Clinical Analysis of Radiologic Measurements in Patients with Basilar Invagination

Reliability and head-loading effects in imaging diagnosis of vertical subluxation in patients with rheumatoid arthritis

OBJECTIVES

The purpose of this study was to examine the reproducibility of vertical subluxation (VS) parameters using X-ray, computed tomography (CT), and tomosynthesis (TS) while comparing the head-loading effects.

METHODS

The VS parameters of 26 patients (retrospective review) were evaluated. Using the intra-class correlation coefficient, we statistically examined the intra-rater and inter-rater reliabilities of the parameters. Head-loaded and -unloaded imagings were compared using a Wilcoxon signed-rank test.

RESULTS

The intra-rater reliability of TS and CT showed intra-class correlation coefficients of ≥0.8 (X-ray range: 0.6-0.8), with similar results for the inter-rater reliabilities. Furthermore, in head-loading imaging, the TS had significantly higher VS scores than that of CT (P < .05).

CONCLUSIONS

In comparison with the X-ray, TS and CT were more accurate and reproducible. In terms of head loading, the VS values for TS were worse than those for CT, indicating that TS was more effective than CT in diagnosing VS.

Modified interfacet technique using shaped autologous occipital bone mass for basilar invagination

PURPOSE

In economically undeveloped areas, surgery for basilar invagination (BI) is still a serious economic burden for people. This study introduces a modified interfacet technique for the treatment of BI using shaped autologous occipital bone mass to reduce BI and to save economical expenditure.

METHODS

The data of 6 patients with BI who underwent modified interfacet technique using shaped autologous occipital bone mass in our hospital from April 2020 to February 2021 were retrospectively analyzed. During the operation, osteotomy at the external occipital protuberance was performed using ultrasonic osteotome, followed by interfacet release and implantation of shaped autologous occipital bone mass to complete vertical reduction. The atlantodental interval (ADI), Chamberlain's line violation (CLV), clivo-axial angle (CXA) and cervico-medullary angle (CMA) were compared before and after surgery. Additionally, we observed implant stability during the follow-up period to assess the long-term success of the modified interfacet technique.

RESULTS

The surgical procedure was successful in all six patients, with no reported incidents of vascular injury, spinal cord injury, or dural tear. Following the operation, improvements were observed in the ADI, CLV, CXA, and CMA. Throughout the follow-up period, the implants remained stable, demonstrating no complications such as bone resorption of the autologous occipital bone mass, implant fracture, or displacement.

CONCLUSION

The utilization of shaped autologous occipital bone mass in atlantoaxial interfacet bone grafting has demonstrated effectiveness and feasibility. This technique offers simplicity, ease of preparation, and cost-effectiveness, making it a viable option for treating BI.

Radiological assessment and surgical management of cervical spine involvement in patients with rheumatoid arthritis

The purpose of the present systematic review was to describe the diagnostic evaluation of rheumatoid arthritis in the cervical spine to provide a better understanding of the indications and options of surgical intervention. We performed a literature review of Pub-med, Embase, and Scopus database. Upon implementing specific inclusion and exclusion criteria, all eligible articles were identified. A total of 1878 patients with Rheumatoid Arthritis (RA) were evaluated for cervical spine involvement with plain radiographs. Atlantoaxial subluxation (AAS) ranged from 16.4 to 95.7% in plain radiographs while sub-axial subluxation ranged from 10 to 43.6% of cases. Anterior atlantodental interval (AADI) was found to between 2.5 mm and 4.61 mm in neutral and flexion position respectively, while Posterior Atlantodental Interval (PADI) was between 20.4 and 24.92 mm. 660 patients with RA had undergone an MRI. A pannus diagnosis ranged from 13.33 to 85.36% while spinal cord compression was reported in 0-13% of cases. When it comes to surgical outcomes, Atlanto-axial joint (AAJ) fusion success rates ranged from 45.16 to 100% of cases. Furthermore, the incidence of postoperative subluxation ranged from 0 to 77.7%. With regards to AADI it is evident that its value decreased in all studies. Furthermore, an improvement in Ranawat classification was variable between studies with a report improvement frequency by at least one class ranging from 0 to 54.5%. In conclusion, through careful radiographic and clinical evaluation, cervical spine involvement in patients with RA can be detected. Surgery is a valuable option for these patients and can lead to improvement in their symptoms.

