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Dahdaleh N, Cho S, Shlobin N. Os odontoideum: A comprehensive review. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:256-264. [PMID: 36263339 PMCID: PMC9574117 DOI: 10.4103/jcvjs.jcvjs_71_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
Os odontoideum (OO) is a rare craniocervical anomaly that is characterized by a round ossicle separated from the C2 vertebral body. With a controversial etiology and unknown prevalence in the population, OO may be asymptomatic or present in patients with myelopathic and neurological symptoms. In this literature review, we aimed to investigate epidemiology, embryology, pathophysiology, clinical presentation, and the role of diagnostic radiography in OO. By providing an overview of different management strategies, surgical complications, and postoperative considerations for OO, our findings may guide neurosurgeons in providing proper diagnosis and treatment for OO patients. A literature review was conducted using the PubMed, EMBASE, and Scopus databases. A search using the query “os odontoideum” yielded 4319 results, of which 112 articles were chosen and analyzed for insights on factors such as etiology, clinical presentation, and management of OO. The presentation of OO varies widely from asymptomatic cases to severe neurological deficits. Asymptomatic patients can be managed either conservatively or surgically, while symptomatic patients should undergo operative stabilization. Although multiple studies show different techniques for surgical management involving posterior fusion, the diversity of such cases illustrates how treatment must be tailored to the individual patient to prevent complications. Conflicting studies and the paucity of current literature on OO highlight poor comprehension of the condition. Further understanding of the natural history of OO is critical to form evidence-based guidelines for the management of OO patients. More large-center studies are thus needed to promote accurate management of OO patients with optimal outcomes.
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Alexiades NG, Shao B, Braga BP, Bonfield CM, Brockmeyer DL, Browd SR, DiLuna M, Groves ML, Hankinson TC, Jea A, Leonard JR, Lew SM, Limbrick DD, Mangano FT, Martin J, Pahys J, Powers A, Proctor MR, Rodriguez L, Rozzelle C, Storm PB, Anderson RCE. Development of best practices in the utilization and implementation of pediatric cervical spine traction: a modified Delphi study. J Neurosurg Pediatr 2021; 27:649-660. [PMID: 33799292 DOI: 10.3171/2020.10.peds20778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical traction in pediatric patients is an uncommon but invaluable technique in the management of cervical trauma and deformity. Despite its utility, little empirical evidence exists to guide its implementation, with most practitioners employing custom or modified adult protocols. Expert-based best practices may improve the care of children undergoing cervical traction. In this study, the authors aimed to build consensus and establish best practices for the use of pediatric cervical traction in order to enhance its utilization, safety, and efficacy. METHODS A modified Delphi method was employed to try to identify areas of consensus regarding the utilization and implementation of pediatric cervical spine traction. A literature review of pediatric cervical traction was distributed electronically along with a survey of current practices to a group of 20 board-certified pediatric neurosurgeons and orthopedic surgeons with expertise in the pediatric cervical spine. Sixty statements were then formulated and distributed to the group. The results of the second survey were discussed during an in-person meeting leading to further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS After the initial round, consensus was achieved with 40 statements regarding the following topics: goals, indications, and contraindications of traction (12), pretraction imaging (6), practical application and initiation of various traction techniques (8), protocols in trauma and deformity patients (8), and management of traction-related complications (6). Following the second round, an additional 9 statements reached consensus related to goals/indications/contraindications of traction (4), related to initiation of traction (4), and related to complication management (1). All participants were willing to incorporate the consensus statements into their practice. CONCLUSIONS In an attempt to improve and standardize the use of cervical traction in pediatric patients, the authors have identified 49 best-practice recommendations, which were generated by reaching consensus among a multidisciplinary group of pediatric spine experts using a modified Delphi technique. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.
