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Goel A, Blaskovich S, Shah A, Prasad A, Vutha R, Shukla A. Post-traumatic Central or Axial atlantoaxial dislocation (CAAD) presenting with 'atypical' symptoms- Analysing the role of dynamic imaging on the basis of experience with 14 patients treated by atlantoaxial fixation surgery. World Neurosurg 2024:S1878-8750(24)00820-9. [PMID: 38759781 DOI: 10.1016/j.wneu.2024.05.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 05/10/2024] [Indexed: 05/19/2024]
Abstract
AIM This is a report of a series of 14 patients who presented with a range of 'atypical' cranial, spinal and systemic symptoms that started after they suffered relatively severe injury to the head and/or neck several months or years prior to the surgical treatment. Implications of diagnosing and treating central or axial atlantoaxial instability (CAAD) is discussed. Role of dynamic rotatory and lateral head tilt imaging in the diagnosis and treatment is analysed. MATERIAL AND METHODS There were 7 males and 7 females and their ages ranged from 21 to 64 years (average 42 years). Due to the severity of presenting neurological and non-neurological symptoms, all patients lost their occupation and were heavily dependent on painkillers and/or antidepressant drugs. In addition to other tell-tale clinical and radiological evidence, diagnosis of CAAD was made based on facetal alignments on lateral profile imaging in neutral head position. Dynamic head flexion-extension, lateral head tilt and neck rotation imaging confirmed and subclassified CAAD. All patients underwent atlantoaxial fixation surgery. RESULT A personalized self-assessment clinical scoring parameter and the WHODAS 2.0 was used to evaluate the outcome. One patient did not follow-up after surgery. At a minimum follow-up of 6 months after atlantoaxial fixation surgery, there was relief from all major symptoms in the rest of 13 patients. CONCLUSIONS Diagnosing and treating CAAD can have 'major' therapeutic implications in patients presenting with progressively worsening disabling clinical symptoms following relatively severe head/neck trauma.
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Affiliation(s)
- Atul Goel
- Professor and Head, Department of Neurosurgery, Lilavati Hospital and Research Center, Bandra, Mumbai; Professor, Department of Neurosurgery, R.N Cooper Hospital and Medical College, Mumbai; Professor, Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai; Professor, Department of Neurosurgery, K.J. Somaiya Medical College, Hospital and Research Center, Mumbai.
| | - Sasha Blaskovich
- Director, Whiplash and Injury Clinic, Langley, BC V3A2C6, Canada
| | - Abhidha Shah
- Associate Professor, Department of Neurosurgery, K.E.M Hospital and Seth G.S. Medical College, Parel, Mumbai; Consultant Neurosurgeon, K.J. Somaiya Medical College, Hospital and Research Center, Mumbai; Consultant Neurosurgeon, Apollo Hospitals, Navi Mumbai
| | - Apurva Prasad
- Clinical Associate, Department of Neurosurgery, Lilavati Hospital and Research Center, Bandra, Mumbai; Consultant Neurosurgeon, Bhatia Hospital, Tardeo, Mumbai
| | - Ravikiran Vutha
- Consultant Neurosurgeon, K.J. Somaiya Medical College, Hospital and Research Center, Mumbai; Consultant Neurosurgeon, Apollo Hospitals, Navi Mumbai
| | - Ashutosh Shukla
- Senior Resident, Department of Neurosurgery, Lilavati Hospital and Research Center, Bandra, Mumbai
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Patel AA, Greenberg JK, Steinmetz MP, Vorster S, Nevzati E, Spiessberger A. C1-2 hypermobility and its impact on the spinal cord: a finite element analysis. J Neurosurg Spine 2024:1-8. [PMID: 38701531 DOI: 10.3171/2024.2.spine231327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/21/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE The authors present a finite element analysis (FEA) evaluating the mechanical impact of C1-2 hypermobility on the spinal cord. METHODS The Code_Aster program was used to perform an FEA to determine the mechanical impact of C1-2 hypermobility on the spinal cord. Normative values of Young's modulus were applied to the various components of the model, including bone, ligaments, and gray and white matter. Two models were created: 25° and 50° of C1-on-C2 rotation, and 2.5 and 5 mm of C1-on-C2 lateral translation. Maximum von Mises stress (VMS) throughout the cervicomedullary junction was calculated and analyzed. RESULTS The FEA model of 2.5 mm lateral translation of C1 on C2 revealed maximum VMS for gray and white matter of 0.041 and 0.097 MPa, respectively. In the 5-mm translation model, the maximum VMS for gray and white matter was 0.069 and 0.162 MPa. The FEA model of 25° of C1-on-C2 rotation revealed maximum VMS for gray and white matter of 0.052 and 0.123 MPa. In the 50° rotation model, the maximum VMS for gray and white matter was 0.113 and 0.264 MPa. CONCLUSIONS This FEA revealed significant spinal cord stress during pathological rotation (50°) and lateral translation (5 mm) consistent with values found during severe spinal cord compression and in patients with myelopathy. While this finite element model requires oversimplification of the atlantoaxial joint, the study provides biomechanical evidence that hypermobility within the C1-2 joint leads to pathological spinal cord stress.
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Affiliation(s)
- Arpan A Patel
- 1Center for Spine Health, Cleveland Clinic, Cleveland, Ohio
- 2Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Jacob K Greenberg
- 3Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael P Steinmetz
- 1Center for Spine Health, Cleveland Clinic, Cleveland, Ohio
- 2Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Sarel Vorster
- 1Center for Spine Health, Cleveland Clinic, Cleveland, Ohio
- 2Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Edin Nevzati
- 4Department of Neurosurgery, Cantonal Hospital of Lucerne, Switzerland; and
- 5Faculty of Medicine, University of Basel, Switzerland
| | - Alexander Spiessberger
- 1Center for Spine Health, Cleveland Clinic, Cleveland, Ohio
- 2Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
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Seon Y, Cho C, Jung C, Lim JH, Kim SY, Kang BJ. Atlantoaxial joint stabilization using patient-specific 3-D-printed drill guides and 3-D-printed titanium plates or polymethyl methacrylate is effective in toy-breed dogs. Am J Vet Res 2024:1-8. [PMID: 38663445 DOI: 10.2460/ajvr.24.02.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 04/10/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE To report the clinical outcomes in toy-breed dogs with atlantoaxial instability (AAI) stabilized with patient-specific 3-D-printed titanium plates or polymethyl methacrylate (PMMA), both with the assistance of 3-D-printed drill guides. ANIMALS 15 client-owned dogs undergoing surgical treatment for AAI between January 1, 2020, and October 31, 2022. METHODS The clinical characteristics, diagnostic images, and neurological outcomes of 15 dogs treated for AAI using 3-D-printing technology were reviewed. Postoperative CT images were examined to evaluate the screw placement accuracy in the atlas and axis. Clinical outcomes, including postoperative neurological improvement and screw loosening, were evaluated in dogs treated with a patient-specific titanium plate and those treated with PMMA. RESULTS Patient-specific titanium plates (7 dogs) and PMMA (8 dogs) were used for AAI stabilization. The mean follow-up period was 15.2 months (range 7 to 22 months). A reduction of the axis without vertebral canal violation was confirmed on postoperative CT in 14 dogs. The mean deviation from the preoperative planning ranged from 0.30 to 1.27 mm at the insertion and exit points of 84 screws using this method. The neurological grade had improved in each dog postoperatively and at the final follow-up. Screw loosening was noted in 4 dogs in the titanium plates groups without neurological deterioration. CLINICAL RELEVANCE Patient-specific 3-D-printed drill guides and titanium plates or PMMA are effective for AAI stabilization in toy-breed dogs, providing accurate guidance.
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Affiliation(s)
- Yeowool Seon
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, South Korea
| | - Cheongwoon Cho
- Department of Veterinary Surgery, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Changsu Jung
- Ilsan Animal Medical Center, Gyeonggi-do, South Korea
| | - Ji-Hey Lim
- Department of Veterinary Surgical and Radiological Sciences, University of California-Davis, Davis, CA
| | - Sun-Young Kim
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN
| | - Byung-Jae Kang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, South Korea
- BK21 FOUR Future Veterinary Medicine Leading Education and Research Center, Seoul National University, Seoul, South Korea
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Kreinest M, Raisch P, Hörnig L, Vetter SY, Grützner PA, Jung MK. Odontoid Fracture with Accompanying Severe Atlantoaxial Instability in Elderly Patients-Analysis of Treatment, Adverse Events, and Outcome. J Clin Med 2024; 13:1326. [PMID: 38592668 PMCID: PMC10932128 DOI: 10.3390/jcm13051326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 02/19/2024] [Accepted: 02/24/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: In elderly patients with type II odontoid fractures, accompanying severe atlantoaxial instability (AAI) is discussed as a marker possibly warranting more aggressive surgical therapy. This study aimed to characterize adverse events as well as the radiological and functional outcomes of surgical vs. conservative therapy in patients with odontoid fracture and AAI. (2) Methods: Patients aged 65 years and older with type II odontoid fracture and AAI treated were included. AAI was assumed if the mean subluxation across both atlantoaxial facet joints in the sagittal plane was greater than 50%. Data on demographics, comorbidities, treatment, adverse events, radiological, and functional outcomes were analyzed. (3) Results: Thirty-nine patients were included. Hospitalization time was significantly shorter in conservatively treated patients compared to patients with ventral or dorsal surgery. Adverse events occurred in 11 patients (28.2%), affecting 10 surgically treated patients (35.7%), and 1 conservatively treated patient (9.1%). Moreover, 25 patients were followed-up (64.1%). One secondary dislocation occurred in the conservative group (11.1%) and three in the surgical group (18.8%). (4) Conclusions: Despite the potential for instability in this injury, conservative treatment does not seem to lead to unfavorable short-term results, less adverse events, and a shorter hospital stay and should thus be considered and discussed with patients as a treatment option, even in the presence of severe AAI.
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Affiliation(s)
| | | | | | | | | | - Matthias K. Jung
- BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopedic Surgery, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen, Germany (L.H.)
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Duvuru S, Sanker V, Dave T, Agarwal P, Syed N. Stabilizing the unstable: Tuberculosis of the odontoid process with atlanto-occipital instability-Case report and review of literature. Clin Case Rep 2024; 12:e8379. [PMID: 38161635 PMCID: PMC10753637 DOI: 10.1002/ccr3.8379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/26/2023] [Accepted: 12/16/2023] [Indexed: 01/03/2024] Open
Abstract
Key Clinical Message Tuberculosis (TB) of the odontoid process is a rare but potentially, a debilitating condition. Surgical intervention, in the form of stabilizing the spine and decompressing the spinal cord, offers a tailored approach to managing this condition effectively and improving prognosis. Abstract Odontoid process tuberculosis (TB) is a rare condition that can cause spinal instability and neurological complications. Diagnosis of odontoid process TB is difficult and requires a combination of clinical, radiographic, and histopathological examinations. This report describes the treatment of a 46-year-old female with quadriparesis and intermittent fever. Radiological findings showed TB of the odontoid process with atlanto-axial dislocation causing compressive myelopathy. She underwent C1-C3 decompressive laminectomy and stabilization from C1 to C5. GeneXpert for TB was positive and she was started on anti-tuberculous medications. She regained power gradually and at 1 year follow-up she was ambulant without any support. The C1-C5 lateral mass screw and C1-C3 decompressive laminectomy approach, as highlighted in this case, offers an effective solution, enhancing patient quality of life, and preventing disease progression.
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Affiliation(s)
- Shyam Duvuru
- Consultant NeurosurgeonApollo Specialty HospitalsMaduraiTamil NaduIndia
| | - Vivek Sanker
- Team ErevnitesTrivandrumIndia
- Noorul Islam Institute of Medical SciencesTrivandrumIndia
| | - Tirth Dave
- Team ErevnitesTrivandrumIndia
- Bukovinian State Medical UniversityChernivtsiUkraine
| | - Pratik Agarwal
- Team ErevnitesTrivandrumIndia
- Lokmanya Tilak Municipal Medical CollegeMumbaiIndia
| | - Naureen Syed
- Team ErevnitesTrivandrumIndia
- UT MD Anderson Cancer CenterHoustonTexasUSA
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Diyora B, Wankhade R, Devani K, Purandare A, Palave P, Gawali S. Atlantoaxial Instability with Persistent Second Intersegmental Artery. Asian J Neurosurg 2023; 18:805-809. [PMID: 38161620 PMCID: PMC10756845 DOI: 10.1055/s-0043-1776050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Understanding the anatomy of the vertebral artery is essential while manipulating the craniovertebral joint during surgery. Its anomalous course in congenital atlantoaxial dislocation makes it more vulnerable to injury. Preoperative dedicated computed tomography (CT) angiography helps identify the artery's position and plan for surgical procedure. A 13-year-boy presented with neck pain and spastic quadriparesis for 1 year. Radiological imaging of the craniovertebral junction revealed atlantoaxial instability with basilar invagination. His CT angiography of neck and brain vessels revealed an anomalous course of the vertebral artery due to a persistent second intersegment artery. He underwent posterior atlantoaxial fixation after mobilization of the vertebral artery. His clinical condition significantly improved after surgery. We report a case of management of an atlanto axial dislocation with persistent second intersegment artery and describe the role of vertebral artery mobilization during surgery.
