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Acta Neurochirurgica. Supplement 2023This chapter reviews the clinical entity of central or axial atlantoaxial instability (CAAD).
AIM
This chapter reviews the clinical entity of central or axial atlantoaxial instability (CAAD).
MATERIAL AND METHODS
From January 2018 to November 2020, 15 patients were identified as having CAAD, wherein there was no atlantoaxial instability when analyzed by conventional radiological parameters and wherein there was no evidence of neural or dural compression due to the odontoid process. The patients were identified as having atlantoaxial instability on the basis of the alignment of facets on lateral profile imaging and a range of telltale clinical and radiological indicators. The clinical statuses of the patients were recorded both before and after surgical treatment by using the specially designed Goel symptom severity index and visual analog scale (VAS) scores. All patients were treated via atlantoaxial fixation.
RESULTS
There were six men and nine women ranging in age from 18 to 45 years (average: 37 years). The presenting clinical symptoms were relatively subtle and long-standing. Apart from symptoms that are generally related to neural compromise at the craniovertebral junction, a range of nonspecific cranial and spinal symptoms were prominent. The follow-up time after surgery ranged from 6 to 34 months. All patients showed early postoperative and sustained clinical recovery.
CONCLUSIONS
The correct diagnosis and appropriate surgical treatment of CAAD can provide an opportunity for quick and lasting clinical recovery.
Topics: Male; Humans; Female; Adolescent; Young Adult; Adult; Middle Aged; Odontoid Process; Skull
PubMed: 38153480
DOI: 10.1007/978-3-031-36084-8_41 -
Journal of Clinical Medicine Dec 2023In a multilevel cervical laminoplasty operation for patients with cervical spondylotic myelopathy (CSM), a partial or complete C3 laminectomy may be performed at the...
INTRODUCTION
In a multilevel cervical laminoplasty operation for patients with cervical spondylotic myelopathy (CSM), a partial or complete C3 laminectomy may be performed at the upper level instead of a C3 plated laminoplasty. It is unknown whether C3 technique above the laminoplasty affects loss of cervical lordosis or range of motion.
METHODS
Patients undergoing multilevel laminoplasty of the cervical spine (C3-C6/C7) at a single institution were retrospectively reviewed. Patients were divided into two cohorts based on surgical technique at C3: C3-C6/C7 plated laminoplasty ("C3 laminoplasty only", N = 61), C3 partial or complete laminectomy, plus C4-C6/C7 plated laminoplasty (N = 39). All patients had at least 1-year postoperative X-ray treatment.
RESULTS
Of 100 total patients, C3 laminoplasty and C3 laminectomy were equivalent in all demographic data, except for age (66.4 vs. 59.4 years, = 0.012). None of the preoperative radiographic parameters differed between the C3 laminoplasty and C3 laminectomy cohorts: cervical lordosis (13.1° vs. 11.1°, = 0.259), T1 slope (32.9° vs. 29.2°, = 0.072), T1 slope-cervical lordosis (19.8° vs. 18.6°, = 0.485), or cervical sagittal vertical axis (3.1 cm vs. 2.7 cm, = 0.193). None of the postoperative radiographic parameters differed between the C3 laminoplasty and C3 laminectomy cohorts: cervical lordosis (9.4° vs. 11.2°, = 0.369), T1 slope-cervical lordosis (21.7° vs. 18.1°, = 0.126), to cervical sagittal vertical axis (3.3 cm vs. 3.6 cm, = 0.479). In the total cohort, 31% had loss of cervical lordosis >5°. Loss of lordosis reached 5-10° (mild change) in 13% of patients and >10° (moderate change) in 18% of patients. C3 laminoplasty and C3 laminectomy cohorts did not differ with respect to no change (<5°: 65.6% vs. 74.3%, respectively), mild change (5-10°: 14.8% vs. 10.3%), and moderate change (>10°: 19.7% vs. 15.4%) in cervical lordosis, = 0.644. When controlling for age, ordinal regression showed that surgical technique at C3 did not increase the odds of postoperative loss of cervical lordosis. C3 laminectomy versus C3 laminoplasty did not differ in the postoperative range of motion on cervical flexion-extension X-rays (23.9° vs. 21.7°, = 0.451, N = 91).
