and hydrocephalus. Bacterial broad range 16S rRNA gene PCR from the cerebrospinal fluid (CSF) followed by sequencing identified Aggregatibacter aphrophilus as the causative agent, while conventional cultures remained negative due to its fastidious growth. The patient was successfully treated with a lumbar drain and intravenous ceftriaxone. CONCLUSIONS To our knowledge, this is the first report of Aggregatibacter aphrophilus ventriculitis following C1-C2 transarticular screw fixation.
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Affiliation(s)
- Sina Tok
- University Hospital Zurich, Department of Neurosurgery, University of Zurich, Zurich, Switzerland(1).
| | - Marian Christoph Neidert
- University Hospital Zurich, Department of Neurosurgery, University of Zurich, Zurich, Switzerland(1).
| | - Guido Bloemberg
- Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland(2).
| | - Oguzkan Sürücü
- University Hospital Zurich, Department of Neurosurgery, University of Zurich, Zurich, Switzerland(1).
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Menger RP, Storey CM, Nixon MKC, Haydel J, Nanda A, Sin A. Placement of C1 Pedicle Screws Using Minimal Exposure: Radiographic, Clinical, and Literature Validation. Int J Spine Surg 2015; 9:43. [PMID: 26484006 DOI: 10.14444/2043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Traditional C1-2 fixation involves placement of C1 lateral mass screws. Evolving techniques have led to the placement of C1 pedicle screws to avoid exposure of the C1-C2 joint capsule. Our minimal dissection technique utilizes anatomical landmarks with isolated exposure of C2 and the inferior posterior arch of C1. We evaluate this procedure clinically and radiographically through a technical report. METHODS Consecutive cases of cranial-vertebral junction surgery were reviewed for one fellowship trained spinal surgeon from 2008-2014. Information regarding sex, age, indication for surgery, private or public hospital, intra-operative complications, post-operative neurological deterioration, death, and failure of fusion was extracted. Measurement of pre-operative axial and sagittal CT scans were performed for C1 pedicle width and C1 posterior arch height respectively. RESULTS 64 patients underwent posterior cranio-vertebral junction fixation surgery. 40 of these patients underwent occipital-cervical fusion procedures. 7/9 (77.8%) C1 instrumentation cases were from trauma with the remaining two (22.2%) from oncologic lesions. The average blood loss among isolated C1-C2 fixation was 160cc. 1/9 patients (11.1%) suffered pedicle breech requiring sub-laminar wiring at the C1 level. On radiographic measurement, the average height of the C1 posterior arch was noted at 4.3mm (range 3.8mm to 5.7mm). The average width of the C1 pedicle measured at 5.3mm (range 2.8 to 8.7mm). The patient with C1 pedicle screw failure had a pedicle width of 2.78mm on pre-operative axial CT imaging. CONCLUSION Our study directly adds to the literature with level four evidence supporting a minimal dissection of C1 arch in the placement of C1 pedicle screws with both radiographic and clinical validation. CLINICAL RELEVANCE Justification of this technique avoids C2 nerve root manipulation or sacrifice, reduces bleeding associated with the venous plexus, and leaves the third segment of the vertebral artery unexplored. Pre-operative review of imaging is critical in the placement of C1-C2 instrumentation.
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Affiliation(s)
- Richard P Menger
- Department of Neurosurgery, Louisiana State University of Health Sciences, Shreveport LA
| | - Christopher M Storey
- Department of Neurosurgery, Louisiana State University of Health Sciences, Shreveport LA
| | - Menarvia K C Nixon
- Department of Neurosurgery, Louisiana State University of Health Sciences, Shreveport LA
| | - Justin Haydel
- Department of Neurosurgery, Louisiana State University of Health Sciences, Shreveport LA
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University of Health Sciences, Shreveport LA
| | - Anthony Sin
- Department of Neurosurgery, Louisiana State University of Health Sciences, Shreveport LA
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Dolati P, Eichberg DG, Thomas A, Ogilvy CS. Application of Pipeline Embolization Device for Iatrogenic Pseudoaneurysms of the Extracranial Vertebral Artery: A Case Report and Systematic Review of the Literature. Cureus 2015; 7:e356. [PMID: 26623211 PMCID: PMC4658329 DOI: 10.7759/cureus.356] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Traumatic pseudoaneurysms of the vertebral artery (VA) are uncommon vascular lesions and definitive management is often challenging. Between 0% and 8% of craniocervical fusions are complicated by VA injury. In these cases, preserving the vertebral artery while treating the pseudoaneurysm is the goal of any treatment option. We describe the second known case of a patient with and iatrogenic extracranial vertebral artery pseudoaneurysm treated effectively using the Pipeline Embolization Device (PED) (Ev3 Neurovascular, Irvine, CA). Although there have been only two cases reported, the use of flow-diverting stents appears to be efficacious for the treatment of non-actively bleeding traumatic pseudoaneurysms.
