-
Clinical Neurology and Neurosurgery Sep 2016The craniovertebral junction (CVJ) is a complex region of the spine with unique anatomical and functional relationships. To alleviate symptoms associated with... (Meta-Analysis)
Meta-Analysis Review
OBJECT
The craniovertebral junction (CVJ) is a complex region of the spine with unique anatomical and functional relationships. To alleviate symptoms associated with pathological processes involving the odontoid process, decompression is often required, including odontoidectomy. Accurate knowledge of the complication rates following the transoral and transnasal techniques is essential for both patients and surgeons.
METHODS
We conducted MEDLINE, Scopus and Web of Science database searches for studies reporting complications associated with the transoral and transnasal techniques for odontoidectomy. Case series presenting data for less than three patients were excluded. Rates of complication and clinical outcomes were calculated and subsequently analyzed using a fixed-effects model to assess statistical significance.
RESULTS
Of 1288 articles retrieved from MEDLINE, Scopus, and Web of Science, twenty-six met inclusion criteria. Transoral and transnasal procedures resulted in the following respective complication rates: arterial injury 1.9% and 0.0%, intraoperative CSF leak 0.3% and 30.0%, postoperative CSF leak 0.8% and 5.2%, 30-day mortality 2.9% and 4.4%, medical complications 13.9% and 28.6%, meningitis 1.0% and 4.0%, pharyngeal wound dehiscence 1.7% (transnasal not reported), pneumonia 10.3% (transnasal not reported), prolonged or re-intubation 5.6% and 6.0%, reoperation 2.5% and 5.1%, sepsis 1.9% and 7.7%, tracheostomy 10.8% and 3.4%, velopharyngeal insufficiency 3.3% and 6.4% and wound infection 3.3% and 1.9%. None of these differences were statistically significant, except for postoperative tracheostomy, which was significantly higher after transoral odontoidectomy 8.4% (95% CI 4.9% -11.9%) compared to transnasal odontoidectomy 0.8% (95% CI -1.0% -2.9%). Neurologic outcome was improved in 90.0% and worse in 0.9% of patients after transoral compared to 94.0% and 0.0% after transnasal odontoidectomy (p=0.30).
CONCLUSIONS
This work presents a systematic review of complications reported for transoral or transnasal odontoidectomy across a heterogeneous group of surgeons and patients. Due to inconsistent reporting, statistical significance was only achieved for postoperative tracheostomy, which was significantly higher in the transoral group. This investigation sets the framework for further discussions regarding odontoidectomy approach options and their associated complications during the informed consent process.
Topics: Humans; Intraoperative Complications; Mouth; Natural Orifice Endoscopic Surgery; Odontoid Process; Postoperative Complications; Transanal Endoscopic Surgery
PubMed: 27442001
DOI: 10.1016/j.clineuro.2016.07.019 -
North American Spine Society Journal Jun 2023Combined atlas-axis fractures are rare occurrences with substantially higher rates of neurologic deficits compared with isolated injuries. Given the intricate anatomic... (Review)
Review
BACKGROUND
Combined atlas-axis fractures are rare occurrences with substantially higher rates of neurologic deficits compared with isolated injuries. Given the intricate anatomic relationship between the atlas and axis vertebra, variable fracture patterns may occur, warranting special considerations from surgeons.
METHODS
A systematic search of PubMed and EMBASE was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Relevant studies on acute combined atlas-axis fractures that provided data on patient demographics, presentation (injury mechanism, neurologic deficits, fracture type), management, complications, and study conclusions were reviewed.
RESULTS
A total of 22 articles published from 1977 to 2022, comprising 230 patients, were included in the final analysis. Thirty-seven of the 213 patients (17%) presented with neurologic deficits. The most common atlas injuries were posterior arch fractures (54/169 patients; 32%), combined posterior arch/anterior arch fractures (44/169 patients; 26%), and anterior arch fractures (43/169 patients; 25%). The most common axis injuries were type II odontoid fractures (115/175 patients; 66%). Of the 127 patients managed operatively (127/230 patients; 55%), 45 patients (35%) were treated with C1-C2 posterior spinal fusion, 33 patients (26%) were treated with odontoid screw fixation and anterior/posterior C1-C2 trans-articular screws, 16 patients (13%) were treated with occiputocervical fusion and 12 patients (9%) were treated with odontoid screw fixation alone.
