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Nguyen LH, Nguyen KM, Nguyen TLB, Do HM, Bui HM, Nguyen HV. Atlantoaxial dislocation due to Os odontoideum in down syndrome: Literature review and case reports. Int J Surg Case Rep 2024; 120:109888. [PMID: 38852555 PMCID: PMC11193034 DOI: 10.1016/j.ijscr.2024.109888] [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: 04/11/2024] [Revised: 06/02/2024] [Accepted: 06/04/2024] [Indexed: 06/11/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Os odontoideum is a rare condition commonly associated with atlantoaxial instability (AAI) and leading to atlantoaxial dislocation. The incidence of Os odontoideum is higher in patients with Down syndrome. Similar to odontoid fractures, atlantoaxial dislocation in patients with Os odontoideum can result in neurological deficits, disability, and even mortality. CASE PRESENTATION We present two cases of Os odontoideum accompanied by Down syndrome. Both patients were hospitalized due to progressive tetraparesis after falls several months prior. Upon examination, the patients exhibited myelopathy and were unable to walk or stand. MRI revealed spinal stenosis at the C1-C2 level due to atlantoaxial dislocation. C1-C2 fixation using Harms' technique was performed in both cases. One case experienced a complication involving instrument failure, necessitating revision surgery. CLINICAL DISCUSSION Due to the characteristics of transverse ligament laxity, low muscle tone, excessive joint flexibility, and cognitive impairment, children with both Down syndrome and Os odontoideum are at a high risk of disability and even mortality from spinal cord injury. Most authors recommend surgical management when patients exhibit atlantoaxial instability. Additional factors such as low bone density, cognitive impairment, and a high head-to-body ratio may increase the risk of surgical instrument failure and nonunion postoperatively in patients with Down syndrome. CONCLUSION Os odontoideum is a cause of AAI in patients with DS. Indication of surgery in the presence of AAI helps to resolve neurological injury and prevent further deterioration. The use of a cervical collar is considered to prevent instrument failure postoperatively.
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Affiliation(s)
- Long Hoang Nguyen
- Viet Duc University Hospital, Ha Noi, Viet Nam; University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam
| | - Khanh Manh Nguyen
- Viet Duc University Hospital, Ha Noi, Viet Nam; University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam
| | - Tien Le Bao Nguyen
- Viet Duc University Hospital, Ha Noi, Viet Nam; University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam
| | | | - Hoang Minh Bui
- Viet Duc University Hospital, Ha Noi, Viet Nam; University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam.
| | - Hoang Vu Nguyen
- Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen, Viet Nam
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Zhou LP, Zhang RJ, Zhang HQ, Jiang ZF, Shang J, Shen CL. Effect of High-Riding Vertebral Artery on the Accuracy and Safety of C2 Pedicle Screw Placement in Basilar Invagination and Related Risk Factors. Global Spine J 2024; 14:458-469. [PMID: 35719094 PMCID: PMC10802529 DOI: 10.1177/21925682221110180] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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 cohort study. OBJECTIVE To investigate the effect of HRVA on the intrapedicular accuracy of C2PS placement through the freehand method in patients with BI and analyse the possible risk factors for C2PS malpositioning. METHOD A total of 91 consecutive patients with BI who received 174 unilateral C2PS placements through the freehand method were retrospectively included. The unilateral pedicles were assigned to the HRVA and non-HRVA groups. The primary outcome was the intrapedicular accuracy of C2PS placement in accordance with the Gertzbein-Robbins scale. Moreover, the risk factors that possibly affected intrapedicular accuracy were assessed. RESULTS The rate of intrapedicular accuracy in C2PS placement in patients with BI was 23.6%. Results showed that the non-HRVA group had remarkably higher rates of optimal and clinically acceptable C2PS placement than the HRVA group. Nevertheless, the HRVA group exhibited similar results for grade B classification as the non-HRVA group. Moreover, in the HRVA and non-HRVA groups, the most common direction of screw deviations was the lateral direction. Furthermore, the multivariate analyses showed that the obliquity of the lateral atlantoaxial joint in the sagittal plane ≥15°, and that in the coronal plane ≥ 20°, isthmus height < 4.3 mm, and distance from the skin to the spinous process ≥ 2.8 cm independently contributed to a high rate of screw malpositioning in BI patients. CONCLUSION The presence of HRVA in BI patients contributed to the high rate of malpositioning in C2PS placement via the freehand method. However, the rates of intrapedicular accuracy in patients with BI with and without HRVA were considerably low.
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Affiliation(s)
- Lu-Ping Zhou
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ren-Jie Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hua-Qing Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhen-Fei Jiang
- Department of Orthopedics, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Jin Shang
- Department of Radiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Cai-Liang Shen
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Kumarasamy S, Sawarkar DP, Singh PK, Kumar R, Chandra PS, Kale SS. Cervical kyphosis correction in Marfan syndrome: our experience and literature review. Childs Nerv Syst 2024; 40:495-502. [PMID: 37391518 DOI: 10.1007/s00381-023-06046-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/19/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Spinal deformities are common in Marfan syndrome (MFS). They usually involve the thoraco-lumbar spine but rarely involves the cervical spine. Kyphosis is the common spine deformity of the cervical spine and mandates surgical correction as they are at risk of neurological deterioration since they are refractory to conservative management. Few studies of surgical correction of spine deformity included cervical deformity. OBJECTIVES To analyze the challenges faced during surgery, clinical and radiological outcome, and complications following surgical correction for cervical kyphosis in Marfan syndrome. METHODS We identified that 5 patients with a diagnosis of MFS with cervical kyphosis who underwent fusion surgery between the years 2010 and 2022 were reviewed, retrospectively. We analyzed the demographic details, radiological parameters, operative variables (blood loss and nuances), perioperative complications, length of stay, clinical and radiological outcome, and complications following fusion surgery for cervical kyphosis in MFS. RESULTS The mean age of patients was 16.6 ± 4.72 years (range, 12-23 years). The average kyphotic vertebra involved is 3 ± 0.7 bodies (range 2-4) with 2 patients with thoracic deformity. All patients underwent surgical deformity correction. All patients improved clinically with Nurick grade (pre vs. post: 3.4 vs. 2.2) and mJOA (pre vs. post: 8.2 vs. 12.6). There was significant deformity correction from 37.48° to 9.1°. Mean blood loss encountered was 900 ± 173.2 ml. Perioperative complications: wound complication with CSF leak (1). Late complications: ventilator dependence (1) and junctional kyphosis (1). Mean length of hospital stay was 103 ± 178.9 days. All patients were doing symptomatically better after mean follow-up of 58 ± 28.32 months. One patient is bedridden and hospitalized. CONCLUSION Cervical kyphosis is a rare spine deformity in patients with MFS, and they usually present with neurological deterioration mandating surgical correction. Multidisciplinary approach (pediatrics, genetics and cardiology) is required for systematic evaluation of these patients. They should be evaluated with necessary imaging to rule out associated spinal deformity (atlanto-axial subluxation, scoliosis, and intraspinal pathology like ductal ectasia). Our results suggest better surgical outcome in terms of low operative complications with neurologic improvement in MFS patients. These patients require regular follow-up to identify late complications (instrument failure, non-union, and pseudarthrosis).
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Affiliation(s)
- Sivaraman Kumarasamy
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Dattaraj P Sawarkar
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Pankaj Kumar Singh
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Rajinder Kumar
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Poodipedi Sarat Chandra
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, 110029, India
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Joseph VB, Ganesh S, Panicker TV. Surgical strategies in the management of atlantoaxial dislocation in Down syndrome. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:53-60. [PMID: 38644917 PMCID: PMC11029113 DOI: 10.4103/jcvjs.jcvjs_171_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: 12/06/2023] [Accepted: 01/09/2024] [Indexed: 04/23/2024] Open
Abstract
Aims To study the clinicoradiological features and treatment outcomes of atlantoaxial dislocation (AAD) in Down syndrome. Settings and Design Retrospective case series. Subjects and Methods A retrospective chart and radiology review of 9 Down syndrome patients with AAD managed at our center from 2007 to 2018. Statistical Analysis Used Chi-squared/Fisher's exact test. Results There were 4 males and 5 females (n = 9). The median age was 14 years (interquartile range [IQR]: 7-15.5). 77.7% (7/9) of patients had severe spasticity (Nurick Grades 4 and 5). The median duration of symptoms was 9 months (IQR: 5-39). The AAD was reducible in all (n = 9) cases. Eight (88.8%) patients had os odontoideum. The mean atlantodental interval (ADI) was 8.5 mm (±2.9). T2W cord hyperintensity was seen in 66.6% (6/9). Posterior C1-2 transarticular fixation was done in 8 and occipitocervical fusion in 1 patient. Follow-up of more than 6 months (7-57 months) was available in 8/9 (88.9%) patients. There was a significant improvement in spasticity (n = 8, mean Nurick Grade 1.7 (±1.1), P = 0.003). Follow-up radiographs (n = 8) showed good reduction and fusion. A preoperative bedbound patient with poor respiratory reserve expired at 10 months following surgery. There were no other complications. Conclusions Posterior surgical approach for AAD in Down syndrome resulted in good alignment and fusion, with excellent clinical improvement. Patients with elevated PCO2 are poor surgical candidates and require home ventilation facility.
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Affiliation(s)
- Vivek Baylis Joseph
- Department of Neurological Sciences, Christian Medical College, Ranipet Campus, Vellore, Tamil Nadu, India
| | - Swaminathan Ganesh
- Department of Neurological Sciences, Christian Medical College, Ranipet Campus, Vellore, Tamil Nadu, India
| | - Tony Varghese Panicker
- Department of Neurological Sciences, Christian Medical College, Ranipet Campus, Vellore, Tamil Nadu, India
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Calek AK, Altorfer F, Fasser MR, Widmer J, Farshad M. Interspinous and spinolaminar synthetic vertebropexy of the lumbar spine. 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 2023; 32:3183-3191. [PMID: 37284900 DOI: 10.1007/s00586-023-07798-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/14/2023] [Accepted: 05/26/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE To develop and test synthetic vertebral stabilization techniques ("vertebropexy") that can be used after decompression surgery and furthermore to compare them with a standard dorsal fusion procedure. METHODS Twelve spinal segments (Th12/L1: 4, L2/3: 4, L4/5: 4) were tested in a stepwise surgical decompression and stabilization study. Stabilization was achieved with a FiberTape cerclage, which was pulled through the spinous process (interspinous technique) or through one spinous process and around both laminae (spinolaminar technique). The specimens were tested (1) in the native state, after (2) unilateral laminotomy, (3) interspinous vertebropexy and (4) spinolaminar vertebropexy. The segments were loaded in flexion-extension (FE), lateral shear (LS), lateral bending (LB), anterior shear (AS) and axial rotation (AR). RESULTS Interspinous fixation significantly reduced ROM in FE by 66% (p = 0.003), in LB by 7% (p = 0.006) and in AR by 9% (p = 0.02). Shear movements (LS and AS) were also reduced, although not significantly: in LS reduction by 24% (p = 0.07), in AS reduction by 3% (p = 0.21). Spinolaminar fixation significantly reduced ROM in FE by 68% (p = 0.003), in LS by 28% (p = 0.01), in LB by 10% (p = 0.003) and AR by 8% (p = 0.003). AS was also reduced, although not significantly: reduction by 18% (p = 0.06). Overall, the techniques were largely comparable. The spinolaminar technique differed from interspinous fixation only in that it had a greater effect on shear motion. CONCLUSION Synthetic vertebropexy is able to reduce lumbar segmental motion, especially in flexion-extension. The spinolaminar technique affects shear forces to a greater extent than the interspinous technique.
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Affiliation(s)
- Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland.
| | - Franziska Altorfer
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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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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Farshad M, Tsagkaris C, Widmer J, Fasser MR, Cornaz F, Calek AK. Vertebropexy as a semi-rigid ligamentous alternative to lumbar spinal fusion. 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 2023; 32:1695-1703. [PMID: 36930387 DOI: 10.1007/s00586-023-07647-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 01/26/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To develop ligamentous vertebral stabilization techniques ("vertebropexy") that can be used after microsurgical decompression (intact posterior structures) and midline decompression (removed posterior structures) and to elaborate their biomechanical characteristics. METHODS Fifteen spinal segments were biomechanically tested in a stepwise surgical decompression and ligamentous stabilization study. Stabilization was achieved with a gracilis or semitendinosus tendon allograft, which was attached to the spinous process (interspinous vertebropexy) or the laminae (interlaminar vertebropexy) in form of a loop. The specimens were tested (1) in the native state, after (2) microsurgical decompression, (3) interspinous vertebropexy, (4) midline decompression, and (5) interlaminar vertebropexy. In the intact state and after every surgical step, the segments were loaded in flexion-extension (FE), lateral shear (LS), lateral bending (LB), anterior shear (AS) and axial rotation (AR). RESULTS Interspinous vertebropexy significantly reduced the range of motion (ROM) in all loading scenarios compared to microsurgical decompression: in FE by 70% (p < 0.001), in LS by 22% (p < 0.001), in LB by 8% (p < 0.001) in AS by 12% (p < 0.01) and in AR by 9% (p < 0.001). Interlaminar vertebropexy decreased ROM compared to midline decompression by 70% (p < 0.001) in FE, 18% (p < 0.001) in LS, 11% (p < 0.01) in LB, 7% (p < 0.01) in AS, and 4% (p < 0.01) in AR. Vertebral segment ROM was significantly smaller with the interspinous vertebropexy compared to the interlaminar vertebropexy for all loading scenarios except FE. Both techniques were able to reduce vertebral body segment ROM in FE, LS and LB beyond the native state. CONCLUSION Vertebropexy is a new concept of semi-rigid spinal stabilization based on ligamentous reinforcement of the spinal segment. It is able to reduce motion, especially in flexion-extension. Studies are needed to evaluate its clinical application.
