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Frati A, Cimatti M, Ileyassoff H, Capobianco M, Santoro A, Armocida D. Combined Anterior Odontoid Screw Fixation and C1-C2 Jefferson Fracture Anterior Fixation: A Step-by-Step Technical Note. World Neurosurg 2024; 184:112-118. [PMID: 38266989 DOI: 10.1016/j.wneu.2024.01.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Combined triple atlas (C1)-axis (C2) fixation has been described in previous literature as a safe, effective, and minimally invasive procedure for complex atlas and odontoid fractures that allows for a greater range of motion compared with posterior approaches and atlanto-occipital fusion. However, it is rarely performed due to the occipital-cervical diastasis resulting from often-fractured C1 joint masses. No evidence-based consensus has been reached regarding the treatment of complex atlantoaxial fractures, and the choice of surgical strategy is based only on clinical experience. METHODS We report the combined triple C1-C2 fixation technique with manual reduction of the joint masses during patient positioning on the operating table, which allowed for effective stabilization during a single surgical session. We describe our experience in the management of a 75-year-old patient presenting with an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis. RESULTS We provide a step-by-step guide for combined triple C1-C2 anterior fixation with manual fracture reduction and describe the clinical case of an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis. CONCLUSIONS Combined triple C1-C2 fixation represents a safe and efficient minimally invasive anterior approach for complex type II fractures of C1 with type II odontoid fractures. Manual reduction of the joint masses during patient positioning allows for effective stabilization in a single surgical session.
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Affiliation(s)
- Alessandro Frati
- Experimental Neurosurgery Unit, IRCCS Ist Neurologico Mediterraneo Neuromed, Pozzilli, Italy
| | - Marco Cimatti
- Neurosurgery Service, Azienda Ospedaliera-Universitaria Sant'Andrea, Sapienza University of Rome, Rome, Italy
| | - Hernán Ileyassoff
- Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Mattia Capobianco
- Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Antonio Santoro
- Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Daniele Armocida
- Experimental Neurosurgery Unit, IRCCS Ist Neurologico Mediterraneo Neuromed, Pozzilli, Italy; Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.
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Cloney MB, Texakalidis P, Roumeliotis AG, Thirunavu V, Shlobin NA, Swong K, El Tecle N, Dahdaleh NS. The demographic, clinical, and management differences between traumatic dens fracture patients with and without simultaneous atlas fractures. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:21-29. [PMID: 38644924 PMCID: PMC11029115 DOI: 10.4103/jcvjs.jcvjs_147_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/25/2023] [Indexed: 04/23/2024] Open
Abstract
Introduction Atlas fractures often accompany traumatic dens fractures, but existing literature on the management of simultaneous atlantoaxial fractures is limited. Methods We examined all patients with traumatic dens fractures at our institution between 2008 and 2018. We used multivariable logistic regression and ordinal logistic regression to identify factors independently associated with presentation with a simultaneous atlas fracture, as well myelopathy severity, fracture nonunion, and selection for surgery. Results Two hundred and eighty-two patients with traumatic dens fractures without subaxial fractures were identified, including 65 (22.8%) with simultaneous atlas fractures. The distribution of injury mechanisms differed between groups (χ2 P = 0.0360). On multivariable logistic regression, dens nonunion was positively associated with type II fractures (odds ratio [OR] = 2.00, P = 0.038) and negatively associated with having surgery (OR = 0.52, P = 0.049), but not with having a C1 fracture (P = 0.3673). Worse myelopathy severity on presentation was associated with having a severe injury severity score (OR = 102.3, P < 0.001) and older age (OR = 1.28, P = 0.002), but not with having an atlas fracture (P = 0.2446). Having a simultaneous atlas fracture was associated with older age (OR = 1.29, P = 0.024) and dens fracture angulation (OR = 2.62, P = 0.004). Among patients who underwent surgery, C1/C2 posterior fusion was the most common procedure, and having a simultaneous atlas fracture was associated with selection for occipitocervical fusion (OCF) (OR = 14.35, P = 0.010). Conclusions Among patients with traumatic dens, patients who have simultaneous atlas fractures are a distinct subpopulation with respect to age, mechanism of injury, fracture morphology, and management. Traumatic dens fractures with simultaneous atlas fractures are independently associated with selection for OCF rather than posterior cervical fusion alone.
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Affiliation(s)
- Michael Brendan Cloney
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pavlos Texakalidis
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anastasios G. Roumeliotis
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vineeth Thirunavu
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nathan A. Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kevin Swong
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Najib El Tecle
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nader S. Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Cloney MB, Texakalidis P, Roumeliotis AG, Tecle NE, Dahdaleh NS. Atlas fractures with and without simultaneous dens fractures differ with respect to clinical, demographic, and management characteristics. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:418-425. [PMID: 38268695 PMCID: PMC10805171 DOI: 10.4103/jcvjs.jcvjs_126_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 10/16/2023] [Indexed: 01/26/2024] Open
Abstract
Background Patients with simultaneous fractures of the atlas and dens have traditionally been managed according to the dens fracture's morphology, but data supporting this practice are limited. Methods We retrospectively examined all patients with traumatic atlas fractures at our institution between 2008 and 2016. We used multivariable regression and propensity score matching to compare the presentation, management, and outcomes of patients with isolated atlas fractures to patients with simultaneous atlas-dens fractures. Results Ninety-nine patients were identified. Patients with isolated atlas fractures were younger (61 ± 22 vs. 77 ± 14, P = 0.0003), had lower median Charlson Comorbidity Index (3 vs. 5, P = 0.0005), had better presenting Nurick myelopathy scores (0 vs. 3, P < 0.0001), and had different mechanisms of injury (P = 0.0011). Multivariable regression showed that having a simultaneous atlas-dens fracture was independently associated with older age (odds ratio [OR] =1.59 [1.22, 2.07], P = 0.001), worse presenting myelopathy (OR = 3.10 [2.04, 4.16], P < 0.001), and selection for surgery (OR = 4.91 [1.10, 21.97], P = 0.037). Propensity score matching yielded balanced populations (Rubin's B = 23.3, Rubin's R = 1.96) and showed that the risk of atlas fracture nonunion was no different among isolated atlas fractures compared to simultaneous atlas-dens fractures (P = 0.304). Age was the only variable independently associated with atlas fracture nonunion (OR = 2.39 [1.15, 5.00], P = 0.020), having a simultaneous atlas-dens fracture was not significant (P = 0.2829). Conclusions Among patients with atlas fractures, simultaneous fractures of the dens occur in older patients and confer an increased risk of myelopathy and requiring surgical stabilization. Controlling for confounders, the risk of atlas fracture nonunion is equivalent for isolated atlas fractures versus simultaneous atlas-dens fractures.