CONCLUSION
There was no difference in postoperative loss of cervical lordosis or postoperative range of motion in patients who underwent either C3-C6/C7 plated laminoplasty or C3 laminectomy plus C4-C6/C7 plated laminoplasty.
PubMed: 38137663
DOI: 10.3390/jcm12247594 -
World Neurosurgery Mar 2024We sought to evaluate the clinical impact of lordosis orientation (LO) on proximal junctional kyphosis (PJK) development in adult spinal deformity surgery.
OBJECTIVE
We sought to evaluate the clinical impact of lordosis orientation (LO) on proximal junctional kyphosis (PJK) development in adult spinal deformity surgery.
METHODS
This study included 152 patients who underwent low thoracic (T9-T12) to pelvis fusion and were followed up for ≥2 years. In the literature, 6 radiographic parameters representing LO were introduced, such as uppermost instrumented vertebra (UIV) slope, UIV inclination, UIV-femoral angle (UIVFA), thoracolumbar tilt, thoracolumbar slope, and lordosis tilt. Various clinical and radiographic factors including 6 LO parameters were investigated using logistic regression analysis to identify risk factors for PJK.
RESULTS
The mean age was 69.4 years, and 136 patients were females (89.5%). PJK developed in 65 patients (42.8%). Multivariate logistic regression analysis revealed that only small postoperative pelvic incidence (PI)-lumbar lordosis (LL) (odds ratio [OR] = 0.962, 95% confidence interval: 0.929-0.996, P = 0.030) and large UIVFA (OR = 1.089, 95% confidence interval: 1.028-1.154, P = 0.004) were significant for PJK development. UIVFA showed significantly positive correlation with pelvic tilt (CC = 0.509), thoracic kyphosis (CC = 0.384), and lordosis distribution index (CC = 0.223). UIVFA was also negatively correlated with sagittal vertical axis (CC = -0.371). However, UIVFA did not correlate with LL, PI-LL, or T1 pelvic angle.
CONCLUSIONS
LO significantly increases the risk of PJK development in ASD surgery. Multivariate analysis revealed that smaller postoperative PI-LL and greater UIVFA were significant risk factors for PJK. Surgeons should avoid undercorrection and overcorrection to prevent PJK development.
Topics: Adult; Female; Animals; Humans; Aged; Male; Lordosis; Clinical Relevance; Lumbar Vertebrae; Retrospective Studies; Spinal Fusion; Kyphosis; Connective Tissue Diseases; Postoperative Complications; Thoracic Vertebrae
PubMed: 38135150
DOI: 10.1016/j.wneu.2023.12.082 -
JBJS Case Connector Oct 2023A healthy 5-year-old boy presented with a gradual onset of headaches and acute global right-sided weakness over 10 days. The work-up revealed unstable os odontoideum...
CASE
A healthy 5-year-old boy presented with a gradual onset of headaches and acute global right-sided weakness over 10 days. The work-up revealed unstable os odontoideum leading to multiple posterior circulation infarcts with vertebral artery dissection. He underwent antiplatelet therapy, cervical collar immobilization, and delayed occiput to C2 posterior spinal fusion and instrumentation with iliac crest autograft. At 2-year follow-up, the patient had a solid fusion mass, appropriate cervical alignment, and was without neurologic sequelae.
CONCLUSION
This case adds to a sparse body of literature in the management of vertebral artery dissection with vertebrobasilar insufficiency secondary to unstable os odontoideum.