CONCLUSIONS
Management strategies are generally based on the type of axis fracture as well as the condition of the transverse ligament. Patients with stable fractures can be successfully managed nonoperatively with a cervical collar or halo immobilization. Combined atlas-axis fractures with an atlantodental interval >5 mm, C1 lateral mass displacement >7 mm, C2-C3 angulation >11° or an MRI demonstrating a disrupted transverse ligament are suggestive of instability and are often successfully managed with surgical intervention. There is no consensus regarding surgical technique.
PubMed: 37440984
DOI: 10.1016/j.xnsj.2023.100224 -
Clinical Spine Surgery Dec 2017Evidence-based systematic review. (Review)
Review
STUDY DESIGN
Evidence-based systematic review.
OBJECTIVES
To define the optimal treatment of fractures involving the C2 body, including those with concomitant injuries, based upon a systematic review of the literature.
SUMMARY OF BACKGROUND DATA
Axis body fractures have customarily been treated nonoperatively, but there are some injuries that may require operative intervention. High-quality literature is sparse and there are few class I or class II studies to guide treatment decisions.
MATERIALS AND METHODS
A literature search was conducted using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, and Scopus (EMBASE, MEDLINE, COMPENDEX). The quality of literature was rated according to a grading tool developed by the Center for Evidence-based Medicine. Operative and nonoperative treatment of axis body fractures were compared using fracture bony union as the primary outcome measure. As risk factors for nonunion were not consistently reported, cases were analyzed individually.
RESULTS
The literature search identified 62 studies, of which 10 were case reports which were excluded from the analysis. A total of 920 patients from 52 studies were included. The overall bony union rate for all axis body fractures was 91%. Although the majority of fractures were treated nonoperatively, there has been an increasing trend toward operative intervention for Benzel type III (transverse) axis body fractures. Nearly 76% of axis body fractures were classified as type III fractures, of which 88% united successfully. Nearly all Benzel type I and type II axis body fractures were successfully treated nonoperatively. The risk factors for nonunion included: a higher degree of subluxation, fracture displacement, comminution, concurrent injuries, delay in treatment, and older age.
CONCLUSIONS
High rates for fracture union are reported in the literature for axis body fractures with nonoperative treatment. High-quality prospective studies are required to develop consensus as to which C2 body fractures require operative fixation.
Topics: Axis, Cervical Vertebra; Databases, Bibliographic; Fracture Fixation; Fractures, Bone; Humans; Longitudinal Studies
PubMed: 29176489
DOI: 10.1097/BSD.0000000000000309 -
European Spine Journal : Official... Oct 2023Odontoid fractures are the most common cervical spine fractures in the elderly, with a controversial optimal treatment. The objective of this review was to compare the... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Odontoid fractures are the most common cervical spine fractures in the elderly, with a controversial optimal treatment. The objective of this review was to compare the outcome of surgical and conservative treatments in elderly (≥ 65 years), by updating a systematic review published by the authors in 2013.
METHODS
A comprehensive search was conducted in seven databases. Clinical outcome was the primary outcome. Fracture union- and stability were secondary outcomes. Pooled point estimates and their respective 95% confidence intervals (CIs) were derived using the random-effects model. A random-effects multivariable meta-regression model was used to correct for baseline co-variates when sufficiently reported.
RESULTS
Forty-one studies met the inclusion criteria, of which forty were case series and one a cohort study. No clinical differences in outcomes including the Neck Disability Index (NDI, 700 patients), Visual Analogue Scale pain (VAS, 180 patients), and Smiley-Webster Scale (SWS, 231 patients) scores were identified between surgical and conservative treatments. However, fracture union was higher in surgically treated patients (pooled incidence 72.7%, 95% CI 66.1%, 78.5%, 31 studies, 988 patients) than in conservatively treated patients (40.2%, 95% CI 32.0%, 49.0%, 22 studies, 912 patients). This difference remained after correcting for age and fracture type. Fracture stability (41 studies, 1917 patients), although numerically favoring surgery, did not appear to differ between treatment groups.