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Affiliation(s)
- Batuk Diyora
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India
| | - Ravi Wankhade
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India
| | - Kavin Devani
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India
| | - Anup Purandare
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India
| | - Prakash Palave
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India
| | - Sagar Gawali
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India
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Seon Y, Choi SK, Kim WK, Kang BJ. A shape memory alloy implant can be an effective surgical treatment in the atlantoaxial joint stabilization using rabbits as substitutes for toy-breed dogs. Am J Vet Res 2023; 84:ajvr.23.07.0158. [PMID: 37591491 DOI: 10.2460/ajvr.23.07.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE To investigate the feasibility of using shape memory alloy (SMA) implants for atlantoaxial joint stabilization using a rabbit model as a substitute for canines. ANIMALS 20 rabbit cadavers. METHODS We prepared rabbit cadavers from the middle of the skull to the third cervical vertebra. The vertebral body and canal sizes of the atlas and axis were compared using CT data from rabbits, normal dogs, and dogs with atlantoaxial instability (AAI) to assess the feasibility of using rabbits as substitutes for toy-breed dogs. The shape memory alloy (SMA) implants were designed to stabilize the atlantoaxial joint without compromising the spinal canal passage for safety and were classified into SMA-1 and SMA-2 based on their design. To evaluate the strength, the ventrodorsal force was measured with atlantoaxial ligaments intact, after removing the ligaments, and after applying conventional wire or SMA implants to stabilize the atlantoaxial joint. The time taken for implant application was measured. RESULTS No significant difference in vertebral body size of the atlas and axis was observed. A significant difference in vertebral canal size was observed between the animals. In biomechanical testing, the SMA-2 implant provided more stabilization, while the SMA-1 implant had lower strength than the conventional method using wires. The application time of wire was the longest, while that of SMA-1 was the shortest. CLINICAL RELEVANCE SMA implants provide comparable strength and demonstrate superior efficacy compared to conventional dorsal wire fixation of atlantoaxial stabilization. Therefore, SMA implants can be an effective surgical option for AAI.
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Affiliation(s)
- Yeowool Seon
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, South Korea
| | | | - Woo Keyoung Kim
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, South Korea
- BK21 FOUR Future Veterinary Medicine Leading Education and Research Center, Seoul National University, Seoul, South Korea
| | - Byung-Jae Kang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, South Korea
- BK21 FOUR Future Veterinary Medicine Leading Education and Research Center, Seoul National University, Seoul, South Korea
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Chaudhary K, Pennington Z, Rathod AK, Laheri V, Bapat M, Sciubba DM, Suratwala SJ. Pathogenesis and Staging of Craniovertebral Tuberculosis: Radiographic Evaluation, Classification, and Natural History. Global Spine J 2023; 13:2155-2167. [PMID: 35164582 PMCID: PMC10538348 DOI: 10.1177/21925682221074671] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To radiographically evaluate Craniovertebral junction (CVJ) tuberculosis infection pathogenesis and to propose a modification to the Lifeso classification. METHODS A cohort of patients with radiologically or microbiologically identified CVJ tuberculosis treated at a single tertiary referral center in a TB endemic area was queried for characteristics about clinical presentation, treatment, and radiographic evidence of bone destruction and abscess formation were included. Disease was classified according to the Lifeso grading system and bony lesions were classified as either type 1 (preservation of underlying structure) or type 2 (damage of underlying structure). RESULTS 52 patients were identified (mean age 28.5 ± 13.4yr, 48% male; 14% with a prior history of tuberculosis). All presented with neck pain at presentation, 29% with rotatory pain, and 37% with myelopathy. Comparison by Lifeso type showed Lifeso III lesions had longer symptom durations (P = .03) and more commonly had periarticular or predental abscess formation (P < .05), spinal cord compression (P < .01), and more commonly involved the C2 body and atlanto-dental joint. Underlying bony destruction was more common for lesions of the lateral atlantoaxial joints and atlanto-dental joints in Lifeso III cases than in either Lifeso I or II (all P < .05). CONCLUSIONS The radiologic findings of the present series suggest CVJ TB infection may originate in the periarticular fascia with subsequent invasion into the adjacent atlanto-dental and lateral atlantoaxial joints in later disease. To reflect this proposed etiology, we present a modified Lifeso classification to describe the radiologic pathogenesis of CVJ TB.
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Affiliation(s)
- Kshitij Chaudhary
- Department of Orthopaedic Surgery, PD Hinduja Hospital and Medical Research Centre, Mumbai, India
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, Rochester, MN, USA
| | - Ashok K. Rathod
- Department of Orthopaedics, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Vinod Laheri
- Department of Orthopaedics, King Edward VII Memorial Hospital, Mumbai, India
| | - Mihir Bapat
- Department of Orthopaedics, King Edward VII Memorial Hospital, Mumbai, India
| | - Daniel M. Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Sanjeev J Suratwala
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
- Department of Orthopaedic Surgery, New York Orthopaedic and Spine Center, Northwell Health, Great Neck, NY USA
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Lin MS, Huang CW, Tsou HK, Tzeng CY, Kao TH, Lin RH, Chen TY, Li CR, Lee CY. Advances in surgical treatment for atlantoaxial instability focusing on rheumatoid arthritis: Analysis of a series of 67 patients. Int J Rheum Dis 2023; 26:1996-2006. [PMID: 37565304 DOI: 10.1111/1756-185x.14855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/12/2023]
Abstract
AIM An estimated 88% of rheumatoid arthritis (RA) patients experience various degrees of cervical spine involvement. The excessive movement of the atlantoaxial joint, which connects the occiput to the upper cervical spine, results in atlantoaxial instability (AAI). AAI stabilization is usually achieved by C1 lateral mass-to-C2 pedicle screw-rod fixation (LC1-PC2 fixation), which is technically challenging in RA patients who often show destructive changes in anatomical structures. This study aimed to analyze the clinical results and operative experiences of C1-C2 surgery, with emphasis on the advancement of image-guided surgery and augmented reality (AR) assisted navigation. METHODS We presented our two decades of experience in the surgical management of AAI from April 2004 to November 2022. RESULTS We have performed surgery on 67 patients with AAI, including 21 traumatic odontoid fractures, 20 degenerative osteoarthritis, 11 inflammatory diseases of RA, 5 congenital anomalies of the os odontoideum, 2 unknown etiologies, 2 movement disorders, 2 previous implant failures, 2 osteomyelitis, 1 ankylosing spondylitis, and 1 tumor. Beginning in 2007, we performed LC1-PC2 fixation under C-arm fluoroscopy. As part of the progress in spinal surgery, since 2011 we used surgical navigation from presurgical planning to intraoperative navigation, using the preoperative computed tomography (CT) -based image-guided BrainLab navigation system. In 2021, we began using intraoperative CT scan and microscope-based AR navigation. CONCLUSION The technical complexities of C1-C2 surgery can be mitigated by CT-based image-guided surgery and microscope-based AR navigation, to improve accuracy in screw placement and overall clinical outcomes, particularly in RA patients with AAI.
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Affiliation(s)
- Mao-Shih Lin
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chih-Wei Huang
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Houlong, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
- College of Health, National Taichung University of Science and Technology, Taichung, Taiwan, ROC
| | - Chung-Yuh Tzeng
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Houlong, Taiwan, ROC
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Medicinal Botanicals and Foods on Health Applications, Da-Yeh University, Changhua, Taiwan, ROC
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Ting-Hsien Kao
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Ruei-Hong Lin
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Tse-Yu Chen
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Chi-Ruei Li
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Cheng-Ying Lee
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
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Takahata M, Hyakkan R, Oshima S, Oda I, Kanayama M, Hyakumachi T, Fujita R, Endo T, Kajino T, Iwasaki N. Cervical Myelopathy Caused by Non-Rheumatic Retro-Odontoid Pseudotumor: An Investigation of Underlying Mechanisms and Optimal Surgical Strategy. Global Spine J 2023; 13:2053-2062. [PMID: 35000408 PMCID: PMC10556925 DOI: 10.1177/21925682211069542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVE This study aimed to identify the underlying pathologies of non-rheumatic retro-odontoid pseudotumors (NRPs), which would help establish an appropriate surgical strategy for myelopathy caused by NRP. METHODS We identified 35 patients with myelopathy caused by NRP who underwent surgery between 2006 and 2017. An age- and sex-matched control group of 70 subjects was selected from patients with degenerative cervical myelopathy. Radiographic risk factors for NRP were compared between cases and controls. We also assessed surgical outcomes following occipital-cervical (O-C) fusion, atlantoaxial (C1-2) fusion, or C1 laminectomy. RESULTS Patients with NRP had significantly lower C1 sagittal inner diameter, C2-7 range of motion (ROM), C2-7 Cobb angle, and C7 tilt, as well as significantly higher C1-2 ROM, atlantodental interval (ADI), and C1-2 to O-C7 ROM ratio. Multivariate regression analysis revealed that ADI, C2-7 ROM, and C7 tilt were independent risk factors for NRP. Neurological recovery and pseudotumor size reduction were comparable among surgical procedures, whereas post-operative cervical spine function was significantly lower in the O-C fusion group than in the other groups. CONCLUSION Non-rheumatic retro-odontoid pseudotumor was associated with an increase in ADI, suggesting that spinal arthrodesis surgery is a reasonable strategy for NRP. C1-2 fusion is preferable over O-C fusion because of the high prevalence of ankylosis in the subaxial cervical spine. Given that 29% of patients with NRP have C1 hypoplasia, such cases can be treated by posterior decompression alone. Our study highlights the need to select appropriate surgical procedures based on the underlying pathology in each case.
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Affiliation(s)
- Masahiko Takahata
- Department of Orthopedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Hokkaido Spine Study Group, Sapporo, Japan
| | - Ryota Hyakkan
- Department of Orthopedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Hokkaido Spine Study Group, Sapporo, Japan
| | - Shigeki Oshima
- The Spine Center, Hakodate Central General Hospital, Hakodate, Japan
| | - Itaru Oda
- Hokkaido Spine Study Group, Sapporo, Japan
- The Spine Center, Hakodate Central General Hospital, Hakodate, Japan
| | - Masahiro Kanayama
- Hokkaido Spine Study Group, Sapporo, Japan
- The Spine Center, Hakodate Central General Hospital, Hakodate, Japan
| | - Takahiko Hyakumachi
- Department of Orthopedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ryo Fujita
- Department of Orthopedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Hokkaido Spine Study Group, Sapporo, Japan
| | - Tsutomu Endo
- Department of Orthopedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Hokkaido Spine Study Group, Sapporo, Japan
| | - Tomomichi Kajino
- Department of Orthopedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Hokkaido Spine Study Group, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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11
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Choi S, Sullivan L, Long S. Case report: Atlantoaxial instability and subluxation in a dog with Ehlers-Danlos syndrome. Front Vet Sci 2023; 10:1234995. [PMID: 37601761 PMCID: PMC10436340 DOI: 10.3389/fvets.2023.1234995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/14/2023] [Indexed: 08/22/2023] Open
Abstract
Ehlers-Danlos syndrome is a rare, heritable connective tissue disorder characterized by soft, hyperextensible skin, joint hypermobility, and tissue fragility, the severity of which can range from mild to severe. A 9-month-old male entire miniature Dachshund was presented following peracute tetraparesis. Neurological examination was suggestive of intracranial vestibular disease or high cervical myelopathy. MRI revealed atlantoaxial instability and subluxation, resulting in marked spinal cord compression at C1-C2, which was surgically stabilized. On discharge from the hospital, skin fragility was noted as the result of skin tearing during tape removal. A piece of full-thickness antebrachial skin was submitted for histopathology which showed changes consistent with Ehlers-Danlos syndrome. This case report describes the first case of atlantoaxial instability and subluxation in a dog as the result of a confirmed underlying collagenopathy.