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Huang DG, Hao DJ, He BR, Wu QN, Liu TJ, Wang XD, Guo H, Fang XY. Posterior atlantoaxial fixation: a review of all techniques. Spine J 2015; 15:2271-81. [PMID: 26165477 DOI: 10.1016/j.spinee.2015.07.008] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 04/24/2015] [Accepted: 07/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Posterior atlantoaxial fixation is an effective treatment for atlantoaxial instability. Great advancements on posterior atlantoaxial fixation techniques have been made in the past decades. However, there is no article reviewing all the posterior atlantoaxial fixation techniques yet. PURPOSE The aim was to review the evolution and advancements of posterior atlantoaxial fixation. STUDY DESIGN This was a literature review. METHODS The application of all posterior fixation techniques in atlantoaxial stabilization, including wiring techniques, interlaminar clamp fixation, transarticular fixation, screw-plate systems, screw-rod systems, and hook-screw systems, are reviewed and discussed. Recent advancements on the novel technique of atlantoaxial fixation are described. The combination of the C1 and C2 screws in screw-rod systems are described in detail. RESULTS All fixation techniques are useful. The screw-rod system appears to be the most popular approach. However, many novel or modified fixation methods have been introduced in recent years. CONCLUSIONS Great advancements on posterior atlantoaxial fixation techniques have been made in the past decades. The wiring technique and interlaminar clamps technique have fallen out of favor because of the development of newer and superior fixation techniques. The C1-C2 transarticular screw technique may remain the gold standard for atlantoaxial fusion, whereas screw-rod systems, especially the C1 pedicle screw combined with C2 pedicle/pars screw fixation, have become the most popular fixation techniques. Hook-screw systems are alternatives for atlantoaxial fixation.
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Affiliation(s)
- Da-Geng Huang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Ding-Jun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China.
| | - Bao-Rong He
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Qi-Ning Wu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Tuan-Jiang Liu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Xiao-Dong Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Hua Guo
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
| | - Xiang-Yi Fang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 76 Nanguo Rd, Xi'an, Shaanxi, 710054, China
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Impact of Starting Point and Bicortical Purchase of C1 Lateral Mass Screws on Atlantoaxial Fusion. ACTA ACUST UNITED AC 2015; 28:242-53. [DOI: 10.1097/bsd.0b013e31828ffc97] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ji W, Zheng M, Tong J, Huang Z, Chen J, Qu D, Zhu Q. Feasibility and trajectory study of anterior transarticular crossing screw placement for atlantoaxial joint instability: a cadaveric study and description of a novel technique. 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 2015. [PMID: 26208939 DOI: 10.1007/s00586-015-4135-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE In unique clinical situations where C1-C2 anterior transarticular screw (ATS) fixation is not available or has failed, an anterior transarticular crossing screw (ATCS) with transcorporal pathway of the screws inside the contralateral promontory of C2 may enhance the stabilization and achieve atlantoaxial arthrodesis. The present study was to describe a novel technique of ATCS fixation for atlantoaxial joint instability and its applied anatomy, and compared it with ATS fixation method. METHODS Direct measurements using digital calipers and a goniometer were conducted on 30 pairs of dried human C1 and C2 vertebrae. The ATS and ATCS with screws (Φ 4.0 mm) were performed on 11 fresh cervical spine specimens. The screw lengths in the C1 and C2, and screw entry angles of the ATS and ATCS were measured, respectively. Cadaver specimens were dissected to observe the incidence of violation to the important structures surrounding the ATS and ATCS fixation technique. RESULTS There was enough osseous space for ATCS placement. The lateral and incline angle of the ATCS was 36.2° and 28.7°, respectively. Screw purchase in C2 of the ATCS (25.6 mm) was greater than that of the ATS (11.4 mm). The ATCS C1 purchase (14.8 mm) was similar to the ATS C1 purchase (14.9 mm). No violation to the vertebral artery groove, the spinal canal or the atlanto-occipital joint was observed after the ATCS placement. CONCLUSION Anterior transarticular crossing screw is a feasible and viable option for atlantoaxial fixation in selected cases. This technique achieved remarkable longer screw purchase and could enhance the atlantoaxial stability.
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Affiliation(s)
- Wei Ji
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, China
| | - Minghui Zheng
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, China
| | - Jie Tong
- Department of Spinal Surgery, The First People's Hospital of Chenzhou, Chenzhou, Hunan, China
| | - Zhiping Huang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, China
| | - Jianting Chen
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, China
| | - Dongbin Qu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, China
| | - Qingan Zhu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, China.
