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International Forum of Allergy &... Aug 2015Endoscopic endonasal surgery (EES) is a relatively novel approach to the craniovertebral junction (CVJ). The purpose of this analysis is to determine the surgical... (Review)
Review
BACKGROUND
Endoscopic endonasal surgery (EES) is a relatively novel approach to the craniovertebral junction (CVJ). The purpose of this analysis is to determine the surgical outcomes of patients who undergo purely EES of the CVJ.
METHODS
A search for articles related to EES of the CVJ was performed using the MEDLINE/PubMed database. A bibliographic search was done for additional articles. Demographics, presenting symptoms, imaging findings, complications, follow-up, and patient outcomes were analyzed.
RESULTS
Eighty-five patients from 30 articles were included. The mean patient age was 47.9 ± 24.8 years (range, 3 to 96 years), with 44.7% being male. The most common presenting symptom was myelopathy (n = 64, 75.3%). The most common indications for surgery were brainstem compression secondary to basilar invagination (n = 41, 48.2%) and odontoid pannus (n = 20, 23.5%). Odontoidectomy was performed in 97.6% of cases. Intraoperative complications occurred in 16 patients (18.8%) and postoperative complications occurred in 18 patients (21.2%). Six patients developed postoperative respiratory failure necessitating a tracheostomy. Neurologic improvement was seen in 89.4% of patients at a mean follow-up of 22.2 months.
CONCLUSION
Our analysis found that EES of the CVJ results in a high rate of neurologic improvement with acceptable complication rates. Given its minimally invasive nature and high success rate, this approach appears to be a reasonable alternative to the traditional transoral approach in select cases. This study represents the largest pooled sample size of EES of the CVJ to date. Increasing use of the endoscopic endonasal approach will allow for further studies with greater statistical power.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Brain Diseases; Brain Stem; Cervical Vertebrae; Child; Child, Preschool; Endoscopy; Female; Humans; Male; Middle Aged; Odontoid Process; Skull Base; Spinal Cord Compression; Spinal Diseases; Treatment Outcome; Young Adult
PubMed: 25946171
DOI: 10.1002/alr.21537 -
World Neurosurgery Apr 2021Intraoperative vascular injuries in the cervical spine are rare, but carry significant morbidity and mortality when they do occur. There is a need to better characterize... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Intraoperative vascular injuries in the cervical spine are rare, but carry significant morbidity and mortality when they do occur. There is a need to better characterize the risk of vertebral artery injury (VAI) after posterior C1-C2 fusion. The aim of this study was to investigate the rate of VAI in patients undergoing posterior C1-C2 cervical fusion.
METHODS
An electronic database search was performed to identify studies that reported rates of VAI following posterior cervical fusion at C1-C2 level. Patient-specific risk factors, surgical indication, surgical technique, and other data were collected for each study. Forest plots were created to outline the pooled ratios of VAI in the literature.
RESULTS
Eleven studies with 773 patients were identified. Mean age of patients was 48.47 years (range, 6-78 years), and most patients were female (61.7%, n = 399). Trauma was the most frequent indication for surgery (18.8%, n = 146), followed by inflammatory processes affecting the vertebrae (13.2%, n = 102). The rate of VAI per patient was 2% (95% confidence interval = 1%-4%) among 773 patients, while injury rate per screw was 1% (95% confidence interval = 0%-2%) among 2238 screws placed.
CONCLUSIONS
The rate of VAI after C1-C2 posterior cervical fusion was found to be 2% for each operated patient and 1% for each screw placed.
Topics: Atlanto-Axial Joint; Axis, Cervical Vertebra; Cerebral Angiography; Cervical Atlas; Humans; Intraoperative Complications; Postoperative Complications; Postoperative Hemorrhage; Spinal Fusion; Vascular System Injuries; Vertebral Artery
PubMed: 33516865
DOI: 10.1016/j.wneu.2020.12.165 -
World Neurosurgery Apr 2021Arachnoid cysts are benign cerebrospinal fluid collection within a duplication of arachnoid membrane and, when found in the retrocerebellar site, they may be associated...
