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Shiozaki E, Morofuji Y, Kutsuna F, Uchida D, Kawahara I, Ono T, Haraguchi W, Tsutsumi K. Subarachnoid hemorrhage due to a craniocervical junction arteriovenous fistula associated with thrombus formation in the internal jugular vein: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22278. [PMID: 36593679 PMCID: PMC9514286 DOI: 10.3171/case22278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND A craniocervical junction arteriovenous fistula (CCJAVF) is a rare vascular malformation, and its etiology remains unclear. Here, to the best of the authors' knowledge, they present the first case of CCJAVF associated with thrombus formation in the ipsilateral internal jugular vein. OBSERVATIONS An 80-year-old man presented with a sudden occipital headache. Computed tomography revealed a subarachnoid hemorrhage surrounding the brainstem and upper cervical cord. Digital subtraction angiography showed a CCJAVF fed by the left C2 radiculomeningeal artery with ascending intracranial drainage and epidural plexus. After endovascular treatment, the authors retrospectively found that his ipsilateral internal jugular vein and innominate vein were occluded with a huge thrombus at admission. LESSONS This case suggested a restricted antegrade venous flow due to thrombus-induced progressive retrograde intracranial drainage causing hemorrhage. Venous hypertension should be considered one of the causes of hemorrhage due to CCJAVF as well as intracranial arteriovenous fistulas.
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Affiliation(s)
| | | | - Fumiya Kutsuna
- Neurology, Nagasaki Medical Center, Kubara Omura-city, Nagasaki, Japan
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CT angiographic evaluation of the V3 vertebral artery course in cases of occipitalized atlas, a study of 25 cases. Clin Imaging 2020; 71:69-76. [PMID: 33171370 DOI: 10.1016/j.clinimag.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/24/2020] [Accepted: 11/02/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To study the relationship of the 3rd segment of the vertebral artery to the posterior arch of the atlas in patients with occipitalized atlas, using CT angiography. METHODS A retrospective study of 25 cases with complete or partially occipitalized atlas who underwent CT angiography evaluation. Fifty vertebral arteries were analyzed in relation to the respective/related half of the posterior arch of the atlas. RESULTS Out of 50 vertebral arteries, 35 (70%) were anomalous; 31 (62%) traversed though bony canal between the fused occiput and atlas, and 4 (8%) coursed between C1 and C2 (C2 segmental type of vertebral artery). Except one, all anomalous vertebral arteries were associated with a fused corresponding side of posterior arch of atlas. CONCLUSION The V3 portion of the vertebral artery assumes an anomalous course at the craniovertebral junction in most cases of occipitalized atlas, and this is strongly determined by the fusion status of the posterior arch of the atlas. Aberrations in its course are still seen despite expectations based on this fusion status. Preprocedural CT Angiography provides accurate information of its course to prevent iatrogenic VA injuries. ADVANCES IN KNOWLEDGE CT Angiography should be performed before any procedures at the craniovertebral junction in cases of occipitalized atlas to prevent iatrogenic, potentially catastrophic injuries to vertebral artery due to its anomalous course in most of these cases. There are very few such studies in the literature, none in radiology literature. We also describe some rare cases, including a case never described in any literature.
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Lofrese G, Cultrera F, Visani J, Nicassio N, Essayed WI, Donati R, Cavallo MA, De Bonis P. Intraoperative Doppler ultrasound as a means of preventing vertebral artery injury during Goel and Harms C1-C2 posterior arthrodesis: technical note. J Neurosurg Spine 2019; 31:824-830. [PMID: 31419805 DOI: 10.3171/2019.5.spine1959] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 05/28/2019] [Indexed: 11/06/2022]
Abstract
Vertebral artery injury (VAI) is a potential catastrophic complication of Goel and Harms C1-C2 posterior arthrodesis. Meticulous study of preoperative spinal CT angiography together with neuronavigation plays a fundamental role in avoiding VAI. Doppler ultrasonography may be an additional intraoperative tool, providing real-time identification of the vertebral artery (VA) and thus helping its preservation.Thirty-three consecutive patients with unstable odontoid fractures underwent Goel and Harms C1-C2 posterior arthrodesis. Surgery was performed with the aid of lateral fluoroscopic control in 16 cases (control group) that was supplemented by Doppler ultrasonography in 17 cases (Doppler group). Two patients in each group had a C1 ponticulus posticus. In the Doppler group, Doppler probing was performed during lateral subperiosteal muscle dissection, stepwise drilling, and tapping. Blood flow velocity in the V3 segment of the VA was recorded before and after posterior arthrodesis. All patients had a 12-month outpatient follow-up, and outcome was assessed using the Smiley-Webster Pain Scale. Neither VAI nor postoperative neurological impairments were observed in the Doppler group. In the control group, VAIs occurred in the 2 patients with C1 ponticulus posticus. In the Doppler group, 1 patient needed intra- and postoperative blood transfusions, and no difference in terms of Doppler signal or VA blood flow velocity was detected before and after C1-C2 posterior arthrodesis. In the control group, 3 patients needed intra- and postoperative blood transfusions.Useful in supporting fluoroscopy-assisted procedures, intraoperative Doppler may play a significant role even during surgeries in which neuronavigation is used, reducing the chance of a mismatch between the view on the neuronavigation screen and the actual course of the VA in the operative field and supplying the additional data of blood flow velocity.
