Atlanto-axial rotary instability (Fielding type 1): characteristic clinical and radiological findings, and treatment outcomes following alignment, fusion, and stabilization

Halo traction evaluation of craniocervical instability in hereditary connective tissue disorder patients: Case series

INTRODUCTION

Craniocervical instability (CCI) is a condition commonly found in patients with connective tissue disorders such as Ehlers-Danlos Syndrome (EDS), leading to various symptoms. Assessing patients for surgical fusion as a treatment for CCI is challenging due to the complex nature of EDS-related symptoms. This study aimed to evaluate the role of pre-fusion halo-vest traction in alleviating symptoms and determining suitable candidates for fusion surgeries.

METHODS

EDS patients (n = 21) with neurological symptoms underwent insertion of halo-vest traction between 2019 and 2024. Patients completed a CCI Questionnaire before and after the halo-vest traction, reporting symptoms related to headache, vision, hearing, equilibrium, and function. Symptom groups were assigned scores based on patient responses, with one point for each affirmative answer. Before and after scores were analyzed using paired Student's t-test. Patients experiencing over 50 % improvement in the majority of symptoms were considered for definitive fusion surgery. 16 out of 21 patients subsequently underwent fusion for CCI.

RESULTS

The average age of the patients was 35 years, with a female-to-male ratio of 20:1, consistent with existing literature. Significant improvements were observed in various symptom groups after halo-vest traction, including headache (57 % improvement, p < 0.001), brainstem functions (71 % improvement, p < 0.001), cerebellar functions (55 % improvement, p < 0.001), hearing (63 % improvement, p < 0.001), motor functions (51 % improvement,p < 0.001), vision (60 % improvement, p < 0.001), cardiovascular functions (46 % improvement, p < 0.05), sensory and pain (53 % improvement, p < 0.001), high cortical functions (54 % improvement, p < 0.001), GI functions (52 % improvement, p < 0.05), bladder functions (52 % improvement, p < 0.05), and Modified Karnofsky score (30 % improvement, p < 0.05).

CONCLUSION

Halo-vest traction proved to be a simple and effective method for evaluating patients for surgery while providing symptomatic relief in EDS-related CCI cases. It allows surgeons to monitor patients with a now post halo stable craniocervical junctions (CCJ) before committing to surgery.

Overlapping conditions in Long COVID at a multisite academic center

Background

Many patients experience persistent symptoms after COVID-19, a syndrome referred to as Long COVID (LC). The goal of this study was to identify novel new or worsening comorbidities self-reported in patients with LC.

Methods

Patients diagnosed with LC (n = 732) at the Mayo Long COVID Care Clinic in Rochester, Minnesota and Jacksonville, Florida were sent questionnaires to assess the development of new or worsening comorbidities following COVID-19 compared to patients with SARS-CoV-2 that did not develop LC (controls). Both groups were also asked questions screening for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), generalized joint hypermobility (GJH) and orthostatic intolerance. 247 people with LC (33.7%) and 40 controls (50%) responded to the surveys.

Results

In this study LC patients averaged 53 years of age and were predominantly White (95%) women (75%). The greatest prevalence of new or worsening comorbidities following SARS-CoV-2 infection in patients with LC vs. controls reported in this study were pain (94.4% vs. 0%, p < 0.001), neurological (92.4% vs. 15.4%, p < 0.001), sleep (82.8% vs. 5.3%, p < 0.001), skin (69.8% vs. 0%, p < 0.001), and genitourinary (60.6% vs. 25.0%, p = 0.029) issues. 58% of LC patients screened positive for ME/CFS vs. 0% of controls (p < 0.001), 27% positive for GJH compared to 10% of controls (p = 0.026), and a positive average score of 4.0 on orthostatic intolerance vs. 0 (p < 0.001). The majority of LC patients with ME/CFS were women (77%).

Conclusion

We found that comorbidities across 12 surveyed categories were increased in patients following SARS-CoV-2 infection. Our data also support the overlap of LC with ME/CFS, GJH, and orthostatic intolerance. We discuss the pathophysiologic, research, and clinical implications of identifying these conditions with LC.