Coexisting Retrocerebellar Arachnoid Cyst and Chiari Type 1 Malformation: 3 Pediatric Cases of Surgical Management Tailored to the Pathogenic Mechanism and Systematic Review of the Literature.
INTRODUCTION
Arachnoid cysts are benign cerebrospinal fluid collection within a duplication of arachnoid membrane and, when found in the retrocerebellar site, they may be associated with tonsils herniation. This rare situation of coexisting retrocerebellar arachnoid cyst (AC) and Chiari malformation type 1 (CM-1) have been previously reported in few cases (10 patients) with syringomyelia and hydrocephalus described to be the most relevant issues. The aim of this paper is to describe 3 pediatric cases of this condition with a systematic review of the literature, underlining the importance of surgical management tailored to the pathogenic mechanism.
METHODS
A restrospective analysis of patients treated for coexisting CM-1 and ACs at the authors' institution has been carried out.
RESULTS
A case of a 10-month-old baby with coexisting AC and CM-1 with tri-ventricular hydrocephalus treated with endoscopic third ventriculostomy, a case of a 1-year-old child with a huge retrocerebellar AC and CM-1 treated with a cysto-peritoneal shunt, and a case of a 15-year-old child with retrocerebellar AC causing symptomatic CM-1 treated with C0-C2 decompression, AC fenestration and duraplasty are described. A long-term follow-up is reported.
CONCLUSIONS
Surgical management of coexisting ACs and CM-1 should not aim at the complete resolution of the cyst or of tonsil herniation, especially when pediatric patients are treated. Rather, the purpose of the neurosurgeon should be to understand the underlying pathogenic mechanism, and then restoring both the cerebrospinal fluid flow in the posterior fossa and the dynamic equilibrium between ventricles, cyst, and subarachnoid space.
Topics: Adolescent; Arachnoid Cysts; Arnold-Chiari Malformation; Axis, Cervical Vertebra; Cerebrospinal Fluid Shunts; Cranial Fossa, Posterior; Decompression, Surgical; Humans; Hydrocephalus; Infant; Male; Neuroendoscopy; Peritoneal Cavity; Ventriculostomy
PubMed: 33385608
DOI: 10.1016/j.wneu.2020.12.094 -
Neuro-Chirurgie Jul 2023Basilar invagination (BI) is an uncommon clinical condition of the craniocervical junction (CCJ). Surgical management depends on 2 factors: mobility and reducibility;... (Review)
Review
BACKGROUND
Basilar invagination (BI) is an uncommon clinical condition of the craniocervical junction (CCJ). Surgical management depends on 2 factors: mobility and reducibility; in cases of irreducible dislocation or persistent compression, odontoidectomy should be considered.
CASE DISCUSSION
We present the case of a 13-year-old boy with severe BI, causing cervical myelopathy with progressive gait disorder. The patient underwent cervical traction followed by posterior decompression and occipitocervical fusion. Postoperatively, symptoms initially improved, until new neurological deterioraton set in 4 months later. Follow-up neuroimaging showed compression of the bulbo-medullary junction, with severe brainstem kinking and appearance of a cervical syrinx. Secondary surgery via an endoscopic endonasal approach (EEA) was deemed necessary to relieve the compression. Postoperative course was unremarkable, with steady clinical improvement and a return to independent activities of daily living within 6 months.
LITERATURE REVIEW
A systematic literature review indicated that EEA conserves the palate and oropharynx mucosae, thus causing less airway and swallowing complications than the transoral approach.
CONCLUSION
In selected cases with persistent anterior compression, odontoidectomy on EEA is a safe, effective and valid alternative for managing CCJ pathology.
Topics: Male; Humans; Child; Adolescent; Activities of Daily Living; Odontoid Process; Endoscopy; Joint Dislocations; Syringomyelia; Decompression, Surgical
PubMed: 37061181
DOI: 10.1016/j.neuchi.2023.101445 -
World Neurosurgery Jan 2019Retro-odontoid pseudotumor (RP) can be caused by several diseases, especially rheumatoid arthritis, and is usually associated with the presence of atlantoaxial...