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Affiliation(s)
| | | | - Jacopo Visani
- 2Neurosurgery Division, University Hospital S. Anna, Cona di Ferrara, Italy; and
| | | | - Walid Ibn Essayed
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Pasquale De Bonis
- 2Neurosurgery Division, University Hospital S. Anna, Cona di Ferrara, Italy; and
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Potential intraoperative factors of screw-related complications following posterior transarticular C1-C2 fixation: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:400-420. [PMID: 30467736 DOI: 10.1007/s00586-018-5830-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 11/11/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE This study aimed to evaluate the impact of several factors, including patients' intraoperative position, intraoperative visualization technique, fixation method, and type of screws and their parameters, on the frequency of intraoperative screw-associated complications in posterior transarticular C1-C2 fixation. METHODS A systematic review of the PubMed database between January 1986 and March 2018 was performed. The key inclusion criteria comprised detailed descriptions of the surgical technique and post-operative screw-associated complications. RESULTS The initial search resulted in 1041 abstracts, and a total of 54 abstracts were included in the present study. The overall number of operated patients was 2306. In this group, 4439 screws were inserted. The rate of screw-associated complications during the different time periods was estimated upon meta-analysis. Statistical analysis of the screw malposition rate, vertebral artery injury rate, screw breakage rate based on patients' intraoperative position, intraoperative visualization technique, fixation method, and type of implants and their parameters was also performed. CONCLUSIONS The factors that help reduce the rate of screw-associated complications include the intraoperative application of biplanar fluoroscopy or neuronavigation system, the use of 4 mm or thicker lag screws, and screw insertion through contraincisions using cannulated ported instruments. On the other hand, the potential risk factors of screw-associated complications include inadequate intraoperative head fixation using skeletal traction, uniplanar fluoroscopy-guided screw insertion, screw insertion using the posterior midline approach, and the use of 3.5 mm or thinner full-threaded screws. These slides can be retrieved under Electronic Supplementary Material.
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Lagman C, Chung LK, Chitale RV, Yang I. Dural Arteriovenous Fistula and Foix-Alajouanine Syndrome: Assessment of Functional Scores with Review of Pathogenesis. World Neurosurg 2017; 106:206-210. [DOI: 10.1016/j.wneu.2017.06.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/22/2017] [Accepted: 06/24/2017] [Indexed: 12/16/2022]
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Wu X, Liu R, Yu J, Lu L, Yang C, Shao Z, Ye Z. Deviation analysis for C1/2 pedicle screw placement using a three-dimensional printed drilling guide. Proc Inst Mech Eng H 2017; 231:547-554. [PMID: 28056709 DOI: 10.1177/0954411916680382] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cervical transarticular fixation is a technically demanding procedure. This study aimed to develop a safer and more accurate method for C1/2 pedicle screw placement using a three-dimensional printed drilling guide. A total of 20 patients with C1/2 fractures and dislocations were recruited, and their computed tomography scans were evaluated. Under the assistance of the three-dimensional printed drilling guide, bilateral C1/2 pedicle screws were successfully placed in the three-dimensional C1/2 models. Then, sagittal and axial computed tomography scans were obtained, and the accuracy and safety of screw placement were evaluated based on X-Y-Z axis setup. The average depths for C1 and C2 pedicle screws were 30.1 ± 1.12 and 31.81 ± 0.85 mm on the left side and 29.54 ± 1.01 and 31.35 ± 0.27 mm on the right side, respectively. The average dimensional parameters for C1/C2 pedicle screw of both sides were measured and analyzed, which showed no statistically significant differences in the ideal and the actual entry points, inclined angles, and tailed angles. The method of developing a three-dimensional printed drilling guide is an easy and safe technique. This novel technique is applicable for C1/2 pedicle screw fixation; the potential use of the three-dimensional printed guide to place C1/2 pedicle screw is promising.