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Affiliation(s)
- Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christos Tsagkaris
- Institute of Biomechanics, ETH Zurich, Balgrist Campus, Zurich, Switzerland
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jonas Widmer
- Institute of Biomechanics, ETH Zurich, Balgrist Campus, Zurich, Switzerland
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Institute of Biomechanics, ETH Zurich, Balgrist Campus, Zurich, Switzerland
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Frédéric Cornaz
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
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Yuwakosol P. Morphometric Study for C1 Pedicle Screw Placement in Thai Patients. Asian J Neurosurg 2022; 17:429-434. [PMID: 36398178 PMCID: PMC9665985 DOI: 10.1055/s-0042-1756625] [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: 11/17/2022] Open
Abstract
Background
Traumatic atlantoaxial (upper cervical spine) leads to instability in weightbearing movement and neurological deficit. Presently, C1 (axial) lateral mass or pedicle screws for fixation are the most popular because of excellent mechanical performance for internal fixation. C1 pedicle screw fixation can reduce intraoperative blood loss and postoperative occipital neuralgia more than C1 lateral mass screws. However, screws cannot be inserted completely through the pedicle in some patients due to C1 size.
Objective
We aimed to determine the ideal pedicle screw entry point, angle of screw projection, and pedicle height in the Thai population.
Methods
Patient data were collected and measured using the INFINITT program at Mukdahan Hospital from September 2020 to June 2021. The C1 measurements, i.e., distance from the midline to the medial edge of the posterior arch (DPA) and medial edge transverse foramen (DTF), angle of screw projection, and length and height of the pedicle were recorded. Descriptive statistics and
t
-test were used to analyze the data.
Results
The mean Thai pedicle dimensions were DPA = 14.17 mm (range: 11.19–19.70 mm), DTF = 22.09 mm (range: 18.13–26.44 mm), ideal screw entry point = 18.13 mm (range: 15.19–22.00 mm), ideal angle of screw projection medial angulation = 2.67 degrees (range: 0–7 degrees), and height of posterior arch (pedicle) = 4.77 mm (range: 2.68–7.22 mm). Forty of 167 patients (24.0%) had a pedicle height less than 4.0 mm (bilateral 11 patients and unilateral 29 patients).
Conclusions
The ideal C1 pedicle screw entry point is approximately 18.13 mm from the midline. In the Thai samples with C1 pedicle height less than 4.0 mm, the screws cannot be inserted completely through the pedicle. Therefore, screw insertion should be partially through the pedicle (notching technique).
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Affiliation(s)
- Pakorn Yuwakosol
- Neurosurgical Unit, Department of Surgery, Mukdahan Hospital, Thai Board of Neurological Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand,Address for correspondence Pakorn Yuwakosol, MD Neurosurgical Unit, Department of Surgery, Mukdahan HospitalMukdahan, 49000Thailand
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Tatter C, Fletcher-Sandersjöö A, Persson O, Burström G, Edström E, Elmi-Terander A. Fluoroscopy-Assisted C1-C2 Posterior Fixation for Atlantoaxial Instability: A Single-Center Case Series of 78 Patients. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010114. [PMID: 35056423 PMCID: PMC8779556 DOI: 10.3390/medicina58010114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 01/10/2022] [Indexed: 04/21/2023]
Abstract
Background and Objectives: Posterior C1-C2 fixation, with trans-articular screws (TAS) or screw-rod-construct (SRC), is the main surgical technique for atlantoaxial instability, and can be performed with a fluoroscopy-assisted free-handed technique or 3D navigation. This study aimed to evaluate complications, radiological and functional outcome in patients treated with a fluoroscopy-assisted technique. Materials and Methods: A single-center consecutive cohort study was conducted of all adult patients who underwent posterior C1-C2 fixation, using TAS or CRS, between 2005-2019. Results: Seventy-eight patients were included, with a median follow-up time of 6.8 years. Trauma was the most common injury mechanism (64%), and cervicalgia the predominant preoperative symptom (88%). TAS was used in 33%, and SRC in 67% of cases. Surgery was associated with a significant reduction in cervicalgia (from 88% to 26%, p < 0.001). The most common complications were vertebral artery injury (n = 2, 2.6%), and screw malposition (n = 5, 6.7%, of which 2 were TAS and 3 were SRC). No patients deteriorated in their functional status following surgery. Conclusions: Fluoroscopy-assisted C1-C2 fixation with TAS or SRC is a safe and effective treatment for atlantoaxial instability, with a low complication rate, few surgical revisions, and pain relief in the majority of the cases.
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Affiliation(s)
- Charles Tatter
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
- Correspondence: ; Tel.: +46-8-517-74-126
| | - Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Oscar Persson
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Gustav Burström
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Erik Edström
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
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10
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Wang B, Jin J, Shao ZX, Yang GY, Lin Y, Xu HZ, Xie CL, Chen JX, Zhang XL, Hong ZH, Wang XY. Wright's Technique with the Addition of Visualized Axial Cortical Windows in Odontoid Fractures. Orthop Surg 2021; 14:443-450. [PMID: 34914198 PMCID: PMC8867410 DOI: 10.1111/os.13012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 02/24/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022] Open
Abstract
This study sought to investigate and evaluate a modified axial translaminar screw fixation for treating odontoid fractures. We performed a retrospective study at Wenzhou Medical University Affiliated Second Hospital between March 2016 and June 2018. We retrospectively collected and analyzed the medical records of 23 cases with odontoid fractures. All patients were identified as type II odontoid fractures without neurological deficiency and serious diseases following the classification of Anderson. The average age, gender ratio, and body mass index (BMI) were 54.3 ± 11.1 years, 12 men to 11 women, and 22.6 ± 2.4 kg/m2 , respectively. Patients in this study accepted screw fixation using our modified axial translaminar screw fixation combined with atlas pedicle or lateral mass screw fixation. Within the technique, a small cortical "window" was dug in the middle of the axial contralateral lamina, such that the screws in the lamina were visualized to prevent incorrectly implanting the posterior spinal canal through the visualized "window." A total of 46 bone screws were accurately inserted into the axial lamina without using fluoroscopy. The length of all translaminar screws ranged between 26 and 30 mm, while the diameter was 3.5 mm. During the follow-up survey, the visual analog scale (VAS) and neck disability index (NDI) were measured. We provide a simple modification of Wright's elegant technique with the addition of "visualized windows" at the middle of the axial lamina. In all patients, screws were inserted accurately without bony breach and the screw angle was 56.1 ± 3.0°. Mean operative time was 102 ± 28 min with an average blood loss of 50 ± 25 mL. Postoperative hemoglobin and mean length of hospital stay were 12.0 ± 1.4 g/dL and 10.4 ± 3.4 days, respectively. The average follow-up time of all cases was 14.7 months and no internal fixation displacement, loosening, or breakage was found. All patients with odontoid fractures reported being satisfied with the treatment during the recheck period and good clinical outcomes were observed. At 1, 6, and 12 months, NDI and VAS showed that the symptoms of neck pain and limitations of functional disability improved significantly during follow-up. Our results suggest that the modified translaminar screw fixation technique can efficiently treat Anderson type II odontoid fracture, followed by the benefits of less soft tissue dissection, simple operation, no fluoroscopy, and accurate placement of screws.
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Affiliation(s)
- Ben Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China.,Orthopaedic Department, Taizhou Hospital Affiliated to Wenzhou Medical University, Linhai, China
| | - Jie Jin
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Zhen-Xuan Shao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Guang-Yong Yang
- Orthopaedic Department, Taizhou Hospital Affiliated to Wenzhou Medical University, Linhai, China
| | - Yan Lin
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Hua-Zi Xu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Cheng-Long Xie
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Jiao-Xiang Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Xiao-Lei Zhang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Zheng-Hua Hong
- Orthopaedic Department, Taizhou Hospital Affiliated to Wenzhou Medical University, Linhai, China
| | - Xiang-Yang Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
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11
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Traynelis VC, Fontes RBV, Abode-Iyamah KO, Cox EM, Greenlee JD. Posterior fusion for fragility type 2 odontoid fractures. J Neurosurg Spine 2021; 35:644-650. [PMID: 34388709 DOI: 10.3171/2021.2.spine201645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the outcomes of elderly patients with type 2 odontoid fractures treated with an instrumented posterior fusion. METHODS Ninety-three consecutive patients older than 65 years of age in whom a type 2 odontoid fracture had been treated with a variety of C1-2 posterior screw fixation techniques were retrospectively reviewed. RESULTS The average age was 78 years (range 65-95 years). Thirty-seven patients had an additional fracture, 30 of which involved C1. Three patients had cervical spinal cord dysfunction due to their injury. All patients had comorbidities. The average total hospitalization was 9.6 days (range 2-37 days). There were 3 deaths and 19 major complications, the most common of which was pneumonia. No patient suffered a vertebral artery injury. Imaging studies were obtained in 64 patients at least 12 months postsurgery (mean 19 months). Fusion was assessed by dynamic radiographs in all cases and with a CT scan in 80% of the cases. Four of the 64 patients did not achieve fusion (6.25% overall). All patients in whom fusion failed had undergone C1 lateral mass fixation and C2 pars (1/29, 3.4%) or laminar (3/9, 33.3%) fixation. CONCLUSIONS Instrumented posterior cervical fusions may be performed in elderly patients with acceptable morbidity and mortality. The fusion rate is excellent except when bilateral C2 translaminar screws are used for axis fixation.
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Affiliation(s)
- Vincent C Traynelis
- 1Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Ricardo B V Fontes
- 1Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | | | - Efrem M Cox
- 3Department of Neurosurgery, UNLV School of Medicine, Las Vegas, Nevada; and
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12
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Benomar A, Westwick HJ, Obaid S, Nzokou A, Yuh SJ, Shedid D. Atlantoaxial wiring hardware failure resulting in intracranial hemorrhage and hydrocephalus: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21211. [PMID: 35854788 PMCID: PMC9265237 DOI: 10.3171/case21211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Atlantoaxial sublaminar wiring has many known complications related to hardware failure, but intracranial hemorrhage is a rare complication. OBSERVATIONS A 61-year-old female patient with prior atlantoaxial sublaminar wiring for odontoid fracture nonunion experienced decreased level of consciousness due to a subarachnoid and subdural hemorrhage of the posterior fossa with intraventricular extension and hydrocephalus. Rupture of the sublaminar wire with intramedullary protrusion was the cause of the hemorrhage. The patient was treated with ventriculostomy for hydrocephalus and occipital cervical fusion for spinal instability, along with removal of the broken wire and drainage of a hematoma. LESSONS This uncommon cause of intracranial hemorrhage highlights an additional risk of atlantoaxial sublaminar wiring compared with other atlantoaxial fusion techniques. In addition, this case suggests cervical instrumentation failure as a differential diagnosis of subarachnoid and subdural hemorrhage of the posterior fossa when a history of prior instrumentation is known.