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Affiliation(s)
- Michael Brendan Cloney
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Pavlos Texakalidis
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Anastasios G Roumeliotis
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Najib El Tecle
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Nader S. Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
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Ibrahim Y, Li H, Zhao G, Yuan S, Zhao Y, Liu W, Tian Y, Wang L, Liu X. Posterior Temporary C1-2 Pedicle Screws Fixation for the Treatment of Unstable C1-2 Complex Fractures: Minimum of 2-Year Follow-Up. Global Spine J 2023; 13:1522-1532. [PMID: 34409875 PMCID: PMC10448083 DOI: 10.1177/21925682211039186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective. OBJECTIVES To present rarely reported complex fractures of the upper cervical spine (C1-C2) and discuss the clinical results of the posterior temporary C1-2 pedicle screws fixation for C1-C2 stabilization. METHODS A total of 19 patients were included in the study (18 males and 1 female). Their age ranged from 23 to 66 years (mean age of 39.6 years). The patients were diagnosed with complex fractures of the atlas and the axis of the upper cervical spine and underwent posterior temporary C1-2 pedicle screws fixation. The patients underwent a serial postoperative clinical examination at approximately 3, 6, 9 months, and annually thereafter. The neck disability index (NDI) and the range of neck rotary motion were used to evaluate the postoperative clinical efficacy of the patients. RESULTS The average operation time and blood loss were 110 ± 25 min and 50 ± 12 ml, respectively. The mean follow-up was 38 ± 11 months (range 22 to 60 months). The neck rotary motion before removal, immediately after removal, and the last follow-up were 68.7 ± 7.1°, 115.1 ± 11.7°, and 149.3 ± 8.9° (P < 0.01). The NDI scores before and after the operation were 42.7 ± 4.3, 11.1 ± 4.0 (P < 0.01), and the NDI score 2 days after the internal fixation was removed was 7.3 ± 2.9, which was better than immediately after the operation (P < 0.01), and 2 years after the internal fixation was removed. The NDI score was 2.0 ± 0.8, which was significantly better than 2 days after the internal fixation was taken out (P < 0.001). CONCLUSIONS Posterior temporary screw fixation is a good alternative surgical treatment for unstable C1-C2 complex fractures.
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Affiliation(s)
- Yakubu Ibrahim
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Hao Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Geng Zhao
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Suomao Yuan
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Yiwei Zhao
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Wubo Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Yonghao Tian
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Lianlei Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Xinyu Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
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Mohile NV, Kuczmarski AS, Minaie A, Syros A, Geller JS, Maaieh MA. Management of combined atlas and axis fractures: a systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 14:100224. [PMID: 37440984 PMCID: PMC10333716 DOI: 10.1016/j.xnsj.2023.100224] [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: 02/18/2023] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 07/15/2023]
Abstract
Background Combined atlas-axis fractures are rare occurrences with substantially higher rates of neurologic deficits compared with isolated injuries. Given the intricate anatomic relationship between the atlas and axis vertebra, variable fracture patterns may occur, warranting special considerations from surgeons. Methods A systematic search of PubMed and EMBASE was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Relevant studies on acute combined atlas-axis fractures that provided data on patient demographics, presentation (injury mechanism, neurologic deficits, fracture type), management, complications, and study conclusions were reviewed. Results A total of 22 articles published from 1977 to 2022, comprising 230 patients, were included in the final analysis. Thirty-seven of the 213 patients (17%) presented with neurologic deficits. The most common atlas injuries were posterior arch fractures (54/169 patients; 32%), combined posterior arch/anterior arch fractures (44/169 patients; 26%), and anterior arch fractures (43/169 patients; 25%). The most common axis injuries were type II odontoid fractures (115/175 patients; 66%). Of the 127 patients managed operatively (127/230 patients; 55%), 45 patients (35%) were treated with C1-C2 posterior spinal fusion, 33 patients (26%) were treated with odontoid screw fixation and anterior/posterior C1-C2 trans-articular screws, 16 patients (13%) were treated with occiputocervical fusion and 12 patients (9%) were treated with odontoid screw fixation alone. Conclusions Management strategies are generally based on the type of axis fracture as well as the condition of the transverse ligament. Patients with stable fractures can be successfully managed nonoperatively with a cervical collar or halo immobilization. Combined atlas-axis fractures with an atlantodental interval >5 mm, C1 lateral mass displacement >7 mm, C2-C3 angulation >11° or an MRI demonstrating a disrupted transverse ligament are suggestive of instability and are often successfully managed with surgical intervention. There is no consensus regarding surgical technique.
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Affiliation(s)
- Neil V. Mohile
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
| | - Alexander S. Kuczmarski
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
| | - Arya Minaie
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
| | - Alina Syros
- Department of Medical Education, University of Miami Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL 33136, United States
| | - Joseph S. Geller
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
| | - Motasem Al Maaieh
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
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Di Francesco ME, Magunia H, Örgel A, Tatagiba M, Radwan M, Adib SD. Case report: Interdisciplinary treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease requiring bypass surgery. Front Surg 2023; 10:1123947. [PMID: 37260599 PMCID: PMC10228685 DOI: 10.3389/fsurg.2023.1123947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/25/2023] [Indexed: 06/02/2023] Open
Abstract
Background Acute myocardial infarction (MI) frequently leads to consciousness disturbance following hemodynamic collapse. Therefore, MI can occur together with upper cervical spine trauma. Herein, we report the successful treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease (CAD). Case presentation A 70-year-old patient presented in our emergency outpatient clinic after a hemodynamic collapse without neurological deficits or heart-related complaints. Computed tomography (CT) scan of the cervical spine revealed a dislocated odontoid fracture Anderson and D'Alonzo type II and an unstable Gehweiler type III injury (Jefferson's fracture). An intradiploic arachnoid cyst in the posterior wall of the posterior fossa was a coincident radiological finding. Furthermore, coronary angiography confirmed three-vessel CAD with high-grade coronary artery stenosis. Indication for upper cervical spine surgery and bypass surgery was given. An interdisciplinary team of neurosurgeons, cardiothoracic surgeons and anesthesiologists evaluated the patient's case to develop the most suitable therapy concept and alternative strategies. Finally, in first step, C1-C2 fusion was performed by Harms technique under general anesthesia with x-ray guidance, spinal neuronavigation, Doppler ultrasound and cardiopulmonary monitoring. Cardiothoracic surgeons were on standby. One month later bypass surgery was performed uneventfully. Follow-up CT scan of cervical spine revealed intraosseous screw positioning and beginning fusion of the fractures. The patient did not develop neurological deficits and recovered completely from both surgeries. Conclusions Treating complex C1/C2 fractures with concomitant severe CAD requiring treatment is challenging and carries a high risk of complications. To our knowledge, the literature does not provide any guidelines regarding therapy of this constellation. To receive upper cervical spine stability and to prevent both, spinal cord injury and cardiovascular complications, an individual approach is required. Interdisciplinary cooperation to determine optimal therapeutic algorithms is needed.