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Affiliation(s)
- Xinghuo Wu
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Liu
- Department of Orthopaedic Surgery, Puren Hospital of Wuhan, Wuhan University of Science and Technology, Wuhan, China
| | - Jie Yu
- Department of radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Lu
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cao Yang
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zengwu Shao
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhewei Ye
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Akinduro OO, Baum GR, Howard BM, Pradilla G, Grossberg JA, Rodts GE, Ahmad FU. Neurological outcomes following iatrogenic vascular injury during posterior atlanto-axial instrumentation. Clin Neurol Neurosurg 2016; 150:110-116. [PMID: 27618782 DOI: 10.1016/j.clineuro.2016.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/10/2016] [Accepted: 08/13/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Iatrogenic vascular injury is a feared complication of posterior atlanto-axial instrumentation. A better understanding of clinical outcome and management options following this injury will allow surgeons to better care for these patients. The object of the study was to systematically review the neurologic outcomes after iatrogenic vascular injury during atlanto-axial posterior instrumentation. METHODS We performed a systematic review of the Medline database following PRISMA guidelines. In our analysis, we included any retrospective cohort studies, prospective cohort studies, case reports, cases series, or systematic reviews with patients who had undergone posterior atlanto-axial fusion via screw rod constructs (SRC) or transarticular screws (TAS) that reported a patient with an injury to an arterial vessel directly attributable to the surgical procedure. RESULTS Sixty cases of vascular injury were reported in 2078 (2.9%) patients over 27 publications. The average age for this patient population was 55.7+/-17.9. Vascular injury following posterior C1/2 instrumentation resulted in ipsilateral stroke in 10.0% (n=6/60) and non-persistent neurologic deficit in 6.7% (n=4/60) of cases with the deficit being permanent (not including death) in 1.7% (n=1/60) of cases. Four patients (6.7%) died. Arteriovenous fistula or pseudoaneurysm occurred in 8.3% (n=5/60) and 3.3% (n=2/60) of cases, respectively. Eight patients (13.3%) underwent endovascular repair of the injury with no permanent deficit. CONCLUSION Neurological morbidity after iatrogenic vascular injury during posterior C1/2 fixation is higher than previously reported in literature. Some patients may benefit from endovascular treatment. Surgeons should be aware of normal and anomalous vertebral artery anatomy to avoid this potentially catastrophic complication.
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Affiliation(s)
- Oluwaseun O Akinduro
- Department of Neurological Surgery, Mayo Clinic Florida, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA
| | - Griffin R Baum
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite 2200, Atlanta, GA 30322, USA
| | - Brian M Howard
- Department of Neurological Surgery, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite 2200, Atlanta, GA 30322, USA
| | - Gustavo Pradilla
- Department of Neurological Surgery, Emory University School of Medicine, Grady Memorial Hospital, 49 Jesse Hill Drive SE, Room 341, Atlanta GA 30303, USA
| | - Jonathan A Grossberg
- Department of Neurological Surgery, Emory University School of Medicine, Grady Memorial Hospital, 49 Jesse Hill Drive SE, Room 341, Atlanta GA 30303, USA
| | - Gerald E Rodts
- Emory Orthopedics and Spine Center, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, 30329 USA
| | - Faiz U Ahmad
- Department of Neurological Surgery, Emory University School of Medicine, Grady Memorial Hospital, 49 Jesse Hill Drive SE, Room 341, Atlanta GA 30303, USA.
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Tanabe H, Aota Y, Saito T. Laminar screw fixation in the subaxial cervical spine: A report on three cases. World J Orthop 2016; 7:695-699. [PMID: 27795952 PMCID: PMC5065677 DOI: 10.5312/wjo.v7.i10.695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/25/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] Open
Abstract
Although laminar screw fixation is often used at the C2 and C7 levels, only few previous case reports have presented the use of laminar screws at the C3-C6 levels. Here, we report a novel fixation method involving the use of practical laminar screws in the subaxial spine. We used laminar screws in the subaxial cervical spine in two cases to prevent vertebral artery injury and in one case to minimize exposure of the lamina. This laminar screw technique was successful in all three cases with adequate spinal rigidity, which was achieved without complications. The use of laminar screws in the subaxial cervical spine is a useful option for posterior fusion of the cervical spine.
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Sivaraju L, Mani S, Prabhu K, Daniel RT, Chacko AG. Three-dimensional computed tomography angiographic study of the vertebral artery in patients with congenital craniovertebral junction anomalies. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:1028-1038. [DOI: 10.1007/s00586-016-4580-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 11/30/2022]
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Jang HJ, Oh SY, Shim YS, Yoon SH. Endovascular treatment of symptomatic high-flow vertebral arteriovenous fistula as a complication after c1 screw insertion. J Korean Neurosurg Soc 2014; 56:348-52. [PMID: 25371787 PMCID: PMC4219195 DOI: 10.3340/jkns.2014.56.4.348] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 09/25/2014] [Accepted: 10/14/2014] [Indexed: 12/05/2022] Open
Abstract
High-flow vertebral arteriovenous fistulas (VAVF) are rare complications of cervical spine surgery and characterized by iatrogenic direct-communication of the extracranial vertebral artery (VA) to the surrounding venous plexuses. The authors describe two patients with VAVF presenting with ischemic presentation after C1 pedicle screw insertion for a treatment of C2 fracture and nontraumatic atlatoaxial subluxation. The first patient presented with drowsy consciousness with blurred vision. The diffusion MRI showed an acute infarction on bilateral cerebellum and occipital lobes. The second patient presented with pulsatile tinnitus, dysarthria and a subjective weakness and numbness of extremities. In both cases, digital subtraction angiography demonstrated high-flow direct VAVFs adjacent to C1 screws. The VAVF of the second case occurred near the left posterior inferior cerebellar artery originated from the persistent first intersegmental artery of the left VA. Both cases were successfully treated by complete occlusion of the fistulous portion and the involved segment of the left VA using endovascular coil embolization. The authors reviewed the VAVFs after the upper-cervical spine surgery including C1 screw insertion and the feasibility with the attention notes of its endovascular treatment.
