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Qatar Medical Journal 2023We describe the case of a 44-year-old gentleman with hypertension and asthma presenting to the emergency department after noticing right upper-extremity weakness upon...
We describe the case of a 44-year-old gentleman with hypertension and asthma presenting to the emergency department after noticing right upper-extremity weakness upon awakening. Brain imaging did not reveal a stroke. Initial neurological examination pointed to cervical myelopathy with radiculopathy as well as possible underlying length-dependent peripheral neuropathy as there was right arm strength of 4/5 and there were brisker (3+) reflexes all over except at the right biceps reflex and both ankle reflexes. Cervical spine magnetic resonance imaging (MRI) showed myelomalacia at the C2 level and an os odontoideum (OO). Os odontoideum is a chronic condition that occurs due to the failure of the center of ossification of the dens to fuse with the body of C2. By the next day after a few hours of sustaining a fall, weakness progressed to quadriparesis, without a sensory level on examination, followed by urinary retention. This situation was attributed to a possible cervical cord contusion due to the fall in the presence of OO, with other possibilities being spinal cord hemorrhage, infarct and transverse myelitis. However, repeat scanning of the cervical spine (MRI) did not reveal any acute cord changes. The initial examination for common causes of peripheral neuropathy did not reveal any findings. Finally, the diagnosis of Guillain-Barré syndrome (GBS) was considered, and treatment was initiated with intravenous immunoglobulin. Cerebrospinal fluid analysis was normal. The diagnosis was confirmed using electromyography. Our patient's initial presentation of monoparesis and progression in an asymmetric descending manner was unusual for GBS. His initial presentation mimicked a stroke, and the later progression masqueraded as cervical myelopathy secondary to a chronic cervical cord lesion. The presence of a cervical cord lesion (upper motor neuron) concealed the expected areflexia in GBS. The presence of OO on spine imaging, absence of expected areflexia in GBS, and progression to paraparesis after the fall sidetracked the direction of the initial investigation and led to a relative delay in diagnosis. Nonetheless, appraising the diagnostic data in the clinical context led to an appropriate diagnosis. We emphasize the importance of reconciling the available clinical and diagnostic information to reach the correct diagnosis.
PubMed: 37565047
DOI: 10.5339/qmj.2023.16 -
Malaysian Orthopaedic Journal Jul 2023To investigate the use of a tubular retractor to provide access to the craniovertebral junction (CVJ) sparing the soft palate with the aim of reducing complications...
INTRODUCTION
To investigate the use of a tubular retractor to provide access to the craniovertebral junction (CVJ) sparing the soft palate with the aim of reducing complications associated with traditional transoral approach but yet allowing adequate decompression of the CVJ.
MATERIALS AND METHODS
Twelve consecutive patients with severe myelopathy (JOA-score less than 11) from ventral CVJ compression were operated between 2014-2020 using a tubular retractor assisted transoral decompression.
RESULTS
All patients improved neurologically statistically (p=0.02). There were no posterior pharynx wound infections or rhinolalia. There was one case with incomplete removal of the lateral wall of odontoid and one incidental durotomy.
CONCLUSIONS
A Tubular retractor provides adequate access for decompression of the ventral compression of CVJ. As the tubular retractor pushed away the uvula, soft palate and pillars of the tonsils as it docked on the posterior pharyngeal wall, the traditional complications associated with traditional transoral procedures is completely avoided.
PubMed: 37583520
DOI: 10.5704/MOJ.2307.006 -
BMC Musculoskeletal Disorders Jan 2024For patients with multilevel degenerative cervical myelopathy, laminectomy and posterior cervical fusions (PCF) with instrumentation are widely accepted techniques for... (Observational Study)
Observational Study
BACKGROUND
For patients with multilevel degenerative cervical myelopathy, laminectomy and posterior cervical fusions (PCF) with instrumentation are widely accepted techniques for symptom relief. However, hardware failure is not rare and results in neck pain or even permanent neurological lesions. There are no in-depth studies of hardware-related complications following laminectomy and PCF with instrumentation.
