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Richards O, Saeed F, Derham C, Tyagi A. Craniocervical fusion in the paediatric population - case series of 21 patients. Br J Neurosurg 2024; 38:116-121. [PMID: 36722455 DOI: 10.1080/02688697.2023.2170329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 01/15/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE Craniocervical junction instability in a paediatric population presents a formidable challenge to the neurosurgeon. With a variety of anatomical variations, diminutive bony and ligamentous structures, possible superimposed syndromic abnormalities, the craniocervical junction is a technically challenging region to operate within. We aimed to review our series of patients to identify the common pathologies necessitating craniocervical fusion along with the use of intraoperative image guidance. METHODS We performed a retrospective review of twenty-one patients, with a mean age of 8.1 years, undergoing craniocervical fixations, involving either occipitocervical fusion or atlantoaxial fixation, from a single institution over a twelve-year period. The presentation, preoperative investigations, indication for surgery, surgical procedure, use of intraoperative navigation and clinical and radiological results were examined. RESULTS Twelve patients underwent primary C1-2 fixation, with the remaining 9 undergoing occipitocervical fusion. Five patients underwent surgery for traumatic instability, seven for os odontoideum, six for congenital anomalies and three for post-infectious instability. Follow up for 20 patients averaged 34 months (range 2-93 months). Five patients had Trisomy 21 and all underwent C1-2 fixation. Frameless stereotactic image guidance was utilised in five patients. No patients suffered immediate complications resulting from craniocervical junction fusion. Patients were observed to either neurologically improve (n = 6), or arrest their neurological deterioration following surgical intervention (n = 14), with concomitant radiological evidence of osseous fusion at follow up in 18 of 20 patients (90%). Two patients (10%) had radiological evidence of screw lucency, but neither required intervention because of being asymptomatic. CONCLUSIONS Craniocervical fixation in a paediatric population is a viable and safe treatment modality for the management of disorders requiring stabilisation at the craniocervical junction. Our experience of utilising frameless stereotaxy in the setting of grossly distorted anatomical landmarks is also reported.
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Affiliation(s)
- Oliver Richards
- Department of Neurosurgery, The Children's Hospital at The General Infirmary at Leeds, Leeds, United Kingdom
| | - Fozia Saeed
- Department of Neurosurgery, The Children's Hospital at The General Infirmary at Leeds, Leeds, United Kingdom
| | - Christopher Derham
- Department of Neurosurgery, The Children's Hospital at The General Infirmary at Leeds, Leeds, United Kingdom
| | - Atul Tyagi
- Department of Neurosurgery, The Children's Hospital at The General Infirmary at Leeds, Leeds, United Kingdom
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Wada K, Mori S, Shimamoto S, Inoue T, Tamaki R, Okazaki K. Surgical outcomes of intraoperative O-arm versus C-arm fluoroscopy in occipitocervical fixation: a retrospective analysis. Br J Neurosurg 2023:1-6. [PMID: 38146209 DOI: 10.1080/02688697.2023.2297879] [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: 09/04/2023] [Accepted: 12/16/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE This study aims to compare the effect of using O-arm and C-arm fluoroscopy on the surgical outcomes of occipitocervical fixation. METHODS The study included patients who underwent occipitocervical fixation using O-arm or C-arm between 2005 and 2021. Of 56 patients, 34 underwent O-arm-assisted surgery (O-group) and 22 underwent C-arm-assisted surgery (C-group). We assessed surgical outcomes, including operative time, intraoperative blood loss, perioperative complications, and bone union. RESULTS Almost half of the patients had rheumatoid arthritis-related disorders in both groups. Sixteen cases (47.1%) in the O-group and 12 cases (54.5%) in the C-group were fixed from occipito (Oc) to C3, 12 cases (38.2%) in the O-group and 7 cases (31.8%) in the C-group from Oc to C4-7, 5 cases (14.7%) in the O-group, and 3 cases (13.6%) in the C-group from Oc to T2 (p = 0.929). There was no significant difference in operative time (p = 0.239) and intraoperative blood loss (p = 0.595) between the two groups. Dysphagia was the most common complication in both groups (O-group vs. C-group, 11.7% vs. 9.1%). Regarding implant-related complications, occipital plate dislodgement was observed in four cases (18.2%) in the C-group (p = 0.02). The bone union rate was 96.3% in the O-group and 93.3% in the C-group (P = 1). CONCLUSIONS O-arm use is associated with a reduced rate of occipital plate dislodgment and has a similar complication incidence compared with C-arm-assisted surgery and does not prolong operative time despite the time needed for setting and scanning. Accordingly, an O-arm is safe and useful for occipitocervical fixation surgery.
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Affiliation(s)
| | | | - Shuji Shimamoto
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomohisa Inoue
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Ryo Tamaki
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Ken Okazaki
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
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Reyes Soto G, Ovalle Torres CS, Perez Terrazas J, Honda Partida K, Rosario Rosario A, Campero A, Baldoncini M, Ramirez MDJE, Montemurro N. Multiple Myeloma Treatment Challenges: A Case Report of Vertebral Artery Pseudoaneurysm Complicating Occipitocervical Arthrodesis and a Review of the Literature. Cureus 2023; 15:e49716. [PMID: 38161862 PMCID: PMC10757504 DOI: 10.7759/cureus.49716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Multiple myeloma is a hematological neoplasm that frequently affects the spinal column. Less than a fifth of this vertebral involvement corresponds to the cervical spine and cranio-cervical junction. When there is instability or neurological involvement due to compression or deformity, approaches for anterior decompression and occipitocervical stabilization are required. The correct managment of vertebral artery aneurysm associated with occipitocervical arthrodesis requires extensive knowledge of anatomy and pathology. We present a case of a vertebral pseudoaneurysm that occurred late after the resection of a C1-C2 vertebral body multiple myeloma lesion managed with endonasal endoscopic approach and posterior occipitocervical arthrodesis as well as a systematic review of the related literature. The patient recovered well, without major neurological deficits.
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Affiliation(s)
- Gervith Reyes Soto
- Neuroscience Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, MEX
| | | | - Jorge Perez Terrazas
- Spine Surgery, National Autonomous University of Mexico (UNAM) Hospital General de Mexico, Mexico City, MEX
| | - Kaori Honda Partida
- Spine Surgery, National Autonomous University of Mexico (UNAM) Hospital General de Mexico, Mexico City, MEX
| | | | | | - Matias Baldoncini
- Neurosurgery, School of Medicine, University of Buenos Aires, Buenos Aires, ARG
- Neurosurgery, San Fernando Hospital, Buenos Aires, ARG
| | | | - Nicola Montemurro
- Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP) University of Pisa, Pisa, ITA
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Nagashima Y, Nishimura Y, Awaya T, Hata N, Tanei T, Ishii M, Oyama T, Nishii T, Fukaya N, Abe T, Kato H, Saito R. Radiographic Prediction of the Occipito-C2 Angle Variation with Changes in Distance between the Mandible and Cervical Vertebrae: A Preliminary Study. Neurol Med Chir (Tokyo) 2023; 63:200-205. [PMID: 37045771 PMCID: PMC10241534 DOI: 10.2176/jns-nmc.2022-0251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/21/2022] [Indexed: 04/14/2023] Open
Abstract
The Occipito (O) -C2 angle reflects the correct craniocervical spine alignment; however, the poor image quality of standard intraoperative fluoroscopy at times lead to inaccurate measurements. Herein, we preliminarily investigated the relationship between the O-C2 angle and the Gonion-C2 distance, which is based on the positioning of the mandible and the cervical spine. We enrolled patients who underwent cervical spine radiography in neutral, flexion, and extension positions from January 2020 to October 2020. The difference by posture changes for each parameter was defined as the Δ value, and the Spearman's rank correlation coefficient was determined. Furthermore, we determined the cutoff value of the ΔGonion-C2 distance to predict a decrease of > 10° in the ΔO-C2 angle, which is reported to be related to dysphagia and dyspnea. Seventy-four patients were included. Spearman's rank correlations for the neutral, flexion, and extension positions were 0.630 (P < 0.001), 0.471 (P < 0.001), and 0.625 (P < 0.001), respectively, while the cutoff values of the ΔGonion-C2 distance for predicting > 10° in the ΔO-C2 angle were 9.3 mm for the neutral flexion change (sensitivity: 0.435, specificity: 0.882) and 8.3 mm for the extension-neutral change (sensitivity: 0.712, specificity: 0.909). The O-C2 angle and Gonion-C2 distances correlated; however, this correlation was weaker in the flexed position. Nevertheless, the ΔGonion-C2 distance can be used as a warning sign for postoperative complications after posterior occipital bone fusion surgery, because a decrease of > 10° in the ΔO-C2 angle can be predicted with high specificity.
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Affiliation(s)
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | | | | | - Takafumi Tanei
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Motonori Ishii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Takahiro Oyama
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Tomoya Nishii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Nobuhisa Fukaya
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Takashi Abe
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Hiroyuki Kato
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
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Mao G, Kopparapu S, Jin Y, Davidar AD, Hersh AM, Weber-Levine C, Theodore N. Craniocervical instability in patients with Ehlers-Danlos syndrome: controversies in diagnosis and management. Spine J 2022; 22:1944-1952. [PMID: 36028216 DOI: 10.1016/j.spinee.2022.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population.
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Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Srujan Kopparapu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Yike Jin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.
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Muacevic A, Adler JR, Patel J, Jenson M, Rao D. Interrelationship Between Craniocervical Dissociation Spectrum Injuries and Atlantoaxial Instability on Trauma Cervical MRI Examinations. Cureus 2022; 14:e31238. [PMID: 36514650 PMCID: PMC9733797 DOI: 10.7759/cureus.31238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/08/2022] [Indexed: 11/09/2022] Open
Abstract
Background and purpose Craniocervical dissociation injuries encompass a spectrum of osteoligamentous injuries between the skull base and C1-C2 that may be treated via prolonged external immobilization versus occipital cervical fusion depending on the risk of persistent craniocervical instability. However, the presence of atlantoaxial instability (AAI) at C1-C2, as determined by transverse atlantal ligament (TAL) integrity with or without a C1 fracture, may guide the neurosurgical management of craniocervical dissociation spectrum injuries (CDSI) since it implies an overall greater degree of instability at the craniocervical junction (CCJ). Materials and methods Adult trauma patients who suffered a transverse atlantal ligament injury on cervical magnetic resonance imaging (MRI) were identified retrospectively. The cervical computed tomography (CT) and magnetic resonance imaging examinations for these patients were reviewed for additional traumatic findings. Demographic information, treatment, and outcome information were recorded. Results Twenty-nine trauma patients presented to the emergency department (ED) with an acute, midsubstance transverse atlantal ligament tear on cervical magnetic resonance imaging. Thirty-one percent of patients demonstrated a tear in at least one major craniocervical ligament (atlanto-occipital capsular ligaments, alar ligaments, and tectorial membrane {TM}) with 14% demonstrating a tear in two major craniocervical ligaments and no patients demonstrating a tear in all three major craniocervical ligaments. Minor craniocervical ligament injuries (anterior atlanto-occipital membrane complex {AAOMc} and posterior atlanto-occipital membrane complex {PAOMc}) were common and observed in 76% of patients. Conclusions Our study suggests that multiple major craniocervical junction ligamentous injuries on cervical magnetic resonance imaging are relatively uncommon in the setting of transverse atlantal ligament injury.
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Nishikawa M, Bolognese PA, Yamagata T, Naito K, Sakamoto H, Hara M, Ohata K, Goto T. Surgical Management of Chiari Malformation Type I and Instability of the Craniocervical Junction Based on Its Pathogenesis and Classification. Neurol Med Chir (Tokyo) 2022; 62:400-415. [PMID: 36031349 PMCID: PMC9534572 DOI: 10.2176/jns-nmc.2022-0078] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We investigated the mechanism underlying Chiari malformation type I (CM-I) and classified it according to the morphometric analyses of posterior cranial fossa (PCF) and craniocervical junction (CCJ). Three independent subtypes of CM-I were confirmed (CM-I types A, B, and C) for 484 cases and 150 normal volunteers by multiple analyses. CM-I type A had normal volume of PCF (VPCF) and occipital bone size. Type B had normal VPCF and small volume of the area surrounding the foramen magnum (VAFM) and occipital bone size. Type C had small VPCF, VAFM, and occipital bone size. Morphometric analyses during craniocervical traction test demonstrated instability of CCJ. Foramen magnum decompression (FMD) was performed in 302 cases. Expansive suboccipital cranioplasty (ESCP) was performed in 102 cases. Craniocervical posterolateral fixation (CCF) was performed for CCJ instability in 70 cases. Both ESCP and FMD showed a high improvement rate of neurological symptoms and signs (84.4%) and a high recovery rate of the Japanese Orthopaedic Association (JOA) score (58.5%). CCF also showed a high recovery rate of the JOA score (69.7%), with successful joint stabilization (84.3%). CM-I type A was associated with other mechanisms that caused ptosis of the brainstem and cerebellum (CCJ instability and traction and pressure dissociation between the intracranial cavity and spinal canal cavity), whereas CM-I types B and C demonstrated underdevelopment of the occipital bone. For CM-I types B and C, PCF decompression should be performed, whereas for small VPCF, ESCP should be performed. CCF for CCJ instability (including CM-I type A) was safe and effective.