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Affiliation(s)
- Hyun Jun Jang
- Department of Neurosurgery, Inha University School of Medicine and Hospital, Incheon, Korea
| | - Se-Yang Oh
- Department of Neurosurgery, Inha University School of Medicine and Hospital, Incheon, Korea
| | - Yu Shik Shim
- Department of Neurosurgery, Inha University School of Medicine and Hospital, Incheon, Korea
| | - Seung Hwan Yoon
- Department of Neurosurgery, Inha University School of Medicine and Hospital, Incheon, Korea
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Affiliation(s)
- Masashi Neo
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
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Abstract
STUDY DESIGN Anatomical measurements and in vitro biomechanical testing were performed to evaluate a new method for posterior C1 fixation. OBJECTIVE This study sought to assess C1 posterior arch crossing screw fixation for posterior C1-C2 fixation, using anatomical measurements and biomechanical testing with traditional C1 pedicle screws (PS) in a cadaveric model. SUMMARY OF BACKGROUND DATA Atlantoaxial instability often requires surgery, and the current methods for atlas fixation incur some risk to the vascular and neurological tissues. Thus, new, effective, and safe methods are needed for salvage operations. METHODS Morphometric analysis of the C1 posterior arch was performed using 3-dimensional computed tomography. Six fresh ligamentous human cervical spines (C0-C4) were evaluated for their biomechanics. The specimens were tested in their intact condition and after stabilization (C1-C2 PS, C1 posterior arch screws [PAS] with C2 PS) and injury due to 1.5 N·m of pure moment in flexion, extension, lateral bending, and axial rotation. During testing, 3-dimensional angular motion was measured with a motion capture platform (Vicon Nexus). Data for all scenarios were recorded, and statistical analysis was performed. RESULTS Anatomical assessment indicated that 91.51% of C1 posterior tubercles exceeded 7 mm in thickness, 93.40% had a width of the posterior arch of greater than 3.5 mm, and 65.57% had a unilateral screw length of greater than 15 mm, indicating that the posterior arch fixation could be achieved by two 3.5 × 15-mm screws placed in a crossed manner. Twenty-two cases (11%) were not suitable for crossing screw placement because the posterior arch was flat and the entry point was present on the same side. Biomechanical testing showed that the PS and PAS rod-screw systems significantly reduced flexibility in flexion, extension, and rotation compared with the intact position. For lateral bending, there was a trend for the C1 PS and PAS systems toward decreased flexibility in comparison with the intact position. At the same time, C1 PAS decreased C1-C2 movement by 33.0% in left bending (P = 0.171) and 24.4% in right bending (P = 0.095); however, no significant difference was observed for left bending with C1 PAS compared with C1 PS, and the C1 PS and PAS systems significantly reduced the flexibility more than destabilization. CONCLUSION Crossing screw fixation of the C1 posterior arch is straightforward and imposes little risk of injury to the neural and vascular structures as long as the implants remain intraosseous. According to the results of our anatomical and biomechanical study, C1 posterior arch crossing screw fixation may constitute an alternative method for posterior atlantoaxial fixation. LEVEL OF EVIDENCE 3.
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Yoon KW, Ko JH, Cho CS, Lee SK, Kim YJ, Kim YJ. Endovascular treatment of vertebral artery injury during cervical posterior fusion (C1 lateral mass screw). A case report. Interv Neuroradiol 2013; 19:370-6. [PMID: 24070088 DOI: 10.1177/159101991301900316] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 04/14/2013] [Indexed: 11/17/2022] Open
Abstract
We describe two cases of vertebral artery injury during posterior cervical fusion. We treated both cases by an endovascular technique. The vertebral artery injury may result in catastrophic situations, such as, infarction, massive blood loss and even death. Our clinical outcome was good and we prove that endovascular treatment is an effective and less invasive way to treat vertebral artery injury.