A new nomenclature system for the surgical treatment of cervical spine deformity, developing, and validation of SOF system

PURPOSE

To develop and assess the reliability of new nomenclature system that systematically organizes osteotomy techniques and briefly describes the surgical approach, the surgical sequence, and the fixation technique for cervical spine deformity (CSD).

METHODS

We developed a new classification system (SOF system) for CSD surgery that describes the sequence of surgical approach (S), the grade of osteotomy (O), and the information of fixation (F) using alphanumeric codes. Twenty CSD osteotomies (8 anterior osteotomies, 12 posterior osteotomies) were included in this study to evaluate the inter- and intra-observer agreement based on operation records. Six observers performed independent evaluations of the operation records in random order. Each observer described 20 CSD surgeries using the SOF system twice (> 30 days between assessments) based on operation records to validate SOF system.

RESULTS

Overall agreement (among all six observers at the initial assessment) on the anterior and posterior osteotomy was ICC = 0.96 and ICC = 0.91, respectively. Overall agreement (repeat observations after at least 30 days) on the anterior and posterior osteotomy was ICC = 0.96 and ICC = 0.91, respectively. This data showed that both inter- and intra-observer agreement revealed 'excellent'.

CONCLUSION

This study introduces the SOF system of the CSD surgery to understand the surgical sequence, the type of osteotomy and the fixation techniques. The investigation of the inter- and intra-observer agreement revealed 'excellent agreement' for both anterior and posterior osteotomies. Thus, SOF system can provide a consistent description of the various CSD surgeries and its use will provide a common frame for CSD surgery and help communicate between surgeons.

Intraoperative surveillance of the vertebral artery using indocyanine green angiography and Doppler sonography in craniovertebral junction surgeries

OBJECTIVE

The authors sought to evaluate the usefulness of indocyanine green (ICG) angiography and Doppler sonography for monitoring the vertebral artery (VA) during craniovertebral junction (CVJ) surgery and compare the incidence of VA injury (VAI) between the groups with and without the monitoring of VA using ICG angiography and Doppler sonography.

METHODS

In total, 344 consecutive patients enrolled who underwent CVJ surgery. Surgery was performed without intraoperative VA monitoring tools in 262 cases (control group) and with VA monitoring tools in 82 cases (monitoring group). The authors compared the incidence of VAI between groups. The procedure times of ICG angiography, change of VA flow velocity measured by Doppler sonography, and complication were investigated.

RESULTS

There were 4 VAI cases in the control group, and the incidence of VAI was 1.5%. Meanwhile, there were no VAI cases in the monitoring group. The procedure time of ICG angiography was less than 5 minutes (mean [± SD] 4.6 ± 2.1 minutes) and VA flow velocity was 11.2 ± 4.5 cm/sec. There were several cases in which the surgical method had to be changed depending on the VA monitoring. The combined use of ICG angiography and Doppler sonography was useful not only to monitor VA patency but also to assess the quality of blood flow during CVJ surgery, especially in the high-risk group of patients.

CONCLUSIONS

The combined use of ICG angiography and Doppler sonography enables real-time intraoperative monitoring of the VA by detecting blood flow and flow velocity. As the arteries get closer, they provide auditory and visual feedback to the surgeon. This real-time image guidance could be a useful tool, especially for high-risk patients and inexperienced surgeons, to avoid iatrogenic VAI during any CVJ surgery.

Evaluation and Surgical Planning for Craniovertebral Junction Deformity

Craniovertebral junction (CVJ) deformity is a challenging pathology that can result in progressive deformity, myelopathy, severe neck pain, and functional disability, such as difficulty swallowing. Surgical management of CVJ deformity is complex for anatomical reasons; given the discreet relationships involved in the surrounding neurovascular structures and intricate biochemical issues, access to this region is relatively difficult. Evaluation of the reducibility, CVJ alignment, and direction of the mechanical compression may determine surgical strategy. If CVJ deformity is reducible, posterior in situ fixation may be a viable solution. If the deformity is rigid and the C1–2 facet is fixed, osteotomy may be necessary to make the C1–2 facet joint reducible. C1–2 facet release with vertical reduction technique could be useful, especially when the C1–2 facet joint is the primary pathology of CVJ kyphotic deformity or basilar invagination. The indications for transoral surgery are becoming as narrow as a treatment for CVJ deformity. In this article, we will discuss CVJ alignment and various strategies for the management of CVJ deformity and possible ways to prevent complications and improve surgical outcomes.