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Affiliation(s)
- Anass Benomar
- Department of Radiology, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Harrison J. Westwick
- Service of Neurosurgery, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Sami Obaid
- Division of Neurosurgery, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada; and
| | - André Nzokou
- Service of Neurosurgery, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Sung-Joo Yuh
- Division of Neurosurgery, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada; and
| | - Daniel Shedid
- Division of Neurosurgery, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada; and
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13
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Rizvi SAM, Helseth E, Aarhus M, Harr ME, Mirzamohammadi J, Rønning P, Mejlænder-Evjensvold M, Linnerud H. Favorable prognosis with nonsurgical management of type III acute odontoid fractures: a consecutive series of 212 patients. Spine J 2021; 21:1149-1158. [PMID: 33577924 DOI: 10.1016/j.spinee.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/01/2021] [Accepted: 02/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The recommended primary treatment for type III odontoid fractures (OFx) is external immobilization, except for patients having major displacement of the odontoid fragment. The bony fusion rate of type III OFx has been reported to be >85%. High compliance to treatment recommendations is favorable only if the treatment leads to a good outcome. PURPOSE The primary aim of this study was to determine the long-term outcome after conservative and surgical treatment of type III OFx and to reaffirm that primary external immobilization is the best treatment for most type III fractures. STUDY DESIGN/SETTING Retrospective study based on a prospective database. PATIENT SAMPLE Two hundred twelve consecutive patients with type III OFx treated at Oslo University Hospital over an 8-year period (2009-2017). OUTCOME MEASURES Long-term rates of bony fusion, crossover from primary conservative treatment to surgical fixation, new onset spinal cord injury (SCI), severe persistent neck pain (visual analogue scale - VAS), and persistent disability measured with Neck Disability index (NDI). METHODS The present study was based on data extracted from our quality control database for acute cervical spine fractures from a general population. During the years 2018 to 2019 long-term follow-up of alive patients was performed (median follow-up time was 38.0 months; range 3.0-108.0 months). The follow-up included neurological examination, radiological examination and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new onset SCI, neck pain, and Neck Disability Index (NDI score). RESULTS In this consecutive series of 212 patients with type III acute OFx, median patient age was 72 years, 56% had severe preinjury comorbidities (ASA score ≥3) and 22% lived dependently. Severe comorbidities and dependent living were significantly associated with increasing age (p<.001). The trauma mechanism was fall injury in 82%. The median age of patients injured by falls was significantly higher than in patients with a nonfall injury (p<.001). At the time of diagnosis, 4% had an OFx related SCI. Primary treatment was external immobilization alone in 95.3% and open surgical fixation in 4.7%. Patients treated with primary external immobilization alone presented with significantly less translation of the odontoid fragment (p<.001) and less angulation of the odontoid fragment (p=.025) than patients treated with primary surgery. Subsequent crossover to surgical fixation was performed in 5.4%. At long-term follow-up, 95.7% of patients had bony fusion of the OFx, 80.5% had minimal/no neck pain, and none developed new onset SCI. There was no significant difference in long-term follow-up VAS (p=.444) or NDI (p=.562) between the primary external immobilization group and the primary surgical group. CONCLUSION This study reaffirms that nonsurgical treatment remains the preferable option in the majority of patients with type III OFx.
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Affiliation(s)
- Syed Ali Mujtaba Rizvi
- Faculty of Medicine, University of Oslo, Norway; Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.
| | - Eirik Helseth
- Faculty of Medicine, University of Oslo, Norway; Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Mads Aarhus
- Faculty of Medicine, University of Oslo, Norway; Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | | | - Pål Rønning
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | - Hege Linnerud
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
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14
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Bohl MA, Reece EM, Farrokhi F, Davis MJ, Abu-Ghname A, Ropper AE. Vascularized Bone Grafts for Spinal Fusion-Part 3: The Occiput. Oper Neurosurg (Hagerstown) 2021; 20:502-507. [PMID: 33609121 DOI: 10.1093/ons/opab036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/21/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Obtaining successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. This challenge stems from the relatively hypermobile joints between the occipital condyles, the motion that occurs at C1 and C2, as well as the paucity of dorsal bony surfaces for posterior arthrodesis. While multiple different techniques for spinal fixation in this region have been well described, there has been little investigation into auxiliary methods to improve fusion rates. OBJECTIVE To describe the use of an occipital bone graft to augment bony arthrodesis in the supraaxial cervical spine using a multidisciplinary approach. METHODS We review the technique for harvesting and placing a vascularized occipital bone graft in 2 patients undergoing revision surgery at the craniocervical junction. RESULTS The differentiation from nonvascularized bone graft, either allograft or autograft, to a bone graft using vascularized tissue is a key principle of this technique. It has been well established that vascularized bone heals and fuses in the spine better than structural autogenous grafts. However, the morbidity and added operative time of harvesting a vascularized flap, such as from the fibula or rib, precludes its utility in most degenerative spine surgeries. CONCLUSION By adapting the standard neurosurgical procedure for a suboccipital craniectomy and utilizing the tenets of flap-based reconstructive surgery to maintain the periosteal and muscular blood supply, we describe the feasibility of using a vascularized and pedicled occipital bone graft to augment instrumented upper cervical spinal fusion. The use of this vascularized bone graft may increase fusion rates in complex spine surgeries.
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Affiliation(s)
- Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Farrokh Farrokhi
- Department of Neurosurgery, Virginia Mason Hospital, Seattle, Washington, USA
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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15
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Liu DD, Rivera-Lane K, Leary OP, Pertsch NJ, Niu T, Camara-Quintana JQ, Oyelese AA, Fridley JS, Gokaslan ZL. Supplementation of Screw-Rod C1-C2 Fixation With Posterior Arch Femoral Head Allograft Strut. Oper Neurosurg (Hagerstown) 2021; 20:226-231. [PMID: 33269389 DOI: 10.1093/ons/opaa336] [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: 05/13/2020] [Accepted: 08/10/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Numerous C1-C2 fixation techniques exist for the treatment of atlantoaxial instability. Limitations of screw-rod and sublaminar wiring techniques include C2 nerve root sacrifice and dural injury, respectively. We present a novel technique that utilizes a femoral head allograft cut with a keyhole that rests posteriorly on the arches of C1 and C2 and straddles the C2 spinous process, secured by sutures. OBJECTIVE To offer increased fusion across C1-C2 without the passage of sublaminar wiring or interarticular arthrodesis. METHODS A total of 6 patients with atlantoaxial instability underwent C1-C2 fixation using our method from 2015 to 2016. After placement of a C1-C2 screw/rod construct, a cadaveric frozen femoral head allograft was cut into a half-dome with a keyhole and placed over the already decorticated dorsal C1 arch and C2 spinous process. Notches were created in the graft and sutures were placed in the notches and around the rods to secure it firmly in place. RESULTS The femoral head's shape allowed for creation of a graft that provides excellent surface area for fusion across C1-C2. There were no intraoperative complications, including dural tears. Postoperatively, no patients had sensorimotor deficits, pain, or occipital neuralgia. 5 patients demonstrated clinical resolution of symptoms by 3 mo and radiographic (computed tomography) evidence of fusion at 1 yr. One patient had good follow-up at 1 mo but died due to complications of Alzheimer disease. CONCLUSION The posterior arch femoral head allograft strut technique with securing sutures is a viable option for supplementing screw-rod fixation in the treatment of complex atlantoaxial instability.
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Affiliation(s)
- David D Liu
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kendall Rivera-Lane
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Owen P Leary
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nathan J Pertsch
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Tianyi Niu
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joaquin Q Camara-Quintana
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jared S Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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16
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Braga BP, Sillero R, Pereira RM, Urgun K, Swift DM, Rollins NK, Hogge AJ, Dowling MM. Dynamic compression in vertebral artery dissection in children: apropos of a new protocol. Childs Nerv Syst 2021; 37:1285-1293. [PMID: 33155060 DOI: 10.1007/s00381-020-04956-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/28/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Our goals are (1) to report a consecutive prospective series of children who had posterior circulation stroke caused by vertebral artery dissection at the V3 segment; (2) to describe a configuration of the vertebral artery that may predispose to rotational compression; and (3) to recommend a new protocol for evaluation and treatment of vertebral artery dissection at V3. METHODS All children diagnosed with vertebral artery dissection at the V3 segment from September 2014 to July 2020 at our institution were included in the study. Demographic, clinical, surgical, and radiological data were collected. RESULTS Sixteen children were found to have dissection at a specific segment of the vertebral artery. Fourteen patients were male. Eleven were found to have compression on rotation during a provocative angiogram. All eleven underwent C1C2 posterior fusion as part of their treatment. Their mean age was 6.44 years (range 18 months-15 years). Mean blood loss was 57.7 mL. One minor complication occurred: a superficial wound infection treated with oral antibiotics only. There were no vascular or neurologic injuries. There have been no recurrent ischemic events after diagnosis and/or treatment. Mean follow-up was 33.3 months (range 2-59 months). We designed a new protocol to manage V3 dissections in children. CONCLUSION Posterior C1C2 fusion is a safe and effective option for treatment of dynamic compression in vertebral artery dissection in children. Institution of and compliance with a strict diagnostic and treatment protocol for V3 segment dissections seem to prevent recurrent stroke.
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Affiliation(s)
- Bruno P Braga
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, USA. .,Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA.
| | - Rafael Sillero
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, USA.,Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA
| | - Rosalina M Pereira
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kamran Urgun
- Department of Neurological Surgery, University of California Irvine, Orange, CA, USA
| | - Dale M Swift
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, USA.,Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA
| | - Nancy K Rollins
- Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA.,Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Amy J Hogge
- Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA.,Anesthesia for Children, Dallas, TX, USA
| | - Michael M Dowling
- Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA.,Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
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17
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Rizvi SAM, Helseth E, Harr ME, Mirzamohammadi J, Rønning P, Mejlænder-Evjensvold M, Linnerud H. Management and long-term outcome of type II acute odontoid fractures: a population-based consecutive series of 282 patients. Spine J 2021; 21:627-637. [PMID: 33346157 DOI: 10.1016/j.spinee.2020.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/24/2020] [Accepted: 11/26/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The surgical fixation rate of type II odontoid fracture (OFx) in the elderly (≥65 years) is much lower than expected if the treatment adheres to current general treatment recommendations. Outcome data after conservative treatment for elderly patients with these fractures are sparse. PURPOSE The main aim of this study was to determine the long-term outcome after conservative and surgical treatments of type II OFx (all age-groups) to evaluate whether nonoperative treatment yields an acceptable outcome. STUDY DESIGN/SETTING Retrospective study based on a prospective database. PATIENT SAMPLE Two hundred eighty-two consecutive patients with type II OFx treated at Oslo University Hospital over an 8-year period. OUTCOME MEASURES Long-term rates of bony fusion, fibrous union, pseudarthrosis, crossover from primary conservative treatment to surgical fixation, new-onset spinal cord injury (SCI), and neck pain were the outcome measures used. METHODS The present study was based on data extracted from our quality control database for acute cervical spine fractures. All ages were included. In addition, long-term follow-up of alive patients was performed during the years 2018-2019. The follow-up included neurological examination, radiological examination, and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new-onset SCI, neck pain, and Neck Disability Index (NDI score). Data are described by counts, percentages, medians, means, ranges and standard deviations where appropriate. For statistical analyses the Mann-Whitney U test, Wilcoxon signed-rank test, and t tests were used. RESULTS During the eight-year study period, we registered 282 consecutive patients with type II OFx; 54% were males, patient age ranged from 15 to 101 years, 84% were ≥65 years of age (WHO definition of elderly), and 51% were ≥80 years of age. Severe comorbidities (American Society of Anesthesiologists, ASA ≥3) were seen in 67%, whereas nonindependent living was registered in 32%. Severe comorbidities and nonindependent living were significantly associated with increasing age (p<.001). SCI secondary to the OFx was seen in 5.3%. Primary treatment of the OFx was conservative (external immobilization alone) in 193 patients (68.4%), open surgical fixation in 87 patients (30.9%), and no treatment in two critically injured patients. At the time of long-term follow-up, 125 patients had died, nine patients declined the invitation to follow-up, and five patients did not respond. Thus, 143 patients were available for follow-up with a median follow-up time of 39 months (range 5-115 months). At long-term follow-up, the fusion status was bony fusion in 39.2% of patients, fibrous union in 57.3%, and pseudarthrosis in 3.5%. The proportion of bony fusion was significantly higher in the primary surgical fixation group (p=.005). No patients had new-onset SCI presenting after the start of primary treatment. The proportion of crossover from primary external immobilization to surgery was 14.4%, whereas proportion of revision surgery in the primary surgical group was 9.5%. There was no significant difference between the primary surgical fixation group and the primary conservative treatment group at long-term follow-up with respect to the proportion of pseudarthrosis and degree of neck pain. CONCLUSIONS Primary conservative treatment of elderly patients with type II OFx appears to be safe and should be regarded a viable treatment option.