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Affiliation(s)
- Kyeong-Wook Yoon
- Department of Neurosurgery, Dankook University College of Medicine; Cheonan, Chungnam, South Korea - E-mail:
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Ahmed R, Menezes AH. Management of operative complications related to occipitocervical instrumentation. Neurosurgery 2013; 72:ons214-28; discussion ons228. [PMID: 23313976 DOI: 10.1227/neu.0b013e31827bf512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The continued evolution of instrumentation techniques for fusions at the craniovertebral junction has enabled surgical treatment of a wide range of developmental, neoplastic, traumatic, and degenerative conditions. There has been an increased recognition of the morbidity associated with the complications secondary to occipitocervical instrumentation. OBJECTIVE To present representative complications secondary to occipitocervical instrumentation in patients who presented to our institution and to emphasize underlying principles in diagnosis and management of craniovertebral disease conditions through illustrative examples of their presentation, management, and follow-up. METHODS Clinical records for patients referred to the senior author (A.H.M.) between 2005 and 2010 for evaluation and management of their symptoms arising as a consequence of surgical intervention by a different primary neurosurgeon were reviewed. RESULTS Eight patients were identified with representative complications secondary to occipitocervical instrumentation. These complications included incorrect surgical technique, persistent instability, hardware misplacement with potential for vascular injury, associated neural injury, and secondary complications of wound healing resulting from methyl methacrylate use. Surgical revision was required in 2 patients. The remaining patients improved with removal of the offending hardware and acrylic cement. All patients reported symptom resolution, and dynamic imaging studies on follow-up indicated stable alignment and bony fusion. CONCLUSION These cases serve as illustrative examples of the spectrum of neural, vascular, biomechanical, and instrument-related complications associated with occipitocervical arthrodesis. Basic principles of occipitocervical instrumentation that enable safe and successful treatment of craniovertebral junction disease conditions have been highlighted. Potential complications and management strategies are discussed.
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Affiliation(s)
- Raheel Ahmed
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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Development of a new technique for pedicle screw and Magerl screw insertion using a 3-dimensional image guide. Spine (Phila Pa 1976) 2012; 37:1983-8. [PMID: 22531473 DOI: 10.1097/brs.0b013e31825ab547] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN We developed a new technique for cervical pedicle screw and Magerl screw insertion using a 3-dimensional image guide. OBJECTIVE In posterior cervical spinal fusion surgery, instrumentation with screws is virtually routine. However, malpositioning of screws is not rare. To avoid complications during cervical pedicle screw and Magerl screw insertion, the authors developed a new technique which is a mold shaped to fit the lamina. SUMMARY OF BACKGROUND DATA Cervical pedicle screw fixation and Magerl screw fixation provide good correction of cervical alignment, rigid fixation, and a high fusion rate. However, malpositioning of screws is not a rare occurrence, and thus the insertion of screws has a potential risk of neurovascular injury. It is necessary to determine a safe insertion procedure for these screws. METHODS Preoperative computed tomographic (CT) scans of 1-mm slice thickness were obtained of the whole surgical area. The CT data were imported into a computer navigation system. We developed a 3-dimensional full-scale model of the patient's spine using a rapid prototyping technique from the CT data. Molds of the left and right sides at each vertebra were also constructed. One hole (2.0 mm in diameter and 2.0 cm in length) was made in each mold for the insertion of a screw guide. We performed a simulated surgery using the bone model and the mold before operation in all patients. The mold was firmly attached to the surface of the lamina and the guide wire was inserted using the intraoperative image of lateral vertebra. The proper insertion point, direction, and length of the guide were also confirmed both with the model bone and the image intensifier in the operative field. Then, drilling using a cannulated drill and tapping using a cannulated tapping device were carried out. Eleven consecutive patients who underwent posterior spinal fusion surgery using this technique since 2009 are included. The screw positions in the sagittal and axial planes were evaluated by postoperative CT scan to check for malpositioning. RESULTS The screw insertion was done in the same manner as the simulated surgery. With the aid of this guide the pedicle screws and Magerl screws could be easily inserted even at the level where the pedicle seemed to be very thin and sclerotic on the CT scan. Postoperative CT scan showed that there were no critical breaches of the screws. CONCLUSION This method employing the device using a 3-dimensional image guide seems to be easy and safe to use. The technique may improve the safety of pedicle screw and Magerl screw insertion even in difficult cases with narrow sclerotic pedicles.