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Affiliation(s)
| | - H. Magunia
- Department of Anesthesiology and Intensive Care Medicine, University of Tuebingen, Tuebingen, Germany
| | - A. Örgel
- Department of Diagnostic and Interventional Neuroradiology, University of Tuebingen, Tuebingen, Germany
| | - M. Tatagiba
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - M. Radwan
- Department of Thoracic and Cardiovascular Surgery, University of Tuebingen, Tuebingen, Germany
| | - S. D. Adib
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
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Patsakos EM, Craven BC, Kua A, Cheng CL, Eng J, Ho C, Noonan VK, Querée M, Bayley MT. Evaluation of the quality of published SCI clinical practice guidelines using the AGREE II instrument: Results from Can-SCIP expert panel. J Spinal Cord Med 2021; 44:S69-S78. [PMID: 34779735 PMCID: PMC8604538 DOI: 10.1080/10790268.2021.1961053] [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: 12/02/2022] Open
Abstract
INTRODUCTION Spinal cord injury (SCI) is a complex condition with substantial adverse personal, social and economic impacts necessitating evidence-based inter-professional care. To date, limited studies have assessed the quality of clinical practice guidelines (CPGs) within SCI. The aim of this study is to evaluate the quality of the development process and methodological rigour of published SCI CPGs across the care continuum from pre-hospital to community-based care. METHODS Electronic health databases and indexes were searched to identify English or French language CPGs within SCI published within the last nine years with specific evidence-based recommendations applicable to the Canadian health care setting. Eligible CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. RESULTS A total of forty-one CPGs that met the inclusion criteria were appraised by at least four raters. There was high variability in quality. Twenty-seven CPGs achieved a good rigour of development domain score of >70%. Other standardized mean domain scores were scope and purpose (85.32%), stakeholder involvement (65.03%), clarity of presentation (84.81%), applicability (55.55%) and editorial independence (75.83%). The agreement between appraisers (intraclass correlation coefficient) was high (intraclass correlation coefficient > 0.80). CONCLUSION There is a paucity of CPGs that address community-based specialized rehabilitation and community reintegration. Furthermore, many CPGs only focus on a single impairment at one time point in the care continuum. As SCI is a complex condition that results in multimorbidity and requires health monitoring and intervention across the lifespan, a rigorously developed CPG that addresses high-quality, interprofessional comprehensive care is needed.
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Affiliation(s)
- Eleni M. Patsakos
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - B. Catharine Craven
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ailene Kua
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Christiana l. Cheng
- Praxis Spinal Cord Institute, International Collaboration on Repair Discoveries (ICORD), University of British Columbia, British Columbia, Canada
| | - Janice Eng
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Chester Ho
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Alberta, Alberta, Canada
| | - Vanessa K. Noonan
- Praxis Spinal Cord Institute, International Collaboration on Repair Discoveries (ICORD), University of British Columbia, British Columbia, Canada
| | - Matthew Querée
- Department of Physiotherapy, Faculty of Medicine, University of British Columbia, GF Strong Rehabilitation Centre, British Columbia, Canada
| | - Mark T. Bayley
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - the Can-SCIP Guideline Expert Panel
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Praxis Spinal Cord Institute, International Collaboration on Repair Discoveries (ICORD), University of British Columbia, British Columbia, Canada
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, British Columbia, Canada
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Alberta, Alberta, Canada
- Department of Physiotherapy, Faculty of Medicine, University of British Columbia, GF Strong Rehabilitation Centre, British Columbia, Canada
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Patsakos EM, Bayley MT, Kua A, Cheng C, Eng J, Ho C, Noonan VK, Querée M, Craven BC. Development of the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline: Methods and overview. J Spinal Cord Med 2021; 44:S52-S68. [PMID: 34779719 PMCID: PMC8604491 DOI: 10.1080/10790268.2021.1953312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Spinal cord injury (SCI) is a life-altering injury that leads to a complex constellation of changes in an individual's sensory, motor, and autonomic function which is largely determined by the level and severity of cord impairment. Available SCI-specific clinical practice guidelines (CPG) address specific impairments, health conditions or a segment of the care continuum, however, fail to address all the important clinical questions arising throughout an individual's care journey. To address this gap, an interprofessional panel of experts in SCI convened to develop the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline. This article provides an overview of the methods underpinning the Can-SCIP Guideline process. METHODS The Can-SCIP Guideline was developed using the Guidelines Adaptation Cycle. A comprehensive search for existing SCI-specific CPGs was conducted. The quality of eligible CPGs was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. An expert panel (n = 52) convened, and groups of relevant experts met to review and recommend adoption or refinement of existing recommendations or develop new recommendations based on evidence from systematic reviews conducted by the Spinal Cord Injury Research Evidence (SCIRE) team. The expert panel voted to approve selected recommendations using an online survey tool. RESULTS The Can-SCIP Guideline includes 585 total recommendations from 41 guidelines, 96 recommendations that pertain to the Components of the Ideal SCI Care System section, and 489 recommendations that pertain to the Management of Secondary Health Conditions section. Most recommendations (n = 281, 48%) were adopted from existing guidelines without revision, 215 (36.8%) recommendations were revised for application in a Canadian context, and 89 recommendations (15.2%) were created de novo. CONCLUSION The Can-SCIP Guideline is the first living comprehensive guideline for adults with SCI in Canada across the care continuum.
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Affiliation(s)
- Eleni M. Patsakos
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Mark T. Bayley
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ailene Kua
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Christiana Cheng
- Praxis Spinal Cord Institute, International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Janice Eng
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Physiotherapy, GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada
| | - Chester Ho
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vanessa K. Noonan
- Praxis Spinal Cord Institute, International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew Querée
- GF Strong Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - B. Catharine Craven
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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9
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Alves OL, Pereira L, Kim SH, Grin A, Shimokawa N, Konovalov N, Zileli M. Upper Cervical Spine Trauma: WFNS Spine Committee Recommendations. Neurospine 2020; 17:723-736. [PMID: 33401853 PMCID: PMC7788417 DOI: 10.14245/ns.2040226.113] [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] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/10/2020] [Indexed: 01/12/2023] Open
Abstract
Craniovertebral junction (CVJ) trauma is a challenging clinical condition. Being a highly mobile functional unit at the junction of the skull and the vertebral column, traumatic events in this area may produce devastating neurological complications and death. Additionally, many of the CVJ traumatic injuries can be left undiagnosed or even raise difficult treatment dilemmas. We present a literature review in the format of recommendations on the diagnosis and management of different scenarios for upper cervical trauma and produce recommendations, which can be applicable to various areas of the globe.