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Affiliation(s)
- Syed Ali Mujtaba Rizvi
- Faculty of Medicine, University of Oslo, Postboks 1078 Blindern, Oslo, 0316 Norway; Department of Neurosurgery, Oslo University Hospital, Postboks 4956 Nydalen, 0424 Oslo, Norway.
| | - Eirik Helseth
- Faculty of Medicine, University of Oslo, Postboks 1078 Blindern, Oslo, 0316 Norway; Department of Neurosurgery, Oslo University Hospital, Postboks 4956 Nydalen, 0424 Oslo, Norway
| | - Marianne Efskind Harr
- Department of Neurosurgery, Oslo University Hospital, Postboks 4956 Nydalen, 0424 Oslo, Norway
| | - Jalal Mirzamohammadi
- Department of Neurosurgery, Oslo University Hospital, Postboks 4956 Nydalen, 0424 Oslo, Norway
| | - Pål Rønning
- Department of Neurosurgery, Oslo University Hospital, Postboks 4956 Nydalen, 0424 Oslo, Norway
| | | | - Hege Linnerud
- Department of Neurosurgery, Oslo University Hospital, Postboks 4956 Nydalen, 0424 Oslo, Norway
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18
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Unni C, Pettakkandy V, P. AJ, Soren SK, K. VK. Atlantoaxial Stabilization by Posterior C1 and C2 Screw-Rod Fixation for Various Pathologies: Case Series and Comprehensive Review of Literature. J Neurosci Rural Pract 2021; 12:228-235. [PMID: 33927515 PMCID: PMC8064858 DOI: 10.1055/s-0041-1722838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
We retrospectively analyzed atlantoaxial dislocation (AAD) of various pathologies, namely, rheumatoid arthritis (RA), os odontoideum, and trauma. Various techniques were discussed in relation to C1-C2 stabilization. The study aims to share our clinical experience in a series of six cases of C1-C2 instability that underwent posterior C1-C2 fusion, with free hand technique and limited fluoroscopy. The clinicoradiological presentation for each patient is described. We reviewed different literatures related to our case vividly and focused on the basic neuroanatomy involved in the atlantoaxial joint. All patients of AAD had evidence of severe canal compromise and chronic compressive spinal cord changes. In our study, the patients age ranged from 28 to 52 years. The study included four males and two females. Out of six patients of AAD, three had history of trauma, two had os odontoideum, and one had chronic inflammatory condition (RA). From our case series, we concluded that the Goel-Harms technique is the most versatile and surgeon friendly technique for C1-C2 fixation. Early recognition and surgical intervention of atlantoaxial joint instability is essential to prevent catastrophic neurological complications.
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Affiliation(s)
- Chandramohan Unni
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| | - Vijayan Pettakkandy
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| | - Abdul Jaleel P.
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| | - Subrat Kumar Soren
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
| | - Vineeth K. K.
- Department of Neurosurgery, Government Medical College, Kozhikode, Kerala, India
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Kirnaz S, Gebhard H, Wong T, Nangunoori R, Schmidt FA, Sato K, Härtl R. Intraoperative image guidance for cervical spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:93. [PMID: 33553386 PMCID: PMC7859826 DOI: 10.21037/atm-20-1101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Intraoperative image-guidance in spinal surgery has been influenced by various technological developments in imaging science since the early 1990s. The technology has evolved from simple fluoroscopic-based guidance to state-of-art intraoperative computed tomography (iCT)-based navigation systems. Although the intraoperative navigation is more commonly used in thoracolumbar spine surgery, this newer imaging platform has rapidly gained popularity in cervical approaches. The purpose of this manuscript is to address the applications of advanced image-guidance in cervical spine surgery and to describe the use of intraoperative neuro-navigation in surgical planning and execution. In this review, we aim to cover the following surgical techniques: anterior cervical approaches, atlanto-axial fixation, subaxial instrumentation, percutaneous interfacet cage implantation as well as minimally invasive posterior cervical foraminotomy (PCF) and unilateral laminotomy for bilateral decompression. The currently available data suggested that the use of 3D navigation significantly reduces the screw malposition, operative time, mean blood loss, radiation exposure, and complication rates in comparison to the conventional fluoroscopic-guidance. With the advancements in technology and surgical techniques, 3D navigation has potential to replace conventional fluoroscopy completely.
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Affiliation(s)
- Sertac Kirnaz
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Harry Gebhard
- Department of Surgery, Canton Hospital Baden, Switzerland.,Department of Trauma, University Hospital Zurich, University of Zurich, Switzerland
| | - Taylor Wong
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Raj Nangunoori
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Franziska Anna Schmidt
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Kosuke Sato
- Hospital for Special Surgery, New York, NY, USA
| | - Roger Härtl
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
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Alexiades NG, Parisi F, Anderson RCE. Pediatric Spine Trauma: A Brief Review. Neurosurgery 2020; 87:E1-E9. [PMID: 32374883 DOI: 10.1093/neuros/nyaa119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 02/20/2020] [Indexed: 12/15/2022] Open
Abstract
Pediatric spinal trauma is a broad topic with nuances specific to each anatomic region of the spinal column. The purpose of this report is to provide a brief review highlighting the most important and common clinical issues regarding the diagnosis and management of pediatric spine trauma. Detailed descriptions of imaging findings along with specific operative and nonoperative management of each fracture and dislocation type are beyond the scope of this review.
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Affiliation(s)
- Nikita G Alexiades
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Frank Parisi
- Department of Neurological Surgery, Columbia University, New York, New York
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21
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Du YQ, Yin YH, Qiao GY, Yu XG. C2 medial pedicle screw: a novel "in-out-in" technique as an alternative option for posterior C2 fixation in cases with a narrow C2 isthmus. J Neurosurg Spine 2020; 33:281-287. [PMID: 32357339 DOI: 10.3171/2020.2.spine191517] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors describe a novel "in-out-in" technique as an alternative option for posterior C2 screw fixation in cases that involve narrow C2 isthmus. Here, they report the preliminary radiological and clinical outcomes in 12 patients who had a minimum 12-month follow-up period. METHODS Twelve patients with basilar invagination and atlantoaxial dislocation underwent atlantoaxial reduction and fixation. All patients had unilateral hypoplasia of the C2 isthmus that prohibited insertion of pedicle screws. A new method, the C2 medial pedicle screw (C2MPS) fixation, was used as an alternative. In this technique, the inner cortex of the narrow C2 isthmus was drilled to obtain space for screw insertion, such that the lateral cortex could be well preserved and the risk of vertebral artery injury could be largely reduced. The C2MPS traveled along the drilled inner cortex into the anterior vertebral body, achieving a 3-column fixation of the axis with multicortical purchase. RESULTS Satisfactory C2MPS placement and reduction were achieved in all 12 patients. No instance of C2MPS related vertebral artery injury or dural laceration was observed. There were no cases of implant failure, and solid fusion was demonstrated in all patients. CONCLUSIONS This novel in-out-in technique can provide 3-column rigid fixation of the axis with multicortical purchase. Excellent clinical outcomes with low complication rates were achieved with this technique. When placement of a C2 pedicle screw is not possible due to anatomical constraints, the C2MPS can be considered as an efficient alternative.
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22
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The internal carotid artery and the atlas: anatomical relationship and implications for C1 lateral mass fixation. Surg Radiol Anat 2020; 43:87-92. [PMID: 32734343 DOI: 10.1007/s00276-020-02537-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The internal carotid artery (ICA) is potentially at risk during posterior fixation of C1. In this study, we performed a CT-based anatomical analysis of the relationship between the internal carotid artery and the lateral mass of the atlas. METHODS We analysed 30 CT angiography of the cervical spine, and we measured on both sides the distance of the carotid artery from the midline, distance of the ICA from the anterior cortex of C1 and from the ideal C1 screw entry point. We measured the angle between the sagittal plane passing through the entry point and the tangent line of the vessel. Separated statistical analysis between left and right sides, between male and female patients, and differentiation by age were also performed. RESULTS Sixty ICAs were studied. The mean distance of the ICA from the midline was 23.3 ± 4.3 mm, with a minimum of 15 mm. The distance between the ICA and the anterior cortical layer of C1 was 4.8 ± 2.7 mm, with a minimum of 1.1 mm. The distance between the screw entry point and the arterial wall was 22.6 ± 2.8 mm, with a minimum of 17.5 mm. The mean angle was 10.4°, with a minimum of 11°. CONCLUSIONS Although rare, intraoperative lesion of the ICA is reported and the spine surgeon must be aware of this risk. Careful preoperative planning is mandatory and the position of the ICA in relation to C1 must be assessed. The anatomical parameters presented in this paper can be useful to reduce the risk of ICA injury.
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Chen Q, Brahimaj BC, Khanna R, Kerolus MG, Tan LA, David BT, Fessler RG. Posterior atlantoaxial fusion: a comprehensive review of surgical techniques and relevant vascular anomalies. JOURNAL OF SPINE SURGERY 2020; 6:164-180. [PMID: 32309655 DOI: 10.21037/jss.2020.03.05] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior atlantoaxial fusion is an important surgical technique frequently used to treat various pathologies involving the cervical 1-2 joint. Since the beginning of the 20th century, various fusion techniques have been developed with improved safety profile, higher fusion rates, and superior clinical outcome. Despite the advancement of technology and surgical techniques, posterior C1-2 fusion is still a technically challenging procedure given the complex bony and neurovascular anatomy in the craniovertebral junction (CVJ). In addition, vascular anomalies in this region are not uncommon and can lead to devastating neurovascular complications if unrecognized. Thus, it is important for spine surgeons to be familiar with various posterior atlantoaxial fusion techniques along with a thorough knowledge of various vascular anomalies in the CVJ. Intimate knowledge of the various surgical techniques in combination with an appreciation for anatomical variances, allows the surgeon develop a customized surgical plan tailored to each patient's particular pathology and individual anatomy. In this article, we aim to provide a comprehensive review of existing posterior C1-2 fusion techniques along with a review of common vascular anomalies in the CVJ.
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Affiliation(s)
- Qi Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Bledi C Brahimaj
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Ryan Khanna
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Mena G Kerolus
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Lee A Tan
- Department of Neurosurgery, UCSF Medical Center, San Francisco, CA, USA
| | - Brian T David
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Richard G Fessler
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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Koffie RM, Larsen AMG, Grannan BL, Hadzipasic M, Yanamadala V, Beaver LV, Shankar GM, Shin JH. Novel Technique for C1-2 Interlaminar Arthrodesis Utilizing a Modified Sonntag Loop-Suture Graft With Posterior C1-2 Fixation. Neurospine 2020; 17:659-665. [PMID: 32054143 PMCID: PMC7538353 DOI: 10.14245/ns.1938344.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/18/2019] [Indexed: 11/20/2022] Open
Abstract
Objective Conventional techniques for atlantoaxial fixation and fusion typically pass cables or wires underneath C1 lamina to secure the bone graft between the posterior elements of C1–2, which leads to complications such as cerebrospinal fluid (CSF) leak and neurological injury. With the evolution of fixation hardware, we propose a novel C1–2 fixation technique that avoids the morbidity and complications associated with sublaminar cables and wires.
Methods This technique entails wedging and anchoring a structural iliac crest graft between C1 and C2 for interlaminar arthrodesis and securing it using a 0-Prolene suture at the time of C1 lateral mass and C2 pars interarticularis screw fixation.
Results We identified 32 patients who underwent surgery for atlantoaxial with our technique. A 60% improvement in pain-related disability from preoperative baseline was demonstrated by Neck Disability Index (p<0.001). There were no neurologic deficits. Complications included 2 patients CSF leaks related to presenting trauma, 1 patient with surgical site infection, and 1 patient with transient dysphagia. The rate of radiographic atlantoaxial fusion was 96.8% at 6 months, with no evidence of instrumentation failure, graft dislodgement, or graft related complications.
Conclusion We demonstrate a novel technique for C1–2 arthrodesis that is a safe and effective option for atlantoaxial fusion.
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Affiliation(s)
- Robert M Koffie
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Benjamin L Grannan
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Muhamed Hadzipasic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vijay Yanamadala
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura Van Beaver
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Tian W, Liu YJ, Liu B, He D, Wu JY, Han XG, Zhao JW, Fan MX. Guideline for Posterior Atlantoaxial Internal Fixation Assisted by Orthopaedic Surgical Robot. Orthop Surg 2020; 11:160-166. [PMID: 31025810 PMCID: PMC6594511 DOI: 10.1111/os.12454] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/19/2019] [Indexed: 12/01/2022] Open
Abstract
Atlantoaxial transarticular facet screw fixation (Magerl technique) and C1 lateral mass screws combined with C2 pedicle screws fixation (Harms technique) are the most commonly used techniques for posterior internal fixation in the upper cervical spine. Upper cervical spinal surgery is a technically demanding and challenging procedure because of complicated anatomical structures and frequent occurrence of anomalies. Accurate insertion of screws allows for stable and secure internal fixation, which is necessary for both techniques. Traditional methods under fluoroscopic assistance in this region cannot meet the requirements of high levels of accuracy and security during the procedure. Robot-assisted spinal surgery can provide accurate and reliable guidance during the screw insertion, which is evidenced in the literature. As a recently developed technique, robot-assisted surgery is supposed to be performed by skilled surgeons who have received standard training for robotic surgery. The standardized upper cervical spinal surgery assisted by the robot system needs to be introduced to these surgeons. Based on the consensus of consultant specialists, the literature review, and our local experience, this guideline included the introduction of the robotic system, the workflow of robot-assisted procedures, and the precautions to take during procedures. This guideline aims to provide a standardization of the robotic surgery for posterior atlantoaxial internal fixation.