METHODS
The present study was a retrospective, single centre, observational study. Patients who underwent laminectomy and PCF with instrumentation in a single institution between January 2019 and January 2021 were included. Patients were divided into hardware failure and no hardware failure group according to whether there was a hardware failure. Data, including sex, age, screw density, end vertebra (C7 or T1), cervical sagittal alignment parameters (C2-C7 cervical lordosis, C2-C7 sagittal vertical axis, T1 slope, Cervical lordosis correction), regional Hounsfield units (HU) of the screw trajectory and osteoporosis status, were collected and compared between the two groups.
RESULTS
We analysed the clinical data of 56 patients in total. The mean overall follow-up duration was 20.6 months (range, 12-30 months). Patients were divided into the hardware failure group (n = 14) and no hardware failure group (n = 42). There were no significant differences in the general information (age, sex, follow-up period) of patients between the two groups. The differences in fusion rate, fixation levels, and screw density between the two groups were not statistically significant (p > 0.05). The failure rate of fixation ending at T1 was lower than that at C7 (9% vs. 36.3%) (p = 0.019). The regional HU values of the pedicle screw (PS) and lateral mass screw (LMS) in the failure group were lower than those in the no failure group (PS: 267 ± 45 vs. 368 ± 43, p = 0.001; LMS: 308 ± 53 vs. 412 ± 41, p = 0.001). The sagittal alignment parameters did not show significant differences between the two groups before surgery or at the final follow-up (p > 0.05). The hardware failure rate in patients without osteoporosis was lower than that in patients with osteoporosis (14.3% vs. 57.1%) (p = 0.001).
CONCLUSIONS
Osteoporosis, fixation ending at C7, and low regional HU value of the screw trajectory were the independent risk factors of hardware failure after laminectomy and PCF. Future studies should illuminate if preventive measures targeting these factors can help reduce hardware failure and identified more risk factors, and perform long-term follow-up.
Topics: Humans; Laminectomy; Lordosis; Retrospective Studies; Cervical Vertebrae; Spinal Fusion; Pedicle Screws; Osteoporosis
PubMed: 38166792
DOI: 10.1186/s12891-023-07116-z -
Is it meaningful and necessary to avoid the seventh cervical vertebra in long level cervical fusion?Turkish Neurosurgery Nov 2023Posterior cervical fusion (PCF) and decompression procedures, which are increasingly performed, can cause multilevel degenerative cervical pathologies or deformities...
AIM
Posterior cervical fusion (PCF) and decompression procedures, which are increasingly performed, can cause multilevel degenerative cervical pathologies or deformities secondary to advanced age. Therefore, while considering the surgical site for multilevel PCF, the inclusion of the C7 vertebra can cause a dilemma. In this study, the clinical and radiological results of patients who underwent multilevel PCF with different end levels (C6 or C7) were compared.
MATERIAL AND METHODS
We collected radiographs and clinical results of all subjects who underwent level 3 or more PCF for degenerative disease from May 2012 to December 2020. Based on the location of the end of fusion during surgery, patients were divided into C6 (group 1) and C7 patients (group 2). The clinical and radiological results of both groups were compared over two years.
RESULTS
A total of 52 patients met the criteria of this study (21 in group 1 and 31 in group 2). The clinical results demonstrated a statistically significant difference with respect to a lower neck visual analog scale score in group 1 than in group 2 at the last follow-up (p=0.03). With regard to the radiological results, the C2-C7 sagittal vertical axis showed significantly greater values in group 2 than in group 1 at the final follow-up (p=0.02). For thoracic kyphosis (TK), group 2 had lower TK values than group 1 (p=0.03), and the T9 spinopelvic inclination was significantly greater in group 2 than in group 1 (p=0.01).
CONCLUSION
In this study, aggravation of cervical kyphosis and neck pain was observed when C7 was included in multilevel PCF surgery. The inclusion of C7 also affected the thoracolumbar parameters and global spine alignment.
PubMed: 38874250
DOI: 10.5137/1019-5149.JTN.44294-23.3 -
World Neurosurgery Dec 2023Odontoid fractures in association with a C1-C2 rotatory luxation reports are seldom found in the literature. The fusion between the lateral mass of C1 and C2 could be of...