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Affiliation(s)
- Simon Choi
- Department of Neurology and Neurosurgery, Veterinary Referral Hospital, Dandenong, VIC, Australia
| | - Louise Sullivan
- Department of Veterinary Pathology, Queensland Medical Laboratory, Murarrie, QLD, Australia
| | - Sam Long
- Department of Neurology and Neurosurgery, Veterinary Referral Hospital, Dandenong, VIC, Australia
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12
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Sanjay N, Y S C, Yadav K, Dudekula A. Basilar Invagination With Chiari Type I Malformation and Atlanto-Axial Instability: A Rare Case Report. Cureus 2023; 15:e44141. [PMID: 37753030 PMCID: PMC10518641 DOI: 10.7759/cureus.44141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
Basilar invagination (BI) and Chiari malformation type I (CM-I) are important anomalies involving the craniovertebral junction (CVJ) involving the skull base and occipitocervical region. The incidence of BI is rare involving < 1% of the general population worldwide. They present with varied and complex clinical-radiological features. We present a 36-year-old male who displayed complaints of persistent reeling sensation at our center. Clinical examination revealed bilateral cerebellar signs along with nystagmus and restricted neck movements. Imaging revealed evidence of BI with cerebellar tonsil herniation of ~14.7 mm. Atlantodens interval of 6 mm was noted. The unexpected findings of C1-C2 fusion and instability were also noted. We describe a rare case of BI with C1 prolapse into the foramen magnum along with CM-1 malformation and congenital fusion of C1-C2. We conclude that the treatment algorithm for these rare cases is not very well established and is individually dependent.
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Affiliation(s)
- Nandini Sanjay
- Orthopaedics, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Chandan Y S
- Neurosurgery, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Krishan Yadav
- Neurosurgery, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Anees Dudekula
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
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13
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Alemán-Iñiguez JM, Astudillo-Pacheco PD, De la Torre JS. [Atlantoid assimilation: malformation, compensation or deformity. Is it part of basilar invagination?]. Acta Ortop Mex 2023; 37:237-243. [PMID: 38373735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
INTRODUCTION atlas assimilation can occur alone or in association with other craniocervical junction malformations and deformities. The etiological and pathological mechanisms are not clear. CASE PRESENTATION patient in her sixth decade of life, who was treated at the "Eugenio Espejo" Hospital, with asymmetric pyramidal symptoms after a low-energy kinetic fall. The condition completely reverted with conservative management. The patient is currently under periodic observation. CONCLUSION the atlas assimilation, a congenital malformation, often asymptomatic; it is part of an embryological compensation when it is associated with other malformations. The appearance of deformity is necessary to reach atlantoaxial instability that it is not early. The knowledge of the concepts and distinction of the craniocervical junction abnormalities allows to indicate the best treatment in order to obtain the most suitable results with the individualization of each case.
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Affiliation(s)
| | | | - J S De la Torre
- Cirugía de Columna, Hospital Metropolitano de Quito, Hospital Vozandes Quito, Ecuador
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14
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Forterre F, Zorgevica-Pockevica L, Precht C, Haenssgen K, Stein V, Düver P. Clinical Evaluation of a New Surgical Augmentation Technique for Transarticular Atlantoaxial Fixation for Treatment of Atlantoaxial Instability. Animals (Basel) 2023; 13:1780. [PMID: 37889687 PMCID: PMC10252017 DOI: 10.3390/ani13111780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 10/29/2023] Open
Abstract
The feasibility of a newly developed augmentation of ventral fixation technique for surgical stabilization of atlantoaxial instability was clinically evaluated in a cohort of eleven dogs, and long-term clinical outcomes were retrospectively analyzed. The new technique combines wire/suture fixation through a transverse hole in the axis anchored by two screws placed in the alae atlantis or at the cranial end of plates used to bridge the atlantoaxial joint ventrally. A previous biomechanical study demonstrated good stability of this technique during shear loading, comparable to the stability achieved with other standard techniques. Ten dogs improved clinically after surgery and returned to a normal life within 3-6 months of surgery. One dog developed aphonia, dysphagia, and died of aspiration pneumonia three days after surgery. The augmentation of conventional ventral atlantoaxial fixation with the transverse bony corridor of the proximal axis body may be a valuable way to enhance stabilization of the atlantoaxial joint.
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Affiliation(s)
- Franck Forterre
- Division of Small Animal Surgery, Department of Clinical Veterinary Medicine, Vetuisse Faculty, University of Bern, 3012 Bern, Switzerland;
| | - Ligita Zorgevica-Pockevica
- Division of Small Animal Surgery, Department of Clinical Veterinary Medicine, Vetuisse Faculty, University of Bern, 3012 Bern, Switzerland;
| | - Christina Precht
- Division of Clinical Radiology, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, 3012 Bern, Switzerland;
| | - Kati Haenssgen
- Division of Veterinary Anatomy, Vetsuisse Faculty, University of Bern, 3012 Bern, Switzerland;
| | - Veronika Stein
- Division of Clinical Neurology, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, 3012 Bern, Switzerland;
| | - Pia Düver
- Division of Small Animal Surgery, Department of Clinical Veterinary Medicine, Vetuisse Faculty, University of Bern, 3012 Bern, Switzerland;
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15
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Isaacs AM, Narapareddy A, Nam A, Hutcheson K, Stone M, Bonfield CM. Surgical treatment of craniovertebral junction instability in children with Down syndrome: a systematic review. J Neurosurg Pediatr 2023:1-10. [PMID: 37119098 DOI: 10.3171/2023.3.peds22353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Down syndrome (DS) affects 1 in 700 live births and approximately one-third of patients develop craniovertebral junction (CVJ) instability, diagnosed by clinical examination and radiological measures such as the atlantodens interval (ADI) and space available for the cord (SAC). Patients with symptomatic CVJ instability are at increased risk for spinal cord injury. There are no guidelines for surgical management of CVJ instability in DS, the existing literature is sparse, and there is a lack of consistent pediatric data. This systematic review aimed to synthesize practice patterns of the surgical management of CVJ stability in pediatric DS patients to facilitate future standardization of care. METHODS Peer-reviewed studies reporting surgical management of CVJ instability in pediatric DS patients were systematically reviewed. Inclusion criteria were studies reporting primary data on patients younger than 18 years with DS, who had CVJ instability evaluation and underwent surgical treatment. Bias risk was assessed. Descriptive statistics of the independent patient data were presented. Interval variables were analyzed using the Wilcoxon rank-sum test. RESULTS Of 1056 records, 38 studies were included. Of the included patients, 169 (6%) underwent surgery. The surgical indication was symptomatic, radiologically confirmed CVJ instability in 81% of the patients, presenting with myelopathy (30%), weakness (25%), abnormal gait (24%), torticollis (15%), and neck pain (14%). A cutoff of ADI ≥ 4 mm or SAC ≤ 14 mm, cord compression, cord signal change, and anomalous bony anatomy were used in diagnosing CVJ instability. Surgical approaches focused on internal fixation with posterior occipitocervical or atlantoaxial instrumented fusion in 57% and 44% of patients, respectively. Autograft, wiring, and allograft constructs were used in 48%, 45%, and 9% of patients. Anterior cervical approaches were performed in 6% of patients. Preoperative and postoperative external orthoses were used in approximately 50% of patients. The surgical mortality rate was 3%, and the complication rate was 36%. CONCLUSIONS Assessment of CVJ instability in DS is based on radiographic and clinical factors. Surgery is recommended if symptoms are present, and the procedure type depends on patient factors, degree of instability, anomalous bony anatomy, and reduction results to relieve cord compression. Most commonly, posterior instrumented fusion is used. However, further research is required to determine the strength of evaluation methods, create standardized guidelines for evaluation and surgical treatment, and investigate the long-term results of different surgical techniques.
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Affiliation(s)
- Albert M Isaacs
- 1Department of Neurosurgery, Vanderbilt University Medical Center, Nashville; and
| | | | - Andrew Nam
- 2Vanderbilt University, Nashville, Tennessee
| | | | - Michelle Stone
- 1Department of Neurosurgery, Vanderbilt University Medical Center, Nashville; and
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16
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Russek LN, Block NP, Byrne E, Chalela S, Chan C, Comerford M, Frost N, Hennessey S, McCarthy A, Nicholson LL, Parry J, Simmonds J, Stott PJ, Thomas L, Treleaven J, Wagner W, Hakim A. Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations. Front Med (Lausanne) 2023; 9:1072764. [PMID: 36743665 PMCID: PMC9893781 DOI: 10.3389/fmed.2022.1072764] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/29/2022] [Indexed: 01/19/2023] Open
Abstract
Experts in symptomatic generalized joint hypermobility (S-GJH) agree that upper cervical instability (UCI) needs to be better recognized in S-GJH, which commonly presents in the clinic as generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome. While mild UCI may be common, it can still be impactful; though considerably less common, severe UCI can potentially be debilitating. UCI includes both atlanto-occipital and atlantoaxial instability. In the absence of research or published literature describing validated tests or prediction rules, it is not clear what signs and symptoms are most important for diagnosis of UCI. Similarly, healthcare providers lack agreed-upon ways to screen and classify different types or severity of UCI and how to manage UCI in this population. Consequently, recognition and management of UCI in this population has likely been inconsistent and not based on the knowledge and skills of the most experienced clinicians. The current work represents efforts of an international team of physical/physiotherapy clinicians and a S-GJH expert rheumatologist to develop expert consensus recommendations for screening, assessing, and managing patients with UCI associated with S-GJH. Hopefully these recommendations can improve overall recognition and care for this population by combining expertise from physical/physiotherapy clinicians and researchers spanning three continents. These recommendations may also stimulate more research into recognition and conservative care for this complex condition.
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Affiliation(s)
- Leslie N. Russek
- Department of Physical Therapy, Clarkson University, Potsdam, NY, United States,St. Lawrence Health System, Potsdam, NY, United States,*Correspondence: Leslie N. Russek,
| | - Nancy P. Block
- Advanced Therapy Programs PT, San Jose, CA, United States
| | - Elaine Byrne
- Central Health Physiotherapy, London, United Kingdom
| | - Susan Chalela
- The Chalela Physical Therapy Institute for EDS/CCI, Charleston, SC, United States
| | - Cliffton Chan
- Department of Health Sciences, Faculty of Medicine, Health, and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Mark Comerford
- Performance Rehab, Brisbane, QLD, Australia,Comera Movement Science, Bristol, United Kingdom
| | | | | | - Ann McCarthy
- Central Health Physiotherapy, London, United Kingdom
| | - Leslie L. Nicholson
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jason Parry
- Central Health Physiotherapy, London, United Kingdom,University College London Hospital Trust, London, United Kingdom
| | - Jane Simmonds
- Central Health Physiotherapy, London, United Kingdom,Faculty of Population Health Sciences, University College London, London, United Kingdom
| | | | - Lucy Thomas
- Neck and Head Research Unit, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Julia Treleaven
- Performance Rehab, Brisbane, QLD, Australia,Neck and Head Research Unit, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD, Australia
| | | | - Alan Hakim
- University College London Hospital Trust, London, United Kingdom,The Ehlers-Danlos Society, London, United Kingdom
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17
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Huang H, Sheng M, Zeng G, Sun C, Li R. Establish a new parameter "horizontal view-axial angle" and explore its role in the treatment of atlantoaxial instability diseases. Front Surg 2023; 9:947462. [PMID: 36684255 PMCID: PMC9852530 DOI: 10.3389/fsurg.2022.947462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 10/21/2022] [Indexed: 01/08/2023] Open
Abstract
Objective The objective of the study is to establish a new parameter that can be clearly measured on x-ray images to complement the description of the sagittal alignment of the craniocervical junction. The authors anticipate that this new parameter will enhance surgeons' understanding of the sagittal alignment of the craniocervical junction and play a positive role in the guidance of intraoperative reduction and in the evaluation of postoperative outcomes of patients with atlantoaxial instability. Methods From November 2018 to June 2020, a total of 159 asymptomatic subjects who underwent frontal and lateral cervical x-ray examination in the Second Affiliated Hospital of Soochow University were included in the study. Age, gender, previous spinal trauma, and disease history of each subject were recorded. After screening, 127 effective samples were finally obtained. When taking lateral cervical radiographs, all subjects placed their neck in a neutral position and looked straight ahead with both eyes. On the obtained lateral x-ray images, a straight line was drawn from the radix to the anterior clinoid process; another line was made along the posterior edge of the C2 vertebral body; and the angle between the two lines was measured, which was defined as the "horizontal view-axial angle." The angle formed by the tangent of the posterior edge of the C2 vertebra and C7 vertebral body is the "C2-C7 angle," which was used to describe the curvature of the lower cervical vertebra. The normal range of horizontal view-axial angle and its relationship with C2-7 angle were evaluated. Results The average C2-C7 angle of male subjects was (14.0° ± 7.4°), while that of female subjects was (11.09° ± 7.36°). The average horizontal view-axial angle of male subjects was (92.79° ± 4.52°), and that of female subjects was (94.29° ± 4.50°). Pearson correlation test showed that there was a significant negative correlation between horizontal view-axis angle and C2-C7 angle. Conclusions For patients with atlantoaxial instability diseases, the horizontal view-axis angle is expected to be a sagittal parameter to guide the intraoperative reduction and evaluate postoperative outcomes.