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Maciejczak A, Wolan-Nieroda A, Jabłońska-Sudoł K. Comparison of fusion rates between rod-based laminar claw hook and posterior cervical screw constructs in Type II odontoid fractures. Injury 2015; 46:1304-10. [PMID: 25687133 DOI: 10.1016/j.injury.2015.01.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 01/23/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study was aimed (i) to compare the fusion rates of rod-based laminar claw hook constructs to that of posterior C1/C2 screw constructs in odontoid fractures, and (ii) to evaluate any complications associated with claw hook/rod constructs. To our knowledge, no study in contemporary literature has presented the effects of using modern rod-based laminar claw hooks for treating odontoid fractures. Unlike laminar clamps from the 1980s, contemporary laminar hook-rod instrumentation systems provide better immobilisation of the cervical spine and allows for building reliable frame-like constructs similar to cervical screw-rod systems. METHODS A retrospective review of a series of 167 consecutive odontoid fractures from a single-institution was conducted. 30 cases from the series were treated using posterior atlantoaxial fusion, 12 using C1/C2 posterior screws (control group), and 18 with rod-based laminar claw hooks (study group). Hooks were mounted bilaterally in a claw manner on each individual lamina and were rigidly fixed to perpendicular rods with a transverse connector whenever feasible. The minimum follow-up period was one year. Bony union was determined using computed tomography (CT) scan, while stability at the fusion site was assessed using dynamic radiograms. RESULTS The study group had an overall fusion rate of 89% (non-geriatric 93% while geriatric subgroup 75%) with a 100% stability rate at the fusion site in all cases. In the control group fusion rate was 100%. There were no major complications in both control and study groups. Four minor complications, three in the control and one in the study group, were noted in 3 patients. CONCLUSION Preliminary results of this study suggest that laminar claw hook-rod systems are useful alternatives to posterior screw techniques. Moreover, the fusion rate in non-geriatric patients is comparable to that of posterior screws. Importantly, they are devoid of the disadvantages and complications posed by screw constructs. Further studies are necessary to confirm these promising results.
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Affiliation(s)
- Andrzej Maciejczak
- Department of Neurosurgery, St Luke Hospital, Tarnow, Poland; Faculty of Medicine, University of Rzeszow, Rzeszow Poland.
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Ohya J, Chikuda H, Kato S, Horiguchi H, Takeshita K, Tanaka S, Yasunaga H. Risks of In-Hospital Death and Complications After Fusion Surgery in Patients with Atlantoaxial Subluxation: Analysis of 1090 Patients Using the Japanese Diagnosis Procedure Combination Database. World Neurosurg 2015; 83:603-7. [DOI: 10.1016/j.wneu.2014.12.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 09/06/2014] [Accepted: 12/10/2014] [Indexed: 11/25/2022]
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Costa F, Ortolina A, Attuati L, Cardia A, Tomei M, Riva M, Balzarini L, Fornari M. Management of C1–2 traumatic fractures using an intraoperative 3D imaging–based navigation system. J Neurosurg Spine 2015; 22:128-33. [DOI: 10.3171/2014.10.spine14122] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Fractures of C-1 and C-2 are complex and surgical management may be difficult and challenging due to the anatomical relationship sbetween the vertebrae and neurovascular structures. The aim of this study was to evaluate the role, reliability, and accuracy of cervical fixation using the O-arm intraoperative 3D image–based navigation system.
METHODS
The authors evaluated patients who underwent a navigation system–based surgery for stabilization of a fracture of C-1 and/or C-2 from August 2011 to August 2013. All of the fixation screws were intraoperatively checked and their position was graded.
RESULTS
The patient population comprised 17 patients whose median age was 47.6 years. The surgical procedures were as follows: anterior dens screw fixation in 2 cases, transarticular fixation of C-1 and C-2 in 1 case, fixation using the Harms technique in 12 cases, and occipitocervical fixation in 2 cases. A total of 67 screws were placed. The control intraoperative CT scan revealed 62 screws (92.6%) correctly placed, 4 (5.9%) with a minor cortical violation (< 2 mm), and only 1 screw (1.5%) that was judged to be incorrectly placed and that was immediately corrected. No vascular injury of the vertebral artery was observed either during exposition or during screw placement. No implant failure was observed.
CONCLUSIONS
The use of a navigation system based on an intraoperative CT allows a real-time visualization of the vertebrae, reducing the risks of screw misplacement and consequent complications.
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Affiliation(s)
| | | | | | | | | | | | - Luca Balzarini
- 2Radiology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
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Kotil K, Muslumanoglu M. C1-2 posterior arthrodesis technique with a left segmental and right transarticular fixation. A hybrid novel (Kotil) technique. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2014; 5:102-5. [PMID: 25210344 PMCID: PMC4158630 DOI: 10.4103/0974-8237.139213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The most commonly used techniques for C1-C2 posterior arthrodesis are Goel and Magerl fixation techniques. Due to the anatomical variations of the region, the prior determination of the surgical technique might be hard. Right side Magerl, left side Goel's C1-C2 posterior arthrodesis case is presented as a new surgical combination technique used due to anatomical difficulties. MATERIALS AND METHODS Posterior C1-C2 arthrodesis operation was indicated for a 56-year-old female patient for the treatment of atlanto-axial subluxation caused by os odontoideum. First it was fixed from the nondominant arterial side (right vertebral artery) with Magerl (transarticular) technique. The left side was not suitable for the anatomical transarticular fixation, and the contralateral Goel fixation technique (segmental) was performed. Eventually, right side transarticular left side segmental fixation techniques were combined in one patient for the first time and C1-C2 fusion combination technique was presented. RESULTS Both Goel and Magerl techniques of C1-C2 posterior fusion techniques were successfully used simultaneously. The operation was initiated with Magerl technique with one screw on the nondominant side. The contralateral side was not suitable for Magerl technique therefore we changed to Goel's technique. Although, fluoroscopy was used 3 times as much during the introduction of the Drill with Magerl technique, twice as much operative time was spent during hemostasis and bleeding, preparation of the C1 entry point, and the reconstruction of polyaxial screws for Goel technique. No neurovascular complications were occurred during both procedures. DISCUSSION Combination of two C1-C2 posterior fusion techniques, Goel and Magerl, in suitable cases caused by anatomical or other reasons appears to be an alternative surgical procedure that protects the patient from complications. For a collection of better data, other studies that include large numbers of patients with high evidential value should be conducted.