BACKGROUND
Odontoid fractures in association with a C1-C2 rotatory luxation reports are seldom found in the literature. The fusion between the lateral mass of C1 and C2 could be of interest to ensure adequate treatment in these particular cases. We report 23 cases where there was coexistence of an odontoid fracture and rotatory subluxation, which were treated surgically using cages between C1 and C2 or just traditional Goel-Harms technique. We evaluated the radiologic fusion rate, reoperation rate, and complications.
METHODS
This was a single-center, retrospective, cohort study of patients with C2 fractures (mixed type and C1-C2 rotatory luxation according to the Fielding classification) who were treated surgically. Radiologic computed tomography scans were used to assess fusion (presence of bridging trabecular bone end plate or pseudoarthrosis) between 6 months and 1.5 years after the surgery.
RESULTS
Twenty-three patients were diagnosed with C2 fractures and C1-C2 rotatory luxation that were treated surgically and were suitable for the analysis; 11 patients underwent C1-C2 fusion with intra-articular cages, and 12 underwent a classical Goel-Harms technique. The fusion rate at the C1-C2 joint was higher in the cages group. Only 12 patients exhibited fusion at the level of the odontoid fracture.
CONCLUSIONS
C2 fractures associated with C1-C2 rotatory dislocation are rare. The fusion rate at the level of the odontoid in these patients appears to be lower than that reported in patients without rotatory dislocation. It may be of special interest to obtain a clear fusion at the C1-C2 joint, where this type of implant seems to offer an advantage.
Topics: Humans; Retrospective Studies; Odontoid Process; Spinal Fractures; Cohort Studies; Fractures, Bone; Spinal Fusion; Joint Dislocations; Atlanto-Axial Joint
PubMed: 37777174
DOI: 10.1016/j.wneu.2023.09.089 -
Clinics in Orthopedic Surgery Dec 2023To evaluate the feasibility of treating odontoid fractures in the Chinese population with two cortical screws based on computed tomography (CT) scans and describe a new...
BACKGROUND
To evaluate the feasibility of treating odontoid fractures in the Chinese population with two cortical screws based on computed tomography (CT) scans and describe a new measurement strategy to guide screw insertion in treating these fractures.
METHODS
A retrospective review of cervical computed tomographic scans of 128 patients (aged 18-76 years; men, 55 [43.0%]) was performed. The minimum external transverse diameter (METD), minimum external anteroposterior diameter (MEAD), maximum screw length (MSL), and screw projection back angle (SPBA) of the odontoid process were measured on coronal and sagittal CT images.
RESULTS
The mean values of METD and MEAD were 10.0 ± 1.1 mm and 12.0 ± 1.0 mm, respectively, in men and 9.2 ± 1.0 mm and 11.0 ± 1.0 mm, respectively, in women. Both measurements were significantly higher in men ( < 0.001). In total, 87 individuals (68%) had METD > 9.0 mm that could accommodate two 3.5-mm cortical screws. The mean MSL value and SPBA range were 34.4 ± 2.9 mm and 13.5°-24.2°, respectively, with no statistically significant difference between men and women.
CONCLUSIONS
The insertion of two 3.5-mm cortical screws was possible for anterior fixation of odontoid fractures in 87 patients (68%) in our study, and there was a statistically significant difference between men and women.
Topics: Female; Humans; Male; Bone Screws; East Asian People; Feasibility Studies; Fracture Fixation, Internal; Fractures, Bone; Odontoid Process; Spinal Fractures; Tomography, X-Ray Computed; Adolescent; Young Adult; Adult; Middle Aged; Aged
PubMed: 38045572
DOI: 10.4055/cios23094 -
Neurosurgery Sep 2023Existing literature suggests that surgical intervention for odontoid fractures is beneficial but often does not control for known confounding factors.
BACKGROUND
Existing literature suggests that surgical intervention for odontoid fractures is beneficial but often does not control for known confounding factors.
OBJECTIVE
To examine the effect of surgical fixation on myelopathy, fracture nonunion, and mortality after traumatic odontoid fractures.
METHODS
We analyzed all traumatic odontoid fractures managed at our institution between 2010 and 2020. Ordinal multivariable logistic regression was used to identify factors associated with myelopathy severity at follow-up. Propensity score analysis was used to test the treatment effect of surgery on nonunion and mortality.