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Affiliation(s)
- Wei Tian
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ya-Jun Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Bo Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Da He
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Jing-Ye Wu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Xiao-Guang Han
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Jing-Wei Zhao
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ming-Xing Fan
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
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Walker CT, Kakarla UK, Chang SW, Sonntag VKH. History and advances in spinal neurosurgery. J Neurosurg Spine 2019; 31:775-785. [PMID: 31786543 DOI: 10.3171/2019.9.spine181362] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 09/03/2019] [Indexed: 01/25/2023]
Abstract
Insight into the historic contributions made to modern-day spine surgery provides context for understanding the monumental accomplishments comprising current techniques, technology, and clinical success. Only during the last century did surgical growth occur in the treatment of spinal disorders. With that growth came a renaissance of innovation, particularly with the evolution of spinal instrumentation and fixation techniques. In this article, the authors capture some of the key milestones that have led to the field of spine surgery today, with an emphasis on the historical advances related to instrumentation, navigation, minimally invasive surgery, robotics, and neurosurgical training.
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C2 Pedicle Screws Combined With C1 Laminar Hooks for Reducible Atlantoaxial Dislocation: An Ideal Salvage Technique for C1-C2 Pedicle Screws. Oper Neurosurg (Hagerstown) 2019; 19:150-156. [DOI: 10.1093/ons/opz332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 09/02/2019] [Indexed: 12/19/2022] Open
Abstract
Abstract
BACKGROUND
A C1 laminar hook can theoretically avoid vertebral artery injury and is less technically demanding. However, only few studies with small samples analyzed the short-term outcomes of C2 pedicle screws combined with C1 laminar hooks (C2PS-C1LH) technique in the treatment of atlantoaxial dislocation. Furthermore, it is not confirmed whether similar clinical outcomes can be achieved with C1-C2 pedicle screw and rod construct (PSRC).
OBJECTIVE
To evaluate the outcomes of C2PS-C1LH and C1-C2 PSRC fixation techniques for treating atlantoaxial dislocation.
METHODS
Data of 52 patients with atlantoaxial dislocation treated by C1-C2 PSRC or C2PS-C1LH fixation were retrospectively reviewed. Outcomes evaluated by visual analog scale score for neck pain (VASSNP), Neck Disability Index (NDI), atlantodental interval (ADI), and the perioperative parameters including blood loss and operation time were analyzed and compared between 2 techniques. Patient satisfaction at final follow-up was also investigated.
RESULTS
There were no complications related to the surgical approach and instrumentation in either group. The mean bone fusion time was 5.06 ± 1.65 mo for the C2PS-C1LH group and 3.93 ± 0.99 mo for the C1-C2 PSRC group (P > .05). Hundred percent of fusion rates were achieved in both groups at month 12 after operation. The ADI, VAS scores, the NDI scores, and the JOA scores were greatly improved in both the groups (P < .05), but there were no significant differences between the 2 groups.
CONCLUSION
C2PS-C1LH fixation technique was comparable to C1-C2 PSRC in the treatment of reducible atlantoaxial dislocation. C2PS-C1LH fixation was an ideal alternative strategy to C1-C2 PSRC fixation.
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Sardhara J, Behari S, Sindgikar P, Srivastava AK, Mehrotra A, Das KK, Bhaisora KS, Sahu RN, Jaiswal AK. Evaluating Atlantoaxial Dislocation Based on Cartesian Coordinates: Proposing a New Definition and Its Impact on Assessment of Congenital Torticollis. Neurosurgery 2019; 82:525-540. [PMID: 28472514 DOI: 10.1093/neuros/nyx196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 03/21/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Conventional 2-dimensional (2-D) definition of atlantoaxial dislocation (AAD) is inadequate for coexisting 3-D displacements. OBJECTIVE To prospectively classify AAD and its related abnormalities along 3 Cartesian coordinates and assess their association with torticollis. METHODS One hundred and fifty-four patients with congenital AAD were prospectively classified according to their C1-2 displacement along 3 Cartesian coordinates utilizing 3-D multiplanar CT. The impact of this 3-D dislocation on occurrence of clinically manifest torticollis was also evaluated and surgical treatment was planned. RESULTS Three dimensional CT assessment detected the following types of C1-2 dislocations: I:translational dislocation (along Z coordinate, n = 37 [24%]); II: central dislocation (along Y coordinate, n = 10 [6.5%]); III: translational+central dislocation (along Z+Y coordinates, n = 42 [27.3%]); IV: translational dislocation+ rotational dislocation+coronal tilt (along Z+X coordinates, (n = 6 [3.9%]); V: central dislocation (basilar invagination)+rotational dislocation+coronal tilt (along Y+X coordinates, n = 11 [7.1%]); VI: translational dislocation+ central dislocation+ rotational dislocation+ coronal tilt (along all 3 axes, n = 48 [31%]). Assessing degree of relative C1-2 rotation revealed that 27 (37%) of 85 patients with <50 rotation and 54 (78%) of 69 patients with >5° rotation had associated torticollis. Translational dislocation had negative association (odds ratio [OR] 0.1, 95% confidence interval [CI; 0.47-0.32], P = .00), while type VI (OR 5.0, 95% CI [2.2-11.19], P = .00), type V (OR 4.44, 95% CI [0.93-21.26], P = .04), and type IV (OR 1.84, 95% CI [0.32-10.38], P = .48) dislocations had strong positive association with torticollis. Sixty-two (40%) patients improved, 68 (44%) remained unchanged, and 24 (16%) patients worsened postoperatively. Twenty-eight patients required second-stage transoral decompression following posterior distraction-fusion due to neurological nonimprovement. CONCLUSION Three-dimensional assessment of AAD including evaluation of culpable C1-2 facet joints addresses anomalous displacements in 3 Cartesian planes. This provides targets for adequate cervicomedullary decompression-stabilization, and helps in the management of accompanying torticollis.
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Affiliation(s)
- Jayesh Sardhara
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Pavaman Sindgikar
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Arun Kumar Srivastava
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kamlesh Singh Bhaisora
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rabi N Sahu
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Awadhesh K Jaiswal
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Srivastava A, Sardhara J, Behari S, Pavaman S, Joseph J, Das K, Mehrotra A, Jaiswal AK, Bhaishora K. Knock and Drill Technique: A Simple Tips for the Instrumentation in Complex Craniovertebral Junction Anomalies without using Fluoroscopy. J Neurosci Rural Pract 2019; 8:14-19. [PMID: 28149076 PMCID: PMC5225702 DOI: 10.4103/0976-3147.193555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Context: Existence of complex variable bony and vertebral artery (VA) anomalies at craniovertebral junction (CVJ) in subset of complex CVJ anomalies demands individualized instrumentation policy and placing screws in each bone requires strategic preoperative planning and intraoperative skills. Aim: To evaluate the clinical accuracy of knock and drill (K and D) technique for the screw placement in complex CVJ anomalies. Settings and Design: Prospective study and operative technical note. Materials and Methods: Totally 36 consecutive patients (16 - pediatrics, 20 - adult patients) of complex CVJ: Complete/partial occipitalized C1 vertebra; at least one hypoplastic (C1/C2) articular mass, rotational component, and variations in the third part of VA were included in this study. Preoperative detail computed tomography (CT) CT CVJ with three-dimensional reconstruction was done for the assessment of CVJ anatomy and facet joint orientation. The accuracy of novel technique was assessed with postoperative CT to evaluate cortical breach in between 5th and 7th postoperative day in all the patients. All patients were underwent clinico-radiological evaluation at 6-month follow-up. Results: Totally 144 screws were placed using K and D technique (pediatric group - 64 screws, adult patients - 80 screws). Total of 12 screws were placed in C1 lateral mass in both age group without any bony cortical breach and complication. Sixteen C2 pedicle screws and 12 C2 pars screw in pediatrics and 18 C2 pedicle screws in adult patients were placed without any bony breach or VA injury. Out of thirty subaxial lateral mass screws in pediatric group, the bony breach was encountered with one screw (3.3%). Total of 38 C2 pars screws was placed in adult group in which bony breach along with VA injury was encounter with 1screw (2.6%). Conclusion: A simple technique of K and D for placing a screw increases the accuracy and spectrum of bony purchase and has the potential to reduce the complication in patients with complex CVJ anomalies.
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Affiliation(s)
- Arun Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sindgikar Pavaman
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jeena Joseph
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh K Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh Bhaishora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Formentin C, Andrade EJD, Maeda FL, Ghizoni E, Tedeschi H, Joaquim AF. Axis screws: results and complications of a large case series. ACTA ACUST UNITED AC 2019; 65:198-203. [PMID: 30892444 DOI: 10.1590/1806-9282.65.2.198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 05/27/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To present the surgical results of patients who underwent axis screw instrumentation, discussing surgical nuances and complications of the techniques used. METHODS Retrospective case-series evaluation of patients who underwent spinal surgery with axis instrumentation using screws. RESULTS Sixty-five patients were included in this study. The most common cause of mechanical instability was spinal cord trauma involving the axis (36 patients - 55.4%), followed by congenital craniocervical malformation (12 patients - 18.5%). Thirty-seven (57%) patients required concomitant C1 fusion. Bilateral axis fixation was performed in almost all cases. Twenty-three patients (35.4%) underwent bilateral laminar screws fixation; pars screws were used in twenty-two patients (33.8%), and pedicular screws were used isolated in only three patients (4.6%). In fourteen patients (21.5%), we performed a hybrid construction. There was no neurological worsening nor vertebral artery injury in this series. CONCLUSION Axis screw instrumentation proved to be a safe and efficient method for cervical stabilization. Laminar and pars screws were the most commonly used.
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Affiliation(s)
- Cleiton Formentin
- Resident - Neurosurgery Division - Department of Neurology, University of Campinas (UNICAMP), Campinas-SP, Brasil
| | - Erion Junior de Andrade
- Resident - Neurosurgery Division - Department of Neurology, University of Campinas (UNICAMP), Campinas-SP, Brasil
| | - Fernando Luis Maeda
- Resident - Neurosurgery Division - Department of Neurology, University of Campinas (UNICAMP), Campinas-SP, Brasil
| | - Enrico Ghizoni
- Assistant Professor - Neurosurgery Division - University of Campinas (UNICAMP), Campinas-SP, Brasil
| | - Helder Tedeschi
- Assistant Professor - Neurosurgery Division - University of Campinas (UNICAMP), Campinas-SP, Brasil
| | - Andrei F Joaquim
- Assistant Professor - Neurosurgery Division - University of Campinas (UNICAMP), Campinas-SP, Brasil
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Chan JJ, Shepard N, Cho W. Biomechanics and Clinical Application of Translaminar Screws Fixation in Spine: A Review of the Literature. Global Spine J 2019; 9:210-218. [PMID: 30984502 PMCID: PMC6448194 DOI: 10.1177/2192568218765995] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVES Translaminar screw (TLS) fixation was first described as a salvage technique for fixation of the axial spine. Better understanding of the spine anatomy allows for advancement in surgical techniques and expansion of TLS indications. The goal of this review is to discuss the anatomic feasibility of the TLS fixation in different region of the spine. METHODS A review of the current literatures on the principles, biomechanics, and clinical application of the translaminar screw technique in the axial, subaxial, and thoracolumbar spine. RESULTS Anatomic feasibility and biomechanical studies have demonstrated that TLS is a safe and strong fixation methods for fusion beyond just the axial spine. However, not all spine segments have wide enough lamina to accept TLS. Preoperative computed tomography scan can help ensure the feasibility and safety of TLS insertion. Recent clinical reports have validated the application of TLS in subaxial spine, thoracic spine, hangman's fracture, and pediatric population. CONCLUSIONS TLS can be used beyond axial spine; however, TLS insertion is only warranted when the lamina is thick enough to avoid further complications such as breakage. Preoperative computed tomography scans can be used to determine feasibility of such fixation construct.
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Affiliation(s)
- Jimmy J. Chan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicholas Shepard
- New York University Hospital for Joint Diseases, New York, NY, USA
| | - Woojin Cho
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY,
USA
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Cadena G, Duong HT, Liu JJ, Kim KD. Atlantoaxial fixation using C1 posterior arch screws: feasibility study, morphometric data, and biomechanical analysis. J Neurosurg Spine 2019; 30:314-322. [PMID: 30554179 DOI: 10.3171/2018.8.spine18160] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 08/15/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVEC1-2 is a highly mobile complex that presents unique surgical challenges to achieving biomechanical rigidity and fusion. Posterior wiring methods have been largely replaced with segmental constructs using the C1 lateral mass, C1 pedicle, C2 pars, and C2 pedicle. Modifications to reduce surgical morbidity led to the development of C2 laminar screws. The C1 posterior arch has been utilized mostly as a salvage technique, but recent data indicate that this method provides significant rigidity in flexion-extension and axial rotation. The authors performed biomechanical testing of a C1 posterior arch screw (PAS)/C2 pars screw construct, collected morphometric data from a population of 150 CT scans, and performed a feasibility study of a freehand C1 PAS technique in 45 cadaveric specimens.METHODSCervical spine CT scans from 150 patients were analyzed to determine the average C1 posterior tubercle thickness and size of C1 posterior arches. Eight cadavers were used to compare biomechanical stability of intact specimens, C1 lateral mass/C2 pars screw, and C1 PAS/C2 pars screw constructs. Paired comparisons were made using repeated-measures ANOVA and Holm-Sidak tests. Forty-five cadaveric specimens were used to demonstrate the feasibility and safety of the C1 PAS freehand technique.RESULTSMorphometric data showed the average craniocaudal thickness of the C1 posterior tubercle was 12.3 ± 1.94 mm. Eight percent (12/150) of cases showed thin posterior tubercles or midline defects. Average posterior arch thickness was 6.1 ± 1.1 mm and right and left average posterior arch length was 28.7 mm ± 2.53 mm and 28.9 ± 2.29 mm, respectively. Biomechanical testing demonstrated C1 lateral mass/C2 pars and C1 PAS/C2 pars constructs significantly reduced motion in flexion-extension and axial rotation compared with intact specimens (p < 0.05). The C1 lateral mass/C2 pars screw construct provided significant rigidity in lateral bending (p < 0.05). There was no statistically significant difference between the two constructs in flexion-extension, lateral bending, or axial rotation. Of the C1 posterior arches, 91.3% were successfully cannulated using a freehand technique with a low incidence of cortical breach (4.4%).CONCLUSIONSThis biomechanical analysis indicates equivalent stability of the C1 PAS/C2 pars screw construct compared with a traditional C1 lateral mass/C2 pars screw construct. Both provide significant rigidity in flexion-extension and axial rotation. Feasibility testing in 45 cadaveric specimens indicates a high degree of accuracy with low incidence of cortical breach. These findings are supported by a separate radiographic morphometric analysis.