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Affiliation(s)
- Kadir Kotil
- Department of Neurosurgery, T.C. Istanbul Arel University, Istanbul, Tepekent/Turkey
| | - Murat Muslumanoglu
- Department of Neurosurgery, T.C. Istanbul Arel University, Istanbul, Tepekent/Turkey
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Yang SY, Boniello AJ, Poorman CE, Chang AL, Wang S, Passias PG. A review of the diagnosis and treatment of atlantoaxial dislocations. Global Spine J 2014; 4:197-210. [PMID: 25083363 PMCID: PMC4111952 DOI: 10.1055/s-0034-1376371] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 04/15/2014] [Indexed: 02/04/2023] Open
Abstract
Study Design Literature review. Objective Atlantoaxial dislocation (AAD) is a rare and potentially fatal disturbance to the normal occipital-cervical anatomy that affects some populations disproportionately, which may cause permanent neurologic deficits or sagittal deformity if not treated in a timely and appropriate manner. Currently, there is a lack of consensus among surgeons on the best approach to diagnose, characterize, and treat this condition. The objective of this review is to provide a comprehensive review of the literature to identify timely and effective diagnostic techniques and treatment modalities of AAD. Methods This review examined all articles published concerning "atlantoaxial dislocation" or "atlantoaxial subluxation" on the PubMed database. We included 112 articles published between 1966 and 2014. Results Results of these studies are summarized primarily as defining AAD, the normal anatomy, etiology of dislocation, clinical presentation, diagnostic techniques, classification, and recommendations for timely treatment modalities. Conclusions The Wang Classification System provides a practical means to diagnose and treat AAD. However, future research is required to identify the most salient intervention component or combination of components that lead to the best outcomes.
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Affiliation(s)
- Sun Y. Yang
- Division of Spinal Surgery, Department of Orthopaedic Surgery, NYU Medical Center Hospital for Joint Diseases, NYU School of Medicine, New York, New York, United States
| | - Anthony J. Boniello
- Division of Spinal Surgery, Department of Orthopaedic Surgery, NYU Medical Center Hospital for Joint Diseases, NYU School of Medicine, New York, New York, United States
| | - Caroline E. Poorman
- Division of Spinal Surgery, Department of Orthopaedic Surgery, NYU Medical Center Hospital for Joint Diseases, NYU School of Medicine, New York, New York, United States
| | - Andy L. Chang
- Division of Spinal Surgery, Department of Orthopaedic Surgery, NYU Medical Center Hospital for Joint Diseases, NYU School of Medicine, New York, New York, United States
| | - Shenglin Wang
- Orthopaedic Department, Peking University Third Hospital, Beijing, China
| | - Peter G. Passias
- Division of Spinal Surgery, Department of Orthopaedic Surgery, NYU Medical Center Hospital for Joint Diseases, NYU School of Medicine, New York, New York, United States
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Maughan PH, Ducruet AF, Elhadi AM, Martirosyan NL, Garrett M, Mushtaq R, Albuquerque FC, Theodore N. Multimodality management of vertebral artery injury sustained during cervical or craniocervical surgery. Neurosurgery 2014; 73:ons271-81; discussion ons281-2. [PMID: 23719054 DOI: 10.1227/01.neu.0000431468.74591.5f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Iatrogenic vertebral artery (VA) injury is a rare but potentially devastating complication associated with cervical and craniocervical surgery. OBJECTIVE To retrospectively evaluate treatment modalities and outcomes associated with iatrogenic VA injury. METHODS Our institutional surgical database was queried for patients who underwent cervical or craniocervical surgery from January 1997 to August 2012. RESULTS During this time period, 8213 patients underwent cervical or craniocervical surgery, and 17 (0.2%) cases of VA injury were identified. Eight (47%) of these injuries occurred during C1-2 instrumentation procedures. Primary microsurgical repair of the VA was performed in 5 patients. Other cases were managed by either surgical or endovascular VA occlusion. Of the 17 patients, 15 underwent immediate angiography, 9 of whom were ultimately treated by the use of endovascular techniques. CONCLUSION VA injury is an uncommon complication of cervical and/or skull base surgery. Standardized management recommendations may help reduce complications associated with these rare but potentially devastating injuries.