Post-Traumatic Central or Axial Atlantoaxial Dislocation Presenting with "Atypical" Symptoms-Analyzing the Role of Dynamic Imaging on the Basis of Experience with 14 Patients Treated by Atlantoaxial Fixation surgery

BACKGROUND

This is a report of a series of 14 patients who presented with a range of "atypical" cranial, spinal, and systemic symptoms that started after they suffered a relatively severe injury to the head and/or neck several months or years before surgical treatment. The implications of diagnosing and treating central or axial atlantoaxial dislocation (CAAD) is discussed. Also, the role of dynamic rotatory and lateral head tilt imaging in the diagnosis and treatment is analyzed.

METHODS

Of the 14 patients, 7 were men and 7 were women, with an age range of 21-64 years (average, 42 years). Due to the severity of the presenting neurological and non-neurological symptoms, all the patients had lost their occupation and were heavily dependent on painkillers and/or antidepressant drugs. In addition to other characteristic clinical and radiological evidence, CAAD was diagnosed made based on the facet alignments on lateral profile imaging in the neutral head position. Dynamic head flexion-extension, lateral head tilt, and neck rotation imaging findings confirmed and subclassified CAAD. All 14 patients underwent atlantoaxial fixation surgery.

RESULT

A personalized self-assessment clinical scoring parameter and the World Health Organization Disability Assessment Schedule 2.0 was used to evaluate the outcome. One patient did not follow-up after surgery. At a minimum follow-up of 6 months after atlantoaxial fixation surgery, the remaining 13 patients experienced relief from all major symptoms.

CONCLUSIONS

Diagnosing and treating CAAD can have major therapeutic implications for patients presenting with progressively worsening disabling clinical symptoms following relatively severe head and/or neck trauma.

Post-Acute Sequelae of SARS-CoV-2 Infection and Its Impact on Adolescents and Young Adults

This review discusses the varying definitions for post-acute sequelae of SARS CoV-2 infection (PASC) in adolescents and young adults (AYAs), symptom profiles of AYAs with PASC, and assessment and management strategies when AYAs present with symptoms concerning for PASC. Additionally, it reviews the impact that PASC can have on AYAs and includes strategies for providers to support AYAs with PASC. Finally, it concludes with a discussion around equity in the care of AYAs with possible PASC.

Atlantoaxial Instability in the Course of Rheumatoid Arthritis in Relation to Selected Parameters of Sagittal Balance

Background: Atlantoaxial instability is the most common cervical instability in patients with rheumatoid arthritis (RA). Its course may differ in different patients and may have different degrees of severity and symptoms. Methods: There are a number of studies on systemic factors associated with the development of this instability, but there are few publications in the scientific literature on the influence of biomechanical factors on the development of cervical instability. One of the areas that allows the study of biomechanical factors influencing spine pathologies is the analysis of sagittal balance using radiological parameters. The study of radiological parameters of sagittal balance has contributed to understanding the pathology of selected spine diseases and is currently an indispensable tool in planning surgical treatment. Results: The presented study, conducted on a group of RA patients with cervical instability, was performed to look for a relationship between C1-C2 instability and sagittal balance parameters. Conclusions: Among the examined selected parameters, a statistically relationship between C1-C2 instability and the Cobb angle C1-C7 and OD-HA parameters has been found. This confirms the need for further in-depth research on this areas.

Treating pain in patients with Ehlers-Danlos syndrome : Multidisciplinary management of a multisystemic disease

BACKGROUND

The clinical picture of people with Ehlers-Danlos syndromes (EDS) is complex and involves a variety of potential causes of pain. This poses major challenges to patients and healthcare professionals alike in terms of diagnosis and management of the condition.

OBJECTIVES

The aim of the article was to provide an overview of the specific pain management needs of patients with EDS and address their background.

MATERIAL AND METHODS

A selective literature search was performed to highlight the current state of research on pain management in EDS patients.

RESULTS

Affected patients require multimodal pain management considering their individual needs, disease-specific features, and comorbidities.