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Affiliation(s)
- Misao Nishikawa
- Department of Neurosurgery, Moriguchi-Ikuno Memorial Hospital
| | - Paolo A Bolognese
- Department of Neurosurgery, Chiari Ehlas Danlos Syndrome Center, Mount Sinai South Nassau, Lake Success
| | - Toru Yamagata
- Department of Neurosurgery, Moriguchi-Ikuno Memorial Hospital
| | - Kentarou Naito
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine
| | - Hiroaki Sakamoto
- Department of Pediatric Neurosurgery, Osaka City General Hospital
| | - Mistuhiro Hara
- Department of Neurosurgery, Moriguchi-Ikuno Memorial Hospital
| | - Kenji Ohata
- Department of Neurosurgery, Naniwa-Ikuno Hospital
| | - Takeo Goto
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine
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Surgical Management of Chiari Malformation Type I Associated with Syringomyelia: Outcome of Surgeries Based on the New Classification and Study of Cerebrospinal Fluid Dynamics. J Clin Med 2022; 11:jcm11154556. [PMID: 35956170 PMCID: PMC9369558 DOI: 10.3390/jcm11154556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: The mainstay of treatment of syringomyelia associated with Chiari malformation type I (CM-I) is the management of CM-I to normalize the cerebrospinal fluid (CSF) flow at the foramen magnum. CM-I is classified into three independent types. Surgical treatment was selected based on the mechanism of hindbrain ptosis in each CM-I type. Materials and Methods: Foramen magnum decompression (FMD: 213 cases), expansive suboccipital cranioplasty (ESCP: 87 cases), and craniocervical fixation (CCF: 30 cases) were performed. CSF flow dynamics were assessed pre- and post-surgery using cine phase contrast magnetic resonance imaging. During surgery, CSF flow dynamics were examined using color Doppler ultrasonography (CDU). Results: ESCP and FMD demonstrated high rates of improvement in neurological symptoms and signs (82.7%), whereas CCF demonstrated a high rate of improvement in neurological symptoms (89%). The pre-operative maximum flow velocity (cm/s) was significantly lower in patients than in controls and increased post-operatively. During surgery, CDU indicated that the volume of the major cistern was 8 mL, and the maximum flow velocity was >3 mL/s. Conclusions: An appropriate surgical treatment should be selected for CM-I to correct hindbrain ptosis. In addition, it is necessary to confirm the normalization of CSF flow at the foramen of Magendie.
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Moser M, Adl Amini D, Okano I, Oezel L, Shue J, Carrino JA, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Trabecular volumetric bone mineral density of the occipital bone at preferred screw placement sites measured by quantitative computed tomography. J Orthop Res 2022; 40:1909-1917. [PMID: 34862648 DOI: 10.1002/jor.25224] [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: 07/27/2021] [Revised: 10/13/2021] [Accepted: 11/20/2021] [Indexed: 02/04/2023]
Abstract
This study aimed at quantifying trabecular volumetric bone mineral density (vBMD) at the external occipital protuberance (EOP) and the upper cervical spine. A retrospective review of patients who underwent non-contrast enhanced computed tomography of the cervical spine that included the occipital bone up to the EOP between 2007 and 2020 was conducted. Measurements of trabecular vBMD were performed in the occipital midline area, with the region of interest extending 4.5 mm above and below the center of the EOP, as well as the C1 lateral masses and the C2 vertebral body using asynchronous quantitative computed tomography. Eighty-six patients (female, 37.2%) were included for analysis. The patient population was 81.4% Caucasian with a mean ± SD age of 62.3 ± 13.1 years. Total bone thickness at the EOP was 16.7 ± 3.4 mm, with a ratio of trabecular to total bone thickness of 0.44. Trabecular vBMD (mean ± SD) was significantly higher at the EOP than at C1 and C2 (EOP = 612.3 ± 145.8 mg/cm3 , C1 average = 290.3 ± 66.5 mg/cm3 , C2 = 305.8 ± 78.8 mg/cm3 ; p < 0.001). A significant strong correlation between trabecular vBMD of C1 and C2 was observed (r = 0.744; p < 0.001), but only low correlations between the EOP and C1 (r = 0.295; p = 0.008) and C2 (r = 0.413; p < 0.001). In individuals > 65 years of age, cervical vBMD was significantly lower, but remained high at the EOP. Clinical significance: Trabecular vBMD at the EOP is significantly higher than at the upper cervical vertebrae and remains high in older populations. Together with morphological information about the occipital bone, these results might be helpful for occipitocervical fixation when deciding about uni- or bicortical screw placement at the EOP.
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Affiliation(s)
- Manuel Moser
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Dominik Adl Amini
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA.,Department of Orthopaedic Surgery and Traumatology, Charité University Hospital Berlin, Berlin, Germany
| | - Ichiro Okano
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA.,Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Lisa Oezel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA.,Department of Orthopaedic Surgery and Traumatology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jennifer Shue
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Andrew A Sama
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Frank P Cammisa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Federico P Girardi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Alexander P Hughes
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
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Minimally invasive lateral occipitocervical fixation: case series and technique description. 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 2022; 31:2714-2722. [PMID: 35771267 DOI: 10.1007/s00586-022-07278-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/18/2022] [Accepted: 05/27/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Occipitocervical junction (OCJ) instability is commonly treated with fixation via open posterior approach. The use of intraoperative navigation allows us to perform occipitocervical fixation via minimally invasive approach. We report a series of patients treated with percutaneous occipitocervical fixation, describing the surgical procedure in detail and discussing the technique. METHODS We prospectively enrolled 8 patients affected by OCJ instability secondary to trauma and rheumatoid arthritis. Traumatic patients were preoperatively evaluated with CT scan and MRI scan if needed. Rheumatoid arthritis group was evaluated with both CT and MR. Patients underwent percutaneous occipitocervical fixation with the assist of intraoperative 3D imaging and navigation. All patients were functionally and radiologically evaluated pre-, at 6 weeks, and at 1 year postoperatively. RESULTS Percutaneous occipitocervical fixation was successfully performed in all of the patients. 33 screws were placed. 29 (87.88%) were placed without any pedicle breach. In 3 (9.09%) screws we observed a minor; and in 1 (3.03%) screw we observed a major pedicle breach. We did not have any postoperative complications. CONCLUSIONS Described method of occipitocervical fixation is a minimally invasive method that has a similar outcome to the open technique. It requires the experience in open techniques and the assist of intraoperative 3D imaging and navigation to be performed efficiently.
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Reisener MJ, Arzani A, Okano I, Salzmann SN, Rentenberger C, Carrino JA, Shue J, Pumberger M, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Mapping of Venous Sinus Anatomy and Occipital Bone Thickness for Safe Screw Placement in 100 Patients with 46,200 Standardized Measurements Using Computed Tomography Angiography. Spine (Phila Pa 1976) 2022; 47:E196-E202. [PMID: 34310535 DOI: 10.1097/brs.0000000000004182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective descriptive study. OBJECTIVE The aim of this study was to create topographical maps of occipital bone thickness and venous sinus (VS) presence to assess the risks of screw insertion in four commercially available occipital plates. SUMMARY OF BACKGROUND DATA Craniocervical junction instability and deformity are serious pathological conditions that require posterior fixation of the occipital bone to the cervical vertebrae. Insertion of occipital bone screws requires evaluation of both occipital bone thickness for effective internal fixation and intracranial VS presence for vascular injury prevention. Despite the surgical risks, there is a paucity of research on safe screw placement. METHODS We created a matrix of 231 standardized measurement points to analyze the occipital bone thickness and VS presence in cervical spine CT angiograms. These measurements were used to create topographical maps of occipital bone thickness and likelihood of VS presence, which we then compared to the screw hole configurations of four occipital plates. RESULTS Hundred patients were assessed. Maximum occipital bone thickness of 13.9 ± 3.3 mm was midline in the occipital bone, 45 mm from the foramen magnum, around the external occipital protuberance (EOP). Regions with thicknesses >8 mm were 2 cm lateral to the EOP at the level of the superior nuchal line and 2.5 cm inferior to the EOP. The area with the highest VS presence rate was around the EOP and the superior nuchal line. The right transverse VS was more prominent in both sexes. CONCLUSION There is a limited area of the occipital bone with thicknesses for enough screw purchase. Previous studies have shown 8 mm as the minimum screw length to reduce the risk of implant failure. In our analysis, only "T"-shaped plates had configurations with thicknesses >8 mm for each screw hole. For every screw hole in the analyzed occipital plates, there was a possibility of VS presence ranging from 8% to 33%.Level of Evidence: 5.
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Affiliation(s)
| | | | - Ichiro Okano
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY
| | - Stephan N Salzmann
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY
| | - Colleen Rentenberger
- Department of Orthopedic and Trauma Surgery, Medical University of Vienna, Vienna, Germany
| | - John A Carrino
- Department for Radiology, Hospital for Special Surgery, New York, NY
| | - Jennifer Shue
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY
| | - Matthias Pumberger
- Department of Orthopedic and Trauma Surgery, Medical University of Berlin, Berlin, Germany
| | - Andrew A Sama
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY
| | - Frank P Cammisa
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY
| | - Federico P Girardi
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY
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12
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Safety analysis and complications of condylar screws in a single-surgeon series of 250 occipitocervical fusions. Acta Neurochir (Wien) 2022; 164:903-911. [PMID: 34820740 PMCID: PMC8913474 DOI: 10.1007/s00701-021-05039-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 10/24/2021] [Indexed: 12/02/2022]
Abstract
Objective
Condylar screw fixation is a rescue technique and an alternative to the conventional configuration of occipitocervical fusion. Condylar screws are utilized when previous surgical bone removal along the supraocciput has occurred which makes anchoring of a traditional barplate technically difficult or impossible. However, the challenging dissection of C0-1 necessary for condylar screw fixation and the concerns about possible complications have, thus far, prevented the acquisition of large surgical series utilizing occipital condylar screws. In the largest case series to date, this paper aims to evaluate the safety profile and complications of condylar screw fixation for occipitocervical fusion. Methods A retrospective safety and complication-based analysis of occipitocervical fusion via condylar screws fixation was performed. Results A total of 250 patients underwent occipitocervical fusions using 500 condylar screws between September 2012 and September 2018. No condylar screw pullouts, or vertebral artery impingements were observed in this series. The sacrifice of condylar veins during the dissection at C0-1 did not cause any venous stroke. Hypotrophic condyles were found in 36.4% (91 of the 250) cases and did not prevent the insertion of condylar screws. Two transient hypoglossal deficits occurred at the beginning of this surgical series and were followed by recovery a few months later. Corrective strategies were effective in preventing further hypoglossal injuries. Conclusions This surgical series suggests that the use of condylar screws fixation is a relatively safe and reliable option for OC fusion in both adult and pediatric patients. Methodical dissection of anatomical landmarks, intraoperative imaging, and neurophysiologic monitoring allowed the safe execution of the largest series of condylar screws reported to date. Separate contributions will follow in the future to provide details about the long-term clinical outcome of this series.
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13
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Abstract
PURPOSE Rigid occipitocervical (O-C) instrumentation can reduce the anterior pathology and has a high fusion rate in children with craniovertebral instability. Typically, axis (C2) screw fixation utilizes C1-C2 transarticular screws or C2 pars screws. However, anatomic variation may preclude these screw types due to the size of fixation elements or by placing the vertebral artery at risk for injury. Pediatric C2 translaminar screw fixation has low risk of vertebral artery injury and may be used when the anatomy is otherwise unsuitable for C1-C2 transarticular screws or C2 pars screws. METHODS We retrospectively reviewed a neurosurgical database at UCSF Benioff Children's Hospital Oakland for patients who had undergone a cervical spinal fusion that utilized translaminar screws for occipitocervical instrumentation between 2002 and 2020. We then reviewed the operative records to determine the parameters of C2 screw fixations performed. Demographic and all other relevant clinical data were then recorded. RESULTS Twenty-five patients ranging from 2 to 18 years of age underwent O-C fusion, with a total of 43 translaminar screws at C2 placed. Twenty-three patients were fused (92%) after initial surgery with a mean follow-up of 43 months. Two patients, both with Down syndrome, had a nonunion. Another 2 patients had a superficial wound dehiscence that required wound revision. One patient died of unknown cause 7 months after surgery. One patient developed an adjacent-level kyphosis. CONCLUSION When performing occipitocervical instrumentation in the pediatric population, C2 translaminar screw fixation is an effective option to other methods of C2 screw fixation dependent on anatomic feasibility.