RESULTS
Three hundred and three patients with traumatic odontoid fracture were identified, of whom 21.6% underwent surgical stabilization. After propensity score matching, populations were well balanced across all analyses (Rubin's B < 25.0, 0.5 < Rubin's R < 2.0). Controlling for age and fracture angulation, type, comminution, and displacement, the overall rate of nonunion was lower in the surgical group (39.7% vs 57.3%, average treatment effect [ATE] = -0.153 [-0.279, -0.028], P = .017). Controlling for age, sex, Nurick score, Charlson Comorbidity Index, Injury Severity Score, and selection for intensive care unit admission, the mortality rate was lower for the surgical group at 30 days (1.7% vs 13.8%, ATE = -0.101 [-0.172, -0.030], P = .005) and at 1 year was 7.0% vs 23.7%, ATE = -0.099 [-0.181, -0.017], P = .018. Cox proportional hazards analysis also demonstrated a mortality benefit for surgery (hazard ratio = 0.587 [0.426, 0.799], P = .0009). Patients who underwent surgery were less likely to have worse myelopathy scores at follow-up (odds ratio = 0.48 [0.25, 0.93], P = .029).
CONCLUSION
Surgical stabilization is associated with better myelopathy scores at follow-up and causes lower rates of fracture nonunion, 30-day mortality, and 1-year mortality.
Topics: Humans; Infant; Spinal Fractures; Odontoid Process; Propensity Score; Retrospective Studies; Fractures, Ununited; Treatment Outcome
PubMed: 37306435
DOI: 10.1227/neu.0000000000002557 -
Zhongguo Xiu Fu Chong Jian Wai Ke Za... May 2024To investigate the imaging characteristics of cervical kyphosis and spinal cord compression in cervical spondylotic myelopathy (CSM) with cervical kyphosis and the...
OBJECTIVE
To investigate the imaging characteristics of cervical kyphosis and spinal cord compression in cervical spondylotic myelopathy (CSM) with cervical kyphosis and the influence on effectiveness.
METHODS
The clinical data of 36 patients with single-segment CSM with cervical kyphosis who were admitted between January 2020 and December 2022 and met the selection criteria were retrospectively analyzed. The patients were divided into 3 groups according to the positional relationship between the kyphosis focal on cervical spine X-ray film and the spinal cord compression point on MRI: the same group (group A, 20 cases, both points were in the same position), the adjacent group (group B, 10 cases, both points were located adjacent to each other), and the separated group (group C, 6 cases, both points were located >1 vertebra away from each other). There was no significant difference between groups ( >0.05) in baseline data such as gender, age, body mass index, lesion segment, disease duration, and preoperative C angle, C sagittal vertical axis (C SVA), C slope (C S), kyphotic Cobb angle, fusion segment height, and Japanese Orthopedic Association (JOA) score. The patients underwent single-segment anterior cervical discectomy with fusion (ACDF). The occurrence of postoperative complications was recorded; preoperatively and at last follow-up, the patients' neurological function was evaluated using the JOA score, and the sagittal parameters (C angle, C SVA, C S, kyphotic Cobb angle, and height of the fused segments) were measured on cervical spine X-ray films and MRI and the correction rate of the cervical kyphosis was calculated; the correlation between changes in cervical sagittal parameters before and after operation and the JOA score improvement rate was analyzed using Pearson correlation analysis.
RESULTS
In 36 patients, only 1 case of dysphagia occurred in group A, and the dysphagia symptoms disappeared at 3 days after operation, and the remaining patients had no surgery-related complications during the hospitalization. All patients were followed up 12-42 months, with a mean of 20.1 months; the difference in follow-up time between the groups was not significant ( >0.05). At last follow-up, all the imaging indicators and JOA scores of patients in the 3 groups were significantly improved when compared with preoperative ones ( <0.05). The correction rate of cervical kyphosis in group A was significantly better than that in group C, and the improvement rate of JOA score was significantly better than that in groups B and C, all showing significant differences ( <0.05), and there was no significant difference between the other groups ( >0.05). The correlation analysis showed that the improvement rate of JOA score was negatively correlated with C angle and kyphotic Cobb angle at last follow-up ( =-0.424, =0.010; =-0.573, <0.001), and positively correlated with the C S and correction rate of cervical kyphosis at last follow-up ( =0.336, =0.045; =0.587, <0.001), and no correlation with the remaining indicators ( >0.05).
