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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 -
Technology in Cancer Research &... 2020It is well known that radiation damage of the pharyngeal constrictor muscles, the glottic larynx, and the supraglottic larynx may lead to dysphagia, an unwanted effect... (Meta-Analysis)
Meta-Analysis
It is well known that radiation damage of the pharyngeal constrictor muscles, the glottic larynx, and the supraglottic larynx may lead to dysphagia, an unwanted effect of head and neck radiotherapy. The reduction of radiotherapy-induced dysphagia might be achieved by adaptive radiotherapy. Although the number of studies concerning adaptive radiotherapy of head and neck cancer is continuously increasing, there are only a few studies concerning changes in dysphagia-related structures during radiotherapy.The goal of this review is to summarize the current knowledge about volumetric, dosimetric, and other changes of the pharyngeal constrictor muscles associated with head and neck radiotherapy. A literature search was performed in the MEDLINE database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The conclusions of 8 studies that passed the criteria indicate a significant increase in the volume and the thickness of the pharyngeal constrictor muscles during radiotherapy. Moreover, the changes in magnetic resonance imaging signal intensity of the pharyngeal constrictor muscles correlate with the absorbed dose (typically higher than 50 Gy) and also with the grade of dysphagia. This systematic review presents 2 variables, which are suitable for estimation of radiotherapy-related pharyngeal constrictor muscles changes-magnetic resonance imaging signal intensity and the thickness. In the case of the thickness, there is no consensus in the level of the measurement-C2 vertebra, C3 vertebra, and the middle of the craniocaudal axis are used. It seems that reference to a position associated with a vertebral body could be more reproducible and beneficial for future research. Although late pharyngeal toxicity remains a challenge in head and neck cancer treatment, better knowledge of radiotherapy-related changes in the pharyngeal constrictor muscles contributes to adaptive radiotherapy development and thus improves the treatment results.
Topics: Deglutition Disorders; Head and Neck Neoplasms; Humans; Magnetic Resonance Imaging; Organs at Risk; Pharyngeal Muscles; Radiotherapy Dosage; Tomography, X-Ray Computed
PubMed: 32734851
DOI: 10.1177/1533033820945805 -
European Spine Journal : Official... Feb 2021The primary goal of this study was to conduct a systematic review and meta-analysis of articles focused on odontoid screw fixation (OSF) and screw-related complications... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The primary goal of this study was to conduct a systematic review and meta-analysis of articles focused on odontoid screw fixation (OSF) and screw-related complications or non-union rates.
METHODS
We conducted a systematic review of the PubMed and Crossref databases between January 1982 and December 2019. Inclusion criteria comprised detailed descriptions of the surgical technique and screw-related complications (screw cut-out, loosening, breakage, malposition) or fusion rates.
RESULTS
The initial selection consisted of 683 abstracts. A total of 150 full texts were chosen for detailed study, and 83 articles were included in the analysis. The point estimates for screw-related complications were as follows: 1. screw malposition frequency-4.8%; 2. screw cut-out rate-5.0%; 3. screw loosening/pull-out-3.8%; and 4. screw fracture rate-3.1%. The point estimate for the non-union rate was 9.7%. Statistical analysis of the screw-related complications rate based on surgical technique details was also performed CONCLUSIONS: Double-screw OSF performance in elder patients resulted in a higher risk of post-operative screw cut-out. In other cases, the development of screw-related complications did not depend on the method of intraoperative head fixation, selection of the implant entry point for OSF, type of the used screws, or cannulated instruments application. The outcomes of single-screw fixation through the anterior lip of the C2 vertebra were comparable to other techniques of OSF. Further, statistically reliable studies should be carried out to identify the optimal technique of OSF.
Topics: Aged; Bone Screws; Fracture Fixation, Internal; Fractures, Bone; Humans; Odontoid Process; Spinal Fractures
PubMed: 32556628
DOI: 10.1007/s00586-020-06501-9 -
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 -
World Neurosurgery Mar 2020Instability of the craniovertebral junction (CVJ) following odontoidectomy is relatively common. Traditionally, separate stage posterior atlantoaxial ± occipitocervical...