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Anomalous vertebral arteries in the extra- and intraosseous regions of the craniovertebral junction visualized by 3-dimensional computed tomographic angiography: analysis of 100 consecutive surgical cases and review of the literature. Spine (Phila Pa 1976) 2012; 37:E1389-97. [PMID: 22825480 DOI: 10.1097/brs.0b013e31826a0c9f] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Consecutive case series and literature review. OBJECTIVE To describe the utility of 3-dimensional computed tomographic angiography (3D CTA) for evaluating vertebral artery (VA) anomalies before surgery. SUMMARY OF BACKGROUND DATA Recent advances in instrumentation surgery at the craniovertebral junction (CVJ) enable us to perform rigid internal fixation. However, the risk of VA injury as a complication of the surgery has become a major problem. Thus, the importance of preoperative evaluation of the VA course has been emphasized. METHODS Cases of 100 consecutive patients who underwent CVJ instrumentation surgery since July 1998 were analyzed. Occipitocervical/thoracic or C1-C2 posterior fusion was performed for atlantoaxial subluxation (AAS) in 59 patients and cervical fixation including C2 was required for middle-to-lower cervical lesions in 41 patients. Twenty-seven patients with AAS had a congenital skeletal anomaly (CSA) at the CVJ including os odontoideum and occipitalization of C1 (AAS-CSA[+] group). Anomalous VAs at the extra- and intraosseous regions were evaluated by 3D CTA. RESULTS No neurovascular injury occurred during surgery. Abnormal courses of the VA at the extraosseous region were detected in 10 cases: 2 had fenestration and 8 had a persistent first intersegmental artery. All 10 cases were in the AAS-CSA(+) group. A high-riding VA was detected in 31 cases. Fourteen out of the 31 cases were in the AAS-CSA(+) group, indicating 51.9% of the AAS-CSA(+) group had high-riding VA. In the AAS-CSA(+) group, a C1-C2 transarticular screw and C2 pedicle screw were actually inserted in 58% and 31% of the planned insertions, respectively. CONCLUSION The present findings suggest that the frequency of an abnormal VA at the extra- and intraosseous regions is increased when patients have AAS and CSA at the CVJ. Using preoperative 3D CTA, we can precisely identify anomalous VAs and thereby reduce the risk of their intraoperative injury.
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Posterior C1-2 fusion with C1 lateral mass and C2 isthmic screws: accuracy of screw position, alignment and patient outcome. Acta Neurochir (Wien) 2012; 154:305-12. [PMID: 22200812 DOI: 10.1007/s00701-011-1224-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 11/01/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Transarticular screw fixation is seen as the "gold standard" in instrumented fusion of C1 and C2. However, drawbacks are the necessity of a reduction before instrumentation and a risk of vertebral artery injury. Therefore, C1 lateral mass and C2 isthmic screws are an alternative. The present study assessed the feasibility of C1-2 stabilization with C1 lateral mass and C2 isthmic screws and evaluated quality of life. METHOD All data of 35 consecutive patients treated from May 2006 to September 2009 were collected. Patients had C1 lateral mass and C2 isthmic screws. RESULTS Twenty patients were operated on for traumatic instabilities, six for neoplastic instabilities, five for infectious instabilities and two each for degenerative and congenital instabilities. Sixty-six of 70 C1 screws had an ideal position, while four were placed suboptimal without the need for revision. Twelve of 68 C2 screws were not ideal but acceptable; one screw needed a surgical revision. There was one non-surgery related case of neurological deterioration after multilevel instrumentation. No vascular injuries occurred. Realignment was correct in all patients. After a median follow-up of 12 months, patients showed a reduction of pain, disability and improvements in EQ-5D items. SF36 data compared with a normative population and a historical cohort showed lower levels of function in all domains. CONCLUSION C1-C2 instrumented fusion with lateral mass and isthmic screws is a safe procedure. Sufficient screw position and alignment was possible in all cases. Therefore, at our institution transarticular screws were abandoned in favor of C1 lateral mass and C2 isthmic screws.
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18
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Abstract
The atlantoaxial motion segment, which is responsible for half of the rotational motion in the cervical spine, is a complex junction of the first (C1) and second (C2) cervical vertebrae. Destabilization of this joint is multifactorial and can lead to pathologic motion with neurologic sequelae. Posterior spinal fixation of the C1-C2 articulation in the presence of instability has been well described in the literature. Early reports of interspinous/interlaminar wiring have evolved into modern-day pedicle screw/translaminar constructs, with excellent results. The success of a C1-C2 posterior fusion rests on appropriate indications and surgical techniques.
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Drazin D, Jeswani S, Shirzadi A, Choulakian A, Alexander MJ, Palestrant D, Schievink W. Anterior Spinal Artery Syndrome in a Patient with Vasospasm Secondary to a Ruptured Cervical Dural Arteriovenous Fistula. J Neuroimaging 2011; 24:88-91. [DOI: 10.1111/j.1552-6569.2011.00684.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/18/2011] [Accepted: 11/08/2011] [Indexed: 12/20/2022] Open
Affiliation(s)
- Doniel Drazin
- Department of Neurosurgery; Cedars-Sinai Medical Center; Los Angeles CA
| | - Sunil Jeswani
- Department of Neurosurgery; Cedars-Sinai Medical Center; Los Angeles CA
| | - Ali Shirzadi
- Department of Neurosurgery; Cedars-Sinai Medical Center; Los Angeles CA
| | - Armen Choulakian
- Department of Neurosurgery; Cedars-Sinai Medical Center; Los Angeles CA
| | | | - David Palestrant
- Department of Neurosurgery; Cedars-Sinai Medical Center; Los Angeles CA
| | - Wouter Schievink
- Department of Neurosurgery; Cedars-Sinai Medical Center; Los Angeles CA
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Hamilton DK, Smith JS, Sansur CA, Dumont AS, Shaffrey CI. C-2 neurectomy during atlantoaxial instrumented fusion in the elderly: patient satisfaction and surgical outcome. J Neurosurg Spine 2011; 15:3-8. [PMID: 21456890 DOI: 10.3171/2011.1.spine10417] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The originally described technique of atlantoaxial stabilization using C-1 lateral mass and C-2 pars screws includes a C-2 neurectomy to provide adequate hemostasis and visualization for screw placement, enable adequate joint decortication and arthrodesis, and prevent new-onset postoperative C-2 neuralgia. However, inclusion of a C-2 neurectomy for this procedure remains controversial, likely due in part to a lack of studies that have specifically addressed whether it affects patient outcome. The authors' objective was to assess the surgical and clinical impact of routine C-2 neurectomy performed with C1–2 segmental instrumented arthrodesis in a consecutive series of elderly patients with C1–2 instability.