CONCLUSION
There are three main positional relationships between the cervical kyphosis focal and the spinal cord compression point on imaging, and they have different impacts on the effectiveness and sagittal parameters after ACDF, and those with the same position cervical kyphosis focal and spinal cord compression point have the best improvement in effectiveness and sagittal parameters.
Topics: Humans; Cervical Vertebrae; Kyphosis; Spondylosis; Spinal Cord Compression; Magnetic Resonance Imaging; Spinal Fusion; Treatment Outcome; Spinal Cord Diseases; Decompression, Surgical; Retrospective Studies; Male; Female; Middle Aged
PubMed: 38752239
DOI: 10.7507/1002-1892.202402018 -
World Neurosurgery Jun 2024This study aims to introduce the unilateral biplanar screw-rod fixation (UBSF) technique (a hybrid fixation technique: 2 sets of atlantoaxial screws were placed on the...
OBJETIVE
This study aims to introduce the unilateral biplanar screw-rod fixation (UBSF) technique (a hybrid fixation technique: 2 sets of atlantoaxial screws were placed on the same side), which serves as a salvage method for traditional posterior atlantoaxial fixation. To summarize the indications of this technique and to assess its safety, feasibility, and clinical effectiveness in the treatment of odontoid fractures.
METHODS
Patients with odontoid fractures were enrolled according to special criteria. Surgical duration and intraoperative blood loss were documented. Patients were followed up for a minimum of 12 months. X-ray and computerized tomography scans were conducted and reviewed at 1 day, and patients were asked to return for computerized tomography reviews at 3, 6, 9, and 12 months after surgery until fracture union. Recorded and compared the Neck Visual Analog Scale and Neck Disability Index presurgery and at 1 week and 12 months postsurgery.
RESULTS
Between January 2016 and December 2022, our study enrolled 7 patients who were diagnosed with odontoid fractures accompanied by atlantoaxial bone or vascular abnormalities. All 7 patients underwent successful UBSF surgery, and no neurovascular injuries were recorded during surgery. Fracture union was observed in all patients, and the Neck Visual Analog Scale and Neck Disability Index scores improved significantly at 1 week and 12 months postoperative (P < 0.01).
CONCLUSIONS
The UBSF technique has been demonstrated to be safe, feasible, and effective in treating odontoid fractures. In cases where the atlantoaxial bone or vascular structure exhibits abnormalities, it can function as a supplementary or alternative approach to the conventional posterior C1-2 fixation.
Topics: Humans; Odontoid Process; Male; Female; Adult; Middle Aged; Spinal Fractures; Fracture Fixation, Internal; Bone Screws; Atlanto-Axial Joint; Treatment Outcome; Aged; Young Adult
PubMed: 38537785
DOI: 10.1016/j.wneu.2024.03.101 -
BMC Geriatrics Nov 2023Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures.
BACKGROUND
Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures.
METHODS
Included were patients with the following criteria: age ≥ 65 years, identification of seniors at risk (ISAR score ≥ 2), and odontoid fracture type A/B according to Eysel and Roosen. Three groups were compared: conservative treatment, surgical therapy with ventral screw osteosynthesis or dorsal instrumentation. At a follow-up examination, the range of motion and the trabecular bone fracture healing rate were evaluated. Furthermore, demographic patient data, neurological status, length of stay at the hospital and at the intensive care unit (ICU) as well as the duration of surgery and occurring complications were analyzed.
RESULTS
A total of 72 patients were included and 43 patients could be re-examined (range: 2.7 ± 2.1 months). Patients with dorsal instrumentation had a better rotation. Other directions of motion were not significantly different. The trabecular bone fracture healing rate was 78.6%. The patients with dorsal instrumentation were hospitalized significantly longer; however, their duration at the ICU was shortest. There was no significant difference in complications.
CONCLUSION
Geriatric patients with odontoid fracture require individual treatment planning. Dorsal instrumentation may offer some advantages.
Topics: Humans; Aged; Spinal Fractures; Conservative Treatment; Odontoid Process; Fractures, Bone; Fracture Fixation, Internal; Treatment Outcome
PubMed: 37968595
DOI: 10.1186/s12877-023-04472-2