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Affiliation(s)
- Oscar L Alves
- Department of Neurosurgery, Centro Hospitalar de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Department of Neurosurgery, Hospital Lusiadas Porto, Porto, Portugal
| | - Leopoldina Pereira
- Department of Neurosurgery, Centro Hospitalar de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Se-Hoon Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Andrey Grin
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russian Federation.,A.I. Evdokimov Moscow Medical University, Moscow, Russian Federation
| | | | - Nikolay Konovalov
- N. N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
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Catalino MP, Pate V, Stürmer T, Bhowmick DA. Comparative Propensity-Weighted Mortality After Isolated Acute Traumatic Axis Fractures in Older Adults. Geriatr Orthop Surg Rehabil 2020; 11:2151459320911867. [PMID: 32284902 PMCID: PMC7133078 DOI: 10.1177/2151459320911867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/27/2019] [Accepted: 01/16/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION In older patients with axis fractures, the survival benefit from surgery is unclear due to high baseline mortality. Comparative effectiveness research can provide evidence from population level cohorts. Propensity weighting is the preferred methodology for reducing bias when analyzing national administrative cohort data for these purposes but has not yet been utilized for this important surgical conundrum. We estimate the effect of surgery on mortality after isolated acute traumatic axis fracture in older adults. MATERIALS AND METHODS We used a retrospective population-based cohort of Medicare patients and generated a propensity score-weighted nonsurgical cohort and compared mortality with and without surgery. This balanced the comorbid conditions of the treatment groups. Incident fractures were defined using a predetermined algorithm based on enrollment, code timing, and billing location. The primary outcome was adjusted all-cause 1-year mortality. RESULTS From 12 372 beneficiaries with 1-year continuous enrollment and a coded axis fracture, 2676 patients met final inclusion/exclusion criteria. Estimated incidence was 16.5 per 100 000 person-years overall in 2014 (95% confidence interval [CI]: 15.0-18.0) and was stable from 2008 through 2014. Patients with axis fracture had a mean age of 82.8 years, 30.2% were male, and 91.9% were Caucasian. Mortality was 3.8 times higher (CI 3.6-4.1) compared with the general population of older US adults. Propensity-weighted mortality at 1 year for nonsurgical patients was 26.7 of 100 (CI: 24.5-29.0). Mortality for surgical patients was significantly lower (19.7/100; CI 14.5-25.0). Risk difference was 7.0 fewer surgical deaths per 100 patients (CI: 1.3-12.7). Surgical patients aged 65 to 74 years had the largest difference in mortality with 11.2 fewer deaths per 100 (CI: 1.1-21.3). DISCUSSION Patients with axis fractures are predominantly older Caucasian women and have a higher mortality rate than the general population. Propensity-weighted mortality at 1-year was lower in the surgical patients with the largest risk difference occurring in patients 65 to 74 years old. CONCLUSIONS Surgery may provide an independent survival benefit in patients aged 65 to 75 years, and the mortality difference diminishes thereafter.
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Affiliation(s)
| | - Virginia Pate
- Department of Epidemiology, UNC Gillings School of Global Public Health, NC, USA
| | - Til Stürmer
- Department of Epidemiology, UNC Gillings School of Global Public Health, NC, USA
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11
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Hadley MN, Walters BC. The case for the future role of evidence-based medicine in the management of cervical spine injuries, with or without fractures. J Neurosurg Spine 2019; 31:457-463. [PMID: 31574462 DOI: 10.3171/2019.6.spine19652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/19/2019] [Indexed: 11/06/2022]
Abstract
The authors believe that the standardized and systematic study of immobilization techniques, diagnostic modalities, medical and surgical treatment strategies, and ultimately outcomes and outcome measurement after cervical spinal trauma and cervical spinal fracture injuries, if performed using well-designed medical evidence-based comparative investigations with meaningful follow-up, has both merit and the remarkable potential to identify optimal strategies for assessment, characterization, and clinical management. However, they recognize that there is inherent difficulty in attempting to apply evidence-based medicine (EBM) to identify ideal treatment strategies for individual cervical fracture injuries. First, there is almost no medical evidence reported in the literature for the management of specific isolated cervical fracture subtypes; specific treatment strategies for specific fracture injuries have not been routinely studied in a rigorous, comparative way. One of the vulnerabilities of an evidenced-based scientific review in spinal cord injury (SCI) is the lack of studies in comparative populations and scientific evidence on a given topic or fracture pattern providing level II evidence or higher. Second, many modest fracture injuries are not associated with vascular or neural injury or spinal instability. The application of the science of EBM to the care of patients with traumatic cervical spine injuries and SCIs is invaluable and necessary. The dedicated multispecialty author groups involved in the production and publication of the two iterations of evidence-based guidelines on the management of acute cervical spine and spinal cord injuries have provided strategic guidance in the care of patients with SCIs. This dedicated service to the specialty has been carried out to provide neurosurgical colleagues with a qualitative review of the evidence supporting various aspects of care of these patients. It is important to state and essential to understand that the science of EBM and its rigorous application is important to medicine and to the specialty of neurosurgery. It should be embraced and used to drive and shape investigations of the management and treatment strategies offered patients. It should not be abandoned because it is not convenient or it does not support popular practice bias or patterns. It is the authors' view that the science of EBM is essential and necessary and, furthermore, that it has great potential as clinician scientists treat and study the many variations and complexities of patients who sustain acute cervical spine fracture injuries.
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Affiliation(s)
- Mark N Hadley
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Beverly C Walters
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
- 2Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
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The Decision-Making Process in Traumatic Lesions of the Craniovertebral Junction: An Evidence-Based Approach? Part II. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019. [PMID: 30610339 DOI: 10.1007/978-3-319-62515-7_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
This paper is Part II of a two-part report. Part I of the report covered atlanto-occipital dislocation or dissociation, and isolated condylar fractures. This part of the report covers isolated and combination fractures of the atlas and axis.
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Zhao ZS, Wu GW, Lin J, Zhang YS, Huang YF, Chen ZD, Lin B, Zheng CS. Management of Combined Atlas Fracture with Type II Odontoid Fracture: A Review of 21 Cases. Indian J Orthop 2019; 53:518-524. [PMID: 31303667 PMCID: PMC6590023 DOI: 10.4103/ortho.ijortho_249_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the therapeutic effects of combined atlas fracture with type II (C1-type II) odontoid fractures and to outline a management strategy for it. PATIENTS AND METHODS Twenty three patients with C1-type II odontoid fractures were treated according to our management strategy. Nonoperative external immobilization in the form of cervical collar and halo vest was used in 13 patients with stable atlantoaxial joint. Surgical treatment was early performed in 10 patients whose fractures with traumatic transverse atlantal ligament disruption or atlantoaxial instability. The visual analog scale (VAS), neck disability index (NDI) scale, and American Spinal Injury Association (ASIA) scale at each stage of followup were then collected and compared. RESULTS Compared to pretreatment, the VAS score, NDI score, and ASIA scale were improved among both groups at followup evaluation after treatment. However, in the nonsurgical group, one patient (1/11) developed nonunion which required surgical treatment in later stage and one patient (1/13) with halo vest immobilization had happened pin site infection. Two patients of the surgical group (2/11) had appeared minor complications: occipital cervical pain in one case and cerebrospinal fluid leakage in one case. Two patients (2/23) were excluded from nonsurgical treatment group because their followup period was less than 12 months. Twenty one patients were followed up regularly with an average of 23.9 months (range 15-45 months). CONCLUSIONS We outlined our concluding management principle for the treatment of C1-type II odontoid fractures based on the nature of C1 fracture and atlantoaxial stability. The treatment principle can obtain satisfactory results for the management of C1-type II odontoid fractures.