CONCLUSION
While surgically treated patients showed higher union rates than conservatively treated patients, no clinically relevant differences were observed in NDI, VAS pain, and SWS scores and stability rates. These results need to be further confirmed in well-designed comparative studies with proper adjustment for confounding, such as age, fracture characteristics, and osteoporosis degree.
Topics: Humans; Aged; Cohort Studies; Spinal Fractures; Odontoid Process; Fractures, Bone; Pain; Treatment Outcome
PubMed: 37439865
DOI: 10.1007/s00586-023-07779-1 -
Journal of Neurosurgical Sciences Dec 2016Odontoid fractures (OF) are the most frequent cervical spine fracture type in the elderly, often following low-velocity falls. The rise in life expectancies has led to... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Odontoid fractures (OF) are the most frequent cervical spine fracture type in the elderly, often following low-velocity falls. The rise in life expectancies has led to an increase in octogenarians suffering OF, for which the optimal treatment remains undetermined.
EVIDENCE ACQUISITION
A comprehensive search was conducted (National Library of Medicine MEDLINE, Cochrane Central Register of Controlled Trials) for all articles through 03/2016. Articles were included if the study population evaluated treatment modalities in OF patients aged ≥80-years. Outcomes assessed were mortality, complications, osseous union, and fracture stability. Pooled odds ratios (OR) and 95% confidence intervals (CI) are reported.
EVIDENCE SYNTHESIS
Across 22 case series/retrospective studies, attributable mortality for surgery was 5.4% (8/149) vs. 10.1% (10/99) for nonsurgery (P=0.159). Surgery patients suffered higher complications rates (38.9%, 58/149; vs. 24.5%, 26/106); OR 1.96 ([1.13-3.40], P=0.016). Osseous union was better achieved with surgery (68.5%, 37/54; vs. 43.2%, 16/37); OR 2.86 ([1.20-6.80]; P=0.016). Fracture stability was better achieved with surgery (86.0%, 49/57; vs. 63.6%, 28/44); OR 3.50 ([1.33-9.21], P=0.009).
CONCLUSIONS
In general, octogenarians undergoing surgery for OF showed higher fusion and stability rates compared to nonsurgery, which may be due in part to surgical selection criteria, surgeon preference and patient comorbidities. Higher complications were observed for surgery patients, while no differences were observed for mortality. Prospective trials are greatly needed to identify the optional treatment modality and predictors of clinical outcome in octogenarians suffering OF.
Topics: Aged, 80 and over; Aging; Cervical Cord; Humans; Odontoid Process; Retrospective Studies; Spinal Fractures; Treatment Outcome
PubMed: 27163167
DOI: No ID Found -
European Spine Journal : Official... Feb 2021The primary goal of this study was to conduct a systematic review and meta-analysis of articles focused on odontoid screw fixation (OSF) and screw-related complications... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The primary goal of this study was to conduct a systematic review and meta-analysis of articles focused on odontoid screw fixation (OSF) and screw-related complications or non-union rates.
METHODS
We conducted a systematic review of the PubMed and Crossref databases between January 1982 and December 2019. Inclusion criteria comprised detailed descriptions of the surgical technique and screw-related complications (screw cut-out, loosening, breakage, malposition) or fusion rates.
RESULTS
The initial selection consisted of 683 abstracts. A total of 150 full texts were chosen for detailed study, and 83 articles were included in the analysis. The point estimates for screw-related complications were as follows: 1. screw malposition frequency-4.8%; 2. screw cut-out rate-5.0%; 3. screw loosening/pull-out-3.8%; and 4. screw fracture rate-3.1%. The point estimate for the non-union rate was 9.7%. Statistical analysis of the screw-related complications rate based on surgical technique details was also performed CONCLUSIONS: Double-screw OSF performance in elder patients resulted in a higher risk of post-operative screw cut-out. In other cases, the development of screw-related complications did not depend on the method of intraoperative head fixation, selection of the implant entry point for OSF, type of the used screws, or cannulated instruments application. The outcomes of single-screw fixation through the anterior lip of the C2 vertebra were comparable to other techniques of OSF. Further, statistically reliable studies should be carried out to identify the optimal technique of OSF.