CONCLUSION

Medical awareness and evidence need to be further improved to enhance the medical care situation of these patients with complex needs.

Craniocervical instability in patients with Ehlers-Danlos syndromes: outcomes analysis following occipito-cervical fusion

Craniocervical instability (CCI) is increasingly recognized in hereditary disorders of connective tissue and in some patients following suboccipital decompression for Chiari malformation (CMI) or low-lying cerebellar tonsils (LLCT). CCI is characterized by severe headache and neck pain, cervical medullary syndrome, lower cranial nerve deficits, myelopathy, and radiological metrics, for which occipital cervical fusion (OCF) has been advocated. We conducted a retrospective analysis of patients with CCI and Ehlers-Danlos syndrome (EDS) to determine whether the surgical outcomes supported the criteria by which patients were selected for OCF. Fifty-three consecutive subjects diagnosed with EDS, who presented with severe head and neck pain, lower cranial nerve deficits, cervical medullary syndrome, myelopathy, and radiologic findings of CCI, underwent open reduction, stabilization, and OCF. Thirty-two of these patients underwent suboccipital decompression for obstruction of cerebral spinal fluid flow. Questionnaire data and clinical findings were abstracted by a research nurse. Follow-up questionnaires were administered at 5-28 months (mean 15.1). The study group demonstrated significant improvement in headache and neck pain (p < 0.001), decreased use of pain medication (p < 0.0001), and improved Karnofsky Performance Status score (p < 0.001). Statistically significant improvement was also demonstrated for nausea, syncope (p < 0.001), speech difficulties, concentration, vertigo, dizziness, numbness, arm weakness, and fatigue (p = 0.001). The mental fatigue score and orthostatic grading score were improved (p < 0.01). There was no difference in pain improvement between patients with CMI/LLCT and those without. This outcomes analysis of patients with disabling CCI in the setting of EDS demonstrated significant benefits of OCF. The results support the reasonableness of the selection criteria for OCF. We advocate for a multi-center, prospective clinical trial of OCF in this population.

Case report: Recurrent cervical spinal stenosis masquerading as myalgic encephalomyelitis/chronic fatigue syndrome with orthostatic intolerance

Introduction

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex, chronic, multi-system disorder that is characterized by a substantial impairment in the activities that were well tolerated before the illness. In an earlier report, we had described three adult women who met criteria for ME/CFS and orthostatic intolerance, and had congenital or acquired cervical spinal stenosis. All three experienced substantial global improvements in their ME/CFS and orthostatic intolerance symptoms after recognition and surgical treatment of the cervical stenosis. After a several year period of improvement, one of the individuals in that series experienced a return of ME/CFS and orthostatic intolerance symptoms.

Main symptoms and clinical findings

Radiologic investigation confirmed a recurrence of the ventral compression of the spinal cord due to a shift of the disc replacement implant at the involved cervical spinal level.

Therapeutic intervention

Decompression of the spinal cord with removal of the implant and fusion at the original C5-C6 level was once again followed by a similar degree of improvement in function as had been observed after the first operation.

Conclusion

This recapitulation of the outcomes after surgical management of cervical stenosis provides further evidence in support of the hypothesis that cervical spinal stenosis can exacerbate pre-existing or cause new orthostatic intolerance and ME/CFS. Especially for those with refractory symptoms and neurological signs, surgical interventions may offer relief for selected patients with this complex condition.

A Case Study of Successful Application of the Principles of ME/CFS Care to an Individual with Long COVID

Persistent fatigue is one of the most common symptoms of post-COVID conditions, also termed long COVID. At the extreme end of the severity spectrum, some individuals with long COVID also meet the criteria for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), raising the possibility that symptom management approaches for ME/CFS may benefit some long COVID patients. We describe the long-term outcomes of a 19-year-old male who developed profound impairment consistent with ME/CFS after a SARS-CoV-2 infection early in the pandemic. We evaluated and treated him using our clinic’s approach to ME/CFS. This included a history and physical examination that ascertained joint hypermobility, pathological reflexes, physical therapy maneuvers to look for a range of motion restrictions in the limbs and spine, orthostatic testing, and screening laboratory studies. He was found to have profound postural tachycardia syndrome, several ranges of motion restrictions, and mast cell activation syndrome. He was treated according to our clinic’s guidelines for managing ME/CFS, which included manual physical therapy maneuvers and both non-pharmacologic measures and medications directed at postural tachycardia syndrome and mast cell activation. He experienced significant improvement in his symptoms over 30 months. His case emphasizes how the application of the principles of treating ME/CFS has the potential to provide a direction for treating long COVID.

