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Baisden JL, Varghese V, Banerjee A, Yoganandan N. Regional variations in C1-C2 bone density on quantitated computed tomography and clinical implications. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 14:100228. [PMID: 37440985 PMCID: PMC10333715 DOI: 10.1016/j.xnsj.2023.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 07/15/2023]
Abstract
Background Our elderly population is growing and the number of spine fractures in the elderly is also growing. The elderly population in general may be considered as poor surgical candidates experience a high rate of fractures at C1 and C2 compared with the general population. Nonoperative management of upper cervical fractures is not benign as there is a high nonunion rate for both C1 and C2 fractures in the elderly, and orthosis compliance is often suboptimal, or complicated by skin breakdown. The optimal technique for upper cervical stabilization in the elderly may be different than in younger populations as the bone quality is inferior in the elderly. The objective of this basic science study is to determine whether the bone mineral density (BMD) of C1 and C2 vary by region, and if this is a gender difference in this elderly age group. Methods Twenty cadaveric spines from 45 to 83 years of age were used to obtain BMD using quantitated computed tomography (QCT). BMD was measured using a QCT. For C1, 8 regions were determined: anterior tubercle, bilateral anterior and medial lateral masses, bilateral posterior arches, and posterior tubercle. For C2, 7 regional BMDs were determined: top of odontoid, base of odontoid-body interface, mid body, bilateral lateral masses, anterior inferior body near the discs space, and the C2 spinous process. Results The BMD was greatest at the C1 anterior tubercle (564.4±175.8 mg/cm3) and C1 posterior ring (420.8±110.2 mg/cm3), and least at the anterior and medial lateral masses (262.8±59.5 mg/cm3, 316.9±72.6 mg/cm3). At C2 QCT BMD was greatest at the top of the dens (400.6±107.9 mg/cm3) decreasing down through the odontoid-C2 body junction (267.8±103.5 mg/cm3) and least in the mid C2 body 249.1±68.8 mg/cm3). The posterior arch of C1 and the spinous process of C2 had higher BMD's 420.8±110.2 mg/cm3 and 284.1±93.0 mg/cm3, respectively. A high correlation was observed between the BMD at the interface of the dens-vertebral body with the vertebral body with a Pearson correlation coefficient of 0.86. The BMD of the top of dens was significantly higher (p<.05) than all the regions in C2. Conclusions Regional and segmental BMD variations at C1 and C2 have clinical implications for surgical constructs in the elderly population. Given the higher BMDs of the C1 and C2 spinous process and posterior arches, consideration should be given to incorporate these areas using various C1-C2 wiring techniques. In the elderly, lateral masses particularly at C1 with lower BMD may result in potential screw loosening and nonunion in this age group. Old-school wiring techniques have a track record of efficacy and safety with less blood loss, reduced operative time, reduced X-ray exposure, and should be considered in the elderly as a primary stabilization technique or a belt-over suspenders approach based on regional variations in BMD in the elderly.
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Affiliation(s)
- Jamie L Baisden
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, United States
| | - Vicky Varghese
- Department of Orthopedics, Skokie Hospital, NorthShore University Health System, 9600 Gross Point Rd, Skokie, IL 60076, United States
| | - Anjishnu Banerjee
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Narayan Yoganandan
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, United States
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Chen J, Cen J, Ma T, Du Y, Liang T, Liao S, Yu C, Sun X, Li J, Jiang J, Chen T, Li H, Chen W, Ye Z, Yao Y, Guo H, Zhan X, Liu C. Feasibility of 3.5mm C2 pedicle screws in children: Part II, a computerized tomography analysis. Clin Anat 2022; 35:347-353. [PMID: 35088448 DOI: 10.1002/ca.23837] [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: 11/25/2021] [Revised: 12/21/2021] [Accepted: 01/21/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There have been no studies with large sample sizes on growth of the pedicle of C2 in children. In the present study we measured the pedicle of C2 through computed tomography (CT) imaging in children aged less than 14 years and evaluated the suitability of the 3.5-mm screw for the pedicle in such children. METHODS The study was conducted on CT morphometric images of 420 children in our hospital between June 2018 and June 2020. The width (D1), length (D2), height (D3), inclination angle (α), and tail angle (β) of the C2 pedicle were measured. One-way analysis of variance and Student's t test were used for statistical analyses. The least-square method was used to analyze the curve fitting the trend of anatomical change in the pedicle. The largest degree of goodness of fit determined the best-fitting curve. RESULTS The size of the pedicle of C2 increased with age. The median ranges of D1, D2, D3, α, and β were 3.312-5.431 mm, 11.732-23.645 mm, 3.597-8.038 mm, 32.583°-36.640°, and 24.867°-31.567°, respectively. The curves fitting the trends of D1 and D3 were power functions, whereas D2 was fitted by a logarithmic curve. However, no curve fitted α or β. CONCLUSION A 3.5-mm screw can be placed in the pedicle of C2 in children aged more than one year. The growth and development trend of this pedicle can provide an anatomical reference for deciding on posterior cervical surgery and for selecting and designing pedicle screws for children.