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Affiliation(s)
- Nikita G Alexiades
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Belinda Shao
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York.,2Rutgers New Jersey Medical School, Newark, New Jersey
| | - Bruno P Braga
- 3Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher M Bonfield
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Douglas L Brockmeyer
- 5Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 6Department of Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Michael DiLuna
- 7Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Mari L Groves
- 8Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Hankinson
- 9Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Andrew Jea
- 10Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey R Leonard
- 11Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Sean M Lew
- 12Department of Pediatric Neurosurgery, Children's Wisconsin, Milwaukee, Wisconsin
| | - David D Limbrick
- 13Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Francesco T Mangano
- 14Division of Pediatric Neurosurgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jonathan Martin
- 15Division of Pediatric Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut
| | - Joshua Pahys
- 16Department of Pediatric Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Alexander Powers
- 17Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mark R Proctor
- 18Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luis Rodriguez
- 19Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Curtis Rozzelle
- 20Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham; and
| | - Phillip B Storm
- 21Department of Neurosurgery, University of Pennsylvania/Children's Hospital of Philadelphia, Pennsylvania
| | - Richard C E Anderson
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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Tirado-Caballero J, Moreno-Madueño G, Rivero-Garvia M, Mayorga-Buiza MJ, Valencia-Anguita J, Márquez-Rivas J. Two-Stage Approach for Unstable Pediatric Craniocervical Junction Anomalies with a Halo Vest and Delayed Occipitocervical Fusion: Technical Note, Case Series, and Literature Review. World Neurosurg 2020; 146:e1021-e1030. [PMID: 33227530 DOI: 10.1016/j.wneu.2020.11.079] [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: 10/08/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Malformations in the craniocervical junction (CCJ) are rare in the pediatric population but often need surgical treatment. We present a pediatric case series of patients treated with a 2-stage surgical approach with a halo vest and occipitocervical fusion and review complications and outcomes. METHODS A retrospective analysis of a single-center case series was performed. Pediatric patients affected by congenital craniocervical junction anomalies and treated with a 2-stage approach were included. A halo vest was implanted in the first surgery, and ambulatory progressive reduction was performed. When a favorable anatomic situation was observed, arthrodesis was performed. Safety analysis was undertaken by analyzing the incidence of complications in both procedures. Effectivity analysis was carried out analyzing radiologic and clinical outcome (Goel grade and modified Japanese Orthopaedic Association score). Student t test was used for statistical analysis. RESULTS Sixteen cases were included. Mean age of patients was 9.38 years. Safety analysis showed 2 halo loosenings, 1 pin infection, 2 wound infections, 1 cerebrospinal fluid leak, and 2 delayed broken rods. No major complications were observed. Radiologic analysis showed an improvement in the tip of the odontoid process to the McRae line distance (from -3.26 mm to -6.16 mm), atlantodental interval (from 3.05 mm to 1.88 mm), clival-canal angle (from 134.61° to 144.38°), and cervical kyphosis (from 6.39° to 1.54°). Clinical analysis also showed improvement in mean Goel grade (from 1.75 to 1.44) and modified Japanese Orthopaedic Association score (from 15.12 to 16.41). CONCLUSIONS The 2-stage approach was a suitable and effective treatment for craniocervical junction anomalies in pediatric patients.
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Affiliation(s)
- Jorge Tirado-Caballero
- Neurosurgery Service, Virgen del Rocío University Hospital, Seville, Spain; Group of Applied Neuroscience, Biomedicine Institute of Seville, Seville, Spain; Neurosurgery Service, 12 de Octubre University Hospital, Madrid, Spain.
| | | | - Mónica Rivero-Garvia
- Neurosurgery Service, Virgen del Rocío University Hospital, Seville, Spain; Group of Applied Neuroscience, Biomedicine Institute of Seville, Seville, Spain
| | - María José Mayorga-Buiza
- Pediatric Anesthesia Service, Virgen del Rocío University Hospital, Seville, Spain; Group of Advanced Neurology, Seville, Spain
| | - Julio Valencia-Anguita
- Neurosurgery Service, Virgen del Rocío University Hospital, Seville, Spain; Group of Applied Neuroscience, Biomedicine Institute of Seville, Seville, Spain
| | - Javier Márquez-Rivas
- Neurosurgery Service, Virgen del Rocío University Hospital, Seville, Spain; Group of Applied Neuroscience, Biomedicine Institute of Seville, Seville, Spain; Group of Advanced Neurology, Seville, Spain
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Verhofste BP, Glotzbecker MP, Birch CM, O'Neill NP, Hedequist DJ. Halo-gravity traction for the treatment of pediatric cervical spine disorders. J Neurosurg Pediatr 2019; 25:384-393. [PMID: 31881541 DOI: 10.3171/2019.10.peds19513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Halo-gravity traction (HGT) is an effective and safe method for gradual correction of severe cervical deformities in adults. However, the literature is limited on the use of HGT for cervical spine deformities that develop in children. The objective of the present study was to evaluate the safety and efficacy of HGT for pediatric cervical spine deformities. METHODS Twenty-eight patients (18 females) whose mean age was 11.3 ± 5.58 years (range 2-24.9 years) underwent HGT. Common indications included kyphosis (n = 12), rotatory subluxation (n = 7), and basilar invagination (n = 6). Three children (11%) received traction to treat severe occipitocervical instability. For these 3 patients, traction combined with a halo vest, with bars attached rigidly to the vest, but with the ability to slide through the connections to the halo crown, was used to guide the corrective forces and moments in a specific and controlled manner. Patients ambulated with a wheelchair or halo walker under constant traction. Imaging was done before and during traction to evaluate traction efficacy. The modified Clavien-Dindo-Sink classification was used to categorize complications. RESULTS The mean duration of HGT was 25 days (IQR 13-29 days), and the mean traction was 29% ± 13.0% of body weight (IQR 19%-40% of body weight). The mean kyphosis improved from 91° ± 20.7° (range 64°-122°) to 56° ± 17.6° (range 32°-96°) during traction and corresponded to a mean percentage kyphosis correction of 38% ± 13.8% (range 21%-57%). Twenty-five patients (89%) underwent surgical stabilization, and 3 patients (11%) had rotatory subluxation that was adequately reduced by traction and were treated with a halo vest as their definitive treatment. The mean hospital stay was 35 days (IQR 17-43 days).Nine complications (32%) occurred: 8 grade I complications (28%), including 4 cases of superficial pin-site infection (14%) and 4 cases of transient paresthesia (14%). One grade II complication (4%) was seen in a child with Down syndrome and a preexisting neurological deficit; this patient developed flaccid paralysis that rapidly resolved with weight removal. Six cases (21%) of temporary neck discomfort occurred as a sequela of a preexisting condition and resolved without treatment within 24-48 hours. CONCLUSIONS HGT in children is safe and effective for the gradual correction of cervical kyphosis, atlantoaxial subluxation, basilar invagination, and os odontoideum. Cervical traction is an additional tool for the pediatric spine surgeon if uncertainties exist that the spinal alignment required for internal fixation and deformity correction can be safely achieved surgically. Common complications included grade I complications such as superficial pin-site infections and transient paresthesias. Halo vest gravity traction may be warranted in patients with baseline neurological deficits and severe occipitocervical instability to reduce the chance of catastrophic movement.