Posterior cervical spinal fusion in the pediatric population using modern adult instrumentation - clinical outcome and safety

PURPOSE

Traditionally, less rigid fixation techniques have been applied to the pediatric cervical spine. There is a lack of long-term outcome data for rigid fixation techniques. The purpose of this study was to define the clinical outcome and safety of posterior instrumented fusion in the pediatric population using adult posterior instrumentation.

METHODS

A multicenter, retrospective review of pediatric patients who underwent posterior cervical fusion using a 3.5 mm posterior cervical system for any indication was performed. Outcome parameters included complications, revision and fusion rates, operative time (OR), blood loss, and postoperative neurologic status. Outcomes were compared between patient groups (posterior only versus anterior/posterior approach, short versus intermediate versus long fusion, and between different etiologies) using Mann-Whitney and chi-square test.

RESULTS

Seventy-nine patients with a mean age of 9.9 years and mean follow-up of 2.8 years were included. At baseline 44 (56%) had an abnormal neurologic exam. Congenital deformities and basilar invagination were the most common indications for surgery. Posterior-only surgery was performed in 71 (90%) cases; mean number of levels fused was 4 (range 1-15). Overall, 4 (5%) operative complications and 4 (5%) revisions were reported at an average postoperative time of 2.6 years. Neurologic status remained unchanged in 74%, improved in 23%, and worsened in 3%. When comparing outcome measures between the various groups, 2 significant differences were found: OR was longer in the anterior/posterior approach group and decline of neuro status was more frequent in the long fusion group.

CONCLUSION

Posterior cervical fusion with an adult 3.5 mm posterior cervical system was safe in this cohort of 79 pediatric patients irrespective of surgical technique, fusion length, and etiology, resulting in a high fusion and low complication/revision rate.

Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations

Experts in symptomatic generalized joint hypermobility (S-GJH) agree that upper cervical instability (UCI) needs to be better recognized in S-GJH, which commonly presents in the clinic as generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome. While mild UCI may be common, it can still be impactful; though considerably less common, severe UCI can potentially be debilitating. UCI includes both atlanto-occipital and atlantoaxial instability. In the absence of research or published literature describing validated tests or prediction rules, it is not clear what signs and symptoms are most important for diagnosis of UCI. Similarly, healthcare providers lack agreed-upon ways to screen and classify different types or severity of UCI and how to manage UCI in this population. Consequently, recognition and management of UCI in this population has likely been inconsistent and not based on the knowledge and skills of the most experienced clinicians. The current work represents efforts of an international team of physical/physiotherapy clinicians and a S-GJH expert rheumatologist to develop expert consensus recommendations for screening, assessing, and managing patients with UCI associated with S-GJH. Hopefully these recommendations can improve overall recognition and care for this population by combining expertise from physical/physiotherapy clinicians and researchers spanning three continents. These recommendations may also stimulate more research into recognition and conservative care for this complex condition.

Central Atlantoaxial Dislocation: Presenting Symptoms, Diagnostic Parameters, and Surgical Treatment from Reports on 15 Surgically Treated Patients

AIM

This chapter reviews the clinical entity of central or axial atlantoaxial instability (CAAD).

MATERIAL AND METHODS

From January 2018 to November 2020, 15 patients were identified as having CAAD, wherein there was no atlantoaxial instability when analyzed by conventional radiological parameters and wherein there was no evidence of neural or dural compression due to the odontoid process. The patients were identified as having atlantoaxial instability on the basis of the alignment of facets on lateral profile imaging and a range of telltale clinical and radiological indicators. The clinical statuses of the patients were recorded both before and after surgical treatment by using the specially designed Goel symptom severity index and visual analog scale (VAS) scores. All patients were treated via atlantoaxial fixation.