BACKGROUND
Retro-odontoid pseudotumor (RP) can be caused by several diseases, especially rheumatoid arthritis, and is usually associated with the presence of atlantoaxial instability. On the other hand, a different group of patients have been identified in whom RP is observed without radiologic findings of atlantoaxial instability. The pathophysiology, clinical characteristics, and prognosis of this latter group of patients are not well described in the literature.
METHODS
A PubMed and Scopus search adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed to include studies reporting patients with RP without radiologic instability (RPWRI). The data gathered from this review were analyzed to characterize RPWRI.
RESULTS
The search yielded 36 articles with a total of 62 patients. All studies were case reports and small case series. Different characteristics of RPWRI are described, including causes, pathophysiology, and treatment.
CONCLUSIONS
The results of this review show that RPWRI has different causes such as hypermobility, deposition of substances, and perhaps disc herniation. Depending on the cause of RPWRI, the pathophysiologic mechanism is different. Treatment should be tailored based on the primary cause of RP and the degree of compression of the cervicomedullary junction. Different degrees of improvement are usually observed after surgical treatment in these patients regardless of the treatment used, but a higher rate of mass regression was observed in those patients in whom the atlantoaxial joint was stabilized.
Topics: Atlanto-Axial Joint; Humans; Joint Instability; Odontoid Process; Spinal Diseases
PubMed: 30315972
DOI: 10.1016/j.wneu.2018.10.011 -
The Spine Journal : Official Journal of... Oct 2018Odontoid process fractures, of which type II constitute the majority, are an increasingly important cause of morbidity and mortality in the elderly population. The... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Odontoid process fractures, of which type II constitute the majority, are an increasingly important cause of morbidity and mortality in the elderly population. The incidence of geriatric type II fractures is steadily increasing in line with the aging population. However, the decision between surgical and non-surgical intervention for type II fractures in the elderly remains controversial.
PURPOSE
The present study aims to synthesize the current published literature comparing outcomes following surgical and non-surgical interventions for type II odontoid fractures in the elderly population (≥65 years old).
STUDY DESIGN/SETTING
Systematic review and meta-analysis were performed.
METHODS
A systematic search of MEDLINE, MEDLINE In-Progress & Other Non-Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed to identify available evidence in English language. Studies with extractable data for all type II odontoid fractures in participants aged 65 years or older and which compared surgical and non-surgical intervention were included. Methodological quality was assessed using the Downs & Black checklist. Primary outcomes were mortality at short-term follow-up (≤3 months), mortality at long-term follow-up (predetermined study endpoint or mean follow-up length), and radiological union rate. Funding was provided by The University of Edinburgh for travel expenses to present this paper at the Society of British Neurological Sciences 2016 Conference ($170).
RESULTS
Twelve studies (n=1,098), all non-randomized, met eligibility criteria. Methodological quality was particularly poor in the confounding, bias, and power domains of assessment. Substantial methodological and statistical heterogeneity allowed only a narrative synthesis of the primary outcomes. Overall, data on mortality at short-term follow-up appeared to favor neither surgical nor non-surgical intervention. A small favorable outcome in surgically managed patients over non-surgically managed patients in terms of mortality at long-term follow-up was not proven conclusive because of considerable heterogeneity in study methodologies. Inadequate reporting of the time point of union assessment introduced the potential for significant intra- and interstudy heterogeneity and precluded assessment of union rates.
CONCLUSIONS
Evidence on this controversial topic is sparse, markedly heterogeneous, and of poor quality. Well-designed prospective trials adhering to guidance published by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative are required to inform clinical practice on this contentious but growing issue. Future randomized controlled trials should include an assessment of frailty and medical comorbidities with suitable patients subsequently randomized to surgical or non-surgical treatment.