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Affiliation(s)
- Peter Hanks Maughan
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Oh CH, Ji GY, Seo HS, Yoon SH, Hyun D, Park HC. Repeated complication following atlantoaxial fusion: a case report. KOREAN JOURNAL OF SPINE 2014; 11:7-11. [PMID: 24891865 PMCID: PMC4040632 DOI: 10.14245/kjs.2014.11.1.7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 03/14/2014] [Accepted: 03/17/2014] [Indexed: 11/19/2022]
Abstract
A patients with atlantoaixial instability and osodontoideum underwent atlantoaixial fusion (Harms and Melcher technique) with demineralized bone matrix. But, unfortunately, the both pedicle screws in C2 were fractured within 9 weeks follow-up periods after several suspected episode of neck hyper-flexion. Fractured screws were not contact to occipital bone in several imaging studies, but it could irritate the occipital bone when neck extension because the relatively close distance between the occipital bone and C1 posterior arch. The patient underwent revision operation with translaminar screw fixation with autologus iliac bone graft. Postsurgical course were uneventful except donor site pain, but the bony fusion was not satisfied after 4 months follow-up. The patient re-underwent revision operation in other hospital. Continuous complication after atlantoaixial fusion is rare, but the clinical course could be unlucky to patients. Postoperative immobilization could be important to prevent the unintended clinical course of patients.
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Affiliation(s)
- Chang Hyun Oh
- Department of Neurosurgery, Guro TeunTeun Hospital, Seoul, Korea
| | - Gyu Yeul Ji
- Department of Neurosurgery, Guro TeunTeun Hospital, Seoul, Korea
| | - Hyun Sung Seo
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Seung Hwan Yoon
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Dongkeun Hyun
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Hyeong-Chun Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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Chiaramonti BC, Kim SY, Marchese LRD, Letaif OB, Marcon RM, Cristante AF. Tomographic correlation for Magerl's technique in C1-C2 arthrodesis in children. ACTA ORTOPEDICA BRASILEIRA 2014; 21:255-7. [PMID: 24453677 PMCID: PMC3875001 DOI: 10.1590/s1413-78522013000500002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 07/12/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE: To analyze through tomographic studies, the morphology and dimensions of the C1-C2 vertebrae in pediatric patients, to evaluate the possibility of application of Magerl's technique in these patients, and to contribute with data for the usage of the technique in safety. METHOD: Forty normal cervical tomographies, from patients at an age range of 24-120 months of age and from both genders, were retrospectively analyzed. Data was statistically analyzed to obtain mean value and variations of each measurement: length from the C2's pedicle to C1's lateral mass, thickness of the pedicle of C2, the attack angle of the screw at the C2 isthmus with the horizontal axis and the distance from the odontoid to the anterior arch of C1. RESULTS: The mean values obtained were: length right 30.86 mm, left 31.47 mm; thickness right 5.28 mm, left 5.26 mm; attack angle right 46.250 , left 44.500 ; distance from odontoid to anterior arch of C1 2,17 mm. CONCLUSION: The Magerl technique, after tomographic study, seems to be a viable option to be used in pediatric patients. Level of Evidence IV, Case Series.
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Affiliation(s)
- Bárbara Camargo Chiaramonti
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo - SP, Brazil
| | - So Yeon Kim
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo - SP, Brazil
| | - Luiz Roberto Delboni Marchese
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo - SP, Brazil
| | - Olavo Biraghi Letaif
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo - SP, Brazil
| | - Raphael Martus Marcon
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo - SP, Brazil
| | - Alexandre Fogaça Cristante
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo - SP, Brazil
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Atlantoaxial Fusion: Transarticular Screws versus Screw-Rod Constructs. World Neurosurg 2013; 80:516-7. [DOI: 10.1016/j.wneu.2012.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 11/09/2012] [Indexed: 12/13/2022]
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Marchese LRD, Bonadio MB, Letaif OB, Cristante AF, Oliveira RP, de Barros TEP. Tomographic correlation of the Magerl technique for C1-C2 arthrodesis in rheumatoid arthritis. ACTA ORTOPEDICA BRASILEIRA 2013; 21:195-7. [PMID: 24453667 PMCID: PMC3862007 DOI: 10.1590/s1413-78522013000400002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 08/21/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE: To use the tomographic analysis of C1 and C2 vertebrae to assess the possibility of using Magerl's technique in patients with rheumatoid arthritis. Other objectives were to obtain anatomical data for the choice of the surgical technique in general, to establish safety parameters and obtain epidemiological data of the population in question. METHODS: We retrospectively reviewed the CT scans of 20 patients with rheumatoid arthritis of the Outpatient Spine Group, IOT-HCFMUSP. Data were analyzed statistically to obtain the mean values and the variance of each measurement: the length of the C2 pedicle to the C1 lateral mass, the thickness of the pedicle and the angle of attack of the screw in the isthmus of C2 to the horizontal. RESULTS: The mean values were, respectively: right 23.08 mm and left 23.16 mm, right 6.46 mm and left 6.50 mm, right 44.50o and left 44.95o. Discussion: The leading screw's manufacturers have implants compatible with the anatomical measurements found in this work. Considering the wide diffusion and mastery of Magerl's technique in our country and around the world, this is a safe surgical option that provides mechanical stability. CONCLUSION: Magerl's technique, according to tomographic analysis, can be used in patients with rheumatoid arthritis. Levels of Evidence IV,Case Series.