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14
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Occipitocervical fusion as treatment of instability in Chiari malformation. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh220203041z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction. Occipitocervical (OC) fusion is a method for fixation of the OC
junction when there is instability of that segment. Arnold Chiari
malformation is a congenital disorder where cerebellar tonsils descend
through the foramen magnum, which can lead to cervicomedular compression and
formation of syrinx. While treating this condition, for the purpose of
decompression, the foramen magnum is expanded which can potentially harm the
stability of the OC junction. Case outline. We are presenting the case of a
16 year old female who was surgically treated (suboccipital craniectomy and
decompression) because of Arnold Chiari malformation type I. One-year
post-op multislice computed tomography verified a slight enlargement of
basion-axial and basion-dens intervals, with signs of spinal cord
compression. Surgery was performed - occipitocervical fusion, canal
decompression on C1 and C2 levels with a plate on occipital bone and screws
placed in the third, fourth, and fifth cervical vertebra. Conclusion.
Occipitocervical fusion is a complex surgical procedure (vital neurovascular
structures), but it is a reliable method for treatment of instability of the
OC junction.
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15
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Sun Y, Yang F, Ma HN, Gong L, Wang YL, Song JP, Hao QY, Tan MS. Occipitocervical Revision Surgery Using the Bicortical Screw and Plate System for Failed Craniovertebral Junction Stabilization. Orthop Surg 2021; 14:238-245. [PMID: 34904372 PMCID: PMC8867430 DOI: 10.1111/os.13086] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/07/2021] [Accepted: 05/10/2021] [Indexed: 11/28/2022] Open
Abstract
Background To evaluate the clinical efficacy and safety of the modified technique utilizing the occipital bicortical screws and plate system in occipitocervical revision surgery. Methods Between October 2010 and May 2018, 12 consecutive patients were retrospectively evaluated. All patients had posterior occipitocervical resurgery utilizing modified technique of bicortical screws and occipital plate. The measurements of extracranial occiput on midline were conducted on computed tomography (CT) scans. The thickness of the occipital bone at the location of external occipital protuberance and below 15 mm were evaluated, respectively. For the procedure, the trajectory was drilled perpendicular to the external occipital protuberance for the specified depth with a depth‐limited drilling, 2 mm away from the internal bone plate, then the trajectory was deepened at intervals of 1 mm each time until reaching the internal bone plate. Meanwhile, a probe was used to explore all the walls of the trajectory. Bicortical screws were inserted to the occipital plate and the depth of penetration was less than 2 mm from the internal bone plate. Clinical efficacy and radiographic evaluation were followed up. Results The thickest point was the external occipital protuberance, which was 15.49 ± 1.47 mm and decreased gradually on the midline to 13.41 ± 1.60 mm at below 15 mm. Twelve cases (mean age 41.17 years; range, 24–62 years), including five males and seven females, were followed up for 24.08 months (14–32 months). The interval time was 40.42 months (3–156 months) after the initial operation. At the final follow‐up, JOA score increased from 8.58 ± 2.53 before surgery to 12.67 ± 1.84 (P < 0.05) and VAS score improved from 6.17 ± 1.21 to 2.08 ± 1.32 (P < 0.05). Besides, clinical symptoms were relieved in all patients after revision surgery. All patients had rigid internal fixations with bone fusion and no major complications occurred. Conclusions Posterior occipitocervical plate‐screw system with bicortical screws had the advantages of safety, simple and promising efficacy without excessive tissue release or intraspinal manipulation, proving that it's valuable as a modified technique for occipitocervical revision surgery.
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Affiliation(s)
- Yan Sun
- Beijing University of Chinese Medicine, Beijing, China.,Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China
| | - Feng Yang
- Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China
| | - Hao-Ning Ma
- Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China
| | - Long Gong
- Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical College, Beijing, China
| | - Yan-Lei Wang
- Beijing University of Chinese Medicine, Beijing, China.,Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China
| | - Ji-Peng Song
- Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical College, Beijing, China
| | - Qing-Ying Hao
- Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China
| | - Ming-Sheng Tan
- Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China
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16
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Sakti YM, Lanodiyu ZA, Wijanarko S, Alhaq ZA, Sakadewa GP, Ahmad H, Desfiandi P, Magetsari R. Occipitocervical fixation: A case report of our techniques and results. Int J Surg Case Rep 2021; 90:106633. [PMID: 34902699 PMCID: PMC8669366 DOI: 10.1016/j.ijscr.2021.106633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/05/2021] [Accepted: 11/21/2021] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Occipitocervical fixation (OCF) can provide good fusion rate to treat various craniovertebral junction (CVJ) pathologies. Biomechanically it gives rigid fixation, good fusion rate, and allows for effective decompression. However, rigid fixation on the mobile occipitocervical junction has shortcomings that affect the post-operative clinical functional outcomes and range of motion. This study aimed to evaluate and elaborate the functional outcomes, range of motions, and radiographic findings in our patients underwent OCF. CASE REPORT We presented a report of 3 patients underwent posterior decompression procedure followed by occipitocervical fixation. All three patients' clinical outcome was assessed clinically by, Japanese Orthopaedic Association (JOA) score and grading, Karnofsky, range of motion and radiographic cervical alignment evaluation parameters. RESULT All patients have seen improvement (minimal 1 grade in JOA and >30 points of Karnofsky score) in 3 months after the procedure, had a tolerable range of motion limitation, normal range of cervical lordotic and cervical brow vertebral angle (CBVA). Unfortunately, one patient with loss of cranial fixation may be related to history of infection and lack of post-operative wound care. CONCLUSSION Our cases conclude that Occipitocervical fixation is a safe technique that provides excellent fusion rate with good functional outcome and tolerable range of motion limitation. Due to its unique anatomy and technically demanding, serial post-operative monitoring evaluation of this procedure is paramount.
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Affiliation(s)
- Yudha Mathan Sakti
- Staff of Department of Orthopaedics and Traumatology, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Sleman Regency, Yogyakarta Special Region, Indonesia.
| | - Zikrina Abyanti Lanodiyu
- Staff of Department of Orthopaedics and Traumatology, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Sleman Regency, Yogyakarta Special Region, Indonesia
| | - Sonny Wijanarko
- Resident of Department of Orthopaedics and Traumatology, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Sleman Regency, Yogyakarta Special Region, Indonesia
| | - Zaky Asad Alhaq
- Resident of Department of Orthopaedics and Traumatology, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Sleman Regency, Yogyakarta Special Region, Indonesia
| | - Galih Prasetya Sakadewa
- Resident of Department of Orthopaedics and Traumatology, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Sleman Regency, Yogyakarta Special Region, Indonesia
| | - Husein Ahmad
- Resident of Department of Orthopaedics and Traumatology, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Sleman Regency, Yogyakarta Special Region, Indonesia
| | - Prisilla Desfiandi
- Resident of Department of Orthopaedics and Traumatology, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Sleman Regency, Yogyakarta Special Region, Indonesia
| | - Rahadyan Magetsari
- Staff of Department of Orthopaedics and Traumatology, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Sleman Regency, Yogyakarta Special Region, Indonesia
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17
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Chakraborty AR, Pelargos PE, Milton CK, Martin MD, Bauer AM, Dunn IF. Occipital condyle screw fixation after posterior decompression for Chiari malformation: Technical report and application. Surg Neurol Int 2021; 12:543. [PMID: 34877029 PMCID: PMC8645510 DOI: 10.25259/sni_26_2021] [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: 01/11/2021] [Accepted: 09/15/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical techniques for stabilization of the occipital cervical junction have traditionally consisted of screw-based techniques applied in conjunction with occipital plating and rods connected to subaxial instrumentation in the form of pars, pedicle, or lateral mass screws. In patients with type 1 Chiari malformation (CM-1) and evidence of occipital cervical junction instability who have undergone posterior decompression, the occipital condyle (OC) represents a potential alternative cranial fixation point. To date, this technique has only been described in pediatric case reports and morphometric cadaver studies. METHODS Patients underwent posterior fossa decompression for treatment of CM. Subsequently, patients received occipital cervical stabilization using OC screws. RESULTS Patients were successfully treated with no post-operative morbidity. Patient 2 was found to have pseudoarthrosis and underwent revision. Both patients continue to do well at 1-year follow-up. CONCLUSION Placement of the OC screw offers advantages over traditional plate-based occipital fixation in that bone removal for suboccipital decompression is not compromised by the need for hardware placement, screws are hidden underneath ample soft tissue in patients with thin skin which prevents erosion, and the OC consists of primarily cortical bone which provides for robust tricortical fixation. These cases demonstrate the novel application of the OC screw fixation technique to the treatment of occipital cervical junction instability in adult patients undergoing simultaneous posterior fossa decompression.
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Affiliation(s)
| | | | | | | | | | - Ian F. Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
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18
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Zileli M, Akıntürk N. Complications of occipitocervical fixation: retrospective review of 128 patients with 5-year mean follow-up. 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 2021; 31:311-326. [PMID: 34725722 DOI: 10.1007/s00586-021-07037-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/18/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Occipitocervical fusion is necessary for many pathologies of the craniocervical junction. The anatomy of the region is unique, and fusion can cause significant morbidity. This retrospective review aims to investigate the complication rates and outcomes of occipitocervical fixation. MATERIAL AND METHODS This is a retrospective review of 128 patients with occipitocervical fixation operated between 1994 and 2020. The average follow-up is 63 months. RESULTS The indications of occipitocervical fixation were basilar invagination (53 patients; 41.4%), trauma (25 patients; 19.5%), tumor (23 patients; 18%), instability due to rheumatoid arthritis (13 patients; 10.2%), cervical deformity (7 patients; 5.5%) and os odontoideum (7 patients; 5.5%). There were six early postoperative (1st month) deaths. We observed complications in 67 patients (52%). Most common complication was implant-related (32%), followed by wound problems (23.4%), systemic and other complications (11.7%), neurologic complications (6.2%). Implants are removed in 31 patients (24%) for different reasons: deep wound infection (7), local pain and restriction of head movements (21), respiratory distress and swallowing problems (2), screw fracture and local pain (1). CONCLUSIONS Occipitocervical fixation has quite large number of complications and significantly restricts head movements. With the advent of our biomechanical concepts, indications should be limited, and shorter cervical fixations should be preferred. LEVEL OF EVIDENCE Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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Affiliation(s)
- Mehmet Zileli
- Ege University Neurosurgery Department, Bornova, Izmir, Turkey.
| | - Nevhis Akıntürk
- Ege University Neurosurgery Department, Bornova, Izmir, Turkey
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19
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Goparaju PVNR, Rangnekar A, Chigh A, Raut SS, Kundnani V. Safety, efficacy, surgical, and radiological outcomes of short segment occipital plate and C2 transarticular screw construct for occipito-cervical instability. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:381-386. [PMID: 35068820 PMCID: PMC8740813 DOI: 10.4103/jcvjs.jcvjs_113_21] [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: 08/07/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: Our study aims to assess the safety, efficacy, clinicoradiological, functional, neurological outcomes, and complications of posterior occipitocervical fixation using an occipital plate and C1-2 transarticular screw (TAS) construct. Study Design: This was a retrospective analysis of prospectively collected data. Methods: Data of 27 patients who underwent occipital plate and C1-2 TAS construct at a single institute from 2010 to 2015 were collected and analyzed. Demographics, clinical parameters (Visual Analog Score, Oswestry Disability Index, and modified JOA score), radiological parameters – mean atlantodens interval, posterior occipitocervical angle, occipitocervical-2 angle, surgical parameters (operative time, blood loss, hospital stay, and fusion), and complications were evaluated. Results: The mean age of the patients was 54.074 ± 16.52 years (18–81 years), the mean operative time was 116.29 ± 12.23 min, and the mean blood loss was 196.29 ± 38.94 ml. The mean hospital stay was 5.22 ± 1.28 days. The mean ± standard deviation follow-up duration was 62.52 ± 2.27 months. There was a significant improvement in clinical parameters and radiological parameters postoperatively. One patient with implant failure, one patient with pseudoarthrosis, one with neurological deterioration, two wound complications, and two dural tears were noted. Conclusion: Posterior occipitocervical reconstruction with O-C1-2 TAS construct provided excellent clinical outcomes, radiological outcomes, optimal correction of malalignment in the occipitocervical region, and with biomechanically sound fixation. Extending the instrumentation into the subaxial spine will lead to a decrease in the range of motion, increased surgical time, blood loss, more extensive muscle damage, and also increase the costs.