Topics: Aged; Aged, 80 and over; External Fixators; Fracture Fixation; Humans; Odontoid Process; Spinal Fractures; Survival Rate; Treatment Outcome
PubMed: 29886165
DOI: 10.1016/j.spinee.2018.05.017 -
Annals of the Rheumatic Diseases Jun 2016Flares may be used as outcomes in axial spondyloarthritis (axSpA) trials or observational studies. The objective was to develop a definition for 'flare' (or worsening)... (Review)
Review
INTRODUCTION
Flares may be used as outcomes in axial spondyloarthritis (axSpA) trials or observational studies. The objective was to develop a definition for 'flare' (or worsening) in axSpA, based on validated composite indices, to be used in the context of clinical trial design.
METHODS
(1) Systematic literature review of definitions of 'flare' in published randomised controlled trials in axSpA. (2) Vignette exercise: 140 scenarios were constructed for a typical patient with axSpA seen at two consecutive visits. Each scenario included a change in one of the following outcomes: pain, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), BASDAI plus C-reactive protein (CRP) or Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP. Each Assessment of Spondyloarthritis (ASAS) expert determined if every scenario from a random sample of 46 scenarios was considered a flare (yes/no). Receiver-operating characteristic (ROC) analyses were applied to derive optimal cut-off values. (3) ASAS consensus was reached.
RESULTS
(1) The literature review yielded 38 studies using some definition of 'flare', with 27 different definitions indicating important heterogeneity. The most frequent definitions were based on BASDAI changes or pain changes. (2) 121 ASAS experts completed 4999 flare assessments. The areas under the ROC curves were high (range: 0.88-0.89). Preliminary cut-offs for pain (N=3), BASDAI (N=5) and ASDAS-CRP (N=4) were chosen, with a range of sensitivity 0.60-0.99 and range of specificity 0.40-0.94 against the expert's opinions.
CONCLUSIONS
This data-driven ASAS consensus process has led to 12 preliminary draft definitions of 'flare' in axSpA, based on widely used indices. These preliminary definitions will need validation in real patient data.
Topics: Adult; Aged; Axis, Cervical Vertebra; Disease Progression; Female; Humans; Male; Middle Aged; Pain; Pain Measurement; ROC Curve; Reference Values; Sensitivity and Specificity; Severity of Illness Index; Spondylarthritis; Surveys and Questionnaires; Symptom Assessment; Young Adult
PubMed: 26847821
DOI: 10.1136/annrheumdis-2015-208593 -
World Neurosurgery Sep 2020Odontoid fracture is a common injury especially in elderly people. Despite some recent studies arguing in favor of surgery, the best treatment is still being debated. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Odontoid fracture is a common injury especially in elderly people. Despite some recent studies arguing in favor of surgery, the best treatment is still being debated.
OBJECTIVE
We systematically review and analyze the comparative literature between surgical and conservative treatments of odontoid fractures.
METHODS
We systematically searched Medline and the Cochrane Library for studies reported from January 1990 to May 2019 in English. Comparative studies evaluating the results of surgical and conservative treatments for odontoid fractures were eligible for inclusion. Combined relative risks (RRs) for mortality at last follow-up, union or nonunion rates, and complications were calculated. Methodological quality was assessed using the Newcastle-Ottawa Scale. Influence of age and year of publication on treatment effect was explored using a meta-regression analysis.
RESULTS
A total of 1438 articles were identified, of which 30 articles with 2463 patients were eligible for inclusion. There was a trend toward lower mortality in the surgical group (RR, 0.80; 95% confidence interval [CI], 0.63-1.02). Nonunion rates (RR, 0.41; 95% CI, 0.28-0.6) were lower in the surgical group. Union rates were higher in the surgical group (RR, 1.26; 95% CI, 1.11-1.45). No significant influence of age or year of publication on treatment effect was found.
CONCLUSIONS
Based on this meta-analysis of nonrandomized comparative studies, surgical treatment seems not to be inferior to conservative treatments. The conclusions of this study remain limited by the low quality of the evidence available. Randomized controlled studies are required.