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Affiliation(s)
- Luiz Roberto Delboni Marchese
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
| | - Marcelo Batista Bonadio
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
| | - Olavo Biraghi Letaif
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
| | - Alexandre Fogaça Cristante
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
| | - Reginaldo Perilo Oliveira
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
| | - Tarcísio Eloy Pessoa de Barros
- Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
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Hueng DY, Tsai CL, Hsu SW, Ma HI. Publication patterns of comparative effectiveness research in spine neurosurgery. Neurosurg Focus 2013; 33:E9. [PMID: 22746241 DOI: 10.3171/2012.5.focus1292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECT The purpose of this study was to investigate publication patterns for comparative effectiveness research (CER) on spine neurosurgery. METHODS The authors searched the PubMed database for the period 1980-2012 using the key words "cost analysis," "utility analysis," "cost-utility," "outcomes research," "practical clinical research," "comparator trial," and "comparative effectiveness research," linked with "effectiveness" and "spine neurosurgery." RESULTS From 1980 through April 9, 2012, neurosurgery CER publications accounted for 1.38% of worldwide CER publications (8657 of 626,330 articles). Spine neurosurgery CER accounted for only 0.02%, with 132 articles. The journal with the greatest number of publications on spine neurosurgery CER was Spine, followed by the Journal of Neurosurgery: Spine. The average annual publication rate for spine neurosurgery CER during this period was 4 articles (132 articles in 33 years), with 68 (51.52%) of the 132 articles being published within the past 5 years and a rising trend beginning in 2008. The top 3 contributing countries were the US, Turkey, and Japan, with 68, 8, and 7 articles, respectively. Only 8 regular articles (6.06%) focused on cost analysis. CONCLUSIONS There is a paucity of publications using CER methodology in spine neurosurgery. Few articles address the issue of cost analysis. The promotion of continuing medical education in CER methodology is warranted. Further investigations to address cost analysis in comparative effectiveness studies of spine neurosurgery are crucial to expand the application of CER in public health.
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Affiliation(s)
- Dueng-Yuan Hueng
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Occipital-C2 transarticular fixation for occipitocervical instability associated with occipitalization of the atlas in patients with klippel-feil syndrome, using intraoperative 3-dimensional navigation system. Spine (Phila Pa 1976) 2013; 38:642-9. [PMID: 23124258 DOI: 10.1097/brs.0b013e31827a330a] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE The aim of this study was to describe the clinical outcomes of cervical reduction and occipital-C2 transarticular (OCTA) fixation with an assistance of intraoperative 3-dimensional navigation system (ITNS) during the treatment of reducible occipitocervical instability (OCI) in patients with Klippel-Feil syndrome (KFS) with occipitalization of the atlas and fusion of C2-C3. SUMMARY OF BACKGROUND DATA Patients with KFS have congenital fusions of at least 2 cervical segments and may gradually develop symptoms at the hypermobile articulations adjacent to the cervical synostosis. This is particularly common in patients with KFS with occipitalization of the atlas and C2-C3 fusion. These patients may be at risk for instability and neurological complications of the occipitocervical junction that require occipitocervical reconstruction and fusion. Numerous treatment techniques are available for this pathological condition. However, there has yet to be a study of reducible OCI, showing successful treatment with intraoperative reduction and posterior OCTA fixation using ITNS. METHODS From 2006 to 2011, 9 patients with KFS with reducible OCI attributed to occipitalization of the atlas and C2-C3 fusion were surgically treated. After a limited foramen magnum decompression, reduction of the OCI was conducted by intraoperative cervical traction and extension, followed by OCTA fixation using a direct posterior approach and with the assistance of ITNS. The follow-up period ranged from 6 to 60 months (mean, 31 mo). RESULTS Good decompression and bone fusion were achieved in all the patients. The clinical symptoms had improved for all patients. There were no intraoperative or postoperative complications. CONCLUSION In patients with KFS with occipitalization of the atlas and C2-C3 fusion, manual cervical traction in tandem with cervical extension, followed by posterior OCTA fixation and fusion provides a safe, effective treatment of OCI and ventral brainstem impingement. IFTN is a feasible tool for monitoring cervical reduction and OCTA screw insertion in patients with KFS with this pathological condition.
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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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Myers KD, Lindley EM, Burger EL, Patel VV. C1-C2 fusion: postoperative C2 nerve impingement-is it a problem? EVIDENCE-BASED SPINE-CARE JOURNAL 2012; 3:53-6. [PMID: 23236306 PMCID: PMC3503508 DOI: 10.1055/s-0031-1298601] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective: The purpose of this comparison case study is to show a potential complication associated with atlantoaxial fusion, and the preoperative evaluation that could help to avoid it. Background data: The use of lateral mass screw fixation in atlantoaxial fusion has provided surgeons the ability to create rigid fixation, with a high success rate of fusion. While the use of screws for fixation is relatively easy to adopt, the risk of causing neurological damage to the patient is ever present. Many major structures, such as the vertebral artery, carotid artery, and spinal cord, must all be considered during surgery. Methods: A comparison of two patients who underwent the same procedure was reviewed—the first had no complications from surgery and the second underwent revision surgery because of the C1 screw impinging on the C1 nerve exiting the foramen. Results: After removal of the C1 screw and converting to a cable technique, the patient made a full recovery and neurological function was restored. Conclusions: When considering C1-C2 lateral mass screw fixation for atlantoaxial fusion, the size of the foramen should be considered. If the foramen is significantly narrowed, alternate fixation should be selected.