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Affiliation(s)
- Praveen V N R Goparaju
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Ameya Rangnekar
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Amit Chigh
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Saijyot Santosh Raut
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Vishal Kundnani
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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20
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Pijpker PAJ, Kuijlen JMA, Kaptein BL, Pondaag W. Three-Dimensional-Printed Drill Guides for Occipitothoracic Fusion in a Pediatric Patient With Occipitocervical Instability. Oper Neurosurg (Hagerstown) 2021; 21:27-33. [PMID: 33728473 PMCID: PMC8203425 DOI: 10.1093/ons/opab060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/25/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pediatric occipitothoracic fusion can be challenging because of small size pedicles and thin occipital bone. Three-dimensional (3D) printing technology can help with accurate screw insertion but has not been described for occipital keel plate positioning so far. OBJECTIVE To describe the novel use of 3D technology to position occipital keel plates during pediatric occipitothoracic fixation. METHODS A young boy with segmental spinal dysgenesis presented with asymmetrical pyramidal paresis in all limbs. Developmental abnormities of the cervical spine caused a thinned spinal cord, and because of progressive spinal cord compression, surgical intervention by means of occipitothoracic fixation was indicated at the age of 3 yr.Because of the small-size pedicles and thin occipital bone, the pedicle screws and occipital plates were planned meticulously using 3D virtual surgical planning technology. The rods were virtually bent in order to properly align with the planned screws. By means of 3D-printed guides, the surgical plan was transferred to the operating theater. For the occipital bone, a novel guide concept was developed, aiming for screw positions at maximal bone thickness. RESULTS The postoperative course was uneventful, and radiographs showed good cervical alignment. After superimposing the virtual plan with the intraoperative acquired computed tomography, it was confirmed that the occipital plate positions matched the virtual plan and that pedicle screws were accurately inserted without signs of breach. CONCLUSION The use of 3D technology has greatly facilitated the performance of the occipitothoracic fixation and could, in the future, contribute to safer pediatric spinal fixation procedures.
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Affiliation(s)
- Peter A J Pijpker
- 3D lab, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jos M A Kuijlen
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Bart L Kaptein
- Department of Orthopedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem Pondaag
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
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21
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Chugh AJS, Patel M, Chua L, Arafah B, Bambakidis NC, Ray A. Management of giant prolactinoma causing craniocervical instability: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2021; 1:CASE2158. [PMID: 36046515 PMCID: PMC9394694 DOI: 10.3171/case2158] [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: 01/25/2021] [Accepted: 02/25/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Giant prolactinomas (>4 cm) are a rare entity, constituting less than 1% of all pituitary tumors. Diagnosis can usually be achieved through endocrinological analysis, but biopsy may be considered when trying to differentiate between invasive nonfunctioning pituitary adenomas and primary clival tumors such as chordomas. OBSERVATIONS The authors presented a rare case of a giant prolactinoma causing significant clival and occipital condyle erosion, which led to craniocervical instability. They provided a review of the multimodal management. Management involved medical therapy with dopamine agonists, and surgery was reserved for acute neural compression or dopamine agonist resistance, with the caveat that surgery was extremely unlikely to lead to normalization of serum prolactin in dopamine agonist-resistant tumors. LESSONS Adjunctive surgical therapy may be necessary in cases of skull base erosion, particularly when erosion or pathological fractures involve the occipital condyles. Modern posterior occipital-cervical fusion techniques have high rates of arthrodesis and can lead to symptomatic improvement. This procedure should be considered early in the multimodal approach to giant prolactinomas because of the often dramatic response to medical therapy and potential for further craniocervical instability.
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Affiliation(s)
| | | | - Lorayne Chua
- Endocrinology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Baha Arafah
- Endocrinology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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22
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Winocour SJ, Xue EY, Bohl MA, Farrokhi F, Davis MJ, Abu-Ghname A, Ropper AE, Reece EM. Vascularized Occipital Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives. Semin Plast Surg 2021; 35:14-19. [PMID: 33994873 DOI: 10.1055/s-0041-1723834] [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: 10/21/2022]
Abstract
Successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. Different techniques for spinal fixation in this region have been well described, along with auxiliary methods to improve fusion rates. The occipital vascularized bone graft is a novel technique that can be used to augment bony arthrodesis in the supra-axial cervical spine. It provides the benefits of a vascularized autologous graft, such as accelerated healing, earlier fusion, and increased strength. This technique can be learned with relative ease and may be particularly helpful in cases with high risk of nonunion or pseudoarthrosis in the upper cervical spine.
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Affiliation(s)
- Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Erica Y Xue
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Farrokh Farrokhi
- Department of Neurosurgery, Virginia Mason Hospital, Seattle, Washington
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | | | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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23
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Wu C, Deng JY, Li T, Zeng BF, Hu HG, Zhu YF, Wei Q. 3D-Printed Screw-Rod Auxiliary System for Unstable Atlas Fractures: A Retrospective Analysis. Orthop Surg 2021; 13:1006-1015. [PMID: 33826254 PMCID: PMC8126899 DOI: 10.1111/os.13015] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/26/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To develop and validate the efficacy of a 3D‐printed screw‐rod auxiliary system for unstable atlas fractures. Methods This research is a retrospective analysis, and a total of 14 patients, including 11 males and three females, were enrolled in our hospital from January 2017 to March 2019 who underwent occipitocervical fusion assisted by the 3D‐printed screw‐rod auxiliary system were reviewed, and with an average age of 53.21 ± 14.81 years, an average body mass index (BMI) of 23.61 ± 1.93 kg/m2. The operation time, blood loss and radiation times during the operation were recorded. The maximum fracture displacement values of pre‐ and post‐operation were measured based on CT imaging. All screw grades were evaluated after surgery. The occipital‐cervical 2 (O‐C2) angle and occipitocervical inclination (OCI) angle of pre‐operation, post‐operation and the last following‐up were measured. The dysphagia scale 3 months after surgery and at the last follow‐up, the Neck Disability Index (NDI) 3 months after surgery and at the last follow‐up were assessed. Results All patients were completed the surgery successfully. There was no patient with severe dysphagia or aggravation of nerve injury. The follow‐up was from 12 to 14 months, and with an average of 12.5 months. The average surgery time, average blood loss and average radiation times for the 14 patients were 112.14 min, 171.43 mL and 5.07 times, respectively. There was a significant difference in maximum fracture displacement between pre‐ and post‐operation values (P < 0.05). A total of 56 screws were inserted in 14 patients, among them, three screws were classified as grade 1, and the other screws were classified as grade 0. There was a significant difference in the O‐C2 between pre‐operation and 3 days after operation (P = 0.002); There was a significant difference in OCI angles between pre‐operation and 3 days after operation (P < 0.05); there was no significant difference in the O‐C2 or OCI angle between 3 days after the operation and the last follow‐up (P = 0.079; P = 0.201). The dysphagia scales of two patients were assessed as mild at 3 months after surgery, and the others were assessed as normal at 3 months after surgery. All patients' dysphagia scores returned to normal at the last follow‐up. The average NDI and average neck Visual Analogue Scale (VAS) scores at the last follow‐up were 2.53 and 8.41, respectively. Conclusion It can objectively restore the OCI to normal with few post‐operative complications under the assistance of a screw‐rod auxiliary system to perform occipitocervical fusion for unstable atlas fractures and atlantooccipital joint instability.
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Affiliation(s)
- Chao Wu
- Orthopaedics Center, Zigong Fourth People's Hospital, Zigong, China.,Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Jia-Yan Deng
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Tao Li
- Orthopaedics Center, Zigong Fourth People's Hospital, Zigong, China
| | - Bo-Fang Zeng
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Hai-Gang Hu
- Orthopaedics Center, Zigong Fourth People's Hospital, Zigong, China
| | - Yuan-Fang Zhu
- Health Management Center, Zigong Fourth People's Hospital, Zigong, China
| | - Qin Wei
- Orthopaedics Center, Zigong Fourth People's Hospital, Zigong, China
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Nishikawa M, Bolognese PA, Kula RW, Ikuno H, Takami T, Ohata K. Surgical Management of Chiari Malformations: Preliminary Results of Surgery According to the Mechanisms of Ptosis of the Brain Stem and Cerebellum. J Neurol Surg B Skull Base 2021; 82:264-272. [PMID: 33816049 PMCID: PMC8009696 DOI: 10.1055/s-0039-1697977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/11/2019] [Indexed: 10/25/2022] Open
Abstract
Introduction We classified Chiari malformation type I (CM-I) according to the mechanism of ptosis of the brain stem and cerebellum, based on a morphometric study of the posterior cranial fossa (PCF) and craniovertebral junction (CVJ). Surgery was performed to manage the mechanism of the hindbrain ptosis. Materials and Methods We calculated the volume of the PCF (VPCF) and the area surrounding the foramen magnum (VSFM) and measured the axial length of the enchondral parts of the occipital bone (occipital bone size) and the hindbrain. According to these measures, we classified CM-I into type A (normal VPCF, normal VSFM, and normal occipital bone size), type B (normal VPCF, small VSFM, and small occipital bone size), and type C (small VPCF, small VSFM, and small occipital bone size). Foramen magnum decompression (FMD) (280 cases) was performed on CM-I types A and B. Expansive suboccipital cranioplasty (ESCP) was performed on CM-I type C. Posterior craniocervical fixation (CCF) was performed in cases with CVJ instability. Lysis of the adhesion and/or sectioning of the filum terminale were performed on cases with tethered cord syndrome. Results Both ESCP and FMD had a high rate of improvement of neurological symptoms (87%) and recovery rate. There was only small number of complications. CCF had a high rate of improvement of neurological symptoms (88%) and joint stabilization. Conclusion In the management of Chiari malformation, appropriate surgical methods that address ptosis of the hindbrain should be chosen. Each surgical approach resulted in a good improvement of neurological symptoms.
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Affiliation(s)
- Misao Nishikawa
- Department of Neurosurgery, Moriguchi-Ikuno Memorial Hospital, Koudoukai Health System, Osaka, Japan
- The Chiari Institute, North Shore University Hospital, New York, United States
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Paolo A. Bolognese
- The Chiari Institute, North Shore University Hospital, New York, United States
- Chiari Neurosurgical Center, Long Island, New York, United State
| | - Roger W. Kula
- The Chiari Institute, North Shore University Hospital, New York, United States
- Chiari Neurosurgical Center, Long Island, New York, United State
| | - Hiromichi Ikuno
- Department of Neuroradiology, Moriguchi-Ikuno Memorial Hospital, Koudoukai Health System, Osaka, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Long-term Radiographic Outcome of Occipitocervical Fixation: An Analysis of Fusion Rate and Spontaneous Subaxial Alignment Change at an Average 7-year Follow-up. Spine (Phila Pa 1976) 2021; 46:152-159. [PMID: 33065696 DOI: 10.1097/brs.0000000000003757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE The aim of this study was to investigate the long-term radiographic outcome of patients who underwent occipitocervical fixation (OCF) using a modern screw/rod system. SUMMARY OF BACKGROUND DATA Few studies have reported fusion rates and radiographic alignment changes in unfused subaxial segments after OCF at a long-term follow-up. METHODS We retrospectively reviewed 22 patients who underwent OCF with a modern screw-based construct. The patients satisfied the minimum 2-year radiographic follow-up. Baseline demographics and the following pre- and postoperative sagittal alignment parameters were investigated. McGregor slope, O-C2 angle (OC2A), and C2-7 Cobb angle (CL). We grouped patients into those whose OC2A increased postoperatively (OC2A-increase group) and those whose OC2A decreased postoperatively (OC2A-decrease group). The postoperative sagittal alignment change was compared between the 2 groups at the final follow-up. The perioperative complications as well as fusion status based on computed tomography (CT) were investigated. RESULTS The average follow-up period was 89.7 months. The lowest instrumented vertebra was at C2 (63.6%), C3 (18.1%), or C4 (18.1%). The fusion rate at the final follow-up was 77.2%. Postoperative dysphasia occurred in two patients (16.6%) in the OC2A-decrease group, whereas distal junctional kyphosis was observed in two patients (20.0%) in the OC2A-increase group. The OC2A-increase group demonstrated a mean 4.8° decrease in CL as a compensation for the 5.1° increase in OC2A. In contrast, the OC2A-decrease group showed a mean 9.2° increase in CL as a compensation for the 6.3° decrease in OC2A. CONCLUSION The CT-confirmed fusion rate of OCF was 77.2% over an average 89.7-month follow-up. Compensatory sagittal alignment change can occur in the unfused subaxial segments in conjunction with the alignment change in the instrumented OC segments, whereas the horizontal gaze was maintained. Strong consideration for the intraoperative measurement of the OC2A should be given during OCF to minimize both early and long-term complications.Level of Evidence: 4.