Topics: Aged; Bone Screws; Fracture Fixation, Internal; Fractures, Bone; Humans; Odontoid Process; Spinal Fractures
PubMed: 32556628
DOI: 10.1007/s00586-020-06501-9 -
British Medical Bulletin Sep 2015Ankylosing spondylitis (AS) can lead to an increased risk of cervical fractures. (Review)
Review
INTRODUCTION
Ankylosing spondylitis (AS) can lead to an increased risk of cervical fractures.
SOURCES OF DATA
A systematic review was undertaken using the keywords 'ankylosing spondylitis', 'spine fractures', 'cervical fractures', 'surgery' and 'postoperative outcomes' on Medline, Pubmed, Google Scholar, Ovid and Embase, and the quality of the studies included was evaluated according to the Coleman Methodology Score.
AREAS OF AGREEMENT
Surgery ameliorates neurological function in patients with unstable AS-related cervical fractures. The combined anterior/posterior and the posterior approaches are more effective than the anterior approach.
AREAS OF CONTROVERSY
The optimal approach, anterior, posterior or combined anterior/posterior, for the management of AS related cervical fractures has not been defined.
GROWING POINTS
Open reduction and internal fixation allows avoiding worsening and enhances neurological function in AS patients with cervical fractures.
AREAS TIMELY FOR DEVELOPING RESEARCH
Adequately powered randomized trials with appropriate subjective and objective outcome measures are necessary to reach definitive conclusions.
Topics: Axis, Cervical Vertebra; Fracture Fixation, Internal; Humans; Patient Selection; Postoperative Complications; Spinal Fractures; Spondylitis, Ankylosing; Treatment Outcome
PubMed: 25800241
DOI: 10.1093/bmb/ldv010 -
Neurosurgery Oct 2015Odontoid fractures are the most common cervical spine fracture in the geriatric population; however, the treatment of type II odontoid fractures in this age group is... (Review)
Review
BACKGROUND
Odontoid fractures are the most common cervical spine fracture in the geriatric population; however, the treatment of type II odontoid fractures in this age group is controversial.
OBJECTIVE
To compare the short-term (<3 months) mortality, long-term (≥12 months) mortality, and complication rates of patients >60 years of age with a type II odontoid fracture managed either operatively or nonoperatively.
METHODS
We performed a systematic review of literature published between January 1, 2000, and February 1, 2015, related to the treatment of type II odontoid fractures in patients >60 years of age. An analysis of short-term mortality, long-term mortality, and the occurrence of complications was performed.
RESULTS
A total of 452 articles were identified, of which 21 articles with 1233 patients met the inclusion criteria. Short-term mortality (odds ratio, 0.43; 95% confidence interval, 0.30-0.63) and long-term mortality (odds ratio, 0.47; 95% confidence interval, 0.34-0.64) were lower in patients who underwent surgical treatment than in those who had nonsurgical treatment, and there were no significant differences in the rate of complications (odds ratio, 1.01; 95% confidence interval, 0.63-1.63). Surgical approach (posterior vs anterior) showed no significant difference in mortality or complication rate. Similarly, no difference in mortality or complication rate was identified with hard collar or a halo orthosis immobilization.
CONCLUSION
The current literature suggests that well-selected patients >60 years of age undergoing surgical treatment for a type II odontoid fracture have a decreased risk of short-term and long-term mortality without an increase in the risk of complications.