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Affiliation(s)
- Gilbert Cadena
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Huy T Duong
- 2Department of Neurosurgery, Kaiser Foundation Medical Center, Sacramento, California
| | - Jonathan J Liu
- 3Department of Neurosurgery, Advocate Lutheran General Hospital, Park Ridge, Illinois; and
| | - Kee D Kim
- 4Department of Neurological Surgery, University of California, Davis, Sacramento, California
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Shang G, Fan T, Hou Z, Liang C, Wang Y, Zhao X, Fan W. A modified microsurgical interfacet release and direct distraction technique for management of congenital atlantoaxial dislocation: technical note. Neurosurg Rev 2019; 42:583-591. [PMID: 30758747 DOI: 10.1007/s10143-019-01084-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 12/31/2018] [Accepted: 01/29/2019] [Indexed: 11/29/2022]
Abstract
Various techniques have been used for management of congenital atlantoaxial dislocation. Recently, the reduction of atlantoaxial dislocation through a single posterior approach has attracted more and more attention. Here, we present a modified technique including direct interfacet release and distraction between C1 and C2 by a specially designed distractor, posterior internal fixation and bone graft fusion. The illustrated technique was performed in 15 consecutive patients, and the outcomes were recorded and analyzed. Follow-up ranged from 12 to 26 months. Clinical symptoms improved in 14 patients (93.3%) and were stable in 1 patient (6.7%). Radiologically, 60-100% reduction was achieved in 13 patients (86.6%). Bone fusion was obtained in all patients at 12 months after the operation. The two-tailed Wilcoxon signed-rank test was used to analyze the preoperative and postoperative Japanese Orthopedic Association scores (JOA), atlas-dens interval (ADI), and cervicomedullary angle (CMA) (P < 0.001). Our results suggested that this direct interfacet release and distraction technique with a specially designed C1-2 distractor can provide a definite effective C1-2 facet distraction and odontoid process restoration through a single posterior approach.
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Affiliation(s)
- GuoSong Shang
- Department of Neurosurgery, Linfen People's Hospital, Shanxi Medical University, Binhe West Road, Yaodu District, Linfen, Shanxi Province, People's Republic of China
| | - Tao Fan
- Spine Center, Sanbo Brain Hospital, Capital Medical University, No. 50 XiangshanYikesong Road, Haidian District, Beijng, People's Republic of China.
| | - Zhe Hou
- Department of Neurosurgery, Beijing Luhe Hospital, Capital Medical University, No. 82 Xinhua South Road, Tongzhou District, Beijing, People's Republic of China
| | - Cong Liang
- Spine Center, Sanbo Brain Hospital, Capital Medical University, No. 50 XiangshanYikesong Road, Haidian District, Beijng, People's Republic of China
| | - YinQian Wang
- Spine Center, Sanbo Brain Hospital, Capital Medical University, No. 50 XiangshanYikesong Road, Haidian District, Beijng, People's Republic of China
| | - XinGang Zhao
- Spine Center, Sanbo Brain Hospital, Capital Medical University, No. 50 XiangshanYikesong Road, Haidian District, Beijng, People's Republic of China
| | - Wayne Fan
- Faculty of Science, University of British Columbia, Office of the Dean Earth Sciences Building, 2178-2207 Main Mall, Vancouver, British Columbia, V6T 1Z4, Canada
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Fung M, Frydenberg E, Barnsley L, Chaganti J, Steel T. Clinical and radiological outcomes of image guided posterior C1-C2 fixation for atlantoaxial osteoarthritis (AAOA). JOURNAL OF SPINE SURGERY 2019; 4:725-735. [PMID: 30714004 DOI: 10.21037/jss.2018.12.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Atlantoaxial (C1-C2) osteoarthritis (AAOA) causes severe suboccipital pain exacerbated by lateral rotation. The pain is usually progressive and resistant to conservative therapy. Posterior fusion surgery is performed to stabilise the C1-C2 segment. This is the first Australian study reporting the outcome of posterior atlantoaxial fixation including hybrid fixations performed for AAOA. Methods All patients who underwent posterior atlantoaxial fixation surgery for AAOA from 2005 to 2015 at our institutions were enrolled (N=23). Patient demographics and surgical technique were recorded. These techniques included transarticular screw (TAS) fixation using image guidance with iliac crest bone graft and supplemental posterior Sonntag wiring, or C1-C2 lateral mass fixation (Harms technique). Some patients required a combination of fixation due to anatomical variation. Primary outcome measures including patient satisfaction, pain, disability scores and range of motion were recorded for all patients pre- and post-operatively. Post-operative assessment was supplemented with CT and X-ray imaging. Results Twenty-three patients (19 women, 4 males, mean age 71.8±6.3 years) underwent surgical fixation. Eight underwent TAS fixation, 8 had Harms fixation, and 7 had a hybrid fixation. All patients reported statistically significant improvement in pain scores [Visual Analogue Scale (VAS) 9.4 pre-op compared to 2.9 post-op, P<0.005]. Disability scores [Neck Disability Index (NDI)] were statistically significantly reduced from 72.2±12.9 pre-operatively to 18.9±11.9 post-operatively, P<0.005. Mean follow-up was 55.3±36.1 months. Results did not vary according to the construct type. Ninety-five point five percent of patients showed radiographic evidence of fusion. Ninety-one percent of patients said they would undergo the surgery again. Conclusions Posterior atlantoaxial fixation with TAS and Harms constructs are highly effective for the surgical treatment of intractable neck pain secondary to atlantoaxial lateral mass osteoarthritis (AAOA). Surgery offers a high rate of symptom relief. If anatomical variability exists, both transarticular and pedicle screw fixation could be safely used in the same patient.
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Affiliation(s)
- Mitchell Fung
- Department of Neurosurgery, St Vincents Hospital, Darlinghurst, NSW, Australia.,School of Medicine, University of New South Wales, NSW, Australia
| | - Ellen Frydenberg
- Department of Neurosurgery, St Vincents Hospital, Darlinghurst, NSW, Australia.,School of Medicine, University of New South Wales, NSW, Australia
| | - Leslie Barnsley
- Department of Rheumatology, Concord Repatriation General Hospital, NSW, Australia.,School of Medicine, The University of Sydney, NSW, Australia
| | - Joga Chaganti
- Department of Radiology, St Vincents Hospital, Darlinghurst, NSW, Australia
| | - Timothy Steel
- Department of Neurosurgery, St Vincents Hospital, Darlinghurst, NSW, Australia.,School of Medicine, University of New South Wales, NSW, Australia
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Saro A, Abdelhameid AK, Fadl KN. Surgical outcome of type II odontoid fracture, Harms technique. EGYPTIAN JOURNAL OF NEUROSURGERY 2019. [DOI: 10.1186/s41984-019-0031-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Comparison of Two Posterior Three-Point Fixation Techniques for Treating Reducible Atlantoaxial Dislocation. Spine (Phila Pa 1976) 2019; 44:E60-E66. [PMID: 29939972 DOI: 10.1097/brs.0000000000002754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To compare the outcomes of C1-C2 transarticular screw combined with C1 laminar hook (TAS+C1H) and C1-C2 transarticular screw combined with modified Gallie technique (TAS+G) for treating reducible atlantoaxial dislocation (AAD). SUMMARY OF BACKGROUND DATA Both TAS+C1H and TAS+G fixation were 3-point fixation techniques for AAD. TAS+C1H technique was comparable to TAS+G technique in biomechanics. However, it is unknown whether it can achieve same outcomes as TAS+G technique. METHODS Data of the 63 patients who underwent TAS+C1H or TAS+G fixation and fusion because of AAD were retrospectively reviewed. Bone fusion time was recorded. The outcomes evaluated by visual analog scale score for neck pain (VASSNP), Nurick scale, neck stiffness (none/mild/severe), patient satisfaction, and Neck Disability Index (NDI) were compared between two groups. RESULTS At the final follow-up, bone graft fusion rates were 100% in both groups (P > 0.05). Nurick scales were significantly improved in both groups (P < 0.05), but with no significant differences between groups (P > 0.05). There were no significant differences between two groups in VASSNP, neck stiffness, patient satisfaction, or NDI (all P > 0.05). There were no complications related to the surgical approach and instrumentation in either group. CONCLUSION Both TAS+C1H and TAS+G fixation were effective in the treatment of reducible AAD. TAS+C1H was safer than TAS+G because it could potentially reduce the risk of spinal cord and venous plexus injury associated with sublaminar cables. LEVEL OF EVIDENCE 3.
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Alshafai NS, Kramarz A, Behboudi M. Insights into the Past and Future of Atlantoaxial Stabilization Techniques. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:265-271. [PMID: 30610332 DOI: 10.1007/978-3-319-62515-7_38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Over the past century, atlantoaxial stabilization techniques have improved considerably. To our knowledge there has been a scarcity of articles published that focus specifically on the history of atlantoaxial stabilization. Examining the history of instrumentation allows us to evaluate the impact of early influences on current modern stabilization techniques. It also provides inspiration to further develop the techniques and prevents repetition of mistakes. This paper reviews the evolution of C1-C2 instrumentation techniques over time and provides insights into the future of these practices.We did an extensive literature search in PubMed, Embase and Google Scholar, using the following search terms: 'medical history', 'atlantoaxial', 'C1/C2', 'stabilization', 'instrumentation', 'fusion', 'arthrodesis', 'grafting', 'neuroimaging', 'biomechanical testing', 'anatomical considerations' and 'future'.Many different entry zones have been tested, as well as different constructs, from initial attempts with use of silk threads to use of hooks and rod-wire techniques, and handling of bone grafts, which eventually led to the development of the advanced screw-rod constructs that are currently in use. Much of this evolution is attributable to advancements in neuroimaging, a wide range of new materials available and an improvement in biomechanical understanding in relation to anatomical structures.
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Affiliation(s)
| | - Agnieszka Kramarz
- Alshafai Neurosurgical Academy (ANA), Toronto, ON, Canada
- Department of Neurosurgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Minou Behboudi
- Alshafai Neurosurgical Academy (ANA), Toronto, ON, Canada
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Wang H, Xue R, Wu L, Ding W, Ma L. Comparison of clinical and radiological outcomes between modified Gallie graft fusion-wiring technique and posterior cervical screw constructs for Type II odontoid fractures. Medicine (Baltimore) 2018; 97:e11452. [PMID: 30024518 PMCID: PMC6086456 DOI: 10.1097/md.0000000000011452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The aim of this study was to compare clinical and radiological outcomes between modified Gallie graft fusion-wiring technique and posterior cervical screw constructs for Type II odontoid fractures, and hope to provide references in decision making and surgical planning for both spinal surgeons and surgically treated patients.This is a retrospective study. By retrieving the medical records from January 2005 to July 2015 in our hospital, 53 Type II odontoid fracture patients were reviewed. According to the instrumentation type, patients were divided into 2 groups: Wiring group and Screw group. Three categorized factors were analyzed statistically: patient characteristics: age, body mass index, preoperative neurological status, duration, complicated injuries; surgical variables: surgery time, blood loss, vertebral artery injury, spinal cord or nerve root injury, major systemic complications, wound infection, pain at the bone donor area, instrumentation failure, revision rate; and radiographic parameters: preoperative and final follow-up data of C0-2 curvature, C2-7 curvature, C2-C7 sagittal vertical axis, C7 slope, fracture classification, separation, and displacement of odontoid fracture, fusion rate. An additional comparison of surgical outcomes was done, including patient satisfaction, visual analog scale score for neck pain, neck stiffness, medical expense.There was no statistically significant difference between the 2 groups in patient characteristics of age, sex, body mass index, preoperative neurological status, duration, and complicated injuries. No statistically significant difference was noted in surgical variables of blood loss, vertebral artery injury, spinal cord or nerve root injury, major systemic complications, wound infection, bone harvested zone pain, instrumentation failure, revision rate. The surgery time was shorter in Wiring group than that in Screw group, with a statistically significant difference. We noted no significant difference between the 2 groups when comparing radiographic parameters of preoperative and final follow-up data of C0-2 curvature, C2-C7 sagittal vertical axis, fracture classification, the separation and displacement of odontoid fracture, and fusion rate. Although we noted no significant difference in preoperative C2-7 curvature and C7 slope, the final follow-up data showed that C2-7 curvature and C7 slope were smaller in Wiring group than that in Screw group. We noted no significant difference in visual analog scale score, neck stiffness, and neurological status at final follow-up. The medical expense was less in Wiring group; the patient satisfaction was lower in the Wiring group than that in the Screw group.The modified Gallie graft fusion-wiring technique provided solid fusion and stabilization for patients with Type II odontoid fractures, Gallie graft fusion-wiring resulted in less surgery time, less medical expense, but lower patient satisfaction when compared with the posterior cervical screw constructs.