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Zou Q, Wang L, Yang X, Song Y, Liu L, Wang L, Zhou Z, Hu B, Liu H, Chen T. [Predictive abilities of O-C2 angle, O-EA angle, and Oc-Ax angle for the development of dysphagia in patients after occipitocervical fusion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:33-38. [PMID: 33448196 DOI: 10.7507/1002-1892.202007113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To compare the predictive abilities of O-C2 angle (O-C2a), O-EA angle (O-EAa), and Oc-Ax angle (Oc-Axa) for development of dysphagia in patients after occipitocervical fusion (OCF). Methods Between April 2010 and May 2019, 114 patients who underwent OCF and met the selection criteria were selected as the research objects. Among them, 54 were males and 60 were females; they were 14-76 years old, with an average of 50.6 years old. The follow-up time was 13-122 months (median, 60.5 months). The O-C2a, O-EAa, Oc-Axa, and the narrowest oropharyngeal airway space (nPAS) were measured by the lateral X-ray films before operation and at last follow-up, and the differences before and after operation (dO-C2a, dO-EAa, dOc-Axa, and dnPAS) were calculated. Patients were divided into two groups according to whether they had developed postoperative dysphagia. The general data including age, gender, fixed segment, proportion of patients with rheumatoid arthritis (RA), atlantoaxial subluxation (AS), and combined with anterior release surgery (ARS), and imaging indicators were compared between the two groups. The correlations between dO-C2a, dO-EAa, and dOc-Axa and dnPAS in 114 patients were analyzed to further compare the predictive value of three imaging indicators for occurrence of dysphagia after OCF. Results Dysphagia occurred after OCF in 31 cases with the incidence of 27.2%. There was significant difference in gender between the dysphagia group and the non-dysphagia group ( χ 2=7.940, P=0.005). There was no significant difference between the two groups in age, fixed segment, the proportion of patients with RA, the proportion of patients with AS, and the proportion of patients combined with ARS ( P>0.05). There was no significant difference in O-C2a and Oc-Axa of 114 patients before operation and at last follow-up ( P>0.05). The differences in O-EAa and nPAS were significant ( P<0.05). There was no significant difference in preoperative O-EAa, Oc-Axa, and nPAS between the dysphagia group and the non-dysphagia group ( P>0.05); the difference in the O-C2a was significant ( t=2.470, P=0.016). At last follow-up, the differences in the above imaging indicators were significant ( P<0.05). There were significant differences in the dO-C2a, dO-EAa, dOc-Axa, and dnPAS between the two groups ( P<0.05). Correlation analysis showed that the dO-C2a, dO-EAa, dOc-Axa were all positively correlated with dnPAS ( P<0.05). The dO-C2a≤-5°, postoperative O-EAa≤100°, postoperative Oc-Axa≤65° were all related to postoperative dysphagia ( P<0.05), and the highest risk factor suffering postoperative dysphagia was dO-C2a ≤-5° with a significant OR of 14.4. Conclusion The dO-C2a, postoperative O-EAa, and postoperative Oc-Axa can be used as the predictive indexes of dysphagia after OCF, among which dO-C2a has the highest predictive value.
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Affiliation(s)
- Qiang Zou
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Linnan Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Xi Yang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yueming Song
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Limin Liu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Lei Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Zhongjie Zhou
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Bowen Hu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Hao Liu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Taiyong Chen
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Orthopedic Research Institute of West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Houten JK, Kinon MD, Weinstein GR. 4-Point C2 Fixation for Occipitocervical Fusion: Technical Case Report. World Neurosurg 2021; 148:38-43. [PMID: 33422720 DOI: 10.1016/j.wneu.2020.12.159] [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: 11/17/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Occipitocervical fusion is an important surgical procedure to treat instability of the upper cervical and craniocervical junction. Fixation to the dense cortical bone of the occiput, contemporaneously typically accomplished with a plate and screws, is known to be strong and durable, but there are many competing methods used to secure an adequate number of fixation points of sufficient strength at the cervical end. Extension of hardware to the midcervical region to acquire additional fixation points, however, results in loss of subaxial motion segments and additional potential morbidity. The C2 vertebra is unique in that its morphology and dimensions permit fixation with longer screws than are typically possible to place in the midcervical lateral masses. Translaminar and pars screw techniques, both commonly used to achieve C2 fixation, are not mutually exclusive, as their respective trajectories are considerably different and engage different portions of the bony anatomy. METHODS We describe a novel, 4-point C2 fixation technique for OC fusion that may avoid the need to extend fusion to the subaxial spine. RESULTS This technical note illustrates how 4-point C2 fixation can be employed in occiptocervical fusion. CONCLUSIONS 4-point fixation of C2 combining translaminar and pars screw placement is technically feasible and may be a suitable strategy to spare subaxial motion segments in OC fusion procedures. Futher investigation may establish its applicability to additional surgical procedures.
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Affiliation(s)
- John K Houten
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.
| | - Merritt D Kinon
- Department of Neurological Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Gila R Weinstein
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA
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Bellabarba C, Karim F, Tavolaro C, Zhou H, Bremjit P, Nguyen QT, Agel J, Bransford RJ. The mandible-C2 angle: a new radiographic assessment of occipitocervical alignment. Spine J 2021; 21:105-113. [PMID: 32673731 DOI: 10.1016/j.spinee.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/28/2020] [Accepted: 07/08/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Occipitocervical fusion is a rare and often challenging surgical procedure. Significant morbidity can result if care is not taken to achieve physiologic alignment. This is especially true for patients needing occipitocervical fusion in the setting of trauma where preoperative alignment is unknown. PURPOSE To assess the radiographic angles normally subtended between the C2 body and the mandible ramus, in a series of patients with neutral physiologic alignment and no pathology, and to assess its validity as a possible intraoperative radiographic tool to determine a neutral craniocervical alignment. DESIGN Validation and reliability study of radiographic parameters. PATIENT SAMPLE Hundred lateral, neutral, cervical radiographs from patients with "normal" radiographic findings. OUTCOME MEASURES Radiographic parameters of occipital-cervical alignment with assessment of reliability and correlation in data. METHODS One hundred neutral lateral cervical spine radiographs in the upright position of patients with no complaints or known pathology were obtained from two medical clinics between December of 2014 and January of 2017. Three physicians, at different levels of spine surgery training, took measurements of radiographic parameters. The new technique used four different angles measured between the C2-body/dens complex and the mandibular ramus (anterior/posterior C2 body and anterior/posterior mandible lines angles), and compared these with the Occipito-C2 angle, which is a validated assessment of occipitocervical alignment. Statistical analysis was performed to assess correlation in data and measure reproducibility. RESULTS Between the three reviewers, the mean±standard deviation were 18.0°±6.5° for Occipito-C2 angle (O-C2A), -4.2°±5.4° for anterior C2-body/anterior mandible line angle (AB/AM), -4.2°±5.9° for anterior C2-body/posterior mandible line angle (AB/PM), 5.1°±5.8° for posterior C2 body/anterior mandible line angle (PB/AM) and 5.6°±6.2° for posterior C2 body/ posterior mandible line angle (PB/PM). Overall the measurements obtained were correlative with an appropriate range for the standard deviation. Mean intraclass correlation coefficient were 0.889 for O-C2A, 0.795 for AB/AM, 0.859 for AB/PM, 0.876 for PB/AM, and 0.750 for PB/PM, showing high interobserver reliability for all the radiographic measures. Across the five techniques, 87%-92% of measurements fell within 10° of the median, 76%-83% fell within 7.5°, and 55%-66% within 5°. CONCLUSIONS The mandible-C2 angle offers a reproducible alternative to the validated O-C2A technique for determining appropriate intraoperative occipitocervical alignment, which may be especially useful when preoperative radiographic alignment is unknown, such as occurs with trauma patients, with the goal of decreasing alignment-related complications in the setting of occipitocervical stabilization.
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Affiliation(s)
- Carlo Bellabarba
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Farhan Karim
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Celeste Tavolaro
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Haitao Zhou
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Prashoban Bremjit
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Quynh T Nguyen
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Julie Agel
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA
| | - Richard J Bransford
- Department of Orthopaedics & Sport Medicine, Harborview Medical Center, 325 Ninth Ave Seattle, WA 98104, USA.
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Zou X, Ouyang B, Yang H, Wang B, Ge S, Chen Y, Ni L, Zhang S, Xia H, Yang J, Ma X. Surgical treatment for basilar invagination with irreducible atlantoaxial dislocation: transoral atlantoaxial reduction plate fixation vs occipitocervical fixation. BMC Musculoskelet Disord 2020; 21:825. [PMID: 33292209 PMCID: PMC7724810 DOI: 10.1186/s12891-020-03838-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/25/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Transoral atlantoaxial reduction plate (TARP) fixation or occipitocervical fixation (OF) is an effective treatment for basilar invagination (BI) with irreducible atlantoaxial dislocation (IAAD). But, all current clinical studies involved a single surgical procedure. The clinical effects of TARP and OF operation for BI with IAAD have yet to be compared. We therefore present this report to compare the treatment of TARP and OF procedure for BI with IAAD. METHODS Fifty-six patients with BI with IAAD who underwent TARP or OF operation from June 2011 to June 2017 were retrospectively analyzed. Among these, 35 patients underwent TARP operation (TARP group), and 21 patients underwent OF operation (OF group). We compared the difference of clinical, radiological, and surgical outcomes between the TARP and OF groups postoperatively. RESULTS Compared with OF group, the operative time and blood loss in TARP group were lower. There was no statistical difference in the atlantodental interval (ADI), clivus canal angle (CCA), cervicomedullary angle (CMA), distance between the top of the odontoid process and the Chamberlain line (CL) and Japanese Orthopaedic Association (JOA) score between the TARP and OF groups preoperatively, but the improvements of these parameters in the TARP group were superior to those in the OF group postoperatively. The fusion rates were higher in the TARP group than those in the OF group at the early stage postoperatively. CONCLUSIONS TARP and OF operations are effective surgical treatment for BI with IAAD, but the performance of reduction and decompression and earlier bone fusion rates of TARP procedure are superior to those of OF.
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Affiliation(s)
- Xiaobao Zou
- The First School of Clinical Medicine, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China.,Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Bieping Ouyang
- The First School of Clinical Medicine, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China.,Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Haozhi Yang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Binbin Wang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Su Ge
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Yuyue Chen
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Ling Ni
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Shuang Zhang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Hong Xia
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Jingcheng Yang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China.
| | - Xiangyang Ma
- The First School of Clinical Medicine, Southern Medical University, No.1838 North of Guangzhou Road, Guangzhou, 510515, People's Republic of China. .,Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, No.111 Liuhua Road, Guangzhou, 510010, People's Republic of China.
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Germaneau A, Vendeuvre T, Delmotte A, D'Houtaud S, Brèque C, Petureau L, Doumalin P, Dupré JC, Brémand F, Maxy P, Richer JP, Rigoard P. Should we recommend occipital plate fixation using bicortical screws or inverted occipital hooks to optimize occipito-cervical junction fusion? A biomechanical study combining an experimental and analytical approach. Clin Biomech (Bristol, Avon) 2020; 80:105173. [PMID: 33010700 DOI: 10.1016/j.clinbiomech.2020.105173] [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: 01/14/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Occipito-cervical fusion can be necessary in case of cranio-cervical junction instability. Proximal stabilisation is usually ensured by bi-cortical occipital screws implanted through one median or two lateral occipital plate(s). Bone thickness variability as well as the proximity of vasculo-nervous elements can induce substantial morbidity. The choice of site and implant type remains difficult for surgeons and is often empirically based. Given this challenge, implants with smaller pitch to increase bone interfacing are being developed, as is a surgical technique consisting in inverted occipital hook clamps, a potential alternative to plate/screws association. We present here a biomechanical comparison of the different occipito-cervical fusion devices. METHODS We have developed a 3D mark tracking technique to measure experimental mechanical data on implants and occipital bone. Biomechanical tests were performed to study the mechanical stiffness of the occipito-cervical instrumentation on human skulls. Four occipital implant systems were analysed: lateral plates+large pitch screws, lateral plates+hooks, lateral plates+small pitch screws and median plate+small pitch screws. Mechanical responses were analysed using 3D displacement field measurements from optical methods and compared with an analytical model. FINDINGS Paradoxical mechanical responses were observed among the four types of fixations. Lateral plates+small pitch screws appear to show the best accordance of displacement field between bone/implant/system interface providing higher stiffness and an average maximum moment around 50 N.m before fracture. INTERPRETATION Stability of occipito-cervical fixation depends not only on the site of screws implantation and occipital bone thickness but is also directly influenced by the type of occipital implant.