Instability of the craniovertebral junction (CVJ) following odontoidectomy is relatively common. Traditionally, separate stage posterior atlantoaxial ± occipitocervical fusion is used for treatment. A transmucosal approach using a clean-contaminated route is associated with hypothetical risks of infectious complications. There is a paucity of information in the literature assessing the risk of surgical site infection (SSI) using the transmucosal approach for hardware placement. The authors conducted a literature search through PubMed identifying patients with pathology requiring transmucosal (i.e., transnasal or transoral) CVJ fixation. Studies that described 1) cases requiring a transmucosal approach and 2) associated infectious complications were included. Rates of SSIs, device removal, unplanned reoperation, and hardware failures were analyzed. Descriptive statistics and odds ratios (ORs) were used to compare complications. Nine studies with a total of 431 patients were identified. There were 4 (0.93%) superficial SSIs and 4 (0.93%) deep SSIs. In total, 1.86% of patients experienced SSI. There were 18 (4.18%) cases of unplanned reoperation, 4 (0.93%) related to SSI. Five (1.16%) patients required removal of their anterior fixation device, 4 (0.93%) related to SSI. ORs comparing our results with Medvedev et al's retrospective National Surgical Quality Improvement Program study assessing the risk associated with posterior cervical fixation showed no statistical difference between postoperative infection rates (OR = 0.72, P = 0.36). An extensive review of the literature found no evidence to suggest placement of spinal hardware via transmucosal corridor is associated with an increased risk of SSI.
Topics: Atlanto-Axial Joint; Atlanto-Occipital Joint; Device Removal; Humans; Mouth Mucosa; Nasal Mucosa; Odontoid Process; Reoperation; Spinal Cord Compression; Spinal Fusion; Surgical Wound Infection
PubMed: 31811965
DOI: 10.1016/j.wneu.2019.11.168 -
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 -
Neurosurgical Review Sep 2019There are still controversies on characteristics and risk factors for proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients. The objective of this... (Meta-Analysis)
Meta-Analysis
There are still controversies on characteristics and risk factors for proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients. The objective of this study is to explore the characteristics and risk factors for PJK in ASD. A systematic online search in databases including PubMed, EMBASE, Web of Science, and the Cochrane Library was performed to identify eligible studies. OR and weight mean difference with 95% CI were used to evaluate characteristics and risk factors. A total of 31 studies were finally included. ASD patients with PJK had larger proximal junctional angle (PJA), thoracic kyphosis (TK), pelvic incidence minus lumbar lordosis (PI-LL), and sagittal alignment. Age, female gender, and low BMD/osteoporosis were demographic risk factors for PJK. Using hooks at upper instrumented vertebra (UIV) and the selection of UIV above T8 could reduce the occurrence of PJK, while pelvic fixation was significantly associated with increased occurrence of PJK. Preoperative LL, preoperative pelvic tilt (PT), preoperative LL-TK, preoperative PI-LL, preoperative sagittal vertical axis (SVA), preoperative global spine alignment (GSA), postoperative PJA, change in PJA, postoperative TK, change in LL, change in SVA, and postoperative GSA were identified as risk factors for PJK. In conclusion, PJK patients had larger PJA, larger TK, smaller PI-LL, and larger sagittal alignment. Older female ASD patients with low BMD/osteoporosis are more likely to suffer from PJK. We recommend the following: (1) using hooks at UIV; (2) UIV should be chosen above T8, and pelvic fixation should be avoided if possible; (3) ideal correction of sagittal alignment should be performed to prevent the occurrence of PJK.
Topics: Adult; Child; Humans; Kyphosis; Neurosurgical Procedures; Orthopedic Procedures; Risk Factors; Spinal Curvatures
PubMed: 29982856
DOI: 10.1007/s10143-018-1004-7 -
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 -
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