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Affiliation(s)
- Kurt D Myers
- The Spine Center, Department of Orthopaedics, University of Colorado, Denver, CO, USA
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Elliott RE, Tanweer O, Boah A, Smith ML, Frempong-Boadu A. Comparison of safety and stability of C-2 pars and pedicle screws for atlantoaxial fusion: meta-analysis and review of the literature. J Neurosurg Spine 2012; 17:577-93. [PMID: 23039110 DOI: 10.3171/2012.9.spine111021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECT Some centers report a lower incidence of vertebral artery (VA) injury with C-2 pars screws compared with pedicle screws without sacrificing construct stability, despite biomechanical studies suggesting greater load failures with C-2 pedicle screws. The authors reviewed published series describing C-2 pars and pedicle screw implantation and atlantoaxial fusions and compared the incidence of VA injury, screw malposition, and successful atlantoaxial fusion with each screw type. METHODS Online databases were searched for English-language articles between 1994 and April of 2011 describing the clinical and radiographic outcomes following posterior atlantoaxial fusion with C-1 lateral mass and either C-2 pars interarticularis or pedicle screws. Thirty-three studies describing 2975 C-2 pedicle screws and 11 studies describing 405 C-2 pars screws met inclusion criteria for the safety analysis. Seven studies describing 113 patients treated with C-2 pars screws and 20 studies describing 918 patients treated with C-2 pedicle screws met inclusion criteria for fusion analysis. Standard and formal meta-analysis techniques were used to compare outcomes. RESULTS All studies provided Class III evidence. Ten instances of VA injury occurred with C-2 pedicle screws (0.3%) and no VA injury occurred with pars screws. The point estimate of VA injury for C-2 pedicle screws was 1.09% (95% CI 0.73%-1.63%) and was similar to that of C-2 pars screws (1.48%, 95% CI 0.62%-3.52%). Similarly, there was no statistically significant difference in the rate of clinically significant screw malpositions (1.14% [95% CI 0.77%-1.69%) vs 1.69% [95% CI 0.73%-3.84%]). Radiographically identified screw malposition occurred in a higher proportion of C-2 pedicle screws compared with C-2 pars screws (6.0% [95% CI 3.7%-9.6%] vs 4.0% [95% CI 2.0%-7.6%], p < 0.0001). Pseudarthrosis occurred in a greater proportion of patients treated with C-2 pars screws (5 [4.4%] of 113) compared with those treated with C-2 pedicle screws (2 [0.22%] of 900). Point estimates with 95% confidence intervals show a slightly higher rate of successful atlantoaxial fusion in the pedicle screw cohort (97.8% [CI 96.0%-98.8%] vs 93.5% [CI 86.6%-97.0%]; p < 0.0001). Q-testing ruled out heterogeneity between the study groups. CONCLUSIONS With a thorough knowledge of axis anatomy, surgeons can place both C-2 pars and C-2 pedicle screws accurately with a small risk of VA injury or clinically significant malposition. There may be subtle trade-off of safety for rigidity when using axial pedicle instead of pars screws, and the decision to use either screw type must be made only after careful review of the preoperative CT imaging and must take into account the surgeon's expertise and the particular demands of the clinical scenario in any given case.
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Surgical management of symptomatic os odontoideum with posterior screw fixation performed using the magerl and harms techniques with intraoperative 3-dimensional fluoroscopy-based navigation. Spine (Phila Pa 1976) 2012; 37:1839-46. [PMID: 22475730 DOI: 10.1097/brs.0b013e3182578fd8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE To evaluate the accuracy of screw fixation using intraoperative three-dimensional fluoroscopy-based navigation (ITFN) and to assess the clinical outcomes of this treatment regimen. SUMMARY OF BACKGROUND DATA The surgical management of symptomatic os odontoideum poses considerable difficulties due to the highly variable anatomy of the upper cervical spine and surrounding neurovascular structures. Various methods have been described for the treatment of symptomatic os odontoideum, all of which have limitations. METHODS Nineteen patients with symptomatic os odontoideum were investigated. Pain scores were assessed using the visual analogue scale. Myelopathy was assessed using the Nurick scale and Odom's criteria. Radiological imaging was carried out in all patients for diagnosis and to assess the atlantodens interval, space available for cord, and presence of intramedullary hyperintensity signals on T2-weighted images at the C1-C2 level. Posterior stabilization was performed for all patients by using ITFN. RESULTS The mean Nurick score improved from 2.3 before surgery to 0.7 at the time of follow-up. The mean follow-up period was 34.7 months (range, 12-65 mo). According to Odom's criteria, outcomes were as follows: excellent, 47%; good, 37%; fair, 11%; and poor, 5%. All patients with preoperative neck pain had symptom relief or improvement, with all of these patients having more than 83.7% improvement in visual analogue scale scores. The mean preoperative space available for cord value of 9.3 mm improved to 17.7 mm. Solid fusion and reduction of atlantoaxial dislocation were achieved in every patient without screw failure. Sixty screws were placed in 19 patients. Two C2 polyaxial screws in 2 patients and 1 transarticular screw in 1 patient slightly penetrated the transverse foramen with no vascular injury and clinical sequelae. CONCLUSION ITFN is a safe, accurate, and effective tool for screw placement in patients with symptomatic os odontoideum.