RESULTS

There were six men and nine women ranging in age from 18 to 45 years (average: 37 years). The presenting clinical symptoms were relatively subtle and long-standing. Apart from symptoms that are generally related to neural compromise at the craniovertebral junction, a range of nonspecific cranial and spinal symptoms were prominent. The follow-up time after surgery ranged from 6 to 34 months. All patients showed early postoperative and sustained clinical recovery.

CONCLUSIONS

The correct diagnosis and appropriate surgical treatment of CAAD can provide an opportunity for quick and lasting clinical recovery.

Neurosurgical management of patients with Ehlers-Danlos syndrome: A descriptive case series

Introduction

Ehlers-Danlos syndrome (EDS) is a connective tissue disorder that has been linked to several neurological problems including Chiari malformations, atlantoaxial instability (AAI), craniocervical instability (CCI), and tethered cord syndrome. However, neurosurgical management strategies for this unique population have not been well-explored to date. The purpose of this study is to explore cases of EDS patients who required neurosurgical intervention to better characterize the neurological conditions they face and to better understand how neurosurgeons should approach the management of these patients.

Methods

A retrospective review was done on all patients with a diagnosis of EDS who underwent a neurosurgical operation with the senior author (FAS) between January 2014 and December 2020. Demographic, clinical, operative, and outcome data were collected, with additional radiographic data collected on patients chosen as case illustrations.

Results

Sixty-seven patients were identified who met the criteria for this study. The patients experienced a wide array of preoperative diagnoses, with Chiari malformation, AAI, CCI, and tethered cord syndrome representing the majority. The patients underwent a heterogeneous group of operations with the majority including a combination of the following procedures- suboccipital craniectomy, occipitocervical fusion, cervical fusion, odontoidectomy, and tethered cord release. The vast majority of patients experienced subjective symptomatic relief from their series of procedures.

Conclusions

EDS patients are prone to instability, especially in the occipital-cervical region, which may predispose these patients to require a higher rate of revision procedures and may require modifications in neurosurgical management that should be further explored.

Craniocervical Instability in Ehlers-Danlos Syndrome-A Systematic Review of Diagnostic and Surgical Treatment Criteria

STUDY DESIGN

Systematic review.

OBJECTIVE

Ehlers-Danlos Syndrome (EDS) comprises a spectrum of connective tissue disorders, which may be associated with cranio-cervical instability (CCI). There is a lack of consensus on diagnostic imaging parameters, indications, and outcomes of surgical treatment.

METHODS

This systematic review analyses the literature on diagnostic methods and/or criteria for CCI, screening the databases Ovid Medline, Embase, Cochrane Library, and PubMed. Articles were included based on the PRISMA guidelines and assessed using the Newcastle-Ottawa Quality Assessment Scale (NOS) and according to their evidence level.

RESULTS

Sixteen articles, including 78 surgical patients, met the inclusion criteria. The main diagnostic measures for CCI were dynamic x-rays and CT imaging. Ten different radiographic parameters were reported, of which 4 were the most frequently applied for surgical decision-making: the clivo-axial angle (CXA), the Harris measurement, the Grabb-Mapstone-Oakes measurement, and the angular displacement of C1 to C2. The evidence level ranged between III and V and the article quality between 4 and 8 out of 9 stars on the NOS Scale.

CONCLUSIONS

There is a lack of high quality, prospective evidence regarding the evaluation of suspected CCI in patients with EDS. Based on our systematic review, we recommend that the CXA, Harris measurement, Grabb-Mapstone-Oakes measurement, and the angular displacement of C1 to C2 be used to evaluate suspected CCI in EDS patients. Surgical fixation of suspected CCI should only be performed in cases with clear radiographic presence of instability and concordant symptoms/signs. Consensus-based guidelines and care pathways are required.