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Affiliation(s)
- Hongxiang Huang
- Department of Neurosurgery, Hainan General Hospital, Haikou, China
| | - Minfeng Sheng
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Guangliang Zeng
- Department of Neurosurgery, Changshu No. 2 Peoples’ Hospital, Changshu, China
| | - Chao Sun
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Rujun Li
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, China,Correspondence: Rujun Li
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18
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Lang Z, Han X, Fan M, Liu Y, He D, Tian W. Posterior atlantoaxial internal fixation using Harms technique assisted by 3D-based navigation robot for treatment of atlantoaxial instability. BMC Surg 2022; 22:378. [PMCID: PMC9636711 DOI: 10.1186/s12893-022-01826-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
Background To evaluate the accuracy of screw placement using the TiRobot surgical robot in the Harms procedure and to assess the clinical outcomes of this technique. Methods This retrospective study included 21 patients with atlantoaxial instability treated by posterior atlantoaxial internal fixation (Harms procedure) using the TiRobot surgical robot between March 2016 and June 2021. The precision of screw placement, perioperative parameters and clinical outcomes were recorded. Screw placement was assessed based on intraoperative guiding pin accuracy measurements on intraoperative C-arm cone-beam computed tomography (CT) images using overlay technology and the incidence of screw encroachment identified on CT images. Results Among the 21 patients, the mean age was 44.8 years, and the causes of atlantoaxial instability were os odontoideum (n = 11), rheumatoid arthritis (n = 2), unknown pathogenesis (n = 3), and type II odontoid fracture (n = 5). A total of 82 screws were inserted with robotic assistance. From intraoperative guiding pin accuracy measurements, the average translational and angular deviations were 1.52 ± 0.35 mm (range 1.14–2.25 mm) and 2.25° ± 0.45° (range 1.73°–3.20º), respectively. Screw placement was graded as A for 80.5% of screws, B for 15.9%, and C for 3.7%. No complications related to screw misplacement were observed. After the 1-year follow-up, all patients with a neurological deficit experienced neurological improvement based on Nurick Myelopathy Scale scores, and all patients with preoperative neck pain reported improvement based on Visual Analog Scale scores. Conclusions Posterior atlantoaxial internal fixation using the Harms technique assisted by a 3D-based navigation robot is safe, accurate, and effective for treating atlantoaxial instability.
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Affiliation(s)
- Zhao Lang
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
| | - Xiaoguang Han
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
| | - Mingxing Fan
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
| | - Yajun Liu
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
| | - Da He
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
| | - Wei Tian
- grid.414360.40000 0004 0605 7104Department of Spine Surgery, Peking University 4th Clinical Medical College, Beijing Jishuitan Hospital, No. 31, Xinjiekou East Street, Xicheng District, Beijing, 100035 People’s Republic of China
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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] [What about the content of this article? (0)] [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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Eun J, Oh Y. Traumatic lateral atlantoaxial dislocation combined with a type II odontoid fracture in a patient with ankylosing spondylitis: A case report. Medicine (Baltimore) 2022; 101:e30912. [PMID: 36221340 PMCID: PMC9542739 DOI: 10.1097/md.0000000000030912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
RATIONALE Traumatic lateral atlantoaxial dislocation (AAD) combined with an odontoid fracture is extremely rare. The standards applicable to management of the traumatic lateral AAD are still in flux due to the infrequency of this injury. PATIENT CONCERNS We present a unique case of traumatic lateral AAD combined with a type II odontoid fracture in a patient with ankylosing spondylitis (AS). DIAGNOSIS Spinal computed tomography showed ankylosis of the entire spine from the sacroiliac joint to the cervical spine. On the cervical X-ray the head was rotated to the right with anterior subluxation of the C1 and odontoid tip relative to C2. The coronal computed tomography (CT) scan also revealed left lateral dislocation of C1 on C2 with a horizontal translation of the odontoid tip. On the axial and sagittal CT scan, the left C1 lateral mass was displaced anteriorly and locked by C2 body. INTERVENTIONS We performed occipito-cervical fusion (OCF) after successful manual reduction under general anesthesia. OUTCOMES The patient's recovery from surgery was uneventful and without complication. At the 3 year follow-up the patient was asymptomatic and reportedly satisfied with the surgery. LESSONS Traumatic AAD with an odontoid fracture is an exceedingly uncommon cervical spine injury. A lateral subluxation with a type II odontoid fracture in a patient with AS is rarer still, so much so that this type of subluxation was not classifiable using any of the previously developed classification systems. In this patient with AS, posterior OCF with internal fixation was necessary to avoid hardware failure, particularly in light of the intensive stress caused by AS.
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Affiliation(s)
- Jongpil Eun
- Department of Neurosurgery, Research Institute of Clinical Medicine of Jeonbuk National University, Jeonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Youngmin Oh
- Department of Neurosurgery, Research Institute of Clinical Medicine of Jeonbuk National University, Jeonbuk National University Medical School and Hospital, Jeonju, Korea
- * Correspondence: Youngmin Oh, Department of Neurosurgery, Jeonbuk National University Medical School/Hospital, Geonjiro 20, Deokjingu, Jeonju, 54907, South Korea (e-mail: )
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Singh DK, Shankar D, Singh N, Singh RK, Chand VK. C2 Screw fixation techniques in atlantoaxial instability: A technical review. J Craniovertebr Junction Spine 2022; 13:368-377. [PMID: 36777907 PMCID: PMC9910137 DOI: 10.4103/jcvjs.jcvjs_128_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
Atlantoaxial instability (AAI) is surgically a complex entity due to its proximity to vital neurovascular structures. C1-C2 fusion has been an established standard in its treatment for a considerable time now. Here, we have outlined the most common techniques for C2 screw fixation in practice at present such as C2 pedicle, C2 pars, C2 translaminar, C2 subfacetal, C2-C3 transfacetal, and C2 inferior facet screw. We have discussed in detail the technical as well as biomechanical aspects of each technique of C2 screw fixation in AAI and explored the intricacies of each technique.
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Affiliation(s)
- Deepak Kumar Singh
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Diwakar Shankar
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Neha Singh
- Department of Radiodiagnosis, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rakesh Kumar Singh
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vipin Kumar Chand
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Lee HR, Lee DH, Cho JH, Hwang ES, Seok SY, Park S, Lee CS. Feasibility of lateral mass screw insertion in patients with the risky triad of C1: evaluation of the over-the-arch technique. J Neurosurg Spine 2022; 36:822-829. [PMID: 34826808 DOI: 10.3171/2021.8.spine21695] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/24/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the feasibility and complications of the over-the-arch (OTA) technique for screw insertion into the C1 lateral mass in patients in whom conventional techniques (i.e., posterior arch [PA] and inferior lateral mass [ILM]) are not feasible due to 1) PA with a very small height (< 3.5 mm), 2) a caudally tilted PA blocking the inferior part of the C1 lateral mass, or 3) loss of height at the ILM (< 3.5 mm). METHODS The authors reviewed the medical records of 60 patients who underwent C1 screw fixation with the OTA technique (13 screws) and the PA/ILM technique (107 screws) between 2011 and 2019. Vertebral artery (VA) injuries, screw malposition, and bony union were radiologically assessed. Clinical outcome measures, including Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA) scale score, and occipital neuralgia, were recorded. RESULTS Thirteen OTA screws were successfully inserted without any major complications. NDI and JOA scale scores did not show significant differences between the two groups at final follow-up. No VA injuries were recognized during screw insertion. There was no evidence of ischemic damage to the VA or bony erosion in the occiput or atlas. Medial wall violation was observed in 1 screw (7.7%); however, no C0-1, C1-2, or lateral wall violations were observed. No patients developed new-onset neuralgia postoperatively after C1 fixation with the OTA technique. CONCLUSIONS The OTA technique was safe and useful for C1 screw fixation in patients in whom conventional techniques could not be employed.
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Affiliation(s)
- Hyung Rae Lee
- 1Department of Orthopedic Surgery, Uijeongbu Eulji Medical Center, Uijeongbusi, Republic of Korea
| | - Dong-Ho Lee
- 2Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Hwan Cho
- 2Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eui Seung Hwang
- 3College of Art and Science, Emory University, Atlanta, Georgia
| | - Sang Yun Seok
- 4Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Daejeon, Republic of Korea; and
| | - Sehan Park
- 5Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Republic of Korea
| | - Choon Sung Lee
- 2Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Takahashi F, Hakozaki T, Kanno N, Suzuki S, Harada Y, Soeta S, Nakamura S, Yamaguchi S, Hara Y. Influence of ventral fixation techniques on atlantoaxial joint fusion in canine models with dens partial resection. J Vet Med Sci 2022; 84:694-699. [PMID: 35387953 PMCID: PMC9177397 DOI: 10.1292/jvms.21-0315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We evaluated the completeness of bony fusion of the atlantoaxial joint (AAJ) through polymethylmethacrylate fixation (PMF) and atlantoaxial plate fixation (APF) using six canine models with
dens partial resection. In both groups, the hydroxyapatite content at the AAJ was measured up to 7 months postoperatively using quantitative computed tomography. Histological assessment
revealed fibrous fusion in the PMF group. Meanwhile, in the APF group, only one dog achieved fibrous fusion, whereas the remaining three showed bony fusion. To our knowledge, this study was
the first to evaluate AAJ fusion histologically after PMF and APF. The present study demonstrates that PMF and APF may stabilize the AAJ without clinical complications. Therefore, PMF and
APF are clinically useful fixation methods for atlantoaxial instability.
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Affiliation(s)
- Fumitaka Takahashi
- The Laboratory of Veterinary Surgery, School of Veterinary Medicine, Nippon Veterinary and Life Science University
| | - Takaharu Hakozaki
- The Laboratory of Veterinary Surgery, School of Veterinary Medicine, Nippon Veterinary and Life Science University
| | - Nobuo Kanno
- The Laboratory of Veterinary Surgery, School of Veterinary Medicine, Nippon Veterinary and Life Science University
| | - Shuji Suzuki
- The Laboratory of Veterinary Surgery, School of Veterinary Medicine, Nippon Veterinary and Life Science University
| | - Yasuji Harada
- The Laboratory of Veterinary Surgery, School of Veterinary Medicine, Nippon Veterinary and Life Science University
| | - Satoshi Soeta
- The Laboratory of Veterinary Anatomy, School of Veterinary Medicine, Nippon Veterinary and Life Science University
| | | | - Shinya Yamaguchi
- The Laboratory of Veterinary Surgery, School of Veterinary Medicine, Nippon Veterinary and Life Science University
| | - Yasushi Hara
- The Laboratory of Veterinary Surgery, School of Veterinary Medicine, Nippon Veterinary and Life Science University
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24
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Tatter C, Fletcher-Sandersjöö A, Persson O, Burström G, Edström E, Elmi-Terander A. Fluoroscopy-Assisted C1-C2 Posterior Fixation for Atlantoaxial Instability: A Single-Center Case Series of 78 Patients. Medicina (Kaunas) 2022; 58:medicina58010114. [PMID: 35056423 PMCID: PMC8779556 DOI: 10.3390/medicina58010114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 01/10/2022] [Indexed: 04/21/2023]
Abstract
Background and Objectives: Posterior C1-C2 fixation, with trans-articular screws (TAS) or screw-rod-construct (SRC), is the main surgical technique for atlantoaxial instability, and can be performed with a fluoroscopy-assisted free-handed technique or 3D navigation. This study aimed to evaluate complications, radiological and functional outcome in patients treated with a fluoroscopy-assisted technique. Materials and Methods: A single-center consecutive cohort study was conducted of all adult patients who underwent posterior C1-C2 fixation, using TAS or CRS, between 2005-2019. Results: Seventy-eight patients were included, with a median follow-up time of 6.8 years. Trauma was the most common injury mechanism (64%), and cervicalgia the predominant preoperative symptom (88%). TAS was used in 33%, and SRC in 67% of cases. Surgery was associated with a significant reduction in cervicalgia (from 88% to 26%, p < 0.001). The most common complications were vertebral artery injury (n = 2, 2.6%), and screw malposition (n = 5, 6.7%, of which 2 were TAS and 3 were SRC). No patients deteriorated in their functional status following surgery. Conclusions: Fluoroscopy-assisted C1-C2 fixation with TAS or SRC is a safe and effective treatment for atlantoaxial instability, with a low complication rate, few surgical revisions, and pain relief in the majority of the cases.