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Affiliation(s)
- Zhong-Sheng Zhao
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Guang-Wen Wu
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Jie Lin
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Ying-Sheng Zhang
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Yan-Feng Huang
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Zhi-Da Chen
- Department of Orthopedics, The 175th Hospital of PLA, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, Fujian, China
| | - Bin Lin
- Department of Orthopedics, The 175th Hospital of PLA, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, Fujian, China,Address for correspondence: Dr. Chun-Song Zheng, Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, 1 Qiuyang Road, Fuzhou 350122, Fujian, China. E-mail:
Prof. Bin Lin, Department of Orthopedics, the 175th Hospital of PLA, The Affiliated Southeast Hospital of Xiamen University, 269 Zhanghua Road, Zhangzhou 363000, Fujian, China. E-mail:
| | - Chun-Song Zheng
- Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China,Address for correspondence: Dr. Chun-Song Zheng, Institute of Orthopedic Diseases, Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, 1 Qiuyang Road, Fuzhou 350122, Fujian, China. E-mail:
Prof. Bin Lin, Department of Orthopedics, the 175th Hospital of PLA, The Affiliated Southeast Hospital of Xiamen University, 269 Zhanghua Road, Zhangzhou 363000, Fujian, China. E-mail:
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Carneiro GDS, Bezerra Júnior DL, Chaves JR, Quinino SCDM, Trindade AFD. REDUCTION AND INTERNAL FIXATION OF COMPLEX FRACTURES OF THE ODONTOID BY THE TRANSORAL APPROACH. COLUNA/COLUMNA 2018. [DOI: 10.1590/s1808-185120181704172951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Type II odontoid fractures with irreducible posterior displacement are uncommon, and can cause spinal cord compression, respiratory failure and even death. Treatment is usually surgical, with transoral decompression and posterior fusion or with reduction and fusion of C1-C2 by the transoral approach. We describe a case of type II odontoid fracture with irreducible posterior atlantoaxial dislocation that was treated exclusively by the transoral approach with osteosynthesis of the odontoid, thus preserving functional segmental mobility. Level of Evidence III; therapeutic study.
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DiDomenico J, Abode-Iyamah K, Khanna R, Roberts H, Hitchon PA, Smith ZA, Dahdaleh NS. Management of acute combined fractures of the atlas and axis: A retrospective study of two trauma centers. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 8:311-315. [PMID: 29403241 PMCID: PMC5763586 DOI: 10.4103/jcvjs.jcvjs_53_17] [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: 11/13/2022] Open
Abstract
Background: Management of combination fractures of the atlas and axis varies from nonoperative immobilization to selective early surgical intervention. In this study, we present our experience in managing these injuries. Materials and Methods: Electronic databases from two level 1 trauma centers were queried to identify all patients diagnosed with C1-C2 combination fractures from 2009 to present. Patient demographics, fracture characteristics, treatment modality, complications, Frankel scores, and fusion status were collected. Patients were separated into operative and nonoperative cohorts, and comparisons were made between the two groups. Results: Forty-eight patients were included, of which 19 received operative management and 29 were treated nonoperatively. The mean age was 76.1 and 75.3 years, respectively (P = 0.877). Frankel grade distribution was similar on presentation in both groups, with most being neurologically intact. C1 fractures of both the anterior and posterior arch were present in 41.2% patients undergoing fusions compared to 27.6% of patients treated nonoperatively. No significant differences in comorbidities, neurologic deficits, or radiographic measurements were observed across the two groups. Conclusions: This study demonstrates the variety of treatment strategies used for the management of combined C1-C2 fractures. Patients managed operatively tend to have both anterior and posterior C1 arch fractures, while patients managed nonoperatively tend to have either anterior or posterior arch fractures. In general, treatments should be tailored to patients’ needs depending on the stability of the fractures, neurological state, and medical comorbidities.
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Affiliation(s)
- Joseph DiDomenico
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-2911, USA
| | - Kingsley Abode-Iyamah
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Ryan Khanna
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-2911, USA
| | - Helena Roberts
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-2911, USA
| | - Patrick A Hitchon
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Zachary A Smith
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-2911, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-2911, USA
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16
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Dyas AR, Niemeier TE, Mcgwin G, Theiss SM. Ability of magnetic resonance imaging to accurately determine alar ligament integrity in patients with atlanto-occipital injuries. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 9:241-245. [PMID: 30783347 PMCID: PMC6364359 DOI: 10.4103/jcvjs.jcvjs_81_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective: The objective of this study is to evaluate the the reliability of magnetic resonance imaging (MRI) in diagnosing alar ligament disruption in patients with potential atlanto-occipital dissociation (AOD). Materials and Methods: Three-blinded readers performed retrospective review on 6 patients with intra-operative confirmed atlanto-occipital dissocation in addition to a comparison cohort of patients with other cervical injuries that did not involve the atlanto-occipital articulation. Ligament integrity was graded from 1 to 3 as described by Krakenes et al. The right and left ligaments were assessed separately. Inter-observer agreement by patient, by group (AOD vs. non-AOD), and intra-observer agreement was calculated using weighted Cohen's kappa. Results: Interobserver agreement of alar ligament grade for individual patients ranged from slight to fair (κ = 0.05–0.30). Interobserver agreement of alar ligament grade for each group (AOD vs. non-AOD) ranged from fair to substantial (κ = 0.37–0.66). No statistically significant difference in categorical analysis of groups (AOD vs. non-AOD) and grade (0–1 vs. 2–3) was observed. Intraobserver agreement of individual patient's alar ligament grade ranged from moderate to substantial (κ = 0.50–0.62). Conclusion: The use of MRI to detect upper cervical ligament injuries in AOD is imperfect. Our results show inconsistent and unsatisfactory interobserver and intraobserver reliability in evaluation of alar ligament injuries. While MRI has immense potential for detection of ligamentous injury at the craniovertebral junction, standardized algorithms for its use and interpretation need to be developed.
