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Annals of the Rheumatic Diseases May 2021MAXIMISE (Managing AXIal Manifestations in psorIatic arthritis with SEcukinumab) trial was designed to evaluate the efficacy of secukinumab in the management of axial... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
MAXIMISE (Managing AXIal Manifestations in psorIatic arthritis with SEcukinumab) trial was designed to evaluate the efficacy of secukinumab in the management of axial manifestations of psoriatic arthritis (PsA).
METHODS
This phase 3b, double-blind, placebo-controlled, multi-centre 52-week trial included patients (≥18 years) diagnosed with PsA and classified by ClASsification criteria for Psoriatic Arthritis (CASPAR) criteria, with spinal pain Visual Analogue Score ≥40/100 and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score ≥4 despite use of at least two non-steroidal anti-inflammatory drugs (NSAIDs). Patients were randomised (1:1:1) to secukinumab 300 mg, secukinumab 150 mg or placebo weekly for 4 weeks and every 4 weeks thereafter. At week 12, placebo patients were re-randomised to secukinumab 300/150 mg. Primary endpoint was ASAS20 (Assessment of SpondyloArthritis international Society) response with secukinumab 300 mg at week 12.
RESULTS
Patients were randomly assigned; 167 to secukinumab 300 mg, 165 to secukinumab 150 mg and 166 to placebo. Secukinumab 300 mg and 150 mg significantly improved ASAS20 response versus placebo at week 12 (63% and 66% vs 31% placebo). The OR (95% CI) comparing secukinumab 300 mg and 150 mg versus placebo, using a logistic regression model after multiple imputation, was 3.8 (2.4 and 6.1) and 4.4 (2.7 and 7.0; p<0.0001).
CONCLUSIONS
Secukinumab 300 mg and 150 mg provided significant improvement in signs and symptoms of axial disease compared with placebo in patients with PsA and axial manifestations with inadequate response to NSAIDs.
TRIAL REGISTRATION NUMBER
NCT02721966.
Topics: Adult; Antibodies, Monoclonal, Humanized; Antirheumatic Agents; Arthritis, Psoriatic; Axis, Cervical Vertebra; Double-Blind Method; Female; Humans; Male; Middle Aged; Severity of Illness Index; Treatment Outcome
PubMed: 33334727
DOI: 10.1136/annrheumdis-2020-218808 -
Acta Neurochirurgica. Supplement 2019The craniovertebral junction (CVJ) has unique anatomical bone and neurovascular structure architecture. It not only separates the skull base from the subaxial cervical... (Review)
Review
The craniovertebral junction (CVJ) has unique anatomical bone and neurovascular structure architecture. It not only separates the skull base from the subaxial cervical spine but also provides a special cranial flexion, extension and axial rotation pattern. Stability is provided by a complex combination of osseous and ligamentous supports, which allow a large degree of motion. Perfect knowledge of CVJ anatomy and physiology allows us to better understand instrumentation procedures of the occiput, atlas and axis, and the specific diseases that affect the region. Therefore, a review of the vascular, ligamentous and bony anatomy of the region, in relation to all possible surgical approaches to this anatomically unique segment of the cervical spine, appears to be absolutely mandatory in order to preview and to overcome possible anatomy-related complications of CVJ surgery; moreover, knowledge of the basic principles of instrumentation and of the kinematics of the region, since they interact with the anatomy, seems to be strategic in preoperative planning.Historically considered a no man's land, CVJ surgery, or the CVJ specialty, has recently attracted strong consideration as a symbol of challenging surgery as well as selective top-level qualifying surgery.Although many years have passed since the beginning of this pioneering surgery, managing lesions situated in the anterior aspect of the CVJ still remains a challenging neurosurgical problem. Many studies are available in the literature, aiming to examine the microsurgical anatomy of both the anterior and posterior extradural and intradural aspects of the CVJ, as well as the differences in all possible surgical exposures obtained by the 360° approach philosophy. In this paper the author provides a short but quite complete at-a-glance tour of personal experience and publications and the more recent literature available.
Topics: Atlanto-Axial Joint; Atlanto-Occipital Joint; Axis, Cervical Vertebra; Biomechanical Phenomena; Cervical Atlas; Cervical Vertebrae; Humans; Neurosurgical Procedures; Skull Base
PubMed: 30610295
DOI: 10.1007/978-3-319-62515-7_1 -
Advanced Emergency Nursing JournalOdontoid fractures remain the most common C2 fracture and of those individuals older than 65 years. The type of optimal management remains in question given...
Odontoid fractures remain the most common C2 fracture and of those individuals older than 65 years. The type of optimal management remains in question given comorbidities, risk of nonunion, and limitations in mobility when surgical fusion is the treatment selected. These fractures are of particular importance, given the high incident of morbidity and mortality following an odontoid fracture. Overall quality of life remains a significant consideration when selecting the best intervention following careful examination and confirmation with radiographic imaging. The literature continues with controversies in the best treatment interventions for these fractures, resulting in a case-by-case decision-making process.