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Affiliation(s)
- Charles Tatter
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
- Correspondence: ; Tel.: +46-8-517-74-126
| | - Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Oscar Persson
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Gustav Burström
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Erik Edström
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Neurosurgery, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.F.-S.); (O.P.); (G.B.); (E.E.); (A.E.-T.)
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
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25
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Tabanez J, Gutierrez-Quintana R, Kaczmarska A, José-López R, Nadal VG, Rotter C, Leblond G. Evaluation of a Novel Dorsal-Cemented Technique for Atlantoaxial Stabilisation in 12 Dogs. Life (Basel) 2021; 11:1039. [PMID: 34685410 DOI: 10.3390/life11101039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022] Open
Abstract
Dorsal atlantoaxial stabilisation (DAAS) has mostly been described to treat atlantoaxial instability using low stiffness constructs in dogs. The aim of this study was to assess the feasibility and surgical outcome of a rigid cemented DAAS technique using bone corridors that have not previously been reported. The medical records of 12 consecutive dogs treated with DAAS were retrospectively reviewed. The method involved bi-cortical screws placed in at least four of eight available bone corridors, embedded in polymethylmethacrylate. Screw placement was graded according to their position and the degree of the breach from the intended bone corridor. All DAAS procedures were completed successfully. A total of 72 atlantoaxial screws were placed: of those, 51 (70.8%) were optimal, 17 (23.6%) were suboptimal, and 4 (5.6%) were graded as hazardous (including 2 minor breaches of the vertebral canal). Surgical outcome was assessed via a review of client questionnaires, neurological examination, and postoperative CT images. The clinical outcome was considered good to excellent in all but one case that displayed episodic discomfort despite the appropriate atlantoaxial reduction. A single construct failure was identified despite a positive clinical outcome. This study suggests the proposed DAAS is a viable alternative to ventral techniques. Prospective studies are required to accurately compare the complication and success rate of both approaches.
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26
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Bunmaprasert T, Trirattanapikul V, Sugandhavesa N, Phanphaisarn A, Liawrungrueang W, Phinyo P. Reducible Nonunited Type II Odontoid Fracture with Atlantoaxial Instability: Outcomes of Two Different Fixation Techniques. Int J Environ Res Public Health 2021; 18:ijerph18157990. [PMID: 34360289 PMCID: PMC8345345 DOI: 10.3390/ijerph18157990] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022]
Abstract
Displaced nonunited type II odontoid fracture can result in atlantoaxial instability, causing delayed cervical myelopathy. Both Magerl's C1-C2 transarticular screw fixation technique and Harms-Goel C1-C2 screw-rod segmental fixation technique are effective techniques to provide stability. This study aimed to demonstrate the results of two surgical fixation techniques for the treatment of reducible nonunited type II odontoid fracture with atlantoaxial instability. Medical records of patients with reducible nonunited type II odontoid fracture hospitalized for spinal fusion between April 2007 and April 2018 were reviewed. For each patient, specific surgical fixation, either Magerl's C1-C2 transarticular screw fixation technique augmented with supplemental wiring or Harms-Goel C1-C2 screw-rod fixation technique, was performed according to our management protocol. We reported the fusion rate, fusion period, and complications for each technique. Of 21 patients, 10 patients were treated with Magerl's C1-C2 transarticular screw fixation technique augmented with supplemental wiring, and 11 were treated with Harms-Goel C1-C2 screw-rod fixation technique. The bony fusion rate was 100% in both groups. The mean time to fusion was 69.7 (95%CI 53.1, 86.3) days in Magerl's C1-C2 transarticular screw fixation technique and 75.2 (95%CI 51.8, 98.6) days in Harms-Goel C1-C2 screw-rod fixation technique. No severe complications were observed in either group. Displaced reducible, nonunited type II odontoid fracture with cervical myelopathy should be treated by surgery. Both fixation techniques promote bony fusion and provide substantial construct stability.
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Affiliation(s)
- Torphong Bunmaprasert
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Vorapop Trirattanapikul
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Nantawit Sugandhavesa
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Areerak Phanphaisarn
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Wongthawat Liawrungrueang
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Musculoskeletal Science and Translational Research (MSTR) Cluster, Chiang Mai University, Chiang Mai 50200, Thailand
- Correspondence: ; Tel.: +66-53-935-180
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27
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Gilbert E, Driver CJ. Surgical management of traumatic atlantoaxial subluxation in two cats. JFMS Open Rep 2021; 7:20551169211027070. [PMID: 34285810 PMCID: PMC8264740 DOI: 10.1177/20551169211027070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Case series summary We describe here the surgical management of two pure breed cats with traumatic atlantoaxial subluxation. One cat was ambulatory tetraparetic on presentation and the second was tetraplegic, both with cervical spinal pain and acute onset of paresis with subsequent deterioration. MRI was performed in both cases, demonstrating spinal cord injury. Flexed lateral cervical radiographs were needed to confirm atlantoaxial subluxation in one case. CT was performed for surgical planning and surgical stabilisation was achieved with threaded pins and polymethyl methacrylate (PMMA) cement; odontoidectomy was required in one case. Both cats showed improvement postoperatively, with no complications or deterioration seen. Following surgery, one cat made a complete recovery; however, the second cat retained significant deficits. Relevance and novel information We present the first report of surgically managed atlantoaxial subluxation of traumatic aetiology in cats, and report its occurrence in two novel breeds for this disease, Ragdoll and Persian. One case required odontoidectomy due to previous fracture and malunion of the odontoid process of the axis; both cases underwent surgical stabilisation of the atlantoaxial joint utilising multiple threaded pins and PMMA cement without transarticular implants – a technique that has not been previously reported in cats.
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28
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Raut S, Kundnani VG, Meena MK, Patel JY, Asati S, Patel A. Anthropometric evaluation for surgical feasibility of C1-C2 transarticular screw stabilization in Indian population. J Craniovertebr Junction Spine 2021; 12:129-135. [PMID: 34194158 PMCID: PMC8214229 DOI: 10.4103/jcvjs.jcvjs_175_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/18/2021] [Indexed: 11/05/2022] Open
Abstract
Study Design: This study was a radiographic observational study for C1–C2 anthropometry. Purpose: The purpose of the study was to understand the anatomic relationship of C1–C2 in view of transarticular screw (TAS) fixation, to overcome the difficulties related with TAS placement, and to minimize the technique-related complications. Materials and Methods: It was an anthropometric observational study with retrospectively obtained anatomical data of randomly selected 116 patients from a single center. The anatomical measurements such as pars width, pars height, screw trajectory, and length were evaluated on the axial, sagittal, and three-dimensional reconstructed cervical CT scan using the radiant DICOM viewer software by the two fellowship trained spine surgeons which were blind to the study group details. The intra- and interobserver reliability with regard to the measured parameters was statistically analyzed. Results: The mean age of male and female was 28 and 29 years. The average BMI was calculated to be 23.5 and 25 for males and females, respectively. The mean right pars width in males was 5.78 ± 0.93 (range: 3.1–6.5 mm), while in female, it was 5.84 ± 0.95 (range: 3.1–6.5). The mean left pars width in males was 5.95 ± 1.13 (range: 3.8–8.1 mm), while in females, it was 5.70 ± 1.18 (range: 3.7–8.1 mm). Right side mean pars height in males was 5.90 ± 1.2 (range: 3.7–9.4 mm), and in females, it was 6.11 ± 1.04 (range: 3.8–9.3 mm). Left-sided mean pars height in males was 6.0 ± 1.1 (range: 3.2–9.4 mm) as compared to females, in which it was 5.77 ± 1.23 (range: 4.1–9.3 mm). The mean lateral angulation angle in males was 9.99° ± 1.70° (8.1°–15°), while in females, it was 10.15° ± 1.73° (8.1°–15°). The mean sagittal angulation in males was 26.33° ± 3.32° (21.0°–32.80°), while in females, it was 27.18 ± 3.05 (21.0°–32.10°). The average screw length in males was 41.74 ± 5.63 (34–54.8 mm), whereas in females, it was 41.35 ± 4.77 (34–54.8 mm). Conclusion: This study provides a morphometric database which is characteristic of the C1–C2 vertebrae in the normal Indian population with regard to the anatomic feasibility of the TAS fixation for various C1–C2 pathologies. The C2 pars width and height measured in the current study can guide the selection of TAS screws in the Indian population. This study could serve in providing the baseline anatomic parameters assessed in the healthy individuals to design and develop customized screws and related implant assembly which might provide wider clinical applicability.
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Affiliation(s)
- Saijyot Raut
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Vishal G Kundnani
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Mohit Kumar Meena
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Jwalant Y Patel
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Sanjeev Asati
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Ankit Patel
- Department of Orthopaedics, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Patkar SV, Patkar P. Basilar Invagination: Surgical Treatment by Novel Anterior Implant. J Orthop Case Rep 2021; 11:36-39. [PMID: 35437498 PMCID: PMC9009472 DOI: 10.13107/jocr.2021.v11.i06.2248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Anterior retropharyngeal realignment, distraction, and atlantoaxial fixation are an option for the treatment of symptomatic basilar invagination (BI). The anterior implants for distraction and fixation for atlantoaxial joints are still evolving. We share our experience using a novel implant which can easily, safely, and rigidly fix both lateral masses to the body of the axis. Methods After exposing both the atlantoaxial joints anteriorly, the joints were prepared, distracted with wedge shaped autologous tricorticate bone grafts and realigned to correct the cervicomedullary strain. The atlantoaxial joints were fixed using a novel titanium plate by passing screws upwards and laterally into the lateral masses of the atlas and centrally into the body of the axis. Post-operative imaging showed effective correction of BI and atlantoaxial dislocation. Post-operative dynamic X-ray images confirmed maintenance of rigid fixation at 6 months. Conclusion This new plate screw construct is safe, easy, cost-efficient, and biomechanically appealing option for the treatment of symptomatic BI.
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Affiliation(s)
- Sushil V Patkar
- Department of Neurosurgery, Poona Hospital and Research Center, Pune, Maharashtra, India
| | - Pradnya Patkar
- Department of Neurosurgery, Royal Preston Hospital, Fulwood, Preston, United Kingdom
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30
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Nituleasa A, Liu ED, Amidon RF, Ordookhanian C, Kaloostian P. The Aging Population Faces Increased Risk for Musculoskeletal Pathologies: The Problematic Atlas-Axis Instability. Cureus 2021; 13:e15068. [PMID: 34141512 PMCID: PMC8206866 DOI: 10.7759/cureus.15068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2021] [Indexed: 11/13/2022] Open
Abstract
Spinal cord injury (SCI), particularly of the traumatic variety, is a relatively common condition that disproportionately affects the elderly. Cases of SCI with nontraumatic etiologies in the geriatric population have increased over the last 20 years, however. Pannus formation, resulting from chronic inflammation of the spine, is one such etiology that may progress to SCI and potentially result in rapid neurological degeneration. Here we describe a case of an elderly woman who presented with a sudden onset of quadriplegia without a history of trauma. Radiography revealed upper cervical instability and fracture due to the presence of a large erosive pannus formation. Unfortunately, in the context of severe SCI, the reversibility of neurological decline is not always guaranteed. Additionally, surgical intervention is not always appropriate, especially among the elderly population, where medical management and end-of-life care are more often delivered.