Topics: Aged; Aged, 80 and over; Humans; Middle Aged; Odontoid Process; Spinal Fractures; Treatment Outcome
PubMed: 26378359
DOI: 10.1227/NEU.0000000000000942 -
Rheumatology (Oxford, England) Jul 2016The aim was to evaluate whether anti-TNF discontinuation and tapering strategies are efficacious for maintaining remission or low disease activity (LDA) in patients with... (Review)
Review
OBJECTIVE
The aim was to evaluate whether anti-TNF discontinuation and tapering strategies are efficacious for maintaining remission or low disease activity (LDA) in patients with axial spondyloarthritis.
METHODS
A systematic literature review up to September 2014 was performed using Medline, EMBASE and Cochrane databases. Longitudinal studies evaluating the efficacy of discontinuation/tapering of anti-TNF therapy to maintain clinical response achieved after receiving a standard dose of the same drug were included. The results were grouped according to the type of strategy (discontinuation or tapering) evaluated.
RESULTS
Thirteen studies out of 763 retrieved citations were included. Overall, published data are scarce and the level of evidence of the studies is weak. Five studies provided evidence for assessing discontinuation strategy. The frequency of patients developing flare during the follow-up period ranged between 76 and 100%. The median (range) follow-up period was 52 (36-52) weeks and time to flare 16 (6-24) weeks. Additionally, eight studies evaluating tapering strategy were selected. The percentage of patients maintaining LDA or remission was reported in five studies and ranged between 53 and 100%. The remaining three studies reported the mean change in BASDAI and CRP after reducing the anti-TNF dose and did not observe any relevant increase in these parameters.
CONCLUSION
Published data indicate that a tapering strategy for anti-TNF therapy is successful in maintaining remission or LDA in most patients with axial spondyloarthritis. However, a discontinuation strategy is not recommended because it leads to flare in most cases. Further studies with an appropriate design covering the whole spectrum of the disease are required to confirm these results.
Topics: Adult; Antirheumatic Agents; Axis, Cervical Vertebra; Disease Progression; Female; Humans; Longitudinal Studies; Male; Spondylarthritis; Tumor Necrosis Factor-alpha; Withholding Treatment
PubMed: 26998860
DOI: 10.1093/rheumatology/kew033 -
World Neurosurgery Nov 2022Odontoidectomy for symptomatic irreducible ventral brainstem compression at the craniovertebral junction may result in spine instability requiring subsequent... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Odontoidectomy for symptomatic irreducible ventral brainstem compression at the craniovertebral junction may result in spine instability requiring subsequent instrumentation. There is no consensus on the importance of C1 anterior arch preservation in prevention of iatrogenic instability. We conducted a systematic review of the impact of C1 anterior arch preservation on postodontoidectomy spine stability.
METHODS
PubMed, Embase, Scopus, Web of Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients undergoing odontoidectomy. Random-effect model meta-analyses were performed to compare spine stability between C1 anterior arch preservation versus removal and posttreatment outcomes between transoral approaches (TOAs) versus endoscopic endonasal approaches (EEAs).
RESULTS
We included 27 studies comprising 462 patients. The most common lesions were basilar invagination (73.3%) and degenerative arthritis (12.6%). Symptoms included myelopathy (72%) and neck pain (43.9%). Odontoidectomy was performed through TOA (56.1%) and EEA corridors (34.4%). The C1 anterior arch was preserved in 16.7% of cases. Postodontoidectomy stabilization was performed in 83.3% patients. Median follow-up was 27 months (range, 0.1-145). Rates of spine instability were significantly lower (P = 0.004) when the C1 anterior arch was preserved. Postoperative clinical improvement and pooled complications were reported in 78.8% and 12.6% of patients, respectively, with no significant differences between TOA and EEA (P = 0.892; P = 0.346). Patients undergoing EEA had significantly higher rates of intraoperative cerebrospinal fluid leaks (P = 0.002).
CONCLUSIONS
Odontoidectomy is safe and effective for treating craniovertebral junction lesions. Preservation of the C1 anterior arch seems to improve maintenance of spine stability. TOA and EEA show comparable outcomes and complication rates.
Topics: Humans; Spine; Nose; Decompression, Surgical; Spinal Cord Diseases; Spinal Diseases; Odontoid Process
PubMed: 36049722
DOI: 10.1016/j.wneu.2022.08.105