-
Surgical Neurology International 2023Craniovertebral junction (CVJ) pathologies include atlantoaxial instability/deformities resulting in myelopathy, respiratory failure, and even death. Here, we describe...
BACKGROUND
Craniovertebral junction (CVJ) pathologies include atlantoaxial instability/deformities resulting in myelopathy, respiratory failure, and even death. Here, we describe the indications, preoperative planning, and intra-operative/postoperative complications following surgical management of CVJ anomalies.
METHODS
A prospective analysis of 34 patients with CVJ pathology was evaluated between 2015 and 2022. Their various etiologies included atlantoaxial instability, trauma, tuberculosis, Down's syndrome, Morquio syndrome, os odontoideum, and atlantoaxial abnormalities. Clinical outcomes were assessed using the American spinal injury association (ASIA) impairment scale score and Benzel's modified Japanese Orthopedic Association (mJOA) score. Surgical assessments included length of hospital stay, operative time, blood loss, and intraoperative postoperative complications. Radiological parameters included fusion (i.e., implant loosening/implant failure), preoperative/ postoperative atlanto-dens interval (ADI), clivus canal angle (CCA), and space available for cord (SAC).
RESULTS
Five patients were managed conservatively, while 29 patients had surgery. Operations included occipitocervical fusion (14 patients), C1-2 fusion (10 patients), C1-2 transarticular screw fixation (four patients), and one patient underwent anterior corpectomy decompression/fusion. Seven patients had vertebral artery anomalies, and 13 patients had atlantoaxial abnormalities. At the final follow-up, atlantoaxial instability (i.e., mean preoperative ADI of 6.6 ± 2.3 mm) was restored to 4.2 ± 0.6 mm, significant cord compression (i.e., with mean SAC of 8.3 ± 2.9 mm) was relieved to 17.2 ± 1.6 mm, and the mean preoperative CCA (i.e., 130.2 ± 15.3) was improved to 143.3 ± 8.3°. There was also a statistically significant improvement in the ASIA scale and mJOA score.
CONCLUSION
Surgical management of CVJ abnormalities requires expertise and meticulous planning to avoid devastating complications such as wound dehiscence and catastrophic vertebral artery injury.
PubMed: 38053702
DOI: 10.25259/SNI_790_2023 -
European Radiology Aug 2023To introduce novel parameters in determining directions of os odontoideum (OO) with atlantoaxial displacement (AAD) and compensations of cervical sagittal alignment...
Axial superior facet slope may determine anterior or posterior atlantoaxial displacement secondary to os odontoideum and compensatory mechanisms of the atlantooccipital joint and subaxial cervical spine.
OBJECTIVE
To introduce novel parameters in determining directions of os odontoideum (OO) with atlantoaxial displacement (AAD) and compensations of cervical sagittal alignment after displacement.
METHODS
Analysis was performed on 96 cases receiving surgeries for upper cervical myelopathy caused by OO with AAD from 2011 to 2021. Twenty-four patients were included in the OO group and divided into the OO-anterior displacement (AD) group and the OO-posterior displacement (PD) group by displacement. Seventy-two patients were included as the control (Ctrl) group and divided into Ctrl-positive (Ctrl-P) group and Ctrl-negative (Ctrl-N) group by axial superior facet slope (ASFS) in a neutral position. ASFS, the sum of C2 slope (C2S) and axial superior facet endplate angle (ASFEA), was measured and calculated by combining cervical supine CT with standing X-ray. Cervical sagittal parameters were measured to analyse the atlantoaxial facet and compensations after AAD.
RESULTS
Atlas inferior facet angle (AIFA), ASFS, and ASFEA in Ctrl-P significantly differed from OO-AD.C0-C1, C1-C2, C0-C2, C2-C7, C2-C7 SVA, and C2S in Ctrl-P significant differed from the OO-AD group. C2-C7 SVA and C2S in Ctrl-N significantly were smaller than the OO-PD group. C1-C2 correlated with C0-C1 and C2-C7 negatively in the OO group. Slight kyphosis of C1-C2 in OO-AD was compared with lordosis of C1-C2 in Ctrl-P, inducing increased extension of C0-C1 and C2-C7. Mildly increased lordosis of C1-C2 in OO-PD was compared with C1-C2 in Ctrl-N, triggering augmented flexion of C0-C1 and C2-C7.
CONCLUSION
ASFS was vital in determining directions of OO with AAD and explaining compensations. ASFS and ASFEA could provide pre- and intraoperative guidelines.
KEY POINTS
• ASFS may determine the directions and compensatory mechanisms of AAD secondary to OO. • ASFS could be achieved by the sum of ASFEA and C2S.