Topics: Humans; Odontoid Process; Quality of Life; Fractures, Bone
PubMed: 38285420
DOI: 10.1097/TME.0000000000000495 -
Annals of the Rheumatic Diseases Jan 2018Therapeutic targets have been defined for axial and peripheral spondyloarthritis (SpA) in 2012, but the evidence for these recommendations was only of indirect nature....
Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force.
Therapeutic targets have been defined for axial and peripheral spondyloarthritis (SpA) in 2012, but the evidence for these recommendations was only of indirect nature. These recommendations were re-evaluated in light of new insights. Based on the results of a systematic literature review and expert opinion, a task force of rheumatologists, dermatologists, patients and a health professional developed an update of the 2012 recommendations. These underwent intensive discussions, on site voting and subsequent anonymous electronic voting on levels of agreement with each item. A set of 5 overarching principles and 11 recommendations were developed and voted on. Some items were present in the previous recommendations, while others were significantly changed or newly formulated. The 2017 task force arrived at a single set of recommendations for axial and peripheral SpA, including psoriatic arthritis (PsA). The most exhaustive discussions related to whether PsA should be assessed using unidimensional composite scores for its different domains or multidimensional scores that comprise multiple domains. This question was not resolved and constitutes an important research agenda. There was broad agreement, now better supported by data than in 2012, that remission/inactive disease and, alternatively, low/minimal disease activity are the principal targets for the treatment of PsA. As instruments to assess the patients on the path to the target, the Ankylosing Spondylitis Disease Activity Score (ASDAS) for axial SpA and the Disease Activity index for PSoriatic Arthritis (DAPSA) and Minimal Disease Activity (MDA) for PsA were recommended, although not supported by all. Shared decision-making between the clinician and the patient was seen as pivotal to the process. The task force defined the treatment target for SpA as remission or low disease activity and developed a large research agenda to further advance the field.
Topics: Advisory Committees; Arthritis, Psoriatic; Axis, Cervical Vertebra; Consensus; Decision Making; Humans; Severity of Illness Index; Spondylitis, Ankylosing
PubMed: 28684559
DOI: 10.1136/annrheumdis-2017-211734 -
The Orthopedic Clinics of North America Oct 2021Craniocervical injuries (CCJs) account for 10% to 30% of all cervical spine trauma. An increasing number of patients are surviving these injuries due to advancements in... (Review)
Review
Craniocervical injuries (CCJs) account for 10% to 30% of all cervical spine trauma. An increasing number of patients are surviving these injuries due to advancements in automobile technology, resuscitation techniques, and diagnostic modalities. The leading injury mechanisms are motor vehicle crashes, falls from height, and sports-related events. Current treatment with urgent rigid posterior fixation of the occiput to the cervical spine has resulted in a substantial reduction in management delays expedites treatment of CCJ injuries. Within CCJ injuries, there is a spectrum of instability, ranging from isolated nondisplaced occipital condyle fractures treated nonoperatively to highly unstable injuries with severely distracted craniocervical dissociation. Despite the evolution of understanding and improvement in the management of cases regarding catastrophic failure to diagnose, subsequent neurologic deterioration still occurs even in experienced trauma centers. The purpose of this article is to review the injuries that occur at the CCJ with the accompanying anatomy, presentation, imaging, classification, management, and outcomes.
Topics: Atlanto-Axial Joint; Atlanto-Occipital Joint; Axis, Cervical Vertebra; Cervical Atlas; Cervical Vertebrae; Humans; Joint Dislocations; Occipital Bone; Spinal Fractures; Spinal Injuries; Trauma, Nervous System
PubMed: 34538354
DOI: 10.1016/j.ocl.2021.05.013 -
Nature Reviews. Disease Primers Jul 2015The term axial spondyloarthritis covers both non-radiographic disease and radiographic disease (also known as ankylosing spondylitis). Some studies have been performed... (Review)
Review
The term axial spondyloarthritis covers both non-radiographic disease and radiographic disease (also known as ankylosing spondylitis). Some studies have been performed to investigate the prevalence of axial spondyloarthritis, although most are limited to patients with radiographic disease. A strong genetic association has been shown between axial spondyloarthritis and human leukocyte antigen-B27 (HLA-B27), but the pathogenetic role of HLA-B27 has not yet been clarified. Tumour necrosis factor (TNF), IL-17, IL-23 and downstream pathways also seem to be important - based on the good results of therapies directed against these molecules - but their exact role in the inflammatory process is also not yet clear. Elucidating the interaction between osteoproliferation and inflammation will be crucial for the prevention of long-term structural damage of the bone. The development of new criteria for classification, diagnosis and screening of patients with axial spondyloarthritis will enable earlier intervention for this chronic inflammatory disease. MRI has become an important tool for the early detection of axial spondyloarthritis. NSAIDs and TNF blockers are effective therapies, including in the early non-radiographic stage. Therapeutic blockade of IL-17 or IL-23 seems to be a promising new treatment option. Tools for measuring quality of life in axial spondyloarthritis have become relevant to assess the impact that the disease has on patients. These diagnostic and therapeutic advances will continue to change the management of axial spondyloarthritis, and new insights into the disease pathogenesis will hopefully accelerate this process. For an illustrated summary of this Primer, visit: http://go.nature.com/51b1af.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Axis, Cervical Vertebra; HLA-B27 Antigen; Humans; Interleukin-17; Interleukin-23; Magnetic Resonance Imaging; Spondylarthritis; Spondylitis, Ankylosing; Tumor Necrosis Factor-alpha