Methods
Forty-four consecutive patients (mean age 71 years) underwent C1–2 instrumented fusion, including C-1 lateral mass screw insertion. Bilateral C-2 neurectomies were performed. Standardized clinical assessments were performed both pre- and postoperatively. Numbness or discomfort in a C-2 distribution was documented at follow-up. Fusion was assessed using the Lenke fusion grade.
Results
Among all 44 patients, mean blood loss was 200 ml (range 100–350 ml) and mean operative time was 129 minutes (range 87–240 minutes). There were no intraoperative complications, and no patients reported new postoperative onset or worsening of C-2 neuralgia postoperatively. Outcomes for the 30 patients with a minimum 13-month follow-up (range 13–72 months) were assessed. At a mean follow-up of 36 months, Nurick grade and pain numeric rating scale scores improved from 3.7 to 1.0 (p < 0.001) and 9.4 to 0.6 (p < 0.001), respectively. The mean postoperative Neck Disability Index score was 7.3%. The fusion rate was 97%, and the patient satisfaction rate was 93%. All 24 patients with preoperative occipital neuralgia reported relief. Seventeen patients noticed C-2 distribution numbness only during examination in the clinic, and 2 patients reported C-2 numbness, but it did not affect their daily function.
Conclusions
In this series of C1–2 instrumented arthrodesis in elderly patients, excellent fusion rates were achieved, and patient satisfaction was not negatively affected by C-2 neurectomy. In the authors' experience, C-2 neurectomy enhanced surgical exposure of the C1–2 joint, thereby facilitating hemostasis, placement of instrumentation, and decortication of the joint space for arthrodesis. Importantly, with C-2 neurectomy in the present series, no cases of new onset postoperative C-2 neuralgia occurred, in contrast to a growing number of reports in the literature documenting new-onset C-2 neuralgia without C-2 neurectomy. On the contrary, 80% of patients in the present series had preoperative occipital neuralgia and in all of these patients this neuralgia was relieved following C1–2 instrumented arthrodesis with C-2 neurectomy.
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Affiliation(s)
- D. Kojo Hamilton
- 1Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Justin S. Smith
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Charles A. Sansur
- 1Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Aaron S. Dumont
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher I. Shaffrey
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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Savage JW, Limthongkul W, Park HS, Zhang LQ, Karaikovic EE. A comparison of biomechanical stability and pullout strength of two C1-C2 fixation constructs. Spine J 2011; 11:654-8. [PMID: 21640660 DOI: 10.1016/j.spinee.2011.04.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 03/09/2011] [Accepted: 04/22/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Several fusion techniques are used to treat atlantoaxial instability. Recent literature suggests that intralaminar screw (LS) fixation and pedicle screw (PS) fixation offer similar stability and comparable pullout strength. No studies have compared these characteristics after cyclic loading. PURPOSE To compare the stability and pullout strength of intra-LSs and PSs in a C1-C2 instability model after 1,000 cycles of axial loading. STUDY DESIGN In vitro biomechanical study. OUTCOME MEASURES Stability in axial rotation and screw pullout strength after cyclic loading. METHODS Six fresh-frozen human cadaveric cervical spines (C1-C2) were used in this study. C1-C2 instability was mimicked via odontoidotomy at its base and posterior soft-tissue release, including the supraspinous ligaments and facet joint capsules. Specimens were tested to 1,000 cycles after stabilization with two fixation constructs: C1 lateral mass (LM) screws and C2 intra-LSs (C1LM-C2LS) and C1 LM screws and C2 PSs (C1LM-C2PS). Angular motion was recorded for right and left axial rotation using an Optotrak 3020 system (Northern Digital, Waterloo, Ontario, Canada). Tensile loading to failure was then performed collinear to the longitudinal axis of the screw, and the data were recorded as peak pullout strength in newtons. RESULTS There was no statistically significant difference in stability (measured in degrees of rotation) between the intra-LS and PS constructs at 250, 500, 750, and 1,000 cycles of axial rotation. Furthermore, there was no significant difference in stability at 250 cycles versus 1,000 cycles for the LS (1.30 vs. 1.49, p = .80) or PS (0.84 vs. 0.85, p = .96). Pedicle screws had higher pullout strength when compared with the intra-LSs (757.5 ± 239 vs. 583.4 ± 472 N); however, high standard deviation precluded statistical significance (p = .44). CONCLUSIONS Our data suggest that a C1LM and C2LS construct has similar biomechanical stability when compared with a C1LM and C2PS construct after 1,000 cycles of axial rotation. Furthermore, PSs had higher pullout strength when compared with LSs; however, this result was not statistically significant.