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Affiliation(s)
- Antonia Nituleasa
- Cell, Molecular, and Developmental Biology, University of California Riverside, Riverside, USA
| | - Elizabeth D Liu
- Biochemistry, University of California Riverside, Riverside, USA
| | - Ryan F Amidon
- Medicine, Medical College of Wisconsin, Milwaukee, USA
| | | | - Paul Kaloostian
- Neurological Surgery, Riverside Community Hospital, Riverside, USA
- Neurological Surgery, Paul Kaloostian M.D. Inc., Riverside, USA
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31
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Okumura R, Hasegawa K, Tsuge S, Fukutake K, Nakamura K, Takahashi H, Wada A. Adult Morquio syndrome requiring occipito-thoracic fusion. J Orthop Surg (Hong Kong) 2021; 28:2309499020918424. [PMID: 32329403 DOI: 10.1177/2309499020918424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Morquio syndrome is a relatively rare entity that is often associated with atlantoaxial instability from early childhood due to odontoid dysplasia based on a mucopolysaccharoidal disorder. Here, we present the case of a 55-year-old male patient with Morquio syndrome who developed cervical myelopathy, which is an extremely rare condition in the older population. Myelopathy developed gradually with upper-limb paresthesia and clumsiness of both hands. The patient had a characteristic "gargoyle-like" coarse face with a trunk shortening-type short stature. Imaging of the cervical spine demonstrated several problems, including diminutive structures called platyspondyly with small pedicles and fragile bone quality, hypoplasia of the C1 posterior arch that migrated into the spinal canal, and os odontoideum with atlantoaxial instability. With intraoperative navigation guidance, posterior decompression of C1 followed by occipito-cervico-thoracic spinal fusion was successfully performed in this complicated case. Clinical and radiographic outcomes were both excellent and have been maintained for 2 years postoperatively.
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Affiliation(s)
- Ryosuke Okumura
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Keiji Hasegawa
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Shintarou Tsuge
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Katsunori Fukutake
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Kazumasa Nakamura
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Akihito Wada
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
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32
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Qiu F, Xu X, Ma X, Jiang W, Liu G, Fang Z, Lin Z. [Biomechanical stability evaluation of the fixation technique for crossed rods consisting of occipital plate and C 2 bilateral lamina screws]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2020; 34:1545-1549. [PMID: 33319533 DOI: 10.7507/1002-1892.202005029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To evaluate the stability of the fixation technique for the crossed rods consisting of occipital plate and C 2 bilateral lamina screws by biomechanical test. Methods Six fresh cervical specimens were harvested and established an atlantoaxial instability model. The models were fixed with parallel rods and crossed rods after occipital plate and C 2 bilateral laminae screws were implanted. The specimens were tested in the following sequence: atlantoaxial instability model (unstable model group), under parallel rods fixation (parallel fixation group), and under crossed rods fixation (cross fixation group). The range of motion (ROM) of the C 0-2 segments were measured in flexion-extension, left/right lateral bending, and left/right axial rotation. After the test, X-ray film was taken to observe the internal fixator position. Results The biomechanical test results showed that the ROMs in flexion-extension, left/right lateral bending, and left/right axial rotation were significantly lower in the cross fixation group and the parallel fixation group than in the unstable model group ( P<0.05). There was no significant difference between the cross fixation group and the parallel fixation group in flexion-extension and left/right lateral bending ( P>0.05). In the left/right axial rotation, the ROMs of the cross fixation group were significantly lower than those of the parallel fixation group ( P<0.05). After the test, the X-ray film showed the good internal fixator position. Conclusion The axial rotational stability of occipitocervical fusion can be further improved by crossed rods fixation when the occipital plate and C 2 bilateral lamina screws are used.
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Affiliation(s)
- Feng Qiu
- Department of Orthopaedics, Puning Overseas Chinese Hospital, Puning Guangdong, 515300, P.R.China
| | - Xilin Xu
- Department of Orthopaedics, Puning Overseas Chinese Hospital, Puning Guangdong, 515300, P.R.China
| | - Xiangyang Ma
- Department of Spinal Surgery, Orthopaedics Hospital, General Hospital of Southern Theatre Command, Guangzhou Guangdong, 510010, P.R.China
| | - Weicheng Jiang
- Department of Orthopaedics, Puning Overseas Chinese Hospital, Puning Guangdong, 515300, P.R.China
| | - Gengchao Liu
- Department of Orthopaedics, Puning Overseas Chinese Hospital, Puning Guangdong, 515300, P.R.China
| | - Zhouqun Fang
- Department of Orthopaedics, Puning Overseas Chinese Hospital, Puning Guangdong, 515300, P.R.China
| | - Zejiang Lin
- Department of Orthopaedics, Puning Overseas Chinese Hospital, Puning Guangdong, 515300, P.R.China
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Govindasamy R, Preethish-Kumar V, Gopal S, Rudrappa S. Is Transoral Surgery Still a Relevant Procedure in Atlantoaxial Instability? Int J Spine Surg 2020; 14:657-664. [PMID: 33077434 PMCID: PMC7671436 DOI: 10.14444/7096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The treatment of atlantoaxial instability (AAI) involves stable fixation and fusion with adequate decompression of spinal cord. After the advent of the Goel posterior joint manipulation technique, most of the once irreducible atlantoaxial dislocations (AAD) could be reduced and the need for transoral odontoidectomy became almost nil. Here we tried to iterate the indications of anterior transoral odontoid surgery for AAI in the current scenario. METHODS A retrospective study compiling the clinical, radiological, and surgical characteristics of 6 cases (5 scenarios). These patients underwent anterior transoral surgery alone or in combination with a posterior approach. RESULTS Two patients had a well-formed occipito-cervical fusion mass, with a displaced odontoid and unreduced C1-C2 joint causing cervical myelopathy. A middle-aged woman presented with unreduced AAD following failed C1-C2 joint distraction technique. A displaced dystopic os odontoideum ossicle was found in an adolescent boy, prohibiting the reduction of AAD. A young man had displacement of the fractured odontoid segment with intact transverse alar ligament and C1-C2 joint complex. One patient had a rare scenario of abnormal orientation of the C1-C2 joint. All 6 patients were successfully treated with adequate spinal cord decompression achieved by the anterior transoral route and stabilization by either the anterior approach itself or in combination with posterior surgery. All had significantly better postoperative outcomes except for 1 patient who expired due to poor respiratory reserve. CONCLUSION We tried to emphasize the indications for using transoral anterior odontoid surgery over the posterior approach in the management of AAI. This will prevent the surgical technique of anterior odontoidectomy from becoming an obsolete procedure in the current practice.
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Affiliation(s)
- Ramachandran Govindasamy
- Institute of Neurosciences, Sakra World Hospital, Bellandur, Bangalore, India
- Department of Spine Surgery, Sakra World Hospital, Bellandur, Bangalore, India
| | | | - Swaroop Gopal
- Institute of Neurosciences, Sakra World Hospital, Bellandur, Bangalore, India
| | - Satish Rudrappa
- Institute of Neurosciences, Sakra World Hospital, Bellandur, Bangalore, India
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Goel A, Vutha R, Shah A, Ranjan S, Jadhav N, Jadhav D. Atlantoaxial fixation for failed foramen magnum decompression in patients with Chiari formation. J Craniovertebr Junction Spine 2020; 11:186-192. [PMID: 33100768 PMCID: PMC7546052 DOI: 10.4103/jcvjs.jcvjs_113_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Relationship of atlantoaxial instability with Chiari formation is further analyzed in the report. Objective: The outcome of 25 patients who had failed conventional treatment for Chiari formation that included foramen magnum decompression surgery and were treated by atlantoaxial fixation is analyzed. Materials and Methods: During the period January 2010 to November 2019, we treated 25 patients who had undergone conventionally described surgical procedures; all included foramen magnum decompression for Chiari formation. None of the patients had any craniovertebral junction anomaly. All patients had syringomyelia. All patients had worsened in their neurological condition following surgery either in the immediate or in the delayed postoperative phase. Atlantoaxial instability was diagnosed on the basis of facetal alignment and on the basis of direct observation of joint status by bone manipulation during surgery. The patients were treated by atlantoaxial fixation. Goel clinical grading scale and Japanese Orthopedic Association Score assessed the clinical status both before and after surgery. Results: Following surgery, all patients improved in the clinical condition. The improvement began in the immediate postoperative period and progressed. During the follow-up period that ranged from 4 to 123 months, “significant” neurological recovery and amelioration of presenting symptoms were observed. During the period of follow-up, reduction in the size of syrinx was observed in 14 out of 18 cases where postoperative magnetic resonance imaging was possible. Conclusions: Clinical results reinforce the belief that atlantoaxial instability is the nodal point of pathogenesis of Chiari formation. Atlantoaxial fixation is the treatment.
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Affiliation(s)
- Atul Goel
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Mumbai, Maharashtra, India
| | - Ravikiran Vutha
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Mumbai, Maharashtra, India
| | - Abhidha Shah
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Mumbai, Maharashtra, India
| | - Shashi Ranjan
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Mumbai, Maharashtra, India
| | - Neha Jadhav
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Mumbai, Maharashtra, India
| | - Dikpal Jadhav
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Mumbai, Maharashtra, India
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Abstract
BACKGROUND Based on established posterior atlantoaxial fixation techniques, we present a novel technique that uses a polyaxial screw rod system and utilizes a combination of C1 lateral mass and C1-C2 transarticular screws. METHODS We conducted a retrospective review of six men and four women (mean age: 57, range: 20-86). Indication for atlantoaxial fixation was type II odontoid fractures or pseudarthrosis after odontoid fracture (n = 7), rheumatoid arthritis (n = 2) and os odontoideum (n = 1). RESULTS The mean follow-up time was 48 months (range: 24-72). There were no intraoperative complications such as vertebral artery, nerve root or spinal cord injury. Post-operative imaging showed no screw malposition. During follow-up, no patient had screw loosening, screw fracture or bone absorption around the screws. Clinically, patient neck pain improved in all cases. CONCLUSIONS C1 lateral mass and C1-C2 transarticular polyaxial screw rod fixation is a novel and potentially effective surgical technique for achieving immediate rigid immobilization of the C1-C2 motion segment. However, further biomechanical studies should be performed to prove our clinical results.
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Affiliation(s)
- Ali Harati
- Neurosurgical Department, Klinikum Dortmund, Dortmund, Germany
| | - Paul Oni
- Neurosurgical Department, Klinikum Dortmund, Dortmund, Germany
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Terai H, Nakamura H. Surgical Management of Spinal Disorders in People with Mucopolysaccharidoses. Int J Mol Sci 2020; 21:E1171. [PMID: 32050679 DOI: 10.3390/ijms21031171] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/04/2020] [Accepted: 02/07/2020] [Indexed: 12/19/2022] Open
Abstract
Mucopolysaccharidoses (MPS) are a group of inherited, multisystem, lysosomal storage disorders involving specific lysosomal enzyme deficiencies that result in the accumulation of glycosaminoglycans (GAG) secondary to insufficient degradation within cell lysosomes. GAG accumulation affects both primary bone formation and secondary bone growth, resulting in growth impairment. Typical spinal manifestations in MPS are atlantoaxial instability, thoracolumbar kyphosis/scoliosis, and cervical/lumbar spinal canal stenosis. Spinal disorders and their severity depend on the MPS type and may be related to disease activity. Enzyme replacement therapy or hematopoietic stem cell transplantation has advantages regarding soft tissues; however, these therapeutic modalities are not effective for bone or cartilage and MPS-related bone deformity including the spine. Because spinal disorders show the most serious deterioration among patients with MPS, spinal surgeries are required although they are challenging and associated with high anesthesia-related risks. The aim of this review article is to provide the current comprehensive knowledge of representative spinal disease in MPS and its surgical management, including the related pathology, symptoms, and examinations.
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Du YQ, Li T, Ma C, Qiao GY, Yin YH, Yu XG. Biomechanical evaluation of two alternative techniques to the Goel-Harms technique for atlantoaxial fixation: C1 lateral mass-C2 bicortical translaminar screw fixation and C1 lateral mass-C2/3 transarticular screw fixation. J Neurosurg Spine 2020; 32:682-688. [PMID: 31952043 DOI: 10.3171/2019.11.spine191178] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors conducted a study to investigate the biomechanical feasibility and stability of C1 lateral mass-C2 bicortical translaminar screw (C1LM-C2TL) fixation, C1 lateral mass-C2/3 transarticular screw (C1LM-C2/3TA) fixation, and C1LM-C2/3TA fixation with transverse cross-links (C1LM-C2/3TACL) as alternative techniques to the Goel-Harms technique (C1 lateral mass-C2 pedicle screw [C1LM-C2PS] fixation) for atlantoaxial fixation. METHODS Eight human cadaveric cervical spines (occiput-C7) were tested using an industrial robot. Pure moments that were a maximum of 1.5 Nm were applied in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). The specimens were first tested in the intact state and followed by destabilization (a type II odontoid fracture) and fixation as follows: C1LM-C2PS, C1LM-C2TL, C1LM-C2/3TA, and C1LM-C2/3TACL. For each condition, the authors evaluated the range of motion and neutral zone across C1 and C2 in all directions. RESULTS Compared with the intact spine, each instrumented spine significantly increased in stability at the C1-2 segment. C1LM-C2TL fixation demonstrated similar stability in FE and LB and greater stability in AR than C1LM-C2PS fixation. C1LM-C2/3TA fixation was equivalent in LB and superior in FE to those of C1LM-C2PS and C1LM-C2TL fixation. During AR, the C1LM-C2/3TA-instrumented spine failed to maintain segmental stability. After adding a cross-link, the rotational stability was significantly increased in the C1LM-C2/3TACL-instrumented spine compared with the C1LM-C2/3TA-instrumented spine. Although inferior to C1LM-C2TL fixation, the C1LM-C2/3TACL-instrumented spine showed equivalent rotational stability to the C1LM-C2PS-instrumented spine. CONCLUSIONS On the basis of our biomechanical study, C1LM-C2TL and C1LM-C2/3TACL fixation resulted in satisfactory atlantoaxial stabilization compared with C1LM-C2PS. Therefore, the authors believe that the C1LM-C2TL and C1LM-C2/3TACL fixation may serve as alternative procedures when the Goel-Harms technique (C1LM-C2PS) is not feasible due to anatomical constraints.