PubMed: 27188328
DOI: 10.1038/nrdp.2015.13 -
The Journal of the American Academy of... Feb 2020Os odontoideum is a rare entity of the second cervical vertebra, characterized by a circumferentially corticated ossicle separated from the body of C2. The ossicle is a... (Review)
Review
Os odontoideum is a rare entity of the second cervical vertebra, characterized by a circumferentially corticated ossicle separated from the body of C2. The ossicle is a distinct entity from an odontoid fracture or a persistent ossiculum terminale. The diagnosis may be made incidentally on imaging obtained for the workup of neck pain or neurologic signs and symptoms. Diagnosis usually can be made with plain radiographs. MRI and CT can assess spinal cord integrity and C1-C2 instability. The etiology of os odontoideum is a topic of debate, with investigative studies supporting both congenital and traumatic origins. A wide clinical range of symptoms exists. Symptoms may present as nondescript pain or include occipital-cervical pain, myelopathy, or vertebrobasilar ischemia. Asymptomatic cases without evidence of radiologic instability are typically managed with periodic observation and serial imaging. The presence of atlantoaxial instability or neurological dysfunction necessitates surgical intervention with instrumentation and fusion for stability.
Topics: Axis, Cervical Vertebra; Child; Humans; Joint Instability; Spinal Fusion
PubMed: 31977608
DOI: 10.5435/JAAOS-D-18-00637 -
The Veterinary Clinics of North... Mar 2016Atlantoaxial instability is a congenital neurologic condition predominantly affecting toy breed dogs. Neurologic signs of a cranial cervical myelopathy typically present... (Review)
Review
Atlantoaxial instability is a congenital neurologic condition predominantly affecting toy breed dogs. Neurologic signs of a cranial cervical myelopathy typically present at a young age and can range from cervical pain (hyperesthesia) to paralysis. Diagnosis is often based on survey radiographs, although advanced diagnostic imaging can facilitate surgical planning, allow evaluation of spinal cord parenchyma, and rule out concurrent neurologic conditions. Treatment options consist of medical or surgical management, with surgical management being preferable in patients with neurologic deficits or those with unresolved cervical pain despite medical management. The prognosis for surgery is generally favorable.
Topics: Animals; Atlanto-Axial Joint; Axis, Cervical Vertebra; Cat Diseases; Cats; Diagnosis, Differential; Dog Diseases; Dogs; Spinal Cord Diseases; Treatment Outcome
PubMed: 26631590
DOI: 10.1016/j.cvsm.2015.10.005 -
Spine Nov 2014In vitro biomechanical study.
STUDY DESIGN
In vitro biomechanical study.
OBJECTIVES
To investigate mechanisms of odontoid fracture.
SUMMARY OF BACKGROUND DATA
Odontoid fractures in younger adults occur most often due to high-energy trauma including motor vehicle crashes and in older adults due to fall from standing height.
METHODS
Horizontally aligned head impacts into a padded barrier were simulated using a human upper cervical spine specimen (occiput through C3) mounted to a surrogate torso mass on a sled and carrying a surrogate head. We divided 13 specimens into 3 groups on the basis of head impact location: upper forehead in the midline, upper lateral side of the forehead, and upper lateral side of the head. Post-impact fluoroscopy and anatomical dissection documented the injuries. Time-history biomechanical responses were determined.
RESULTS
Four of the 5 specimens subjected to impact to the upper forehead in the midline sustained type II or high type III odontoid fractures due to abrupt deceleration of the head and continued forward torso momentum. Average peak force reached 1787.1 N at the neck at 50.3 milliseconds. Subsequently, the motion peaks occurred for the head relative to C3 reaching 15.2° for extension, 2.1 cm for upward translation, and 5.3 cm for horizontal compression, between 62 and 68 milliseconds.
CONCLUSION
We identified impact to the upper forehead in the midline as a mechanism that produced odontoid fracture and associated atlas and ligamentous injuries similar to those observed in real-life trauma. We were not able to create odontoid fractures during impacts to the upper lateral side of the forehead or upper lateral side of the head. Dynamic odontoid fracture was caused by rapid deceleration of the head, which transferred load inferiorly combined with continued torso momentum, which caused spinal compression and anterior shear force and forward displacement of the axis relative to the atlas.
Topics: Aged, 80 and over; Biomechanical Phenomena; Cadaver; Cervical Vertebrae; Craniocerebral Trauma; Deceleration; Dissection; Female; Fluoroscopy; Forehead; Fractures, Bone; Head; Humans; Male; Motion; Odontoid Process; Torso
PubMed: 25271495
DOI: 10.1097/BRS.0000000000000609 -
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