Topics: Humans; Lordosis; Cervical Vertebrae; Kyphosis; Neck; Axis, Cervical Vertebra; Retrospective Studies
PubMed: 36947189
DOI: 10.1007/s00330-023-09544-w -
Asian Journal of Neurosurgery Dec 2023Understanding the anatomy of the vertebral artery is essential while manipulating the craniovertebral joint during surgery. Its anomalous course in congenital...
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.
PubMed: 38161620
DOI: 10.1055/s-0043-1776050 -
Turkish Journal of Medical Sciences 2023Craniocervical junction (CCJ) can be involved in inflammatory arthritis. We aimed to define types of CCJ involvement in rheumatoid arthritis (RA), spondyloarthritis...
BACKGROUND/AIM
Craniocervical junction (CCJ) can be involved in inflammatory arthritis. We aimed to define types of CCJ involvement in rheumatoid arthritis (RA), spondyloarthritis (SpA), and psoriatic arthritis (PsA) and compare them with patients without inflammatory arthritides.
MATERIALS AND METHODS
In this retrospective analysis, cervical CT or MRIs of patients with RA, SpA, or PsA, taken for any reason between 2010 and 2020, according to ICD-10 codes, were scanned. Demographic data of the patients were recorded. CCJ involvements (atlantoaxial, vertical, or subaxial subluxation, odontoid process involvement) were reevaluated by an experienced radiologist. The control group consisted of consecutive patients without inflammatory arthritis.
RESULTS
Exactly 459 patients (204 RA, 200 SpA, and 55 PsA) and 78 patients in the control group were included in the study. CCJ involvement was detected in 101 (49.5%) RA, 53 (26.5%) SpA, 10 (18.2%) PsA, and 4 patients (5.1%) in the control group (p < 0.001). The odontoid process was one of the main targets, especially in RA patients (69 (33.8%)), which was significantly higher than in the SpA, PsA, and control groups. Although vertical subluxation (VS) was numerically higher in the RA and SpA groups compared to the control group, VS-related brainstem compression was relatively uncommon: 6 (2.9%) in RA, 1 (0.5%) in AS, and none in the PsA and control groups.
CONCLUSION
CCJ involvement can often be detected in patients with inflammatory arthritis, especially in RA and SpA patients. The odontoid process is the main target of inflammation.
Topics: Humans; Female; Male; Middle Aged; Retrospective Studies; Arthritis, Rheumatoid; Adult; Magnetic Resonance Imaging; Tomography, X-Ray Computed; Spondylarthritis; Aged; Arthritis, Psoriatic; Atlanto-Axial Joint; Cervical Vertebrae; Odontoid Process
PubMed: 38813511
DOI: 10.55730/1300-0144.5740 -
Skeletal Radiology Sep 2023Down syndrome, also known as trisomy 21, is associated with congenital cervical spine abnormalities, including atlantoaxial instability with or without os odontoideum,...
Down syndrome, also known as trisomy 21, is associated with congenital cervical spine abnormalities, including atlantoaxial instability with or without os odontoideum, atlanto-occipital instability, and hypoplasia of the atlas. Herein, we report a case of Down syndrome complicated by congenital atlanto-occipital dislocation. The patient presented with severe cervical myelopathy at 13 years of age after a 10-year follow-up. Radiography and computed tomography revealed os odontoideum protruding into the foramen magnum and congenital anterior atlanto-occipital dislocation. Additionally, a bifurcated internal occipital crest with a thinned central portion of the occipital bone was noted. Magnetic resonance imaging revealed kyphotic alignment of the spinal cord with severe compression at the foramen magnum level. As the neurological impairment was partially improved by halo vest immobilization, we performed in situ O-C2 fusion with an iliac autograft and decompression of the foramen magnum and posterior arch of C1. An improvement was observed immediately after surgery. Two years after surgery, radiography and computed tomography showed solid O-C2 segment fusion. The accumulation of similar cases is essential for determining the prognosis or optimal treatment for this rare congenital condition.
Topics: Humans; Down Syndrome; Joint Dislocations; Joint Instability; Spinal Cord Diseases; Radiography; Spinal Diseases; Spinal Fusion; Atlanto-Axial Joint
PubMed: 36773086
DOI: 10.1007/s00256-023-04297-5 -
Journal of Craniovertebral Junction &... 2024To study the clinicoradiological features and treatment outcomes of atlantoaxial dislocation (AAD) in Down syndrome.
AIMS
To study the clinicoradiological features and treatment outcomes of atlantoaxial dislocation (AAD) in Down syndrome.
SETTINGS AND DESIGN
Retrospective case series.
SUBJECTS AND METHODS
A retrospective chart and radiology review of 9 Down syndrome patients with AAD managed at our center from 2007 to 2018.
STATISTICAL ANALYSIS USED
Chi-squared/Fisher's exact test.