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Affiliation(s)
- Yue-Qi Du
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
| | - Teng Li
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
| | - Chao Ma
- 2Key Laboratory of Modern Measurement and Control Technology, Ministry of Education, Beijing Information Science and Technology University, Beijing, China
| | - Guang-Yu Qiao
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
| | - Yi-Heng Yin
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
| | - Xin-Guang Yu
- 1Department of Neurosurgery, Chinese PLA General Hospital, Beijing; and
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Naito K, Yamagata T, Kawahara S, Ohata K, Takami T. High Cervical Lateral Approach to Safely Remove the Cystic Retro-odontoid Pseudotumor: Technical Note. Neurol Med Chir (Tokyo) 2019; 59:392-397. [PMID: 31406052 PMCID: PMC6796063 DOI: 10.2176/nmc.tn.2019-0060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Surgery for neoplastic or vascular lesions at the craniovertebral junction remains one of the major challenges for neurosurgeons, because of issues such as the complex functional anatomy and vascular structures. We present three cases in which the high cervical lateral approach was used to safely remove the cystic retro-odontoid pseudotumor, not associated with rheumatoid arthritis, severely compressing the spinal cord. The mean age of patients was 74.7 years (range, 73–77 years). Neurological condition was assessed based on the neurosurgical cervical spine scale. A high cervical lateral approach was applied to remove the pseudotumor safely. Mean duration of follow-up after surgery was 21.3 months (range, 18–24 months). Mean recovery rate was 77.8%. All patients showed acceptable or satisfactory functional recovery, although one patient (Case 2) developed mild paralysis of the facial and spinal accessory nerve on the surgical approach side, but that completely recovered within about 1 month after surgery. Postoperative assessment at the recent follow-up suggested no significant aggravation of neck movement. This technical note suggests that the high cervical lateral approach can be considered as a surgical option for cystic retro-odontoid pseudotumor, not associated with rheumatoid arthritis, severely compressing the spinal cord. Safe management of the vertebral artery is one of the key considerations.
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Affiliation(s)
- Kentaro Naito
- Department of Neurosurgery, Osaka City University Graduate School of Medicine
| | - Toru Yamagata
- Department of Neurosurgery, Osaka City General Hospital
| | - Shinichi Kawahara
- Department of Neurosurgery, Osaka City University Graduate School of Medicine
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine
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Goel A, Prasad A, Shah A, Rai S, Patil A, Vutha R. Atlantoaxial fixation for craniovertebral anomaly associated with absent posterior elements of the axial vertebra: report of 3 cases. J Neurosurg Spine 2019; 31:654-659. [PMID: 31299647 DOI: 10.3171/2019.5.spine19185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/06/2019] [Indexed: 11/06/2022]
Abstract
This is a report of 3 relatively rare clinical cases in which the absence of posterior elements of the axis was associated with basilar invagination and multiple other craniovertebral junction musculoskeletal and neural abnormalities. Atlantoaxial fixation resulted in remarkable clinical recovery in all 3 cases. C2-3 fixation was not done, and bone decompression was not done. On the basis of their experience, the authors conclude that atlantoaxial fixation is a satisfactory form of surgical treatment in patients having an association of basilar invagination with absent posterior elements of axis.
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Affiliation(s)
- Atul Goel
- 1Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai; and
- 2Department of Neurosurgery, Lilavati Hospital and Research Centre, Bandra West, Mumbai, India
| | - Apurva Prasad
- 2Department of Neurosurgery, Lilavati Hospital and Research Centre, Bandra West, Mumbai, India
| | - Abhidha Shah
- 1Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai; and
| | - Survendra Rai
- 1Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai; and
| | - Abhinandan Patil
- 1Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai; and
| | - Ravikiran Vutha
- 1Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai; and
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Mueller K, MacConnell A, Berkowitz F, Voyadzis JM. Morphological classification of the tubercle of insertion of the transverse atlantal ligament: A computer tomography-based anatomical study of 200 subjects. Neuroradiol J 2019; 32:426-430. [PMID: 31290720 DOI: 10.1177/1971400919857211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND AND PURPOSE The atlantal tubercle is the attachment point of the transverse atlantal ligament, the main stabilizer of the atlantoaxial complex. No system of classification of the tubercle exists in the literature. We aimed to develop a morphologically based classification system of the atlantal tubercle to aid clinicians who deal with craniocervical pathology. MATERIALS AND METHODS A retrospective review of computed tomography (CT) scans of the cervical spine was performed. The morphology of the atlantal tubercle was classified into four variants: rounded (classical), pointed, flattened, and hypoplastic. Age, presence, and morphological type were recorded. RESULTS A total of 200 CT scans were identified and reviewed. The tubercle was present bilaterally in all patients. Patients were equally distributed over various age ranges. The following morphological types were recorded: rounded (227/400; 56.8%), pointed (13/400; 3.3%), flattened (126; 31.5%), and hypoplastic (34/400; 8.5%). The same type was seen bilaterally in 68% (135/200) of patients. Morphological types appear equally on the right and left side of the atlas. CONCLUSIONS The first morphologically based classification system of the atlantal tubercle utilizing CT is presented. Morphology type, especially hypoplastic type, may confer an increased risk for subsequent need for posterior fusion.
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Affiliation(s)
- Kyle Mueller
- Department of Neurosurgery, Medstar Georgetown University Hospital, USA
| | | | - Frank Berkowitz
- Department of Neuroradiology, Medstar Georgetown University Hospital, USA
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Takahashi F, Kouno S, Yamaguchi S, Hara Y. Evaluation of atlantooccipital overlapping and cerebral ventricle size in dogs with atlantoaxial instability. J Vet Med Sci 2019; 81:229-236. [PMID: 30584199 PMCID: PMC6395205 DOI: 10.1292/jvms.17-0553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study investigated cerebral ventricle size and concurrent craniocervical junction
abnormality in relation to atlantooccipital overlapping (AOO) in dogs with atlantoaxial
instability (AAI). A total of 61 dogs were treated with atlantoaxial ventral fixation.
Medical records of each dog, including magnetic resonance (MR) and computed tomography
(CT) images, were retrospectively reviewed. CT images were assessed for the presence of
AOO and the dogs were then assigned to either an AOO group or a non-AOO group accordingly.
CT images were also evaluated to determine the foramen magnum (FM) index. Syringomyelia,
cerebellar compression, dorsal compression, and the degree of enlargement of each cerebral
ventricle were evaluated using MR images. Of the 61 dogs, 23 had AOO and 38 did not.
Furthermore, the ventricle/brain height ratio, the fourth ventricle height/cerebellum
length ratio, and the fourth ventricle width/cerebellum length ratio were significantly
higher in the AOO group than in the non-AOO group. However, the FM index, third
ventricle/brain height ratio, and incidence of syringomyelia did not differ significantly
between the two groups. Dogs with concurrent AOO exhibited significantly more dilatation
of the lateral and fourth ventricles.
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Affiliation(s)
- Fumitaka Takahashi
- The Laboratory of Veterinary Surgery, Nippon Veterinary and Life Science University, 1-7-1 Kyonan, Musashino-shi, Tokyo 180-0023, Japan.,YPC Tokyo Animal Orthopedic Surgery Hospital, 7-1-13 Oojima, Koutou-ku, Tokyo 136-0072, Japan
| | - Shigenori Kouno
- The Laboratory of Veterinary Surgery, Nippon Veterinary and Life Science University, 1-7-1 Kyonan, Musashino-shi, Tokyo 180-0023, Japan
| | - Shinya Yamaguchi
- The Laboratory of Veterinary Surgery, Nippon Veterinary and Life Science University, 1-7-1 Kyonan, Musashino-shi, Tokyo 180-0023, Japan.,YPC Tokyo Animal Orthopedic Surgery Hospital, 7-1-13 Oojima, Koutou-ku, Tokyo 136-0072, Japan
| | - Yasushi Hara
- The Laboratory of Veterinary Surgery, Nippon Veterinary and Life Science University, 1-7-1 Kyonan, Musashino-shi, Tokyo 180-0023, Japan
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Patkar S. Craniovertebral fixation … a new technique of occipital - cervical fixation. Neurol Res 2017; 39:1125-1128. [PMID: 29057717 DOI: 10.1080/01616412.2017.1389425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Craniovertebral instability following transoral odontoid excision is usually treated by posterior occipital-cervical fixation using occipital plate and cervical lateral mass fixation with screw rod construct. A patient previously operated for basilar invagination had postoperative infection of both the transoral wound and the posterior implant site which needed removal of the posterior implant earlier. CLINICAL PRESENTATION The patient presented with severe neck pain, myelopathy, and chronic discharging sinus in the posterior lower aspect the previous neck surgery wound. Reimaging revealed incomplete odontoid excision. He underwent repeat transoral odontoid excision. Treatment of the instability needed occipitocervical fixation avoiding, the atlas, axis (weakened by infection and previous implants), and the infected posterior cervical wound. A new technique using a customized plate rod construct, fixed anteriorly to the mid cervical vertebrae (by a standard mid cervical exposure) with the rods contoured to reach posteriorly through the safe paraspinal corridor and connected with domino connectors to occipital plate rods fixed on either side of midline by additional posterior exposure avoiding the midline scar was planned and executed successfully. CONCLUSION This construct transfers the weight of the cranium to the cervical vertebral bodies along the physiological line of weight transmission and can be considered for distraction and reduction of basilar invagination with atlantoaxial dislocation. The technique seems to be safe and reproducible, but will need to tested over time with more cases.
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Affiliation(s)
- Sushil Patkar
- a Bhartividyapeeth Medical College & Hospital , Pune , India.,b Poona Hospital & Research Center , Pune , India
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Patkar S. Anterior retropharyngeal plate screw fixation with bilateral anterior transarticular screws for odontoid fractures ... a new comprehensive technique. Neurol Res 2017; 39:581-586. [PMID: 28403693 DOI: 10.1080/01616412.2017.1315881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION A certain group of odontoid fractures (Anderson and D' Alonzo Type-2) are usually offered surgical treatment. Common surgical option is an anterior odontoid screw. Some of the fractures are not suitable for anterior odontoid screw (anterior oblique, displaced distal fragments and those with atlantoaxial instability) and these are usually offered posterior transarticular screws (Magerl's) or posterior atlantoaxial screw rod/plate fixation (Goel-Harms technique). Posterior surgery involves atlantoaxial fixation with an indirect attempt to reduce and fuse the fracture . Posterior surgery has a risk of injury to the vertebral arteries, hemorrhage from the paravertebral venous plexus and the C2 root ganglion. METHODS A direct anterior submandibular retropharyangeal approach with open reduction and fixation (ORIF) using a customized variable screw placement (VSP) plate was used to realign and fix the fracture fragments in compression mode under direct vision. Twenty patients of type-II odontoid fractures (unsuitable for anterior odontoid screw) underwent an anterior retropharyngeal approach with anterior variable screw position (VSP) plate and screw fixation and eight amongst them, who had associated atlantoaxial instability underwent additional bilateral anterior transarticular screws. RESULTS All patients treated by this technique had 100% fracture site bone union without any implant failure. Longest follow-up has been for 3 years. CONCLUSION Anterior retropharyangeal approach allows direct fracture fragment realignment under vision with an opportunity to fix in compression mode using the VSP plate, which ensures early fusion across the type-II odontoid fracture. Any associated instability can be treated by additional bilateral anterior transarticular screws. The approach is simple and safe without any risk to the vertebral arteries and biomechanically appealing.
