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Henderson FC, Schubart JR, Narayanan MV, Tuchman K, Mills SE, Poppe DJ, Koby MB, Rowe PC, Francomano CA. Craniocervical instability in patients with Ehlers-Danlos syndromes: outcomes analysis following occipito-cervical fusion. Neurosurg Rev 2024; 47:27. [PMID: 38163828 PMCID: PMC10758368 DOI: 10.1007/s10143-023-02249-0] [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: 06/16/2023] [Revised: 11/30/2023] [Accepted: 12/09/2023] [Indexed: 01/03/2024]
Abstract
Craniocervical instability (CCI) is increasingly recognized in hereditary disorders of connective tissue and in some patients following suboccipital decompression for Chiari malformation (CMI) or low-lying cerebellar tonsils (LLCT). CCI is characterized by severe headache and neck pain, cervical medullary syndrome, lower cranial nerve deficits, myelopathy, and radiological metrics, for which occipital cervical fusion (OCF) has been advocated. We conducted a retrospective analysis of patients with CCI and Ehlers-Danlos syndrome (EDS) to determine whether the surgical outcomes supported the criteria by which patients were selected for OCF. Fifty-three consecutive subjects diagnosed with EDS, who presented with severe head and neck pain, lower cranial nerve deficits, cervical medullary syndrome, myelopathy, and radiologic findings of CCI, underwent open reduction, stabilization, and OCF. Thirty-two of these patients underwent suboccipital decompression for obstruction of cerebral spinal fluid flow. Questionnaire data and clinical findings were abstracted by a research nurse. Follow-up questionnaires were administered at 5-28 months (mean 15.1). The study group demonstrated significant improvement in headache and neck pain (p < 0.001), decreased use of pain medication (p < 0.0001), and improved Karnofsky Performance Status score (p < 0.001). Statistically significant improvement was also demonstrated for nausea, syncope (p < 0.001), speech difficulties, concentration, vertigo, dizziness, numbness, arm weakness, and fatigue (p = 0.001). The mental fatigue score and orthostatic grading score were improved (p < 0.01). There was no difference in pain improvement between patients with CMI/LLCT and those without. This outcomes analysis of patients with disabling CCI in the setting of EDS demonstrated significant benefits of OCF. The results support the reasonableness of the selection criteria for OCF. We advocate for a multi-center, prospective clinical trial of OCF in this population.
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Affiliation(s)
- Fraser C Henderson
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA.
| | - Jane R Schubart
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Malini V Narayanan
- Division of Neurosurgery, University of Maryland Capital Region Medical Center, Largo, Maryland, USA
| | - Kelly Tuchman
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
| | - Susan E Mills
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Dorothy J Poppe
- Bobby Jones Chiari & Syringomyelia Foundation, Staten Island, New York, USA
| | - Myles B Koby
- Luminis Health, Doctors Community Medical Center, Lanham, Maryland, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Nicholson LL, Rao PJ, Lee M, Wong TM, Cheng RHY, Chan C. Reference values of four measures of craniocervical stability using upright dynamic magnetic resonance imaging. LA RADIOLOGIA MEDICA 2023; 128:330-339. [PMID: 36715785 PMCID: PMC10020271 DOI: 10.1007/s11547-023-01588-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 01/04/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE To establish reference ranges for four most commonly used diagnostic measures of craniocervical instability (CCI) in three cervical sagittal positions. This necessitated development of a reliable measurement protocol using upright, dynamic MRI (udMRI), to determine differences in the extent of motion between positions, and whether age and sex correlate with these measures. MATERIALS AND METHODS Deidentified udMRIs of 50 adults, referred for reasons other than CCI, were captured at three positions (maximal flexion, maximal extension and neutral). Images were analyzed, providing measures of basion-axial interval, basion-axial angle, basion-dens interval (BDI) and the Grabb-Oakes line (GOL) for all three positions (12 measures per participant). All measures were independently recorded by a radiologist and neurosurgeon to determine their reliability. Descriptive statistics, correlations, paired and independent t-tests were used. Mean (± 2 SD) identified the reference range for all four measures at each craniocervical position. RESULTS The revised measurement protocol produced inter-rater reliability indices of 0.69-0.97 (moderate-excellent). Fifty adults' (50% male; mean age 41.2 years (± 9.7)) reference ranges for all twelve measures were reported. Except for the BDI and GOL when moving between neutral and full flexion, significant extents of movement were identified between the three craniocervical positions for all four measures (p ≤ 0.005). Only a minor effect of age was found. CONCLUSIONS This is the first study to provide a rigorous standardized protocol for four diagnostic measures of CCI. Reference ranges are established at mid and ends of sagittal cervical range corresponding to where exacerbations of signs and symptoms are commonly reported.