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Affiliation(s)
- Jiarui Chen
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Jiemei Cen
- Respiratory Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Teng Ma
- First Clinical Medical College, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Yuwang Du
- First Clinical Medical College, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Tuo Liang
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Shian Liao
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Chaojie Yu
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Xuhua Sun
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Jiakun Li
- Spine Ward, Yulin Orthopedic Hospital of Integrated Traditional Chinese and Western Medicine
| | - Jie Jiang
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Tianyou Chen
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Hao Li
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Wuhua Chen
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Zhen Ye
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Yuanlin Yao
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Hao Guo
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Xinli Zhan
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Chong Liu
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
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Vakharia VN, Smith L, Tahir Z, Sparks R, Ourselin S, Tucker S, Thompson D. Occipitocervical instrumented fixation utilising patient-specific C2 3D-printed spinal screw trajectory guides in complex paediatric skeletal dysplasia. Childs Nerv Syst 2021; 37:2643-2650. [PMID: 34148128 DOI: 10.1007/s00381-021-05260-2] [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: 05/11/2021] [Accepted: 06/09/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Instability of the craniocervical junction in paediatric patients with skeletal dysplasia poses a unique set of challenges including anatomical abnormalities, poor bone quality, skeletal immaturity and associated general anaesthetic risks. Instrumented fixation provides optimal stabilisation and fusion rates. The small vertebrae make the placement of C2 pedicle screws technically demanding with low margins of error between the spinal canal and the vertebral artery. METHODS We describe a novel clinical strategy utilising 3D-printed spinal screw trajectory guides (3D-SSTG) for individually planned C2 pedicle and laminar screws. The technique is based on a pre-operative CT scan and does not require intraoperative CT imaging. This reduces the radiation burden to the patient and forgoes the associated time and cost. The time for model generation and sterilisation was < 24 h. RESULTS We describe two patients (3 and 6 years old) requiring occipitocervical instrumented fixation for cervical myelopathy secondary to Morquio syndrome with 3D-SSTGs. In the second case, bilateral laminar screw trajectories were also incorporated into the same guide due to the presence of high-riding vertebral arteries. Registration of the postoperative CT to the pre-operative imaging revealed that screws were optimally placed and accurately followed the predefined trajectory. CONCLUSION To our knowledge, we present the first clinical report of 3D-printed spinal screw trajectory guides at the craniocervical junction in paediatric patients with skeletal dysplasia. The novel combination of multiple trajectories within the same guide provides the intraoperative flexibility of potential bailout options. Future studies will better define the potential of this technology to optimise personalised non-standard screw trajectories.
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Affiliation(s)
- Vejay N Vakharia
- Department of Neurosurgery, Great Ormond Street Hospital, UCL Great Ormond Street Institute of Child Health, London, UK. .,Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK.