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Affiliation(s)
- Adam R Dyas
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas E Niemeier
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gerald Mcgwin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Steven M Theiss
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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17
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Cao L, Yang E, Xu J, Lian X, Cai B, Liu X, Zhang G. "Direct vision" operation of posterior atlantoaxial transpedicular screw fixation for unstable atlantoaxial fractures: A retrospective study. Medicine (Baltimore) 2017; 96:e7054. [PMID: 28640081 PMCID: PMC5484189 DOI: 10.1097/md.0000000000007054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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
BACKGROUND The posterior screw fixation in atlas via posterior arch and lateral mass, also called C1 "pedicle" screw, combined with C2 pedicle screw fixiation has shown better biomechanical stability in unstable atlantoaxial fractures. However, its popularization has to fulfill the limitation imposed by anatomical characteristics. The aim of this study was to explore the manipulation, effect, and safety of the atlantoaxial transpedicular screw fixation under "direct vision" for the treatment of unstable atlantoaxial fracture. METHODS All the patients diagnosed with unstable atlantoaxial fracture, who received surgery treatment of C1,C2 internal fixation from January 2012 to December 2014 were reviewed. Only these patients that were diagnosed with atlantoaxial unstability secondary to trauma and were treated with atlantoaxial transpedicular screw fixation under "direct vision" and iliac autograft were included. The safety of transpedicular screw placement, postoperative outcome, atlantoaxial stability, autograft fusion, and complications was observed and analyzed retrospectively. The pain visual analog scale (VAS) and the Japanese Orthopedic Association (JOA) score were used as surgical curative effect evaluation standards. RESULTS We reviewed a total of 92 patients diagnosed with unstable atlantoaxial fracture, who received surgery treatment of C1,C2 internal fixation from January 2012 to December 2014, and 87 patients were treated with atlantoaxial transpedicular screw fixation under "direct vision" and were included this analysis. A total of 306 transpedicular screws in atlas and axis were placed successfully. All cases were followed-up >12 months. The overall breach rate was 11.36%. None of the breaches resulted in new-onset neurological sequela. The neurological status in cases with bilateral upper extremities numbness and lower extremities weakness had improved after surgery. At the latest follow-up, the neck VAS and JOA scores were significantly improved (P < .01) than those preoperatively. No cases demonstrated implantation failure and bone graft absorption on the postoperative x-ray films and CT scans. CONCLUSION Atlantoaxial transpedicular screw fixation under "direct vision" and iliac autograft for the treatment of unstable atlantoaxial fracture has shown simple manipulation and efficient performance. Thus, the technique of C1-C2 fixation is feasible in treating unstable atlantoaxial fracture.
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Affiliation(s)
- Liangliang Cao
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Erzhu Yang
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Jianguang Xu
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Xiaofeng Lian
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Bin Cai
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
| | - Xiaokang Liu
- Department of Orthopedics, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Guowang Zhang
- Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai
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The spectrum of traumatic injuries at the craniocervical junction: a review of imaging findings and management. Emerg Radiol 2017; 24:377-385. [DOI: 10.1007/s10140-017-1490-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/14/2017] [Indexed: 12/15/2022]
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Mourelo Fariña M, Salvador de la Barrera S, Montoto Marqués A, Ferreiro Velasco ME, Galeiras Vázquez R. Update on traumatic acute spinal cord injury. Part 2. Med Intensiva 2017; 41:306-315. [PMID: 28161027 DOI: 10.1016/j.medin.2016.10.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 10/25/2016] [Accepted: 10/31/2016] [Indexed: 12/17/2022]
Abstract
The aim of treatment in acute traumatic spinal cord injury is to preserve residual neurologic function, avoid secondary injury, and restore spinal alignment and stability. In this second part of the review, we describe the management of spinal cord injury focusing on issues related to short-term respiratory management, where the preservation of diaphragmatic function is a priority, with prediction of the duration of mechanical ventilation and the need for tracheostomy. Surgical assessment of spinal injuries based on updated criteria is discussed, taking into account that although the type of intervention depends on the surgical team, nowadays treatment should afford early spinal decompression and stabilization. Within a comprehensive strategy in spinal cord injury, it is essential to identify and properly treat patient anxiety and pain associated to spinal cord injury, as well as to prevent and ensure the early diagnosis of complications secondary to spinal cord injury (thromboembolic disease, gastrointestinal and urinary disorders, pressure ulcers).
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Affiliation(s)
- M Mourelo Fariña
- Unidad de Cuidados Intensivos, Complexo Hospitalario Universitario de A Coruña, A Coruña, España
| | - S Salvador de la Barrera
- Unidad de Lesionados Medulares, Complexo Hospitalario Universitario de A Coruña, A Coruña, España
| | - A Montoto Marqués
- Unidad de Lesionados Medulares, Complexo Hospitalario Universitario de A Coruña, A Coruña, España; Departamento de Medicina, Universidad de A Coruña, A Coruña, España
| | - M E Ferreiro Velasco
- Unidad de Lesionados Medulares, Complexo Hospitalario Universitario de A Coruña, A Coruña, España
| | - R Galeiras Vázquez
- Unidad de Cuidados Intensivos, Complexo Hospitalario Universitario de A Coruña, A Coruña, España.
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The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma. Insights Imaging 2016; 8:29-47. [PMID: 27815845 PMCID: PMC5265194 DOI: 10.1007/s13244-016-0530-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/09/2016] [Accepted: 10/13/2016] [Indexed: 12/15/2022] Open
Abstract
Imaging of the blunt traumatic injuries to the craniocervical junction can be challenging but central to improving morbidity and mortality related to such injury. The radiologist has a significant part to play in the appropriate management of patients who have suffered injury to this vital junction between the cranium and the spine. Knowledge of the embryology and normal anatomy as well as normal variant appearances avoids inappropriate investigations in these trauma patients. Osseous injury can be subtle while representing important radiological red flags for significant underlying ligamentous injury. An understanding of bony and ligamentous injury patterns can also give some idea of the biomechanics and degree of force required to inflict such trauma. This will assist greatly in predicting risk for other critical injuries related to vital neighbouring structures such as vasculature, brain stem, cranial nerves and spinal cord. The embryology and anatomy of the craniocervical junction will be outlined in this review and the relevant osseous and ligamentous injuries which can arise as a result of blunt trauma to this site described together. Appropriate secondary radiological imaging considerations related to potential complications of such trauma will also be discussed. TEACHING POINTS • The craniocervical junction is a distinct osseo-ligamentous entity with specific functional demands. • Understanding the embryology of the craniocervical junction may prevent erroneous radiological interpretation. • In blunt trauma, the anatomical biomechanical demands of the ligaments warrant consideration. • Dedicated MRI sequences can provide accurate evaluation of ligamentous integrity and injury. • Injury of the craniocervical junction carries risk of blunt traumatic cerebrovascular injury.