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Affiliation(s)
- Arnaud Germaneau
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France; Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France.
| | - Tanguy Vendeuvre
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France; Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France
| | - Alexandre Delmotte
- Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France; Centre du Rachis de la Sauvergarde, 69009 Lyon, France
| | - Samuel D'Houtaud
- Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France; Service de Neurochirurgie Clinique, La Rochelle, France
| | - Cyril Brèque
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France; ABS Lab, Université de Poitiers, France
| | - Louis Petureau
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France
| | - Pascal Doumalin
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France
| | | | - Fabrice Brémand
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France
| | - Philippe Maxy
- Medtronic, Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | | | - Philippe Rigoard
- Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France; Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Poitiers, France
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Fiani B, Houston R, Siddiqi I, Arshad M, Reardon T, Gilliland B, Davati C, Kondilis A. Retro-Odontoid Pseudotumor Formation in the Context of Various Acquired and Congenital Pathologies of the Craniovertebral Junction and Surgical Techniques. Neurospine 2020; 18:67-78. [PMID: 33211944 PMCID: PMC8021814 DOI: 10.14245/ns.2040402.201] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/24/2020] [Indexed: 12/03/2022] Open
Abstract
Retro-odontoid pseudotumor formation consists of an abnormal growth of granulation tissue typically posterior to the odontoid process, resulting as a manifestation of atlantoaxial instability. This instability can occur as a result of conditions ranging from severe mechanical trauma to metabolic disease or autoimmune conditions such as rheumatoid arthritis. A pseudotumor may impinge on the spinal nerves or even the spinal cord and brainstem, manifesting symptoms from severe neck pain to cervicomedullary compression or myelopathy, and in some cases even sudden death. The objective of this review is to consolidate the findings in published case reports and relevant prior literature reviews regarding the formation of retro-odontoid pseudotumor. We address the pathophysiology involved in acquired and congenital pseudotumor formation, including those associated with rheumatoid arthritis (panni). Additionally, we discuss past and current operative techniques designed to curtail and ultimately regress a retro-odontoid pseudotumor and pannus. Surgical techniques that are addressed include ventral decompression (both transoral and transnasal), dorsal decompression, and indications for posterior instrumentation in pannus formation, particularly in cases that may be sufficiently treated in lieu of an anterior approach. Finally, we will examine the role of external orthoses as both a method of conservative treatment as well as a potential adjunct to the aforementioned surgical procedures.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Rebecca Houston
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Imran Siddiqi
- Western University of Health Sciences College of Osteopathic Medicine, Pomona, CA, USA
| | - Mohammad Arshad
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Taylor Reardon
- University of Pikeville, Kentucky College of Osteopathic Medicine, Pikeville, KY, USA
| | | | - Cyrus Davati
- New York Institute of Technology College of Osteopathic Medicine, Glen Head, NY, USA
| | - Athanasios Kondilis
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
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Ramos-Dávila EM, Meléndez-Flores JD, Álvarez-Pérez R, Barrera-Flores FJ, Martínez-Cobos MC, Pinales-Razo R, Quiroga-Garza A, Zarate-Garza P, Sanchez-Gomez A, Guzman-Lopez S, Elizondo-Omaña RE. Occipital condyle screw fixation viability according to age and gender anatomy: A computed tomography-based analysis. Clin Neurol Neurosurg 2020; 200:106358. [PMID: 33223342 DOI: 10.1016/j.clineuro.2020.106358] [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: 09/29/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the Occipital condyle morphology in an all-age population of Northeastern Mexico, and determine age and gender related changes for surgical viability. METHODS A total of 175 consecutive HRCT scans were included and divided into 5 age groups. The condylar length, width, height, sagittal angle, anterior, posterior and medial intercondylar distances, and intercondylar angle of the OC were measured. RESULTS Mean condylar length, width, and height in total population were 20.58 mm, 9.42 mm, and 9.02 mm, respectively. Differences were observed in most morphometric parameters when comparing age groups. Significant intergender differences in total population were observed in most parameters, when individualizing each age group the height remained significant in all. The group with the least height measurement was aged 5-9 years, this however, could allow the OC screw (≥6.5 mm) placement. CONCLUSION Differences in most morphometric parameters of OC were observed between age groups and gender, particularly patients with 5-9 years. However, all groups presented a minimum height that allows the placement of a standard screw. A preoperative imaging study is always recommended due to the variability and complexity of the region.
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Affiliation(s)
| | | | - Ricardo Álvarez-Pérez
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José Eleuterio González", Department of Radiology and Imaging, Monterrey, Mexico.
| | | | - Maria C Martínez-Cobos
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José Eleuterio González", Department of Radiology and Imaging, Monterrey, Mexico.
| | - Ricardo Pinales-Razo
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José Eleuterio González", Department of Radiology and Imaging, Monterrey, Mexico.
| | | | - Patricio Zarate-Garza
- Human Anatomy Department, Faculty of Medicine, Universidad Autónoma, Monterrey, Mexico.
| | - Arnulfo Sanchez-Gomez
- Human Anatomy Department, Faculty of Medicine, Universidad Autónoma, Monterrey, Mexico.
| | - Santos Guzman-Lopez
- Human Anatomy Department, Faculty of Medicine, Universidad Autónoma, Monterrey, Mexico.
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3D-printed navigation template in cervical spine fusion: a systematic review and meta-analysis. 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 2020; 30:389-401. [DOI: 10.1007/s00586-020-06601-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 06/28/2020] [Accepted: 09/05/2020] [Indexed: 12/19/2022]
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Mahtabfar A, Mazza J, Franco D, Gonzalez GA, Hines K, Chalouhi N, Jabbour P, Harrop J, Heller J. Cranial Settling Causing Intracranial Hemorrhage Through Violation of the Skull Base by Cervical Spine Instrumentation. World Neurosurg 2020; 145:178-182. [PMID: 32890852 DOI: 10.1016/j.wneu.2020.08.193] [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: 06/12/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic inflammatory polyarthropathy that affects many synovial joints favoring the hands, knees, and vertebral articulations. Joint laxity manifests as subaxial instability, atlantoaxial instability, and cranial settling (CS). CASE DESCRIPTION A 70-year-old woman with past medical history of RA, Hashimoto's thyroiditis, osteoporosis, history of C1-2 fusion for instability 15 years prior, with subsequent revision cervicothoracic fusion for degeneration, and trauma 2 years prior presents with new onset headache, nausea, and vomiting of 36-hour duration. Neurologic examination was only notable for mild right dysmetria. Workup revealed acute hemorrhage in the posterior fossa with migration of the right rod implant and screw tulip, as a result of CS. The patient underwent occipital-cervical fusion with removal of the migratory hardware. CONCLUSIONS Intracranial rod migration and hemorrhage secondary to CS is a rare complication that must be brought to the attention of surgeons operating on patients with RA.
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Affiliation(s)
- Aria Mahtabfar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
| | - Jacob Mazza
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Daniel Franco
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Glenn A Gonzalez
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kevin Hines
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - James Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Joshua Heller
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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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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Kim KD, Panchal R, Moldavsky M, Wang W, Bucklen BS. Effects of pre-contoured and in situ contoured rods on the mechanical strength and durability of posterior cervical instrumentation: a finite-element analysis and scanning electron microscopy investigation. Spine Deform 2020; 8:569-576. [PMID: 32430793 DOI: 10.1007/s43390-020-00078-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 12/18/2019] [Indexed: 12/01/2022]
Abstract
STUDY DESIGN Finite-element analysis. OBJECTIVES Intraoperative contouring of rods is a common procedure for spine surgeons to match the native curvature of the spine, but it may lead to premature weakening of the rod. This study investigated the effect of different bending methods on rod fatigue performance. Rod failure in the cervical spine is of clinical concern, particularly when spanning the cervicothoracic region and when considering corrective osteotomies for deformity correction and global spinal alignment. METHODS Finite-element models were developed to simulate rod bending (3.5 mm D, 40 mm L) to achieve a 23° angle with 3 different bending methods: French single, multiple bending, and in situ bending. Simulations were conducted in 4 steps: rod bending, rod spring back, residual stress relaxation, and F1717 mechanical test simulation. RESULTS French single bending resulted in the highest residual stress concentrations for both titanium (TiAlV) and cobalt chrome (CoCr) at 783 MPa and 507 MPa, respectively. During F1717 test simulation, the French single bent rod had its highest tensile stress in the middle, with 917 MPa and 623 MPa, respectively, for TiAlV and CoCr, compared to in situ (580 MPa and 586 MPa for TiAlV and CoCr) and the French multiple bent rod (765 MPa and 619 MPa for TiAlV and CoCr). The computational model found that CoCr rods made the construct least prone to deformation. CONCLUSIONS French single bend with TiAlV rods put the construct at highest risk of failure. CoCr rods led to minimal physical changes in microstructure while showing evidence of flattening.
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Affiliation(s)
- Kee D Kim
- UC Davis Medical Center, UC Davis School of Medicine, 4860 Y Street, Suite 3740, Sacramento, CA, 95817, USA
| | - Ripul Panchal
- American Neurospine Institute, PLLC 4001 West 15th Street, Suite 445, Plano, TX, 75093-5845, USA
| | - Mark Moldavsky
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA, 19403, USA
| | - Wenhai Wang
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA, 19403, USA.
| | - Brandon S Bucklen
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA, 19403, USA
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Wang YC, Zhou ZZ, Wang B, Zhang K, Chen H, Chen KW, Mao HQ. Occipitocervical Fusion via Cervical Pedicle Fixation Assisted with O-arm Navigation. Orthop Surg 2020; 12:1100-1107. [PMID: 32697041 PMCID: PMC7454157 DOI: 10.1111/os.12704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 11/30/2022] Open
Abstract
Objective To describe the clinical outcomes of occipitocervical fusion (OCF) using cervical pedicle fixation with assistance of O‐arm navigation and present its clinical feasibility. Methods From January 2015 to December 2016, eight patients with a variety of diagnoses were surgically treated with occipitocervical fusion using cervical pedicle screws under O‐arm navigation. All patients received full workup consisting of clinical and radiological assessments. Perioperative parameters including operating time, intraoperative blood loss, postoperative complications, surgical outcomes were recorded. Postoperative data were acquired resorting to the scheduled follow‐up 3, 6 and 12 months after their discharge and annually afterwards. The Japanese Orthopaedic Association (JOA) Scores and American Spinal Injury Association (ASIA) Scale were used to evaluate neurological function. The accuracy of screw placement was classified according to a modified classification of Gertzbein and Robbins. The fusion status was evaluated in reference to the Bridwell's posterior fusion grades. Results The patient cohort comprised of five males and three females, with the average age of 51.9 years (range from 18 to 74 years). The patients all showed indications for OCF and were performed with polyaxial screws through cervical pedicles. The average operation time was 274 min (range from 226 to 380 min), with the intraoperative blood loss of 437.5 mL and the blood transfusion volume of 481.3 mL. The average follow‐up time was 23.5 months (range from 17 to 32 months). All patients exhibited radiographic evidence of osseous fusion by X‐ray and computed tomography (CT) at the final follow‐up. No neurovascular complications were found during the follow‐up time, and the clinical symptoms were observed to be significantly improved in all the patients. Thirty‐four cervical pedicle screws were implanted within the eight patients, with the accuracy of cervical pedicle screw placements as 94.1% (32/34), among which, two pedicle screws were found to broken through the cervical pedicles that were evaluated as Grade II. Conclusions Occipitocervical fusion via cervical pedicle fixation assisted with O‐arm navigation is a feasible and safe procedure with a vast range of indications.