Topics: Male; Humans; Child, Preschool; Vertebral Artery Dissection; Odontoid Process; Atlanto-Axial Joint; Axis, Cervical Vertebra; Spinal Fusion; Infarction
PubMed: 38134303
DOI: 10.2106/JBJS.CC.23.00466 -
Journal of Neuroendovascular Therapy 2023Basilar artery occlusion (BAO) secondary to traumatic vertebral artery (VA) dissection caused by vertebral fracture is a rare cause of acute ischemic stroke, and optimal...
OBJECTIVE
Basilar artery occlusion (BAO) secondary to traumatic vertebral artery (VA) dissection caused by vertebral fracture is a rare cause of acute ischemic stroke, and optimal management, such as antithrombotic agents, surgical fixation, and parent artery occlusion (PAO), has been controversial. We report a case in which mechanical thrombectomy and PAO were performed for a BAO due to right VA dissection caused by a transverse foramen fracture of the axis vertebra.
CASE PRESENTATION
A patient in her 80s suffered from a backward fall, and a neck CT revealed a fracture and dislocation of the right lateral mass of the axis and a compressed transverse foramen. The patient was instructed to admit and to remain in bed rest; however, she suddenly lost consciousness the following day. The CTA revealed right VA occlusion and BAO; therefore, the patient underwent mechanical thrombectomy and the BAO was successfully reperfused but the VA stenotic dissection remained. PAO of the right VA was performed on the fifth day after the accident to prevent BAO recurrence.
CONCLUSION
Mechanical thrombectomy is an effective treatment for BAO caused by VA dissection, and PAO may contribute to the prevention of stroke recurrence.
PubMed: 38125961
DOI: 10.5797/jnet.cr.2023-0041 -
Osteoporosis International : a Journal... Apr 2024We conduct a longitudinal study to examine how new VCF alter spinal sagittal balance. New VCF increased SVA by an average of 2.8 cm. Sagittal balance deteriorates as a...
UNLABELLED
We conduct a longitudinal study to examine how new VCF alter spinal sagittal balance. New VCF increased SVA by an average of 2.8 cm. Sagittal balance deteriorates as a VCF develops in the lower lumbar spine. A new fracture below L1 increased the relative risk of a deterioration of sagittal balance 2.9-fold compared to one above Th12.
PURPOSE
Studies on the relationship between osteoporotic vertebral fractures and spinal sagittal balance have all been limited to cross-sectional studies. The aim of this study is to conduct a longitudinal study to examine how new vertebral compression fracture (VCF) alter spinal sagittal balance.
METHODS
Subjects were patients undergoing periodic examinations after treatment of a vertebral fracture or lumbar spinal canal stenosis. Forty patients who developed a new VCF were included in this study. Full-spine standing radiographs were compared before and after the fracture to examine changes in spinopelvic parameters and factors determining the changes in sagittal balance.
RESULTS
The mean age of the patients was 79.0 years. The mean interval between pre- and post-fracture radiographs was 22.7 months, and the mean time between development of a fracture and post-fracture radiographs was 4.6 months. After a fracture, sagittal vertical axis (SVA) increased an average of 2.78 cm and spino-sacral angle (SSA) decreased an average of 5.3°. Both ⊿SVA and ⊿SSA were not related to pre-fracture parameters. The wedge angle of the fractured vertebra was not related to changes in sagittal balance. ⊿SVA increased markedly in patients with a fracture of the lower lumbar vertebrae. receiver operating characteristic analysis revealed that the relative risk of a deterioration of sagittal balance was 2.9 times higher for a new fracture below L1 than for a fracture above Th12.
CONCLUSION
New VCF increased SVA by an average of 2.8 cm. Sagittal balance deteriorates as a new fracture develops in the lower lumbar spine. Early intervention in osteoporosis is vital for the elderly.
Topics: Humans; Aged; Fractures, Compression; Spinal Fractures; Longitudinal Studies; Cross-Sectional Studies; Osteoporotic Fractures; Lumbar Vertebrae; Bone Diseases, Metabolic; Retrospective Studies
PubMed: 38108858
DOI: 10.1007/s00198-023-06976-4 -
The Spine Journal : Official Journal of... Apr 2024Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their...