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Punyarat P, Buchowski JM, Klawson BT, Peters C, Lertudomphonwanit T, Riew KD. Freehand technique for C2 pedicle and pars screw placement: is it safe? Spine J 2018; 18:1197-1203. [PMID: 29155344 DOI: 10.1016/j.spinee.2017.11.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/09/2017] [Accepted: 11/09/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT During placement of C2 pedicle and pars screws, intraoperative fluoroscopy is used so that neurovascular complications can be avoided, and screws can be placed in the proper position. However, this method is time consuming and increases radiation exposure. Furthermore, it does not guarantee a completely safe and accurate screw placement. PURPOSE The objective of this study was to evaluate the safety of the C2 pedicle and pars screw placement without fluoroscopic or other guidance methods. STUDY DESIGN This is a retrospective comparative study. PATIENT SAMPLE One hundred ninety-eight patients who underwent placement of C2 pedicle or pars screws without any intraoperative radiographic guidance were included in the study. OUTCOME MEASURES Medical records and postoperative computed tomography (CT) scans were evaluated. MATERIALS AND METHODS Clinical data were reviewed for intraoperative and postoperative complications. The accuracy of screw placement was evaluated with postop CT scans using a previously published cortical-breach grading system (described by the location and the percentage of the screw diameter over the cortical edge [0=none, Grade I≤25% of the screw diameter, Grade II=26%-50%, Grade III=51%-75%, and Grade IV=76%-100%]). RESULTS A total of 148 pedicle screws and 219 pars screws were inserted by two experienced surgeons. There were no cases of cerebral spinal fluid leakage and no neurovascular complications during screw placement. Postoperative CT scans were available for 76 patients, which included 52 pedicle screws and 87 pars screws. For cases with C2 pedicle screws, there were 12 breaches (23%); these included 10 screws with a Grade I breach (19%), 1 screw with a Grade II breach (2%), and 1 screw with a Grade IV breach (2%). Lateral breaches occurred in seven screws (13%), inferior breaches occurred in three screws (6%), and superior breaches occurred in two screws (4%). For cases with C2 pars screws, there were 10 breaches (11%); these included 6 screws with a Grade I breach (7%), 2 screws with a Grade II breach (2%), and 2 screws with a Grade IV breach (2%). Medial breaches were found in four (5%), lateral breaches in two (2%), inferior breaches in two (2%), and superior breaches in two (2%). Two of the cases with superior breaches (one for pedicle and one for pars) experienced occipital neuralgia months after surgery. There was no statistically significant difference in the incidence of overall and high-grade breaches between the groups (p=.07 and 1.0, respectively). CONCLUSIONS Although even in experienced hands up to 23% of C2 pedicle screws and 11% of C2 pars screws placed using a freehand technique without guidance may be malpositioned, a clear majority of malpositioned screws demonstrated a low-grade breach, and only 2 of 198 patients (1%) experienced complications related to screw placement.
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Affiliation(s)
- Prachya Punyarat
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, 95 Phahonyothin Rd, Klongluang, Pathumthani, 12120, Thailand
| | - Jacob M Buchowski
- Department of Orthopedic Surgery, Washington University School of Medicine in St. Louis, MO, USA.
| | - Benjamin T Klawson
- Department of Orthopedic Surgery, Washington University School of Medicine in St. Louis, MO, USA
| | - Colleen Peters
- Department of Orthopedic Surgery, Washington University School of Medicine in St. Louis, MO, USA
| | - Thamrong Lertudomphonwanit
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd, Ratchathewi, Bangkok, 10400, Thailand
| | - K Daniel Riew
- Department of Orthopedic Surgery, The Spine Hospital, Columbia University, Medical Center, 5141 Broadway, 3 Field West, New York, NY, 10034, USA
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Herzog JP, Zarkadis NJ, Prabhakar G, Kusnezov NA. Biomechanical comparison of a novel C1 posterior U-construct with four other techniques in a C1-C2 fixation model. J Orthop 2018; 15:741-745. [PMID: 29881231 DOI: 10.1016/j.jor.2018.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 05/06/2018] [Indexed: 11/16/2022] Open
Abstract
Background Compare the biomechanical stability of a novel "U" posterior cervical fixation construct to four other posterior cervical atlantoaxial fixation constructs. Methods Eight fresh frozen human cadaver spines were tested after a simulated odontoid fracture, and following stabilization with each construct. Results All constructs significantly decreased flexion-extension and axial rotation compared to the destabilized spine. The U construct provided significantly more axial stability than the Brooks wire technique. Conclusion The novel U construct demonstrated comparable biomechanical stability to the existing constructs in all three planes of motion with the exception of axial rotation, in which it was inferior to TAS.
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Affiliation(s)
- Joshua P Herzog
- Orthopaedic Spine Center, Massachusetts General Hospital, Boston, MA, United States
| | - Nicholas J Zarkadis
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, United States
| | - Gautham Prabhakar
- Paul L. Foster School of Medicine at Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Nicholas A Kusnezov
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, United States
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Larsen AMG, Grannan BL, Koffie RM, Coumans JV. Atlantoaxial Fusion Using C1 Sublaminar Cables and C2 Translaminar Screws. Oper Neurosurg (Hagerstown) 2018; 14:647-653. [PMID: 28962019 DOI: 10.1093/ons/opx164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 06/27/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Atlantoaxial instability, which can arise in the setting of trauma, degenerative diseases, and neoplasm, is often managed surgically with C1-C2 arthrodesis. Classical C1-C2 fusion techniques require placement of instrumentation in close proximity to the vertebral artery and C2 nerve root. OBJECTIVE To report a novel C1-C2 fusion technique that utilizes C2 translaminar screws and C1 sublaminar cables to decrease the risk of injury to the vertebral artery and C2 nerve root. METHODS To facilitate fixation to the atlas, while minimizing the risk of injury to the vertebral artery and to the C2 nerve root, we sought to determine the feasibility of using a soft cable around the C1 arch and affixing it to a rod connected to C2 laminar screws. We reviewed our experience in 3 patients. RESULTS We used this technique in patients in whom we anticipated difficult C1 screw placement. Three patients were identified through a review of the senior author's cases. Atlantoaxial instability was associated with trauma in 2 patients and chronic degenerative changes in 1 patient. Common symptoms on presentation included pain and limited range of motion. All patients underwent C1-C2 fusion with C2 translaminar screws with sublaminar cable harnessing of the posterior arch of C1. There were no reports of postoperative complications or hardware failure. CONCLUSION We demonstrate a novel, technically straightforward approach for C1-C2 fusion that minimizes risk to the vertebral artery and to the C2 nerve root, while still allowing for semirigid fixation in instances of both traumatic and chronic degenerative atlantoaxial instability.
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Affiliation(s)
- Alexandra M Giantini Larsen
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts.,Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Benjamin L Grannan
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts.,Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Robert M Koffie
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts.,Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Jean-Valéry Coumans
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts.,Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
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Antar V, Turk O. Additional Surgical Method Aimed to Increase Distractive Force during Occipitocervical Stabilization : Technical Note. J Korean Neurosurg Soc 2018. [PMID: 29526072 PMCID: PMC5853194 DOI: 10.3340/jkns.2017.0197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Craniovertebral junctional anomalies constitute a technical challenge. Surgical opening of atlantoaxial joint region is a complex procedure especially in patients with nuchal deformity like basilar invagination. This region has actually very complicated anatomical and functional characteristics, including multiple joints providing extension, flexion, and wide rotation. In fact, it is also a bottleneck region where bones, neural structures, and blood vessels are located. Stabilization surgery regarding this region should consider the fact that the area exposes excessive and life-long stress due to complex movements and human posture. Therefore, all options should be considered for surgical stabilization, and they could be interchanged during the surgery, if required. METHODS A 53-year-old male patient applied to outpatients' clinic with complaints of head and neck pain persisting for a long time. Physical examination was normal except increased deep tendon reflexes. The patient was on long-term corticosteroid due to an allergic disease. Magnetic resonance imaging and computed tomography findings indicated basilar invagination and atlantoaxial dislocation. The patient underwent C0-C3-C4 (lateral mass) and additional C0-C2 (translaminar) stabilization surgery. RESULTS In routine practice, the sites where rods are bound to occipital plates were placed as paramedian. Instead, we inserted lateral mass screw to the sites where occipital screws were inserted on the occipital plate, thereby creating a site where extra rod could be bound. When C2 translaminar screw is inserted, screw caps remain on the median plane, which makes them difficult to bind to contralateral system. These bind directly to occipital plate without any connection from this region to the contralateral system. Advantages of this technique include easy insertion of C2 translaminar screws, presence of increased screw sizes, and exclusion of pullout forces onto the screw from neck movements. Another advantage of the technique is the median placement of the rod; i.e., thick part of the occipital bone is in alignment with axial loading. CONCLUSION We believe that this technique, which could be easily performed as adjuvant to classical stabilization surgery with no need for special screw and rod, may improve distraction force in patients with low bone density.
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Affiliation(s)
- Veysel Antar
- Department of Neurosurgery, Istanbul Research and Training Hospital, Istanbul, Turkey
| | - Okan Turk
- Department of Neurosurgery, Istanbul Research and Training Hospital, Istanbul, Turkey
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Turel MK, Kerolus MG, Traynelis VC. Machined cervical interfacet allograft spacers for the management of atlantoaxial instability. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 8:332-337. [PMID: 29403245 PMCID: PMC5763590 DOI: 10.4103/jcvjs.jcvjs_87_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: The use of cervical interfacet spacers (CISs) to augment stability and provide solid arthrodesis at the atlantoaxial joint has not been studied in detail. The aim of this work is to report the outcomes with the use of machined allograft CISs at C1-2. Methods: A retrospective review of 19 patients who underwent an atlantoaxial fusion with the use of CISs was performed. All patients had instability documented with flexion and extension lateral radiographs. This instability was due to trauma, degenerative stenosis, symptomatic C1-2 arthropathy, and os odontoideum. Clinical and radiological outcomes were assessed. Fusion was determined based on a lack of hardware failure, absence of motion on flexion and extension plain X-ray films, and presence of bridging trabecular bone which was most often demonstrated by a computed tomography. Results: The mean age was 69.1 ± 12.9 years. Eight patients had traumatic fractures, six patients had degenerative stenosis, two patients had C2 neuralgia due to C1-2 arthropathy, two patients had C1-2 ligamentous subluxation, and one patient had an unstable os odontoideum. The occiput or subaxial spine was included in the arthrodesis in 10 patients. Rib autograft was utilized in most patients. No patient had postoperative neurological worsening, malposition of hardware, or vertebral artery injury and there were no mortalities. The fusion rate was 95%. The mean follow-up was 12.1 ± 5.5 months. Conclusions: CIS is a promising adjuvant for the treatment of atlantoaxial instability.