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Computer-assisted C1-C2 Transarticular Screw Fixation "Magerl Technique" for Atlantoaxial Instability. Asian Spine J 2012; 6:168-77. [PMID: 22977696 PMCID: PMC3429607 DOI: 10.4184/asj.2012.6.3.168] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 08/12/2011] [Accepted: 09/14/2011] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN A retrospective study. PURPOSE To evaluate the surgical results of computer-assisted C1-C2 transarticular screw fixation for atlantoaxial instability and the usefulness of the navigation system. OVERVIEW OF LITERATURE We used a computed tomography (CT)-based computer navigation system in planning and screw insertion in Magerl's procedure, which provides the most rigid atlantoaxial fusion, to avoid risk of vertebral artery (VA) tear by avoiding high-riding VA during screw insertion. METHODS Twenty patients who underwent atlantoaxial fusion under the CT-based navigation system were studied. The mean observation period was 33.5 months. The evaluated items included the existence of VA stenosis by preoperative magnetic resonance angiography, surgical time, blood loss volume, Japanese Orthopaedic Association (JOA) score and Ranawat's pain criteria before surgery and at final follow-up, postoperative screw position evaluated by CT, and bony fusion. RESULTS The mean operation time was 205 minutes, with the mean blood loss volume of 242 ml. The mean JOA score was 11.6 points before surgery and 13.7 at final follow-up. Occipital and/or cervical pain presented before operation was remitted or resolved in all patients. Evaluation of screw insertion by CT revealed correct penetration to atlantoaxial joints, with a perforation rate of 2.6%. There was no complication, including VA tear, and all patients who were followed-up during one year or more after surgery achieved bony fusion. Some subjects who appeared inappropriate for surgery from CT images were assessed as eligible for surgery based on the evaluation results obtained using the navigation system. CONCLUSIONS It was demonstrated that the CT-based navigation system is an effective support device for Magerl's procedure.
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Xu H, Chi YL, Wang XY, Dou HC, Wang S, Huang YX, Xu HZ. Comparison of the anatomic risk for vertebral artery injury associated with percutaneous atlantoaxial anterior and posterior transarticular screws. Spine J 2012; 12:656-62. [PMID: 22728075 DOI: 10.1016/j.spinee.2012.05.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 10/21/2011] [Accepted: 05/17/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT As a minimally invasive spine surgery, percutaneous atlantoaxial fixation techniques using anterior transarticular screw (ATS) and posterior transarticular screw (PTS) have promising clinical results. However, transarticular screw fixation is technically demanding and carries a potential risk of iatrogenic vertebral artery (VA) injury. There were no available data comparing the anatomic risk of VA injury associated with these screws. PURPOSE To evaluate the trajectories of percutaneous atlantoaxial ATS and PTS through three-dimensional (3D) computerized tomography. STUDY DESIGN To compare the anatomic risk of VA injury between percutaneous ATS and PTS. PATIENT SAMPLE Sixty patients ranged in age from 19 to 75 years (mean, 45.08 years) and included 35 men and 25 women. OUTCOME MEASURES Image measurement of C2 isthmus height and C2 isthmus width and the distance between the medial-most superior articular facet to the medial-most edge of the VA groove of the C2 (D). METHODS Sixty consecutive patients (in total) with lower cervical lesions were evaluated through 3D images reconstructed by a rapid 3D system. The maximum possible diameters of the percutaneous atlantoaxial ATS and PTS trajectories were compared and examined. Mean, range, and standard deviations for each type of screw, for left and right trajectories, and for men and women were calculated from 120 percutaneous atlantoaxial ATS and PTS measurements through SPSS. RESULTS The maximum mean diameter differed significantly between the trajectories of 120 percutaneous atlantoaxial ATS and PTS. For screw trajectories ≤3.5 mm in diameter, 19.2% of the PTS trajectories were judged as risky, whereas all the anterior ones were judged as safe. CONCLUSIONS From an anatomic perspective, percutaneous ATS fixation poses less anatomic risk of VA injury than percutaneous PTS fixation. As an alternative surgical therapy for atlantoaxial subluxation, percutaneous ATS fixation may play a more important role in the future.
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Affiliation(s)
- Hui Xu
- Department of Spinal Surgery, the Second Affiliated Hospital of Wenzhou Medical College, 109 Xueyuanxi Road, Wenzhou, People's Republic of China
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