Type II odontoid fractures in the elderly presenting to the emergency department: an assessment of factors affecting in-hospital mortality and discharge to skilled nursing facilities.
BACKGROUND CONTEXT
Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their epidemiology. Additionally, the optimal management of these injuries remains controversial, and no study has evaluated the short-term outcomes of geriatric patients presenting to emergency departments (ED).
PURPOSE
This study aims to document the epidemiology of geriatric patients presenting to EDs with type II OFs and determine whether surgical management was associated with early adverse outcomes such as in-hospital mortality and discharge to skilled nursing facilities (SNF).
STUDY DESIGN
This is a retrospective cohort study.
PATIENT SAMPLE
Data was used from the 2016-2020 Nationwide Emergency Department Sample. Patient encounters corresponding to type II OFs were identified. Patients younger than 65 at the time of presentation to the ED and those with concomitant spinal pathology were excluded.
OUTCOME MEASURES
The association between the surgical management of geriatric type II OFs and outcomes such as in-hospital mortality and discharge to SNFs.
METHODS
Patient, fracture, and surgical management characteristics were recorded. A propensity score matched cohort was constructed to reduce differences in age, comorbidities, and injury severity between patients undergoing operative and nonoperative management. Additionally, to develop a positive control for the analysis of geriatric patients with type II OFs and no other concomitant spinal pathology, a cohort of patients that had been excluded due to the presence of a concomitant spinal cord injury (SCI) was also constructed. Multivariate regressions were then performed on both the matched and unmatched cohorts to ascertain the associations between surgical treatment and in-hospital mortality, inpatient length of stay, encounter charges, and discharge to SNFs.
RESULTS
A total of 11,325 encounters were included. The mean total charge per encounter was $60,221. 634 (5.6%) patients passed away during their encounters. In total, 1,005 (8.9%) patients were managed surgically. Surgical management of type II OFs was associated with a 316% increase in visit charge (95% CI: 291%-341%, p<.001), increased inpatient length of stay (IRR: 2.87, 95% CI: 2.62-3.12, p<.001), and increased likelihood of discharge to SNFs (OR=2.62, 95% CI: 2.26-3.05, p<.001), but decreased in-hospital mortality (OR=0.32, CI: 0.21-0.45, p<.001). The propensity score matched cohort consisted of 2,010 patients, matching each of the 1,005 that underwent surgery to 1,005 that did not. These cohorts were well balanced across age (78.24 vs 77.91 years), Elixhauser Comorbidity Index (3.68 vs 3.71), and Injury Severity Score (30.15 vs 28.93). This matching did not meaningfully alter the associations determined between surgical management and in-hospital mortality (OR=0.34, CI=0.21-0.55, p<.001) or SNF discharge (OR=2.59, CI=2.13-3.16, p<.001). Lastly, the positive control cohort of patients with concurrent SCI had higher rates of SNF discharge (50.0% vs 42.6%, p<.001), surgical management (32.3% vs 9.7%, p<.001), and in-hospital mortality (28.9% vs 5.6%, p<.001).
CONCLUSIONS
This study lends insight into the epidemiology of geriatric type II OFs and quantifies risk factors influencing adverse outcomes. Patient informed consent should include a discussion of the protective association between definitive surgical management and in-hospital mortality against potential operative morbidity, increased lengths of hospital stay, and increased likelihood of discharge to SNFs. This information may impact patient treatment selection and decision making.
Topics: Humans; Aged; Spinal Fractures; Retrospective Studies; Odontoid Process; Skilled Nursing Facilities; Patient Discharge; Hospital Mortality; Spinal Cord Injuries; Emergency Service, Hospital
PubMed: 38101547
DOI: 10.1016/j.spinee.2023.11.023 -
World Neurosurgery Feb 2024Anterior transpedicular screw (ATPS) internal fixation of the lower cervical spine is an alternative for patients who cannot tolerate combined anterior and posterior...