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Affiliation(s)
- Sushil Patkar
- a Department of Neurosurgery , Poona Hospital & Research Center, Bhartividyapeeth Medical College & Hospital , Pune , India
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Henderson FC, Austin C, Benzel E, Bolognese P, Ellenbogen R, Francomano CA, Ireton C, Klinge P, Koby M, Long D, Patel S, Singman EL, Voermans NC. Neurological and spinal manifestations of the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet 2017; 175:195-211. [PMID: 28220607 DOI: 10.1002/ajmg.c.31549] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The Ehlers-Danlos syndromes (EDS) are a heterogeneous group of heritable connective tissue disorders characterized by joint hypermobility, skin extensibility, and tissue fragility. This communication briefly reports upon the neurological manifestations that arise including the weakness of the ligaments of the craniocervical junction and spine, early disc degeneration, and the weakness of the epineurium and perineurium surrounding peripheral nerves. Entrapment, deformation, and biophysical deformative stresses exerted upon the nervous system may alter gene expression, neuronal function and phenotypic expression. This report also discusses increased prevalence of migraine, idiopathic intracranial hypertension, Tarlov cysts, tethered cord syndrome, and dystonia, where associations with EDS have been anecdotally reported, but where epidemiological evidence is not yet available. Chiari Malformation Type I (CMI) has been reported to be a comorbid condition to EDS, and may be complicated by craniocervical instability or basilar invagination. Motor delay, headache, and quadriparesis have been attributed to ligamentous laxity and instability at the atlanto-occipital and atlantoaxial joints, which may complicate all forms of EDS. Discopathy and early degenerative spondylotic disease manifest by spinal segmental instability and kyphosis, rendering EDS patients prone to mechanical pain, and myelopathy. Musculoskeletal pain starts early, is chronic and debilitating, and the neuromuscular disease of EDS manifests symptomatically with weakness, myalgia, easy fatigability, limited walking, reduction of vibration sense, and mild impairment of mobility and daily activities. Consensus criteria and clinical practice guidelines, based upon stronger epidemiological and pathophysiological evidence, are needed to refine diagnosis and treatment of the various neurological and spinal manifestations of EDS. © 2017 Wiley Periodicals, Inc.
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Huang KY, Lin RM, Fang JJ. A novel method of C1-C2 transarticular screw insertion for symptomatic atlantoaxial instability using a customized guiding block: A case report and a technical note. Medicine (Baltimore) 2016; 95:e5100. [PMID: 27787362 PMCID: PMC5089091 DOI: 10.1097/md.0000000000005100] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Atlantoaxial instability treated with the C1-2 transarticular screw fixation is biomechanically more stable; however, the technique demanding and the potential risk of neurovascular injury create difficulties for clinical usage, and there is still lack of clinical experience till now.We reported an adult female patient with symptomatic atlantoaxial instability due to rheumatoid arthritis that was successfully treated with a bilateral C1-C2 transarticular screw fixation using a customized guiding block. We preoperatively determined the trajectories for bilateral C1-C2 transarticular screws on a 3-dimensional reconstruction model from the computed tomography (CT) and self-developed computer software, and designed a rapid prototyping customized guiding block in order to offer a guide for the entry point and insertion angle of the C1-C2 transarticular screws.The clinical outcome was good, and the follow-up period was >3 years. The accuracy of the screws is good in comparison with preoperative and postoperative CT findings, and no neurovascular injury occurred.The patient was accurately and successfully treated with a bilateral C1-C2 transarticular screw fixation using a customized guiding block.
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Affiliation(s)
- Kuo-Yuan Huang
- Department of Orthopedics, College of Medicine, National Cheng Kung University
| | - Ruey-Mo Lin
- Department of Orthopedics, China Medical University, Tainan Municipal An-Nan Hospital
| | - Jing-Jing Fang
- Department of Mechanical Engineering, National Cheng Kung University, Tainan, Taiwan
- Correspondence: Jing-Jing Fang, Department of Mechanical Engineering, National Cheng Kung University, Tainan, Taiwan (e-mail: )
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Goel A, Jankharia B, Shah A, Sathe P. Three-dimensional models: an emerging investigational revolution for craniovertebral junction surgery. J Neurosurg Spine 2016; 25:740-744. [PMID: 27367939 DOI: 10.3171/2016.4.spine151268] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Complex craniovertebral junctional anomalies can be daunting to treat surgically, and preoperative information regarding the osseous abnormalities, course of the vertebral arteries, size of the pedicles, and location of the transverse foramina is invaluable to surgeons operating on these challenging cases. The authors present their experience with the emerging technology of 3D model acquisition for surgery in 11 cases of complex craniovertebral junction region anomalies. For each case, a 3D printed model was made from thin CT scans using a 64-slice CT scanner. The inclination of the joints, the presence of false articulations, the size of the pedicles, and the course of the vertebral arteries were studied preoperatively on the 3D models. The sizes of the plates and screws to be used and the angle of insertion of the screws were calculated based on the data from the models. The model was scaled to actual size and was kept beside the operating surgeon in its anatomical position during surgery. The potential uses of the models and their advantages over conventional radiological investigations are discussed. The authors conclude that 3D models can be an invaluable aid during surgery for complex craniovertebral junction anomalies. The information available from a real life-size model supersedes the information available from 3D CT reconstructions and can also be superior to virtual simulation. The models are both cost effective and easy to build and the authors suggest that they may form the basis of investigations in the near future for craniovertebral junction surgery.
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Affiliation(s)
- Atul Goel
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College.,Lilavati Hospital and Research Centre; and
| | | | - Abhidha Shah
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College
| | - Prashant Sathe
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College
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Dohzono S, Suzuki A, Koike T, Takahashi S, Yamada K, Yasuda H, Nakamura H. Factors associated with retro-odontoid soft-tissue thickness in rheumatoid arthritis. J Neurosurg Spine 2016; 25:580-585. [PMID: 27341058 DOI: 10.3171/2016.3.spine15787] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Increasing soft-tissue mass posterior to the odontoid process causes spinal cord compression. Retro-odontoid pseudotumors are considered to be associated with atlantoaxial instability in patients with rheumatoid arthritis (RA), but the exact mechanism by which these lesions develop has not been elucidated. The purpose of this study was to identify the relationships between retro-odontoid soft-tissue (ROST) thickness and radiological findings or clinical data in patients with RA. METHODS A total of 201 patients with RA who had been followed up at the outpatient clinic of the authors' institution were enrolled in this study. ROST thickness was evaluated on midsagittal T1-weighted MRI. The correlations between ROST thickness and radiographic findings or clinical data on RA were examined. The independent factors related to ROST thickness were analyzed using stepwise multiple regression analysis. RESULTS The average thickness of ROST was 3.0 ± 1.4 mm. ROST thickness showed an inverse correlation with disease duration (r = -0.329, p < 0.01), Steinbrocker stage (r = -0.284, p < 0.01), the atlantodental interval (ADI) in the neutral position (r = -0.326, p < 0.01), the ADI in the flexion position (r = -0.383, p < 0.01), and the ADI in the extension position (r = -0.240, p < 0.01). On stepwise multiple regression analysis, ADI in the flexion position and Steinbrocker stage were independent factors associated with ROST thickness. CONCLUSIONS Although the correlations were not strong, ROST thickness in patients with RA was inversely correlated with ADI and Steinbrocker stage. In other words, ROST thickness tends to be smaller as atlantoaxial instability and peripheral joint destruction worsen. Clinical trial registration no.: UMIN000000980 (UMIN Clinical Trials Registry).
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Affiliation(s)
- Sho Dohzono
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akinobu Suzuki
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tatsuya Koike
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinji Takahashi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kentaro Yamada
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Yasuda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Kukreja S, Ambekar S, Sin AH, Nanda A. Occipitocervical Fusion Surgery: Review of Operative Techniques and Results. J Neurol Surg B Skull Base 2015; 76:331-9. [PMID: 26401473 DOI: 10.1055/s-0034-1543967] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 10/29/2014] [Indexed: 02/03/2023] Open
Abstract
Objective Varying types of clinicoradiologic presentations at the craniovertebral junction (CVJ) influence the decision process for occipitocervical fusion (OCF) surgery. We discuss the operative techniques and decision-making process in OCF surgery based on our clinical experience and a literature review. Material and Methods A total of 49 consecutive patients who underwent OCF participated in the study. Sagittal computed tomography images were used to illustrate and measure radiologic parameters. We measured Wackenheim clivus baseline (WCB), clivus-canal angle (CCA), atlantodental distance (ADD), and Powers ratio (PR) in all the patients. Results Clinical improvement on Nurick grading was recorded in 36 patients. Patients with better preoperative status (Nurick grades 1-3) had better functional outcomes after the surgery (p = 0.077). Restoration of WCB, CCA, ADD, and PR parameters following the surgery was noted in 39.2%, 34.6%, 77.4%, and 63.3% of the patients, respectively. Complications included deep wound infections (n = 2), pseudoarthrosis (n = 2), and deaths (n = 4). Conclusion Conventional wire-based constructs are superseded by more rigid screw-based designs. Odontoidectomy is associated with a high incidence of perioperative complications. The advent of newer implants and reduction techniques around the CVJ has obviated the need for this procedure in most patients.
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Affiliation(s)
- Sunil Kukreja
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
| | - Sudheer Ambekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
| | - Anthony H Sin
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
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Sasaki M, Matsumoto K, Tsuruzono K, Yoshimura K, Shibano K, Yonenobu K. Anterior transarticular screw fixation as a conventional operation for rigid stabilization. Surg Neurol Int 2015; 5:S544-7. [PMID: 25593774 PMCID: PMC4287909 DOI: 10.4103/2152-7806.148032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 07/31/2014] [Indexed: 11/04/2022] Open
Abstract
Background: Anterior transarticular screw (ATS) fixation is a useful surgical option for atlantoaxial (AA) stabilization. This report presents a revised ATS method for AA fusion. Methods: A 79-year-old male presented with AA instability attributed both to an old odontoid fracture and severe degeneration of the lateral atlantoaxial joints (LAAJs). ATS fixation was performed through the conventional anterior cervical approach. The longest screw trajectories were planned preoperatively using multiplanar reconstruction computed tomography (CT) scans, with entry points of the screws situated at the midpoint on the inferior border of the axial body. The surgical exposure was limited to opening at the entry points alone. Our retractor of choice was the Cusco speculum; it sufficiently secured space for utilizing the required instruments for screw placement while offering sufficient protection of soft tissues. Cannulated full-threaded bicortical screws stabilized the LAAJs. Screw insertion required a significant amount of coronal angulation up to the superior articular process of the atlas under open-mouth and lateral fluoroscopy image guidance. After ATS fixation, bone grafting was performed between the posterior laminae of the axis and the atlas through a conventional posterior approach. Results: Bony fusion between the atlas and the axis was confirmed radiographically. Arthrodesis of the LAAJs occurred despite no bone grafting. Conclusions: Rigid fixation of the LAAJs was obtained by our ATS technique, indicating that it is an alternative method for AA fixation when posterior rigid internal fixation is not applicable.
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Affiliation(s)
- Manabu Sasaki
- Department of Neurosurgery and Spine Surgery, Iseikai Hospital, Osaka, Japan
| | - Katsumi Matsumoto
- Department of Neurosurgery and Spine Surgery, Iseikai Hospital, Osaka, Japan
| | - Koichiro Tsuruzono
- Department of Neurosurgery and Spine Surgery, Iseikai Hospital, Osaka, Japan
| | - Kazuhiro Yoshimura
- Department of Neurosurgery and Spine Surgery, Iseikai Hospital, Osaka, Japan
| | - Katsuhiko Shibano
- Department of Neurosurgery and Spine Surgery, Iseikai Hospital, Osaka, Japan
| | - Kazuo Yonenobu
- Graduate School of Health Care Sciences, Jikei Institute, Osaka, Japan
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Abstract
Posterior atlas arch anomalies are relatively common, but have a variety of presentations ranging from partial clefts to complete agenesis of the posterior arch. Partial clefts are prevalent in 4% of patients and are generally asymptomatic. However, complete agenesis of the posterior arch is extremely rare. We report the case of a 46-year-old man who presented with upper cervical spine and occipital pain as well as left sided headaches. Imaging revealed congenital complete absence of the posterior arch of C1 (Type E) without any radiographic evidence of instability. We discuss our case in light of other reported cases and detail its management.
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Affiliation(s)
- R Khanna
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Z A Smith
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - B J Dlouhy
- Department of Neurological Surgery, Washington University, St. Louis, Missouri, United States
| | - N S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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