RESULTS
There were 4 males and 5 females (n = 9). The median age was 14 years (interquartile range [IQR]: 7-15.5). 77.7% (7/9) of patients had severe spasticity (Nurick Grades 4 and 5). The median duration of symptoms was 9 months (IQR: 5-39). The AAD was reducible in all (n = 9) cases. Eight (88.8%) patients had os odontoideum. The mean atlantodental interval (ADI) was 8.5 mm (±2.9). T2W cord hyperintensity was seen in 66.6% (6/9). Posterior C1-2 transarticular fixation was done in 8 and occipitocervical fusion in 1 patient. Follow-up of more than 6 months (7-57 months) was available in 8/9 (88.9%) patients. There was a significant improvement in spasticity (n = 8, mean Nurick Grade 1.7 (±1.1), = 0.003). Follow-up radiographs (n = 8) showed good reduction and fusion. A preoperative bedbound patient with poor respiratory reserve expired at 10 months following surgery. There were no other complications.
CONCLUSIONS
Posterior surgical approach for AAD in Down syndrome resulted in good alignment and fusion, with excellent clinical improvement. Patients with elevated PCO are poor surgical candidates and require home ventilation facility.
PubMed: 38644917
DOI: 10.4103/jcvjs.jcvjs_171_23 -
Case Reports in Orthopedics 2023The current case series describes three cases of fusion between the 2nd cervical vertebra, the axis (C2), and the 3rd cervical vertebra (C3), creating a C2-C3 osseous...
PURPOSE
The current case series describes three cases of fusion between the 2nd cervical vertebra, the axis (C2), and the 3rd cervical vertebra (C3), creating a C2-C3 osseous complex and highlighting its morphological type of fusion (partial or complete) and morphometric details. The developmental background of this complex is emphasized, pointing out the possible clinical significance.
MATERIALS AND METHODS
The osseous complexes were derived from disarticulated skeletons of body donors and were collected from the osseous collection of the Anatomy Department of the Medical School of the National and Kapodistrian University of Athens.
RESULTS
Three blocked vertebral complexes (2 partial and 1 complete C2-C3 osseous masses) were identified. In two cases, the vertebral bodies were partially fused and in one case were completely fused. In the 1st case, the C2-C3 complex had fused spinous processes and distinct transverse processes. Facets were completely fused on the left and partially fused on the right side. In the 2nd case, the C2-C3 complex had partially fused vertebral bodies and distinguishable spinous processes. In the 3rd case, the C2-C3 complex had completely fused vertebral bodies, facets, laminae, and transverse and spinous processes.
CONCLUSIONS
Among the three (C2-C3) fused osseous complexes, the two were partially and the one was completely ossified. The fused vertebrae were characterized by osteophytic formations (at the dens and C3 area) and osteoporotic lesions. Taking into consideration the C2-C3 fusion, and possible coexisted variants, particular caution should be made in the upper cervical area, to interpret possible neurological manifestations and to reach a safe surgical plan.
PubMed: 38076299
DOI: 10.1155/2023/3577693 -
JMIR Rehabilitation and Assistive... Dec 2023Upper limb motor paresis is a major symptom of stroke, which limits activities of daily living and compromises the quality of life. Kinematic analysis offers an in-depth...
BACKGROUND
Upper limb motor paresis is a major symptom of stroke, which limits activities of daily living and compromises the quality of life. Kinematic analysis offers an in-depth and objective means to evaluate poststroke upper limb paresis, with anticipation for its effective application in clinical settings.
OBJECTIVE
This study aims to compare the movement strategies of patients with hemiparesis due to stroke and healthy individuals in forward reach and hand-to-mouth reach, using a simple methodology designed to quantify the contribution of various movement components to the reaching action.
METHODS
A 3D motion analysis was conducted, using a simplified marker set (placed at the mandible, the seventh cervical vertebra, acromion, lateral epicondyle of the humerus, metacarpophalangeal [MP] joint of the index finger, and greater trochanter of the femur). For the forward reach task, we measured the distance the index finger's MP joint traveled from its starting position to the forward target location on the anterior-posterior axis. For the hand-to-mouth reach task, the shortening of the vertical distance between the index finger MP joint and the position of the chin at the start of the measurement was measured. For both measurements, the contributions of relevant upper limb and trunk movements were calculated.
RESULTS
A total of 20 healthy individuals and 10 patients with stroke participated in this study. In the forward reach task, the contribution of shoulder or elbow flexion was significantly smaller in participants with stroke than in healthy participants (mean 52.5%, SD 24.5% vs mean 85.2%, SD 4.5%; P<.001), whereas the contribution of trunk flexion was significantly larger in stroke participants than in healthy participants (mean 34.0%, SD 28.5% vs mean 3.0%, SD 2.8%; P<.001). In the hand-to-mouth reach task, the contribution of shoulder or elbow flexion was significantly smaller in participants with stroke than in healthy participants (mean 71.8%, SD 23.7% vs mean 90.7%, SD 11.8%; P=.009), whereas shoulder girdle elevation and shoulder abduction were significantly larger in participants with stroke than in healthy participants (mean 10.5%, SD 5.7% vs mean 6.5%, SD 3.0%; P=.02 and mean 16.5%, SD 18.7% vs mean 3.0%, SD 10.4%; P=.02, respectively).