BACKGROUND
Anterior transpedicular screw (ATPS) internal fixation of the lower cervical spine is an alternative for patients who cannot tolerate combined anterior and posterior surgery. The cervical vertebral anatomy varies with many factors, including age, gender, height, weight, and race.
METHODS
Three-dimensional (3D) CT reconstructions were performed on 122 patients. We selected the best level and measured the relevant parameters on both sides of the cervical vertebrae.
RESULTS
We identified the entry point and orientation parameters of ATPS fixation for the C3-C7 vertebrae, and analyzed cervical pedicle parameters. Outer pedicle width (OPW), outer pedicle height (OPH), and pedicle axis length (PAL) were not correlated with body weight and age, but were positively correlated with body height (P < 0.05). After multiple linear regression analysis to exclude the effects of body height, no significant differences in OPW, OPH, and PAL were found between male and female subjects at most cervical levels. Pedicle cortical thickness was negatively correlated with age (P < 0.05). The percentage of pedicles with OPW <4.5 mm was: C3, 38.10%; C4, 34.92%; C5, 12.70%; C6, 9.52%; and C7, 0%. The percentage of pedicles with OPWs ≤4.5 mm, ≤4.0 mm, and ≤3.5 mm was higher among subjects with body height <160 cm.
CONCLUSIONS
This study presents the internal anatomy of the cervical spine and provides accurate preoperative evaluation data for ATPS fixation. OPW, OPH, and PAL are positively correlated with body height, while pedicle cortical thickness is negatively correlated with age.
Topics: Humans; Male; Female; Bone Screws; Tomography, X-Ray Computed; Neck; Cervical Vertebrae; Fracture Fixation, Internal; China
PubMed: 38092354
DOI: 10.1016/j.wneu.2023.12.026 -
Ortopedia, Traumatologia, Rehabilitacja Oct 2023Odontoid fractures are found in two age groups. In younger patients, they occur following traffic accidents, falls from a height and during sports. In older patients...
BACKGROUND
Odontoid fractures are found in two age groups. In younger patients, they occur following traffic accidents, falls from a height and during sports. In older patients with poor bone quality, they are usually caused by falls from one's own height. Most fractures are stable and do not require surgical treatment. Unstable, severely displaced fractures with neurological deficits require surgical treatment. The aim of the study was to evaluate the surgical and functional outcomes of treatment of odontoid fractures with a cannulated screw.
MATERIALS AND METHODS
The study enrolled 20 patients that underwent surgery in the years 2020-2022. The patients were divided into two groups: below 60 (group A) and over 60 years of age (group B). Patients were assessed at one day pre-op, one day post-op, 6 weeks following surgery and 3 months following surgery. Imaging studies were performed to assess the angulation and degree of displacement of bone fragments. After the fracture was surgically fixed with a cannulated screw, bone union and the stability of fracture fixation were assessed. Preoperative and postoperative pain intensity as per a VAS, functional status assessed with the NDI questionnaire, quality of life (EQ-VAS) and neurological status (ASIA scale) were compared.
RESULTS
Good functional and surgical results were obtained in both groups of patients. Performance and quality of life improved, while pain intensity decreased in all patients. In 3 patients with post-traumatic paresis, the dysfunctions gradually subsided. No general medical or perioperative complications were observed. Bone union of the fracture was achieved in 40% of patients in group B and in 80% in group A. Achieving union did not determine the functional status of patients. On functional radiographs, all places of fixation were stable.
CONCLUSIONS
1. Odontoid fracture fixation with a single cannulated screw is a safe method of treatment. It provided a high union rate and good stability of the fracture. 2. Fracture non-union was noted more often in the group of older patients, but it did not negatively impact quality of life and performance.
Topics: Humans; Middle Aged; Aged; Odontoid Process; Spinal Fractures; Quality of Life; Fracture Fixation, Internal; Fractures, Bone; Treatment Outcome; Retrospective Studies
PubMed: 38088099
DOI: 10.5604/01.3001.0053.9673 -
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