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Ducis K, Florman JE, Rughani AI. Appraisal of the Quality of Neurosurgery Clinical Practice Guidelines. World Neurosurg 2016; 90:322-339. [PMID: 26947727 DOI: 10.1016/j.wneu.2016.02.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The rate of neurosurgery guidelines publications was compared over time with all other specialties. Neurosurgical guidelines and quality of supporting evidence were then analyzed and compared by subspecialty. METHODS The authors first performed a PubMed search for "Neurosurgery" and "Guidelines." This was then compared against searches performed for each specialty of the American Board of Medical Specialties. The second analysis was an inventory of all neurosurgery guidelines published by the Agency for Healthcare Research and Quality Guidelines clearinghouse. All Class I evidence and Level 1 recommendations were compared for different subspecialty topics. RESULTS When examined from 1970-2010, the rate of increase in publication of neurosurgery guidelines was about one third of all specialties combined (P < 0.0001). However, when only looking at the past 5 years the publication rate of neurosurgery guidelines has converged upon that for all specialties. The second analysis identified 49 published guidelines for assessment. There were 2733 studies cited as supporting evidence, with only 243 of these papers considered the highest class of evidence (8.9%). These papers were used to generate 697 recommendations, of which 170 (24.4%) were considered "Level 1" recommendations. CONCLUSION Although initially lagging, the publication of neurosurgical guidelines has recently increased at a rate comparable with that of other specialties. However, the quality of the evidence cited consists of a relatively low number of high-quality studies from which guidelines are created. Wider implications of this must be considered when defining and measuring quality of clinical performance in neurosurgery.
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Affiliation(s)
- Katrina Ducis
- Division of Neurosurgery, Department of Surgery, University of Vermont, Burlington, Vermont, USA.
| | - Jeffrey E Florman
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Anand I Rughani
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA; Center for Excellence in Neuroscience, University of New England, Biddeford, Maine, USA
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Dhandapani S, Kapoor A, Meena R. The hyperextension triad of type II odontoid fracture, posterior atlantoaxial dislocation (reducible in flexion), and C1 posterior arch fracture: implications on emergency management and anterior versus posterior surgical approach. Spine J 2016; 16:e43-4. [PMID: 26383497 DOI: 10.1016/j.spinee.2015.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 08/05/2015] [Accepted: 09/03/2015] [Indexed: 02/03/2023]
Affiliation(s)
- Sivashanmugam Dhandapani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Ankur Kapoor
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Rajesh Meena
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
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Lin B, Wu J, Chen ZD, Zeng W, Liu Q, Dai L. Management of combined atlas-axis fractures: a review of forty one cases. INTERNATIONAL ORTHOPAEDICS 2015; 40:1179-86. [PMID: 26686497 DOI: 10.1007/s00264-015-3076-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 12/08/2015] [Indexed: 01/05/2023]
Abstract
PURPOSE To outline a management principle for the combined atlas (C1)-axis (C2) fractures and assess its therapeutic effects. METHODS Forty-one patients with combined C1-C2 fractures were treated according to their C2 fracture types. Non-operative external immobilization in the form of a cervical collar or halo vest was used in 22 patients. Early posterior pedicle screw fixations were performed in 19 patients whose fractures had a combination of any of the three conditions: an atlantodens interval (ADI) ≥ 5 mm, lateral mass displacement (LMD) > 7 mm, and/or C2-C3 angulation > 11°. Thirty-nine patients were followed up regularly with an average of 19.3 months (range, 12 to 45 months). Clinical and radiographic data were then collected and compared. RESULTS At three months following treatment, patients' visual analog scale (VAS), Neck Disability Index (NDI), American Spinal Injury Association (ASIA) scale, and Frankel grades were all significantly improved when compared to pretreatment. These results indicated that the cervical collar, halo vest, and posterior pedicle screw fixation approaches were all able to effectively treat cases of combined C1-C2 fractures. One patient in the non-surgical group developed nonunion which required late surgical treatment and one patient had pin site infection in the non-surgical group (2/22), while there were three minor complications in the surgical group. CONCLUSION We propose a management principle that bases the treatment of a combined C1-C2 fracture on the nature of the C2 fracture. This treatment strategy has yielded promising results as a satisfactory means for the management of combined C1-C2 fractures.
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Affiliation(s)
- Bin Lin
- Department of Orthopaedics, The Affiliated Southeast Hospital of Xiamen University, Orthopaedic Center of People's Liberation Army, Zhangzhou, 363000, China.
| | - Jin Wu
- Department of Orthopaedics, The Affiliated Southeast Hospital of Xiamen University, Orthopaedic Center of People's Liberation Army, Zhangzhou, 363000, China
| | - Zhi-da Chen
- Department of Orthopaedics, The Affiliated Southeast Hospital of Xiamen University, Orthopaedic Center of People's Liberation Army, Zhangzhou, 363000, China
| | - Wenrong Zeng
- Department of Orthopaedics, The Affiliated Southeast Hospital of Xiamen University, Orthopaedic Center of People's Liberation Army, Zhangzhou, 363000, China
| | - Qingjun Liu
- Department of Orthopaedics, The Affiliated Southeast Hospital of Xiamen University, Orthopaedic Center of People's Liberation Army, Zhangzhou, 363000, China
| | - LiLin Dai
- Department of Orthopaedics, The Affiliated Southeast Hospital of Xiamen University, Orthopaedic Center of People's Liberation Army, Zhangzhou, 363000, China
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Roy AK, Miller BA, Holland CM, Fountain AJ, Pradilla G, Ahmad FU. Magnetic resonance imaging of traumatic injury to the craniovertebral junction: a case-based review. Neurosurg Focus 2015; 38:E3. [PMID: 25828497 DOI: 10.3171/2015.1.focus14785] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECT The craniovertebral junction (CVJ) is unique in the spinal column regarding the degree of multiplanar mobility allowed by its bony articulations. A network of ligamentous attachments provides stability to this junction. Although ligamentous injury can be inferred on CT scans through the utilization of craniometric measurements, the disruption of these ligaments can only be visualized directly with MRI. Here, the authors review the current literature on MRI evaluation of the CVJ following trauma and present several illustrative cases to highlight the utility and limitations of craniometric measures in the context of ligamentous injury at the CVJ. METHODS A retrospective case review was conducted to identify patients with cervical spine trauma who underwent cervical MRI and subsequently required occipitocervical or atlantoaxial fusion. Craniometric measurements were performed on the CT images in these cases. An extensive PubMed/MEDLINE literature search was conducted to identify publications regarding the use of MRI in the evaluation of patients with CVJ trauma. RESULTS The authors identified 8 cases in which cervical MRI was performed prior to operative stabilization of the CVJ. Craniometric measures did not reliably rule out ligamentous injury, and there was significant heterogeneity in the reliability of different craniometric measurements. A review of the literature revealed several case series and descriptive studies addressing MRI in CVJ trauma. Three papers reported the inadequacy of the historical Traynelis system for identifying atlantooccipital dislocation and presented 3 alternative classification schemes with emphasis on MRI findings. CONCLUSIONS Recognition of ligamentous instability at the CVJ is critical in directing clinical decision making regarding surgical stabilization. Craniometric measures appear unreliable, and CT alone is unable to provide direct visualization of ligamentous injury. Therefore, while the decision to obtain MR images in CVJ trauma is largely based on clinical judgment with craniometric measures used as an adjunct, a high degree of suspicion is warranted in the care of these patients as a missed ligamentous injury can have devastating consequences.