Topics: Conservative Treatment; Fracture Fixation; Humans; Odontoid Process; Spinal Fractures
PubMed: 32151771
DOI: 10.1016/j.wneu.2020.02.169 -
Surgical Neurology Dec 2005Traumatic hypoglossal nerve palsy is a rare entity and has rarely been described in association with an odontoid fracture.
BACKGROUND
Traumatic hypoglossal nerve palsy is a rare entity and has rarely been described in association with an odontoid fracture.
CASE DESCRIPTION
We present a patient with a posttraumatic odontoid fracture who developed selective weakness of his arms and a unilateral hypoglossal nerve palsy. A systematic review of the literature is presented, and hypothetical causes for the injury are discussed.
CONCLUSION
Bell's cruciate paralysis and central cord syndrome are probably expressions of the same mechanism rather than 2 separate entities based on a preferential damage of pyramidal crossing arm fibers. C2 fractures with concomitant lower cranial nerve injury are relatively rare and have a reasonably good outcome, especially when unilateral.
Topics: Aged; Aged, 80 and over; Humans; Male; Atrophy; Cervical Vertebrae; Fractures, Closed; Hypoglossal Nerve Diseases; Odontoid Process; Syndrome; Tongue
PubMed: 16293473
DOI: 10.1016/j.surneu.2005.04.032 -
Journal of Neurosurgery. Spine Jan 2024Odontoid fractures are the most common fracture of the cervical spine in adults older than 65 years of age. Fracture management remains controversial, given the... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Odontoid fractures are the most common fracture of the cervical spine in adults older than 65 years of age. Fracture management remains controversial, given the inherently increased surgical risks in older patients. The objective of this study was to compare fusion rates and outcomes between operative and nonoperative treatments of type II odontoid fractures in the older population.
METHODS
A systematic literature review was performed to identify studies reporting the management of type II odontoid fractures in patients older than 65 years from database inception to September 2022. A meta-analysis was performed to compare rates of fusion, stable and unstable nonunion, mortality, and complication.
RESULTS
Forty-six articles were included in the final review. There were 2822 patients included in the different studies (48.9% female, 51.1% male), with a mean ± SD age of 81.5 ± 3.6 years. Patients in the operative group were significantly younger than patients in the nonoperative group (81.5 ± 3.5 vs 83.4 ± 2.5 years, p < 0.001). The overall (operative and nonoperative patients) fusion rate was 52.9% (720/1361). The fusion rate was higher in patients who underwent surgery (74.3%) than in those who underwent nonoperative management (40.3%) (OR 4.27, 95% CI 3.36-5.44). The likelihood of stable or unstable nonunion was lower in patients who underwent surgery (OR 0.37, 95% CI 0.28-0.49 vs OR 0.32, 95% CI 0.22-0.47). Overall, 4.8% (46/964) of nonoperatively managed patients subsequently required surgery due to treatment failure. Patient mortality across all studies was 16.6% (452/2721), lower in the operative cohort (13.2%) than the nonoperative cohort (19.0%) (OR 0.64, 95% CI 0.52-0.80). Complications were more likely in patients who underwent surgery (26.0% vs 18.5%) (OR 1.55, 95% CI 1.23-1.95). Length of stay was also higher with surgery (13.6 ± 3.8 vs 8.1 ± 1.9 days, p < 0.001).
CONCLUSIONS
Patients older than 65 years of age with type II odontoid fractures had higher fusion rates when treated with surgery and higher stable nonunion rates when managed nonoperatively. Complications and length of stay were higher in the surgical cohort. Mortality rates were lower in patients managed with surgery, but this phenomenon could be related to surgical selection bias. Fewer than 5% of patients who underwent nonoperative treatment required revision surgery due to treatment failure, suggesting that stable nonunion is an acceptable treatment goal.
Topics: Humans; Male; Female; Aged; Aged, 80 and over; Spinal Fractures; Odontoid Process; Fractures, Bone; Treatment Failure; Treatment Outcome; Retrospective Studies
PubMed: 37877937
DOI: 10.3171/2023.6.SPINE22920