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Affiliation(s)
- Mazda K Turel
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Mena G Kerolus
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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Ghostine SS, Kaloostian PE, Ordookhanian C, Kaloostian S, Zarrini P, Kim T, Scibelli S, Clark-Schoeb SJ, Samudrala S, Lauryssen C, Gill AS, Johnson PJ. Improving C1-C2 Complex Fusion Rates: An Alternate Approach. Cureus 2017; 9:e1887. [PMID: 29392099 PMCID: PMC5788400 DOI: 10.7759/cureus.1887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The surgical repair of atlantoaxial instabilities (AAI) presents complex and unique challenges, originating from abnormalities and/or trauma within the junction regions of the C1-C2 atlas-axis, to surgeons. When this region is destabilized, surgical fusion becomes of key importance in order to prevent spinal cord injury. Several techniques can be utilized to provide for the adequate fusion of the atlantoaxial construct. Nevertheless, many individuals have less than ideal rates of fusion, below 35%-40%, which also involves the C2 nerve root being sacrificed. This suboptimal and unavoidable iatrogenic complication results in the elevated probability of complications typically composed of vertebral artery injury. This review is a retrospective analysis of 87 patients from Cedars Sinai Medical Center in Los Angeles, California, who had the C1-C2 surgical fusion procedure performed within the time frame from 2001 to 2008, with a mean follow-up period of three years. These patients had presented with typical AAI symptoms of fatigability, limited mobility, and clumsiness. Diagnosis of C1-C2 instability was documented via radiographic studies, typically utilizing computed tomography (CT) scans or x-rays. All patients had bilateral C1 lateral masses and C2 pedicle screws. In addition, the C1-C2 joint was accessed by retracting the C2 nerve root superiorly and exposing the joint by utilizing a high-speed burr. The cavity that is developed within the joint is packed with local autologous bone from the cephalad resection of the C2 laminae. Fusion of the C1-C2 joint was achieved in all patients and a final follow-up was conducted approximately three years postoperative. Of the 87 patients, two presented with occipital headaches resulting from the C1 screws impinging on the C2 nerve root. The issue was rectified by removing instrumentation in both patients after documenting complete fusion via radiographic studies, with complete resolution of symptoms. No vertebral artery or spinal cord injuries were reported as a result of the minor complication. Overall, we aim to describe a safe and reliable alternative technique to fuse C1-C2 instability by focusing on intra-articular arthrodesis complementing instrumentation fixation. This methodology is advantageous from a biomechanical standpoint secondary to axial loading, as well as the large surface area available for arthrodesis. Additionally, this technique does not involve the resection of the C2 nerve root, resulting in low risk for vertebral artery or spinal cord injury.
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Affiliation(s)
- Samer S Ghostine
- Neurological Surgery, University of California, Riverside School of Medicine
| | - Paul E Kaloostian
- Neurological Surgery, University of California, Riverside School of Medicine
| | - Christ Ordookhanian
- Neurological Surgery, University of California, Riverside School of Medicine
| | - Sean Kaloostian
- Neurological Surgery, University of California, Irvine School of Medicine
| | | | | | | | | | | | - Carl Lauryssen
- Neurological Surgery, St. David's Round Rock Medical Center
| | - Amandip S Gill
- Neurological Surgery, University of California, Riverside School of Medicine
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Comparison of Outcomes Between C1-C2 Screw-Hook Fixation and C1-C2 Screw-Rod Fixation for Treating Reducible Atlantoaxial Dislocation. Spine (Phila Pa 1976) 2017; 42:1587-1593. [PMID: 28296813 DOI: 10.1097/brs.0000000000002152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To compare the outcomes of C1-C2 transarticular screw with C1 laminar hook (TAS + C1H) fixation and C1 trans-arch lateral mass screw with C2 pedicle screw (C1TLMS + C2PS) fixation in the treatment of reducible atlantoaxial dislocation (AAD). SUMMARY OF BACKGROUND DATA TAS + C1H is comparable to TAS with posterior wiring techniques and superior to C1 lateral mass screw combined with C2 pedicle screw (C1LMS + C2PS) in biomechanics. There were, however, few studies analyzing the differences in outcomes between TAS + C1H technique and modified C1LMS + C2PS technique (C1TLMS + C2PS) for treating AAD. METHODS Data of 30 patients with reducible AAD treated by TAS + C1H fixation and another 30 cases treated by C1TLMS + C2PS fixation were retrospectively analyzed. Bone fusion time was recorded. The outcomes evaluated by American Spinal Injury Association impairment scale, visual analog scale score for neck pain, neck stiffness (none/mild/severe), patient satisfaction, and Neck Disability Index (NDI) were compared between two groups. RESULTS There were no complications related to the surgical approach and instrumentation in either group. At the final follow-up, bone graft fusion rates were 100% in both the TAS + C1H fixation group and the C1TLMS + C2PS fixation group (P > 0.05). The neurological status evaluated by American Spinal Injury Association impairment scale were greatly improved in both screw-hook group (P < 0.001) and screw-rod group (P < 0.001), but with no significant differences between groups (P > 0.05). There were no significant differences between two groups in visual analog scale score for neck pain, neck stiffness, patient satisfaction, or Neck Disability Index (all P > 0.05). CONCLUSION C1TLMS + C2PS fixation was comparable to TAS + C1H fixation in fusion rate and functional outcomes for treating reducible AAD. To reduce the risk of vertebral artery injury, computed tomography scan, and reconstruction should be done to analyze vertebral artery course and C1-C2 anatomic structures before operation. LEVEL OF EVIDENCE 3.
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Lee YC, Brooks F, Sandler S, Yau YH, Selby M, Freeman B. Most Cited Publications in Cervical Spine Surgery. Int J Spine Surg 2017; 11:19. [PMID: 28765803 DOI: 10.14444/4019] [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] [Indexed: 01/24/2023] Open
Abstract
PURPOSE The purpose of this study is to perform a citation analysis on the most frequently cited articles in the topic of cervical spine surgery and report on the top 100 most cited publication in this topic. METHODS We used the Thomson Reuters Web of Science to search citations of all articles from 1945 to 2015 relevant to cervical spine surgery and ranked them according to the number of citations. The 100 most cited articles that matched the search criteria were further analyzed by number of citations, first author, journal, year of publication, country and institution of origin. RESULTS The top 100 cited articles in the topic of cervical spine surgery were published from 1952-2011. The number of citations ranged from 106 times for the 100th paper to 1206 times for the top paper. The decade of 1990-1999 saw the most publications. The Journal of Spine published the most articles, followed by Journal of Bone and Joint Surgery America. Investigators from America authored the most papers and The University of California contributed the most publications. Cervical spine fusion was the most common topic published with 36 papers, followed by surgical technique and trauma. CONCLUSION This article identifies the 100 most cited articles in cervical spine surgery. It has provided insight to the history and development in cervical spine surgery and many of which have shaped the way we practice today.
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Affiliation(s)
- Yu Chao Lee
- Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Yun-Hom Yau
- Royal Adelaide Hospital, Adelaide, Australia
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Dossani RH, Shaughnessy J, Kalakoti P, Nanda A. William Edward Gallie (1882-1959): father of the Gallie wiring technique for atlantoaxial arthrodesis. J Neurosurg 2017; 128:938-941. [PMID: 28548597 DOI: 10.3171/2016.12.jns161224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
William Edward Gallie (1882-1959) was a Canadian general surgeon with special expertise in orthopedic surgery. His experience with surgical management of cervical spine subluxation led him to invent a method of cervical wiring of the atlas to the axis. His method of C1-2 wiring has since been modified, but it still remains one of the three most commonly taught wiring techniques in neurosurgical training programs. Gallie is also hailed for instituting the first surgical training program in Canada, a curriculum his pupils memorialized as the "Gallie course" in surgery. In this historical vignette, the authors describe Gallie's life and depict his contributions to surgery.
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Xu Y, Xiong W, Han SII, Fang Z, Li F. Posterior Bilateral Intermuscular Approach for Upper Cervical Spine Injuries. World Neurosurg 2017; 104:869-875. [PMID: 28546119 DOI: 10.1016/j.wneu.2017.05.051] [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: 03/19/2017] [Revised: 05/07/2017] [Accepted: 05/09/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate a novel intermuscular surgical approach for posterior upper cervical spine fixation. METHODS Twenty-three healthy volunteers underwent magnetic resonance imaging. By using the magnetic resonance imaging scans in transverse view at the level of lower edge of atlas, the distances from the posterior midline to lateral margin of trapezius, to the medial margin of splenius capitis, and to middle line of semispinalis capitis were recorded. The angle between posterior middle line and the line crossing the lateral margin of trapezius and middle point of ipsilateral pedicles. From October 2009 to May 2013, 12 patients with upper cervical spine injuries were operated via the bilateral intermuscular approach. The time required for surgery, blood loss, and pre- and postoperative visual analogue scale scores were analyzed. RESULTS The average distance of 0-T was 39.2 ± 7.5 mm, the angle between the approach and posterior middle line was 33.2 ± 8.4°. The surgical time was 78.3 ± 22.5 minutes (45-140 minutes), and the mean intraoperative blood loss was 87.5 ± 44.2 mL (30-200 mL). Preoperative and postoperative visual analogue scale scores were 6.4 ± 0.8 and 1.8 ± 0.7, respectively. The average follow-up time was 19.7 ± 11.5 months (9-48 months). CONCLUSIONS The posterior bilateral intermuscular approach for upper cervical spine injuries is a valid alternative for Hangmans' fractures type I, type II, and type Ia according to Levine and Edwards classification as well as atlantoaxial subluxation caused by upper cervical spine trauma.
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Affiliation(s)
- Yong Xu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Wei Xiong
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China.
| | - Sung I I Han
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Zhong Fang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Feng Li
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
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Accurate and Simple Screw Insertion Procedure With Patient-Specific Screw Guide Templates for Posterior C1-C2 Fixation. Spine (Phila Pa 1976) 2017; 42:E340-E346. [PMID: 27454537 DOI: 10.1097/brs.0000000000001807] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective clinical trial of the screw insertion method for posterior C1-C2 fixation utilizing the patient-specific screw guide template technique. OBJECTIVE To evaluate the efficacy of this method for insertion of C1 lateral mass screws (LMS), C2 pedicle screws (PS), and C2 laminar screws (LS). SUMMARY OF BACKGROUND DATA Posterior C1LMS and C2PS fixation, also known as the Goel-Harms method, can achieve immediate rigid fixation and high fusion rate, but the screw insertion carries the risk of injury to neuronal and vascular structures. Dissection of venous plexus and C2 nerve root to confirm the insertion point of the C1LMS may also cause problems. We have developed an intraoperative screw guiding method using patient-specific laminar templates. METHODS Preoperative bone images of computed tomography (CT) were analyzed using three-dimensional (3D)/multiplanar imaging software to plan the trajectories of the screws. Plastic templates with screw guiding structures were created for each lamina using 3D design and printing technology. Three types of templates were made for precise multistep guidance, and all templates were specially designed to fit and lock on the lamina during the procedure. Surgery was performed using this patient-specific screw guide template system, and placement of the screws was postoperatively evaluated using CT. RESULTS Twelve patients with C1-C2 instability were treated with a total of 48 screws (24 C1LMS, 20 C2PS, 4 C2LS). Intraoperatively, each template was found to exactly fit and lock on the lamina and screw insertion was completed successfully without dissection of the venous plexus and C2 nerve root. Postoperative CT showed no cortical violation by the screws, and mean deviation of the screws from the planned trajectories was 0.70 ± 0.42 mm. CONCLUSION The multistep, patient-specific screw guide template system is useful for intraoperative screw navigation in posterior C1-C2 fixation. This simple and economical method can improve the accuracy of screw insertion, and reduce operation time and radiation exposure of posterior C1-C2 fixation surgery. LEVEL OF EVIDENCE 3.
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Wada K, Tamaki R, Yui M, Numaguchi D, Murata Y. C1 lateral mass screw insertion caudally from C2 nerve root - An alternate method for insertion of C1 screws: A technical note and preliminary clinical results. J Orthop Sci 2017; 22:213-217. [PMID: 27847133 DOI: 10.1016/j.jos.2016.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/07/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND C1 lateral mass screw was widely used for fixation of the upper cervical spine. However, massive bleeding from the C1-2 venous plexus is sometimes encountered. In this study, we proposed an alternate method for C1 lateral mass screw insertion, which involves insertion of the screws caudally from the C2 nerve root to reduce bleeding from C1-2 venous plexus. METHODS Seven patients with atlantoaxial lesions were included in this study. The mean age at surgery was 65.9 (34-82) years. The mean follow-up period was 23.1 (12-38) months. All patients underwent atlantoaxial fusion with C1 lateral mass screws, which were inserted caudally from the C2 nerve root. All screws were inserted using O-arm based navigation system. Operative time, blood loss, C2 nerve root injury and perioperative complications were investigated. The accuracy of C1 screws and bone union were evaluated using postoperative computed tomography. RESULTS A total of 13 C1 lateral mass screws were inserted using this method. The mean operative time was 224 (144-305) min. The mean blood loss was 209 (100-357) g. One perioperative complication was observed, which was recurrent laryngeal nerve palsy. There were no vertebral artery or spinal cord injuries. No case of massive bleeding from the C1-2 venous plexus was observed. One patient complained of postoperative occipital neuralgia, which disappeared in 2 weeks. No malposition of C1 lateral mass screws was observed on postoperative computed tomography. Bone union was observed in all patients. CONCLUSION The C1 lateral mass screw insertion caudally from the C2 nerve root may become an alternate method for insertion of C1 screws.
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Affiliation(s)
- Keiji Wada
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan.
| | - Ryo Tamaki
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Mitsuru Yui
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Daisuke Numaguchi
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yasuaki Murata
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
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