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Affiliation(s)
- Leslie L Nicholson
- School of Medical Sciences, The University of Sydney, Camperdown, NSW, Australia.
| | - Prashanth J Rao
- Macquarie University Hospital, Macquarie Park, NSW, Australia
- Faculty of Medicine and Health, Macquarie University, Macquarie Park, NSW, Australia
| | - Matthew Lee
- Radiology, Western Imaging Group, Blacktown, NSW, Australia
| | - Tsz Ming Wong
- Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Regen Hoi Yan Cheng
- Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Cliffton Chan
- School of Medical Sciences, The University of Sydney, Camperdown, NSW, Australia
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Tam SKP, Chia J, Brodbelt A, Foroughi M. Assessment of patients with a Chiari malformation type I. BRAIN AND SPINE 2022; 2:100850. [PMID: 36248113 PMCID: PMC9560699 DOI: 10.1016/j.bas.2021.100850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 11/30/2022]
Abstract
Introduction The prevalence of Chiari malformation type I (CM-I) has been estimated as up to 1% of the general population. The majority of patients are asymptomatic and usually do not need treatment. Symptomatic patients, and some asymptomatic patients with associated conditions, may benefit from further assessment and treatment. Research question The aim of this review was to describe the clinical and radiological assessment of patients presenting with a CM-I. Material and methods A literature search was performed using the PubMed and Embase databases focused on clinical assessment and imaging techniques used to diagnose CM-I. Results Following a complete clinical evaluation in patients with symptomatic CM-I and/or radiologically significant CM-I (tonsillar impaction, resulting tonsillar asymmetry and loss of CSF spaces), MRI of the brain and whole spine enables an assessment of the CM-I and potential associated or causative conditions. These include hydrocephalus, syringomyelia, spinal dysraphism, and tethered cord. Flow and Cine MRI can provide information on CSF dynamics at the craniocervical junction, and help in surgical decision-making. Hypermobility or instability at the upper cervical and craniocervical junction is less common and can be measured with CT imaging and flexion/extension or upright MRI. Discussion and conclusion The majority of CM-I detected are incidental findings on MRI imaging of brain or spine, and do not require intervention. Once a radiological diagnosis and concern has been raised, clinical assessment by an appropriate specialist is required. A MRI brain and cervical spine is indicated in all radiologically labelled CM-I. In symptomatic patients or cases of radiologically significant CM-I, MRI of the brain and entire spine is indicated. Further investigations should be tailored to individuals’ needs. A CM-I assessment should include a history and examination and a referral to a specialist. MRI of the brain and spine enables an assessment of the CM-I and potential associated conditions. Flow and Cine MRI can help in surgical decision-making.
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Affiliation(s)
- Sharon Ka Po Tam
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
- Corresponding author.
| | - Jonathan Chia
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
| | | | - Mansoor Foroughi
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
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Chu EC, Zoubi FA, Yang J. Cervicogenic Dizziness Associated With Craniocervical Instability: A Case Report. J Med Cases 2021; 12:451-454. [PMID: 34804305 PMCID: PMC8577610 DOI: 10.14740/jmc3792] [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: 09/15/2021] [Accepted: 10/13/2021] [Indexed: 12/03/2022] Open
Abstract
Cervicogenic dizziness (CGD) is a clinical syndrome characterized by an illusory sensation of motion and disequilibrium secondary to neck pathologies. Reported here is the case of a 40-year-old male presented with neck pain, dizziness, and aural symptoms in the past 12 months. The patient was previously diagnosed with Meniere’s disease and treated with a low-sodium diet, betahistine and vestibular rehabilitation for 4 months, but the symptoms had not been relieved. Subsequently he sought out chiropractic evaluation. Radiographic clues illustrated a subtle anterolisthesis of the occiput on the cervical spine, manifested by a dissociation of the clivo-axial angle (CXA). After exclusion of other neurological, vascular and vestibular causes, craniocervical instability was considered as the cause of the CGD. He was treated with multi-component intervention consisting of spinal manipulation, intermittent motorized traction and ultrasound therapy to release cervical complaints. The patient reported salutary consequences to the 3-month treatment course with no neurologic sequelae. The current study serves as a vivid example of identifying CGD based on a subtle radiographic clue and by utilizing CXA as an assessment tool for craniocervical instability.