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Affiliation(s)
- Yu-Cheng Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China.,Department of Orthopaedic Surgery, Suzhou Hospital of Traditional Chinese Medicine, Suzhou, China
| | - Zhang-Zhe Zhou
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Bin Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China.,Department of Orthopaedic Surgery, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kai Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hao Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Kang-Wu Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hai-Qing Mao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Posterior Occipitocervical Fusion for Unstable Upper Cervical Trauma in Old and Elderly Population, Although Decreases Upper Cervical Rotation, Does Not Significantly Increase Neck Disability Index. Adv Orthop 2020; 2020:7906985. [PMID: 32802518 PMCID: PMC7416230 DOI: 10.1155/2020/7906985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/10/2020] [Indexed: 11/18/2022] Open
Abstract
Background Despite the research progress in the thoraco-lumbo-pelvic balance, cervical spine balance has only recently gained increasing interest. To our knowledge, there is a lack of research regarding sagittal occipitocervical spine balance restoration following posterior occipitocervical fusion (POCF). Purpose The primary outcome measure is the evaluation of sagittal cervical alignment roentgenographic parameters and the secondary is the functional outcome (NDI), following POCF for upper (C1 & C2) cervical trauma (UCT) in coexistence with upper cervical spine degeneration. Patients and Methods. Twenty old and elderly patients aged 62 ± 12 years with evident upper cervical degeneration, who received POCF for upper C1 & C2 unstable cervical spine injuries, were included. C2-C7 lordosis, C2-C7 SVA, spinocranial angle (SCA), T1-slope, neck tilt (NT), thorax inlet angle (TIA), cervical tilt (CT), cranial tilt (CrT), and C0-C1 angle were measured. The subfusion angle was used to study the behavior of the unfused cervical segments below fusion. The Neck Disability Index (NDI) was used for the functional outcome evaluation. 29 age-matched individuals were used as controls for radiographic analysis and self-reported functional status comparison. Results The roentgenographic data were measured 3 and 39 ± 12 months postoperatively. Twelve patients showed no disability, and eight showed mild disability. Postoperatively, the patients stood with less C2-C7 lordosis, SCA, and CT (P < 0.02) but with higher NT (P < 0.02) in comparison to the controls. The patient's neck disability (NDI) was increasing as TIA increases (P=0.023). Subfusion angle seems to adapt to C2-C7 lordosis (P < 0.0033) and C0-C2 angle (P < 0.003) without any changes till the last evaluation. Conclusions POCF sufficiently restored occipitocervical sagittal balance along with functional outcome similar to controls in adult and elderly individuals with evident upper cervical degeneration. We do not recommend POCF for young active individuals without occipitocervical pathology, but in contrary, we recommend the removal of the spinocranial connection hardware after cervical fusion is completed.
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Ortega-Balderas JA, Sada-Treviño MA, Barrera-Flores FJ, Zárate-Garza PP, Lugo-Guillén RA, Gómez-Sánchez A, Pinales-Razo R, Elizondo-Riojas G, Guzmán-López S, Elizondo-Omaña RE. Avoiding iatrogenic injuries to the vertebral artery: A morphometric study of the vertebral artery-free dissection area. Clin Neurol Neurosurg 2020; 196:106001. [PMID: 32534385 DOI: 10.1016/j.clineuro.2020.106001] [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: 04/24/2020] [Revised: 06/03/2020] [Accepted: 06/06/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the area of a safety window that excludes the vertebral artery for the safe access of the occipital condyle screws during occipitocervical fixation. METHODS This study included 138 cervical computed tomography angiograms. Six measurements per side were made in each imaging study. These measurements are from the vertebral artery to (A) the mastoid process, (B) the mastoid incisura, (C) the posterior condylar fossa, (D) the occipital condyle in its midline, and (E) the medial border of the condyle. We also measured from the tip of the mastoid process to the lower border of the occipital condyle on its lateral side (F). RESULTS A total of 276 areas from 138 individuals were included, of which 51.4 % were men. The mean age was 54.2 ± 18.63 years. The mean variable measurements (mm) for all the population were 21 ± 4, 16 ± 3, 6 ± 2, 3 ± 2, 2 ± 1 and 35 ± 4 for variables A-F, respectively. We found significant differences between sex when we compared measurements A (p = 0.003), C (p = 0.001), D (p = 0.000) and F (p = 0.000). The incidence rate of dominance for the vertebral artery was 18.8 % and 30.4 % for right and left respectively. CONCLUSION Women had significantly smaller measures than men. This could indicate a higher risk of iatrogenic injury secondary to a smaller vertebral artery-free area. Results may guide surgeons in the pre-surgical planning aiming to reduce the risk of iatrogenic injuries to the vertebral artery.
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Affiliation(s)
- Jessica A Ortega-Balderas
- Human Anatomy Department, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
| | - Miguel A Sada-Treviño
- Radiology and Imaging Department, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
| | - Francisco J Barrera-Flores
- Human Anatomy Department, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
| | - Pablo P Zárate-Garza
- Human Anatomy Department, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
| | - Roberto A Lugo-Guillén
- Human Anatomy Department, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
| | - Arnulfo Gómez-Sánchez
- Human Anatomy Department, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
| | - Ricardo Pinales-Razo
- Radiology and Imaging Department, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
| | - Guillermo Elizondo-Riojas
- Radiology and Imaging Department, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
| | - Santos Guzmán-López
- Human Anatomy Department, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
| | - Rodrigo E Elizondo-Omaña
- Human Anatomy Department, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico.
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Ji W, Lin S, Bao M, Zou X, Ge S, Ma X, Chen J, Yang J. Anatomical analysis of the occipital bone in patients with basilar invagination: a computed tomography-based study. Spine J 2020; 20:866-873. [PMID: 31972304 DOI: 10.1016/j.spinee.2020.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/09/2020] [Accepted: 01/11/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The occipital bone is often involved in the surgical treatment of basilar invagination (BI). However, the anatomy of the occipital bone associated with BI patients has yet to be investigated. PURPOSE To present a morphological map of the occipital bone in BI patients and help guide screw placement for occipitocervical fusion. STUDY DESIGN A retrospective case-control study. METHODS Radiological measurements of the occipital bone were performed on computed tomography images based on a matrix of 99 points centered around the external occipital protuberance (EOP) in a cohort of 50 BI patients and 50 cases with no head and cervical disease. The comparison between the BI group and the control group was assessed using Student t analysis and p<.05 was considered statistically significant. RESULTS All thicknesses measured from points of the matrix in the BI group were thinner than those in the control group (p<.05). The maximum thicknesses in both groups were located at the center of the EOP, which were 15.11±2.84 mm in the BI group and 17.56±3.03 mm in the control group, respectively. Additionally, thickness decreased with the distance away from the center of EOP. CONCLUSIONS The occipital bone in BI patients is thinner than that in the general population. A limited safe zone in BI patients is available for surgeons to place screws, which may need to be fully evaluated before operation.
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Affiliation(s)
- Wei Ji
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Ave, Guangzhou, China
| | - Shaoyi Lin
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Ave, Guangzhou, China
| | - Minggui Bao
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Ave, Guangzhou, China
| | - Xiaobao Zou
- Department of Spinal Surgery, General Hospital of Southern Theatre Command, 111 Liuhua Rd, Guangzhou, China
| | - Su Ge
- Department of Spinal Surgery, General Hospital of Southern Theatre Command, 111 Liuhua Rd, Guangzhou, China
| | - Xiangyang Ma
- Department of Spinal Surgery, General Hospital of Southern Theatre Command, 111 Liuhua Rd, Guangzhou, China.
| | - Jianting Chen
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Ave, Guangzhou, China.
| | - Jincheng Yang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Ave, Guangzhou, China.
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Bosco A, Aleem I, La Marca F. Occipital condyle screws: indications and technique. JOURNAL OF SPINE SURGERY 2020; 6:156-163. [PMID: 32309654 DOI: 10.21037/jss.2020.03.01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Occipitocervical instability is a life threatening and disabling disorder caused by a myriad of pathologies. Restoring the anatomical integrity and stability of the occipitocervical junction (OCJ) is essential to achieve optimal clinical outcomes. Surgical stabilization of the OCJ is challenging and technically demanding. There is a paucity of options available for anchorage in the cephalad part of the construct in occipitocervical fixation systems due to the intricate topography of the craniocervical junction combined with the risk of injury to the surrounding anatomical structures. Surgical techniques and instrumentation for stabilizing the unstable OCJ have undergone several modifications over the years and have primarily depended on occipital squama-based fixations. At present, the occipital-plate-screw-rod construct is the most commonly adopted technique of stabilizing the OCJ. In certain distinct scenarios like posterior fossa craniectomy (absence of occipital squama for screw placement), malignancy and infection of occipital squama (poor screw purchase in the diseased occipital bone) and in revision surgery for failed occipitocervical stabilization, occipital plate-based instrumentation is not feasible. To overcome these difficulties, recently, a novel technique of occipitocervical stabilization, using the occipital condyle (OC) as the cephalad anchor, namely the direct occipital condyle screw (OCS) fixation was described. Several cadaveric and biomechanical studies have suggested that OCSs are feasible options as additional augmentative anchors in a standard occipital plate-screw-rod construct or as salvage cephalad anchors in previous failed occipital-plate-screw-rod constructs. The OCS placement technique has a steep learning curve. We have done a review of the techniques of OCS fixation and have described the indications, biomechanical and technical considerations, preoperative planning, surgical technique, complications, advantages and limitations of OCS based occipitocervical fixation.
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Affiliation(s)
- Aju Bosco
- Assistant Professor in Orthopedics and Spine Surgery, Orthopedic Spine Surgery Unit, Institute of Orthopedics and Traumatology, Madras Medical College, Chennai, India
| | - Ilyas Aleem
- Department of Orthopedic Surgery, University of Michigan, 2912 Taubman Center, Ann Arbor, MI, USA
| | - Frank La Marca
- Professor of Neurological Surgery, Henry Ford Health System, Jackson, MI, USA
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Occipital Condyle Screw Placement in Patients with Chiari Malformation: A Radiographic Feasibility Analysis and Cadaveric Demonstration. World Neurosurg 2020; 136:470-478. [PMID: 32204299 DOI: 10.1016/j.wneu.2020.01.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/15/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Patients who undergo decompression surgery for Chiari malformation frequently require occipitocervical fixation. This is typically performed with occipital plates, which may cause intracranial injuries due to multiple fixation points. We undertook this study to assess the feasibility of occipital condyle (OC) screw placement as an alternative method of occipitocervical fixation in this patient population. METHODS Using a cadaveric model with navigational assistance, we performed the complete surgical procedure for occipitocervical fixation with OC screws. We then performed a morphometric analysis using measurements from computed tomography scans of 49 patients (32 adult, 17 pediatric) who had undergone occipitocervical fusion with instrumentation following decompression surgery for Chiari malformation. Bilateral morphometric data were analyzed for the adult and pediatric subgroups separately, as well as for the overall group. RESULTS The surgical procedure was successfully performed in the cadaveric model, demonstrating the feasibility of the proposed method. Ninety-eight OCs were studied in the morphometric analysis, and 80 (81.6%) met our eligibility criteria for OC screw placement. However, in 14.1% of adult OCs and 26.5% of pediatric OCs studied, placement of condylar screws would have been challenging or unsafe, according to our criteria. CONCLUSIONS Our findings suggest that OC screws provide a useful option for occipitocervical fixation in a substantial proportion of patients with Chiari malformation. However, rigorous preoperative analysis would be essential to identify appropriate candidates for this technique and exclude those in whom it should not be attempted. Additional study is warranted.
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Abstract
INTRODUCTION Traditionally, fluoroscopy and postoperative computed tomographic (CT) scans are used to evaluate screw position after pediatric cervical spine fusion. However, noncontained screws detected postoperatively can require revision surgery. Intraoperative O-arm is a 3-dimensional CT imaging technique, which allows intraoperative evaluation of screw position and potentially avoids reoperations because of implant malposition. This study's objective was to evaluate the use of intraoperative O-arm in determining the accuracy of cervical implants placed by a free-hand technique using anatomic landmarks or fluoroscopic guidance in pediatric cervical spine instrumentation. METHODS A single-center retrospective study of consecutive examinations of children treated with cervical spine instrumentation and intraoperative O-arm from 2014 to 2018 was performed. In total, 44 cases (41 children, 44% men) with a mean age of 11.9 years (range, 2.1 to 23.5 y) were identified. Instability (n=16, 36%) and deformity (n=10, 23%) were the most frequent indications. Primary outcomes were screw revision rate, neurovascular complications caused by noncontained screws, and radiation exposure. RESULTS A total of 272 screws were inserted (60 occipital and 212 cervical screws). All screws were evaluated on fluoroscopy as appropriately placed. Four screws (1.5%) in 4 cases (9%) were noncontained on O-arm imaging and required intraoperative revision. A mean of 7.7 levels (range, 5 to 13) were scanned. The mean CT dose index and dose-length product were 15.2±6.87 mGy and 212.3±120.48 mGy×cm. Mean effective dose was 1.57±0.818 mSv. There was no association between screw location and noncontainment (P=0.129). No vertebral artery injuries, dural injuries, or neurologic deficits were related to the 4 revised screws. CONCLUSIONS Intraoperative non-navigated O-arm is a safe and efficient method to evaluate screw position in pediatric patients undergoing cervical spine instrumentation. Noncontained screws were detected in 9% of cases (n=4). O-arm delivers low radiation doses, allows for intraoperative screw revision, and negates the need for postoperative CT scans after confirmation of optimal implant position. LEVEL OF EVIDENCE Level IV.