CONCLUSIONS
Compared with healthy participants, participants with stroke achieved a significantly greater distance via trunk flexion in the forward reach task and shoulder abduction and shoulder girdle elevation in the hand-to-mouth reach task, both of these differences are regarded as compensatory movements. Understanding the characteristics of individual motor strategies, such as dependence on compensatory movements, may contribute to tailored goal setting in stroke rehabilitation.
PubMed: 38051570
DOI: 10.2196/50571 -
Scientific Reports Jul 2023Some older adults with spinal deformity maintain standing posture via pelvic compensation when their center of gravity moves forward. Therefore, evaluations of global...
Some older adults with spinal deformity maintain standing posture via pelvic compensation when their center of gravity moves forward. Therefore, evaluations of global alignment should include both pelvic tilt (PT) and seventh cervical vertebra-sagittal vertical axis (C7-SVA). Here, we evaluate standing postures of older adults using C7-SVA with PT and investigate factors related to postural abnormality. This cross-sectional study used an established population-based cohort in Japan wherein 1121 participants underwent sagittal whole-spine radiography in a standing position and bioelectrical impedance analysis for muscle mass measurements. Presence of low back pain (LBP), visual analog scale (VAS) of LBP, and LBP-related disability (Oswestry Disability Index [ODI]) were evaluated. Based on the PT and C7-SVA, the participants were divided into four groups: normal, compensated, non-compensated, and decompensated. We defined the latter three categories as "malalignment" and examined group characteristics and factors. There were significant differences in ODI%, VAS and prevalence of LBP, and sarcopenia among the four groups, although these were non-significant between non-compensated and decompensated groups on stratified analysis. Moreover, the decompensated group was significantly associated with sarcopenia. Individuals with pelvic compensation are at increased risk for LBP and related disorders even with the C7-SVA maintained within normal range.
Topics: Humans; Aged; Cross-Sectional Studies; Sarcopenia; Back Pain; Low Back Pain; Cervical Vertebrae
PubMed: 37481604
DOI: 10.1038/s41598-023-39044-2 -
Journal of Craniovertebral Junction &... 2023In neurosurgery, posterior approaches intended at the craniovertebral junction are frequently used. The most popular procedures for treating upper cervical instability...
OBJECTIVE
In neurosurgery, posterior approaches intended at the craniovertebral junction are frequently used. The most popular procedures for treating upper cervical instability are C1 lateral mass, C2 pedicle, and C1-C2 transarticular screw stabilization. Due to their proximity to neural structures and the presence of the high-riding vertebral artery (VA), these techniques are complicated. The risk of VA damage can be decreased by mobilizing the VA. Using cadaveric specimens in this study was aimed to demonstrate C2 pedicle and C1-C2 transarticular screw placement with VA mobilization and a novel C2 inferior corpus screw placement technique.
METHODS
In this study, twelve adult cadaveric specimens and two adult dry cadaveric C2 bones were used with the permission and decision of the University Research Ethics Committee. Colored silicone was injected into the arteries and veins of these twelve cadaveric specimens. Then, muscle dissection was performed stepwise, and the C2 vertebrae of the cadavers were revealed with a surgical microscope. Each specimen and entire stages of the dissections were recorded photographically. After cadaver dissections, screw placement was performed with three different techniques. Finally, radiological imaging was done with fluoroscopy.
RESULTS
After dissection, the lateral mass of the C2 vertebra was observed, and lateral to it, the transverse process and foramen were detected with the help of a hook. Next, the posterior wall of the VA groove was removed using a 1 mm thin plate Kerrison rongeur until the VA loop could partially be observed the VA. This enables us to find the top of the loop of the VA and mobilize it inferiorly using a dissector. Following this step, the C1-2 transarticular, C2 pedicle, and the novel C2 inferior corpus screw placement can be performed safely by directly visualizing the artery.
CONCLUSIONS
Due to the nearby neurologic and vascular structures, placing the C2 pedicle and C1-2 transarticular screw is a challenging procedure, especially in high-riding VA cases. However, it is possible to place the C2 pedicle, C1-2 transarticular, and novel C2 inferior corpus screw after the mobilization of the VA. This study aimed to show all of them together on a cadaver for the first time, to understand the anatomy of the C2 vertebra, and to use screw placement techniques to minimize the risk of complications.
PubMed: 38268685
DOI: 10.4103/jcvjs.jcvjs_73_23