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Imura T, Inoue G, Nakazawa T, Saito W, Takaso M. Surgical treatment of an atlantoaxial fracture after a delayed diagnosis in a comatose patient. 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; 24 Suppl 4:S623-7. [PMID: 25827309 DOI: 10.1007/s00586-015-3907-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Case report. OBJECTIVE To report a case of fractures of the right lateral atlantoaxial joint and C2 body diagnosed more than 5 months after injury. Misdiagnosis of an injury to the cervical spine has been reported frequently. For patients in whom cervical injury is suspected, the primary screening modality is axial CT from the occiput to T1 with sagittal and coronal reconstructions. The inadequacy of this radiological evaluation could delay diagnosis of fractures and lead to unnecessary surgical treatment of the cervical spine. METHODS We report the case of a 74-year-old woman with an old, displaced combined fracture of the C1 and C2 right facet joint. In this case, CT of the brain was evaluated at the time of injury, but not CT of the cervical spine. As a consequence, diagnosis was delayed and surgical treatment was necessary. RESULTS We performed posterior fusion surgery for C1 and C2. A pedicle screw was not inserted on both sides of C2, because of destruction of the insertional point on the right side and a high-riding VA on the left. Alternatively, a lamina screw and hook were used for C2, fixed with lateral mass screws on C1, with a bone graft harvested from the iliac crest. CONCLUSIONS To avoid unnecessary surgery, surgeons should recognize the possibility of cervical fractures that cannot be detected without CT, especially in patients who are comatose at injury. Atlantoaxial fixation with a hook and lamina screw in C2 is an option for old upper cervical fractures in cases where a pedicle screw cannot be inserted into C2.
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Affiliation(s)
- Takayuki Imura
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
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Malagelada F, Tibrewal S, Lucar GA, Jeyaseelan L, Fahmy A, Gonzalez JS. Combined Type II Odontoid Fracture With Axis Anterior Arch Fracture: A Case Report in an Elderly Patient. Geriatr Orthop Surg Rehabil 2015; 6:37-41. [PMID: 26246952 PMCID: PMC4318804 DOI: 10.1177/2151458514554083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Associated fractures of the atlas and axis are frequent, particularly in the elderly patients following a simple low-energy fall. This injury can be easily misdiagnosed on initial plain radiographs, and therefore computed tomography scan is a useful adjunct in patients with a degenerative spine. There is still no consensus as to the optimal treatment of combined axis-atlas fractures, and the majority of authors propose a therapeutic strategy dependent on the odontoid fracture pattern. We describe a combined atlas and axis fracture in a 92-year-old patient who was managed with nonoperative treatment in a rigid collar. The association of C1 anterior arch with a C2 type II odontoid fracture is a rare combination, which to our knowledge has never been reported following nonoperative treatment. There was a good functional outcome at 1-year follow-up with the fracture progressing to a fibrous nonunion of the odontoid process.
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Affiliation(s)
- Francesc Malagelada
- Department of Orhtopaedic and Trauma Surgery, Hospital de Mataró, Mataró, Barcelona, Spain
| | - Saket Tibrewal
- Department of Orthopaedics, The Royal London Hospital, London, United Kingdom
| | - Gustavo A. Lucar
- Department of Orhtopaedic and Trauma Surgery, Hospital de Mataró, Mataró, Barcelona, Spain
| | | | - Amr Fahmy
- Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Jose Sanchez Gonzalez
- Department of Orhtopaedic and Trauma Surgery, Hospital de Mataró, Mataró, Barcelona, Spain
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Wang L, Liu C, Zhao Q, Tian J. Posterior pedicle screw fixation for complex atlantoaxial fractures with atlanto-dental interval of ≥ 5 mm or C2-C3 angulation of ≥ 11°. J Orthop Surg Res 2014; 9:104. [PMID: 25407360 PMCID: PMC4245791 DOI: 10.1186/s13018-014-0104-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 10/17/2014] [Indexed: 11/18/2022] Open
Abstract
Objective Previous studies have demonstrated that the posterior pedicle screw fixation is an effective and safe method to treat atlantoaxial fractures. However, no report focuses on only the complex atlantoaxial fractures with atlanto-dental interval (ADI) of ≥5 mm or C2-C3 angulation of ≥11°. Methods This study was to retrospectively evaluate the outcome of 15 patients (six females and nine males; age, 27–55 years) who underwent posterior pedicle screw fixation for the above complex atlantoaxial fractures between July 2006 and March 2011. Fracture combinations included three Jefferson-type II odontoid, four anterior ring-type II odontoid, two posterior ring-type II odontoid, one lateral mass-type II odontoid, one Jefferson-hangman’s fracture, three anterior ring-hangman’s fracture, and one lateral mass-hangman’s fracture. Fracture healing and bone fusion were determined on X-ray scan. Upper limbs, lower limbs, and sphincter functions were assessed using the Japanese Orthopaedic Association (JOA) score. The Frankel grading system was used to determine the neurological situation. Results The mean operative time, blood loss, and hospital stays were 108.9 ± 25.8 min, 508.0 ± 209.6 ml, and 13.3 ± 2.0 days. Fracture healing and graft fusion were obtained in all patients within 9 months. The ADI or C2-C3 angulation was reduced to ≤5 mm or ≤11°. The JOA score was significantly improved from 7.27 ± 1.10 preoperatively to 15.7 ± 2.1 postoperatively (P <0.001), with 88.1 ± 18.3% recovery rate and 93.3% excellent and good rate. The neurological situation was improved in all patients by at least 1 grade in the Frankel scale. After a mean of 36.5 months of follow-up (range, 18 to 58 months), no operative complications (spinal cord injury, vertebral artery injury, or cerebrospinal fluid leakage) were observed. Conclusion Posterior pedicle screw fixation is a reliable, effective, and minimally invasive procedure for patients suffering from complex atlantoaxial fractures.
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Affiliation(s)
- Lei Wang
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People's Hospital, 100 Haining Road, Shanghai, 200080, China.
| | - Chao Liu
- Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Qinghua Zhao
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People's Hospital, 100 Haining Road, Shanghai, 200080, China.
| | - Jiwei Tian
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People's Hospital, 100 Haining Road, Shanghai, 200080, China.
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