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Wu A, Jin H, Dou H, Pan X, Sheng S, Huang C, Wang X. Anterior decompression through transoral axis slide and rotation osteotomy for salvage of failed posterior occipitocervical fusion: a novel technique note. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:129. [PMID: 32175422 DOI: 10.21037/atm.2020.02.39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Atlantoaxial dislocation could be caused by odontoid fractures or Os odontoideum. The previous surgical techniques in treatment of atlantoaxial dislocation were based on arch remove decompression or anterior atlantoaxial release and atlantoaxial (occipital-cervical) screw fixation-based reduction and fusion. However, for some clinical situations, all of above techniques cannot be applied. In this study, a patient with atlantoaxial dislocation caused by Os odontoideum treated by posterior occipitocervical fusion 20 years ago and failed. We design a novel anterior decompression through transoral axis slide and rotation osteotomy for salvage of this failed posterior occipitocervical fusion case. The C2 body and odontoid process was ventrally slide and rotation at good position after operation as well as the position of plate and screws, the spinal canal was increased significantly after operation too. We suggest this anterior decompression through transoral "C2 slide and rotation" technique is good choice for salvage of failed posterior occipitocervical fusion and some irreducible atlantoaxial dislocation because of the anterior bony fusion, it could direct decompress the spinal cord anteriorly, avoid the odontoid resection, and is feasible and safe technique.
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Affiliation(s)
- Aimin Wu
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Haiming Jin
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Haicheng Dou
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Xiangxiang Pan
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Sunren Sheng
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Chongan Huang
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Xiangyang Wang
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
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Occipitocervical fusion complicated with cerebellar abscess: a case report. BMC Musculoskelet Disord 2020; 21:129. [PMID: 32111221 PMCID: PMC7049210 DOI: 10.1186/s12891-020-3157-0] [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: 10/31/2019] [Accepted: 02/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occipitocervical (OC) fusion is indicated for OC instability and other conditions. Surgical complications include infection, malunion, and instrument failure. CASE PRESENTATION We described a patient who underwent OC fusion and subsequently developed complication of cerebellar abscess and obstructive hydrocephalus. A 63-year-old male patient had been suffering from long-term neck pain and limb numbness and weakness. Cervical spine examination revealed tight stenosis at C1 level and instability in the C1-C2 joints. A C1 laminectomy with OC fusion was performed, and the patient was discharged. Unfortunately, a few days later, he went to the emergency department and complained of persistent dizziness, vomiting, and unsteady gait. Computed tomography (CT) and magnetic resonance imaging (MRI) images revealed a suspicious cerebellar abscess formation and hydrocephalus. Furthermore, CT images indicated that the left screw was loose, and the diameter of the right screw hole was much larger than the size of the screw. Besides, inappropriate length of the screw penetrated the occipital bone and may cause the disruption of dura mater. The patient underwent external ventricular drainage first, followed by abscess drainage and C1-C2 fixation a few days later. He was discharged without any further neurological deficits or infectious problems. The patient recovered with intact consciousness, full muscle strength, and improved numbness throughout the extremities, with a Nurick grade of 1. A follow-up magnetic resonance imaging at 3 months after surgery revealed near total resolution of the abscess. Inform consent was obtained from this patient. CONCLUSIONS Carefully conducting the procedure using the most tailored approach is essential to successful surgery, but this rare complication should always be kept in mind.
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Grover PJ, Harris LS, Thompson DNP. Craniovertebral junction fixation in children less than 5 years. 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 2020; 29:961-969. [PMID: 32016540 DOI: 10.1007/s00586-020-06313-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/22/2019] [Accepted: 01/18/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Whilst rigid fixation for craniovertebral instability is the gold standard, in very young, small children conventional management may have to be modified. We present a single-centre experience of craniocervical fixation in children under 5 years. METHODS A retrospective review of cases that had undergone atlantoaxial (AA) or occipitocervical (OC) fixation aged under 5 years. Fusion was assessed using computerised tomography or flexion extension X-rays. RESULTS Twenty-six children (median age 2.3, range 0.8-4.9 years, 19 under the age of 3) underwent OC (n = 19) or AA (n = 7) fusion between 1999 and 2016. Pathology comprised 17 congenital, five trauma, two tumour and two post-infection cases. Twenty-one patients underwent sublaminar cable fixation with calvarial, autologous bone graft and halo-body orthosis immobilisation. An occipital plate and rods to sublaminar wire construct were used in four cases. A rigid instrumented fixation with occipital plate and C2 pedicle screws was utilised in one case. Follow-up was for a median of 2.8 years (range 0.03-16.3 years). Initial fusion rate was 91%, reaching 100% following two re-operations. Ninety-two per cent of patients were neurologically stable or improved following surgery. Twenty-one patients had a good overall outcome. Two patients had post-operative neurological deteriorations, and four died due to non-procedure related causes. Pin site morbidity secondary to halo use occurred in five cases. CONCLUSION High fusion rates with good outcomes are achievable using semi-rigid fixation in the under 5-year-olds. Full thickness, autologous calvarial bone graft secured with wire cables and halo external orthosis offers a safe and effective alternative technique when traditional screw instrumentation is not feasible. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Patrick J Grover
- Department of Neurosurgery, Great Ormond Street Hospital, 34 Great Ormond Street, London, WC1N 3JH, UK.
| | - Lauren S Harris
- Department of Neurosurgery, Great Ormond Street Hospital, 34 Great Ormond Street, London, WC1N 3JH, UK
| | - Dominic N P Thompson
- Department of Neurosurgery, Great Ormond Street Hospital, 34 Great Ormond Street, London, WC1N 3JH, UK
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Upadhyaya M, Jain S, Kire N, Merchant Z, Kundnani V, Patel A. Surgical, clinical, and radiological outcomes of occipitocervical fusion using the plate-screw-rod system with allograft in craniocervical instability. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 10:216-223. [PMID: 32089614 PMCID: PMC7008657 DOI: 10.4103/jcvjs.jcvjs_87_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/06/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: We evaluated surgical, clinical, and radiological outcomes of posterior occipitocervical fusion (OCF) using plate–rod–screw construct supplemented with allograft in cases of occipitocervical instability. Study Design: This was a retrospective analysis of prospective collected data. Methods: Data of 52 patients who underwent posterior OCF using plate–screw–rod construct supplemented with allograft at a single institute from 2009 to 2014 were analyzed. Demographics, clinical parameters (Visual Analog Score [VAS], ODI, and mJOA score), functional status (McCormick scale), radiological parameters – mean atlantodens interval, posterior occipitocervical angle, occipitocervical 2 angle, and surgical parameters (operative time, blood loss, hospital stay, and fusion) with complications were evaluated. Results: The mean age of the patients was 54.56 ± 16.21 years with male: female was 28:24. The mean operative time was 142.2 min (90–185 min) and mean blood loss was 250.8 ml. The mean duration of hospital stay was 6.7 days and mean follow-up period was 65.17 ± 5.39 months. There was significant improvement in clinical parameters (modified JOA score, VAS, and Oswestry Disability Index values) postoperatively. Forty patients showed recovery in neurological status at least in Grade 1 in McCormick scale with no neurological deterioration in any patient. Furthermore, radiological parameters at cervicomedullary junction got into acceptable range. Implant-related complications noted in 1 patient and 1 patient had vertebral artery injury. We had dural tear in 3 patients and infection in 2 patients. Fusion was achieved in 46 cases with mean time for fusion was 11.039 months. Conclusion: Patients with occipitocervical instability can successfully undergo posterior OCF using plate–screw–rod construct supplemented with allograft with high fusion rate, good clinical and functional outcomes, and low complication rate.
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Affiliation(s)
- Mihir Upadhyaya
- Bombay Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Sanyam Jain
- Bombay Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Neilakuo Kire
- Bombay Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Zahir Merchant
- Bombay Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Vishal Kundnani
- Bombay Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Ankit Patel
- Bombay Hospital and Research Centre, Mumbai, Maharashtra, India
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Wenning KE, Hoffmann MF. Does isolated atlantoaxial fusion result in better clinical outcome compared to occipitocervical fusion? J Orthop Surg Res 2020; 15:8. [PMID: 31918713 PMCID: PMC6953136 DOI: 10.1186/s13018-019-1525-y] [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: 10/12/2019] [Accepted: 12/18/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The C0 to C2 region is the keystone for range of motion in the upper cervical spine. Posterior procedures usually include a fusion of at least one segment. Atlantoaxial fusion (AAF) only inhibits any motion in the C1/C2 segment whereas occipitocervical fusion (OCF) additionally interferes with the C0/C1 segment. The purpose of our study was to investigate clinical outcome of patients that underwent OCF or AAF for upper cervical spine injuries. METHODS Over a 5-year period (2010-2015), consecutive patients with upper cervical spine disorders were retrospectively identified as having been treated with OCF or AAF. The Numeric Pain Rating Scale (NPRS) and the Neck Disability Index (NDI) were used to evaluate postoperative neck pain and health restrictions. Demographics, follow-up, and clinical outcome parameters were evaluated. Infection, hematoma, screw malpositioning, and deaths were used as complication variables. Follow-up was at least 6 months postoperatively. RESULTS Ninety-six patients (male = 42, female = 54) underwent stabilization of the upper cervical spine. OCF was performed in 44 patients (45.8%), and 52 patients (54.2%) were treated with AAF. Patients with OCF were diagnosed with more comorbidities (p = 0.01). Follow-up was shorter in the OCF group compared to the AAF group (6.3 months and 14.3 months; p = 0.01). No differences were found related to infection (OCF 4.5%; AAF 7.7%) and revision rate (OCF 13.6%; AAF 17.3%; p > 0.05). Regarding bother and disability, no differences were discovered utilizing the NDI score (AAF 21.4%; OCF 37.4%; p > 0.05). A reduction of disability measured by the NDI was observed with greater follow-up for all patients (p = 0.01). CONCLUSION Theoretically, AAF provides greater range of motion by preserving the C0/C1 motion segment resulting in less disability. The current study did not show any significant differences regarding clinical outcome measured by the NDI compared to OCF. No differences were found regarding complication and infection rates in both groups. Both techniques provide a stable treatment with comparable clinical outcome.
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Affiliation(s)
- Katharina E Wenning
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789, Bochum, Germany.
| | - Martin F Hoffmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789, Bochum, Germany
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Patient-specific processes for occipitocervical fixation using biomodelling and additive manufacturing. J Clin Neurosci 2020; 71:251-256. [DOI: 10.1016/j.jocn.2019.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 08/30/2019] [Accepted: 10/04/2019] [Indexed: 11/19/2022]
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Baba S, Matsumoto Y, Kawaguchi K, Iida K, Saiwai H, Okada S, Matsunobu A, Shioyama Y, Nakashima Y. Post-carbon-ion radiotherapy vertebral pathological fractures in upper cervical primary malignant spinal tumors treated by occipito-cervical fusion. Arch Orthop Trauma Surg 2019; 139:1525-1531. [PMID: 30944982 DOI: 10.1007/s00402-019-03183-x] [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: 01/10/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe the characteristic features of post-carbon-ion radiotherapy (CIRT) vertebral pathological fractures (VPFs) in upper cervical primary malignant spinal tumors (PMSTs) treated by occipito-cervical (OC) fusion. METHODS OC fusion was performed for three consecutive patients with post-CIRT VPFs. The clinical results and imaging findings, including bone single-photon emission computed tomography (SPECT)/CT were prospectively collected. RESULTS No surgery-related wound complication and surgical site infection were noted. One patient experienced re-fracture and displacement of dens with the loosening of occipital screws and was treated by posterior revision surgery. At the final follow-up, all patients were alive without evidence of disease, and the solid OC fusion was confirmed. Bone SPECT/CT clearly revealed the effect of CIRT on bone turnover in the irradiated field. CONCLUSION The OC fusion with autologous bone grafts was a reliable option for the treatment of post-CIRT VPCs in the patients with upper cervical PMSTs. In addition, evaluation of the bone turnover at the irradiated field by bone SPECT/CT would help surgeons select an effective plan of care, such as fusion level and postoperative care.
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Affiliation(s)
- Satoshi Baba
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Keiichiro Iida
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Hirokazu Saiwai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | | | | | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
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