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Affiliation(s)
- Bram P Verhofste
- 1Department of Orthopaedic Surgery, Boston Children's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Michael P Glotzbecker
- 3Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center; and
- 4Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Craig M Birch
- 1Department of Orthopaedic Surgery, Boston Children's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Nora P O'Neill
- 1Department of Orthopaedic Surgery, Boston Children's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Daniel J Hedequist
- 1Department of Orthopaedic Surgery, Boston Children's Hospital
- 2Harvard Medical School, Boston, Massachusetts
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Reversible Central Hypoventilation Syndrome in Basilar Invagination. World Neurosurg 2019; 131:120-125. [PMID: 31400526 DOI: 10.1016/j.wneu.2019.07.236] [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: 07/06/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND A noninvasive approach for basilar invagination (BI) and moreover, cervical traction to reduce odontoid invagination, has not been thoroughly described in the literature. We report a case of BI with Arnold-Chiari malformation in which preoperative reduction using Gardner well cervical traction was attempted and the patient developed central hypoventilation syndrome. CASE DESCRIPTION A 15-year-old boy presented with a 6-month history of progressive cervical myelopathy signs and symptoms, modified Japanese orthopedic association score 12 of 18. Radiology showed type A BI with occipitalization of atlas and a posterior arch defect of axis. A preoperative closed cervical traction followed by occipitocervical fusion via a posterior-only approach was planned. The patient developed 3 episodes of apnea on sleeping when on traction. Labeled as central hypoventilation, he was operated by foramen magnum decompression and occipitocervical fusion. CONCLUSIONS Cervical traction followed by posterior fixation is an effective way to manage basilar invagination with Arnold-Chiari malformation and assimilated C1. However, patients should be monitored closely for respiratory dysfunction.
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Yudoyono F, Kang J, Ha Y. Comparison of Cervical Alignment and Clinical Outcomes in Patients with Os Odontoideum versus Non-Os Odontoideum after Atlantoaxial Fixation. KOREAN JOURNAL OF SPINE 2018; 14:143-147. [PMID: 29301174 PMCID: PMC5769938 DOI: 10.14245/kjs.2017.14.4.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 12/21/2017] [Accepted: 12/26/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the effect of atlantoaxial fixation on cervical alignment and clinical outcomes in patients with os odontoideum (OO) versus non-os odontoideum (non-OO). METHODS A total of 119 patients who underwent atlantoaxial fixation for instability were identified between January 1998 and January 2014. Inclusion criteria included age more than 21 years and diagnosis of OO and non-OO. There were 22 OO patients, and 20 non-OO patients. Measuring the Oc-C1 Cobb angle, C1-2 Cobb angle, C2-7 Cobb angle, and C2-7 sagittal vertical axis (SVA) was assessed. Clinical outcome was assessment of suboccipital pain was determined using a visual analogue scale (VAS), and Japanese Orthopedic Association (JOA) scores were obtained in all patients pre- and postoperatively. RESULTS The preoperative C1-2 angle in the OO group (26.02°±10.53°) was significantly higher than the non-OO group (p=0.04). After C1-2 fixation, the OO group had significantly higher kyphotic change in the C1-2 angle (ΔC1-2) (3.2°±7.3° [OO] vs. -1.46°±7.21° [non-OO]) (p=0.04), and higher decrease in postoperative C2-7 SVA (ΔC2-7 SVA) (5.64±11.56 mm [OO] vs. -0.51± 6.57 mm [non-OO]) (p=0.04). Both groups showed improvements in the health related quality of life (HRQOL) after surgery based on the VAS and JOA score (p<0.001). CONCLUSION After fixation, kyphotic angular change in atlantoaxial joint and decrease C2-7 SVA were marked in the OO group. Both the OO and non-OO groups improved in neurological function and outcome after surgery.
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Affiliation(s)
- Farid Yudoyono
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Jiin Kang
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
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