| | - Luke Smith
- Department of Neurosurgery, Great Ormond Street Hospital, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Zubair Tahir
- Department of Neurosurgery, Great Ormond Street Hospital, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rachel Sparks
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, London, UK
| | - Sebastien Ourselin
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, London, UK
| | - Stewart Tucker
- Department of Neurosurgery, Great Ormond Street Hospital, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital, UCL Great Ormond Street Institute of Child Health, London, UK
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Klepinowski T, Limanówka B, Sagan L. Management of post-traumatic craniovertebral junction dislocation: A PRISMA-compliant systematic review and meta-analysis of casereports. Neurosurg Rev 2020; 44:1391-1400. [PMID: 32797319 PMCID: PMC8121741 DOI: 10.1007/s10143-020-01366-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 12/23/2022]
Abstract
Although historically considered fatal, with the advent of improved pre-hospital care, traumatic dislocation of the craniovertebral junction (CVJ) has been increasing in prevalence in neurosurgical centers. As more survivors are reported each year, a timely review with meta-analysis of their management seems necessary. PRISMA checklist was followed step by step. PubMed and Web of Science databases were searched using words “craniovertebral junction dislocation” and their corresponding synonyms. Study eligibility criteria included research studies from 2015 onwards that delineated adult and pediatric patients with confirmed post-traumatic atlantooccipital dislocation (AOD) or atlantoaxial dislocation (AAD) who survived until proper treatment. Of 1475 initial records, 46 articles met eligibility criteria with a total of 141 patients with traumatic CVJ dislocation. Of the patients, 90 were male (63.8%). Mean age of the cohort was 33.3 years (range 1–99 years). Trauma that most often led to this injury was road traffic accident (70.9%) followed by falls (24.6%). The majority of authors support posterior instrumentation of C1-C2 (45.2%) especially by means of Goel-Harms method. At mean follow-up of 15.4 months (range 0.5–60 months), 27.2% of treated patients remained neurologically intact. Of initially symptomatic, 59% improved, 37% were stable, and 4% deteriorated. Instrumenting the occiput in cases of pure AAD was associated with lower chance of neurological improvement in chi-square test (p = 0.0013) as well as in multiple linear regression (β = − 0.3; p = 0.023). The Goel-Harms C1-C2 fusion is currently the most frequently employed treatment. Many survivors remain with no deficits or improve, rarely deteriorate. Involving the occiput in stabilization in cases of AAD without AOD might be related with worse neurological prognosis.
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Affiliation(s)
- Tomasz Klepinowski
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland.
| | - Bartosz Limanówka
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Leszek Sagan
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
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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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Florman JE, Cushing DA, England EC, White E. How to Transect the C2 Root for C1 Lateral Mass Screw Placement: Case Series and Review of an Underappreciated Variable in Outcome. World Neurosurg 2019; 127:e1210-e1214. [PMID: 31004854 DOI: 10.1016/j.wneu.2019.04.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The techniques for atlantoaxial arthrodesis have been modified over the years, and placing C1 lateral mass screws is a modern approach. C2 neuropathy is a complication of concern; however, sacrifice of the C2 nerve is an accepted and often favored adjunct. The impact of the technique for cutting the C2 nerve is not adequately addressed in the literature. The aim of this study was to evaluate the clinical outcomes from a series of roots sacrificed during C1-2 fusion with attention to the C2 transection method. METHODS Clinical data were collected from trauma patients who underwent C1 screw fixation for atlantoaxial fusion. Chart review was performed and outcome assessed through telephone surveys to patients who were at least 6 months postoperative. Quality of life, C2 nerve function, neck pain, and head pain were assessed. RESULTS Sixty-six roots were divided in 35 patients. There were no cases of occipital neuralgia at routine 3-month follow-up. Delayed telephone surveys were completed in 17 patients and exposed 4 cases of severe head/neck pain but none consistent with occipital neuralgia. CONCLUSIONS C2 neuralgia is rare when sharply dividing the C2 root with the aid of bipolar electrocautery at the midportion of the ganglion where it overlies the C1-2 joint. A literature review suggests the impact of the root sacrifice method is an underappreciated modifiable factor in outcome. In future reports, description of the root transection technique is imperative and trials comparing ganglionectomy versus transection proximal to the ganglion or through the ganglion should be considered.
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Affiliation(s)
- Jeffrey E Florman
- Department of Neurosurgery, Maine Medical Center, Portland, Maine, USA.
| | - Deborah A Cushing
- Department of Neurosurgery, Maine Medical Center, Portland, Maine, USA
| | - Emma C England
- Department of Neurosurgery, Maine Medical Center, Portland, Maine, USA
| | - Elbert White
- Department of Neurosurgery, Maine Medical Center, Portland, Maine, USA
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