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Affiliation(s)
- Eric ChunPu Chu
- New York Chiropractic and Physiotherapy Centre, 41/F Langham Place Office Tower, 8 Argyle Street, Hong Kong, China
| | - Fadi Al Zoubi
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, China
| | - Jian Yang
- LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Fiani B, Jarrah R, Sarno E, Kondilis A, Pasko K, Musch B. An investigation of craniocervical stability post-condylectomy. Surg Neurol Int 2021; 12:380. [PMID: 34513147 PMCID: PMC8422489 DOI: 10.25259/sni_456_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: 05/08/2021] [Accepted: 06/23/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Occipital condylectomy is often necessary to gain surgical access to various neurological pathologies. As the lateral limit of the craniovertebral junction (CVJ), partial condylectomy can lead to iatrogenic craniocervical instability. What was once considered an inoperable location is now the target of various complex neurosurgical procedures such as tumor resection and aneurysm clipping. Methods: In this study, we will review the anatomical structure of the CVJ and provide the first comprehensive assessment of studies investigating craniovertebral stability following condylectomy with the transcondylar surgical approaches. Furthermore, we discuss future considerations that must be evaluated to optimize the chances of preserving craniocervical stability postcondylectomy. Results: The current findings postulate upward of 75% of the occipital condyle can be resected without significantly affecting mobility of the CVJ. The current findings have only examined overall dimensions and have not established a significant correlation into how the shape of the occipital condyles can affect mobility. Occipitocervical fusion should only be considered after 50% condyle resection. In terms of indicators of anatomical stability, components of range of motion (ROM) such as the neutral zone (NZ) and the elastic zone (EZ) have been discussed as potential measures of craniocervical mobility. These components differ by the sense that the NZ has little ligament tension, whereas the EZ does represent ROM where ligaments experience tension. NZ is a more sensitive indicator of instability when measuring for instability postcondylectomy. Conclusion: Various transcondylar approaches have been developed to access this region including extreme-lateral and far-lateral condylectomy, with hopes of preserving as much of the condyle as possible and maintaining postoperative craniocervical stability.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, United States
| | - Ryan Jarrah
- College of Arts and Sciences, University of Michigan Flint, Flint, United States
| | - Erika Sarno
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
| | - Athanasios Kondilis
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
| | - Kory Pasko
- School of Medicine, Georgetown University, Washington, District of Columbia, United States
| | - Brian Musch
- College of Osteopathic Medicine, William Carey University, Hattiesburg, Mississippi, United States
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Henderson F, Rosenbaum R, Narayanan M, Mackall J, Korson C. The Neurosurgical Intraoperative Checklist for Surgery of the Craniocervical Junction and Spine. Cureus 2020; 12:e7588. [PMID: 32399322 PMCID: PMC7212711 DOI: 10.7759/cureus.7588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Many sectors within healthcare have adapted checklists to improve quality control. Notwithstanding the reported successful implementation of surgical checklists in the operating theater, a dearth of literature addresses the specific challenges posed by complex surgery in the craniocervical junction and spine. The authors devised an intraoperative checklist to address the common errors and verify the completion of objectives unique to these surgeries. The data over six years is presented retrospectively; no historical control for comparison is available, as those omissions and surgical errors addressed by the checklist are not generally registered in any morbidity and mortality reports. Through six years and approximately 1200 surgeries, the checklist was implemented with 98% compliance. The checklist eliminated the occurrences of mundane surgical errors, minimized iatrogenic complications, and ensured completion of specific objectives. We discuss that preoperative checklists, now in general use in all hospitals, have not addressed the most common, intraoperative omissions. These technical omissions result in part from the complexity of spine surgery and directly impact the surgical outcome. The Neurosurgical Intraoperative Checklist is a practical, rapid, and comprehensive means to prevent common, avoidable errors and iatrogenic complications inherent to spine surgery.
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Affiliation(s)
- Fraser Henderson
- Neurological Surgery, University of Maryland Prince George's Hospital Center, Largo, USA.,Neurological Surgery, Doctors Community Hospital, Lanham, USA
| | - Robert Rosenbaum
- Neurological Surgery, The Metropolitan Neurosurgery Group, Silver Spring, USA.,Neurological Surgery, Walter Reed National Military Medical Center, Bethesda, USA
| | - Malini Narayanan
- Neurological Surgery, University of Maryland Prince George's Hospital Center, Cheverley, USA
| | - John Mackall
- Neurological Surgery, D&K Medical, LLC., Lanham, USA
| | - Clayton Korson
- Emergency Medicine, Creighton University School of Medicine, Omaha, USA
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