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Affiliation(s)
- Jason W Savage
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL 60611, USA.
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Abstract
STUDY DESIGN Anatomic study. OBJECTIVE To measure C1 and C2 critical areas related to the screws trajectory, according to Harms technique, in Latin specimens. To investigate vertebral's artery course in cadavers. SUMMARY OF BACKGROUND DATA To our knowledge there are no studies addressing vertebral surface measurements for screw placement, according to Harms C1-C2 instrumentation technique, nor cadaveric measurements of the trajectory of the vertebral artery in Latin specimens. METHODS C1 and C2 specimens were measured. C1 measurements: height, width, anteroposterior diameter (intraosseus screw length) and convergence in the axial plane of the lateral mass; length from the posterior border of the posterior C1 arch to the anterior cortex of the articular mass (total screw length). C2 measurements: width, height, convergence and sagittal inclination of the pars interarticularis. Direction of the trajectory of the vertebral artery in the suboccipital region in fresh cadavers. RESULTS C1: left mass width 14.20 mm, right: 14.32 mm; left intraosseus screw length: 17.17 mm, right 16.9 mm; left total length of the screw: 27.14 mm, right: 26.72 mm; left mass height: 10.22 mm, right: 10.29 mm. Right mass convergence: 24.68°, left: 22.44°. C2: width: left 8.75 mm, right: 8.53 mm; height: left 10 mm, right 9.81 mm; convergence: left 42.15°, right: 38.98°; sagittal inclination: left 35.50°, right 33.07°. Vertebral artery's medial border is between 13 and 22 mm from the middle line of C1 posterior arch. CONCLUSION Convergence and inclination of the pars are slightly greater than the suggested by Harms. Individual and/or racial variations must be considered. There is enough space for safe placement of a 3.5 mm screw in the lateral masses of C1 and through the pars of C2. Dissecting the superior face of the posterior arch of C1 laterally more than 10 mm from the posterior tubercule could injure the vertebral artery.
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Tubbs RS, Verma K, Riech S, Mortazavi MM, Shoja MM, Loukas M, Curé JK, Zurada A, Cohen-Gadol AA. Persistent fetal intracranial arteries: a comprehensive review of anatomical and clinical significance. J Neurosurg 2011; 114:1127-34. [PMID: 21235309 DOI: 10.3171/2010.11.jns101527] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As fetal intracranial vessels may persist into adulthood, knowledge of their anatomy and potential clinical and surgical complications should be borne in mind by the surgeon. A comprehensive review of these vessels, however, is not easily identified in the literature. Therefore, the present analysis was undertaken so that such information is available to the clinician and morphologist.
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Affiliation(s)
- R Shane Tubbs
- Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama 35233, USA.
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Lalanne LB, OcampoII GA. Artrodesis C1C2 con tornillos transarticulares en artritis reumatoidea: experiencia y revisión de la literatura. COLUNA/COLUMNA 2011. [DOI: 10.1590/s1808-18512011000400007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Describir los resultados clínicos e imagenológicos utilizando la técnica de fijación C1 C2 con tornillos transarticulares y asas de alambre en pacientes portadores de AR en un seguimiento a largo plazo y revisar la literatura actual. MÉTODO: Entre los años 2002 y 2006, 11 pacientes (9 mujeres y 2 hombres) con inestabilidad C1 C2 secundaria a AR fueron intervenidos quirúrgicamente. Se realizó fijación C1 C2 con tornillos transarticulares por vía posterior más asas de alambre y aplicación de injerto óseo autólogo de cresta ilíaca. Se registró Índice de Ranawat pre y posoperatorio, Distancia Anterior Atlas Odontoides (DAAO) pre y posoperatorio, tiempo operatorio, días de hospitalización, complicaciones intra y posoperatorias y tiempo de consolidación radiológica, con un seguimiento promedio de 34 meses. RESULTADOS: Todos los pacientes presentaron mejoría del Índice de Ranawat en el postoperatorio. La DAAO preoperatoria promedio fue de 11,9 mm (DS ± 2,57), rango 7 a 16, y la DAAO postoperatoria promedio fue de 3 mm (DS ± 1,20), rango 2 a 6. El tiempo quirúrgico fue de 94 minutos en promedio y el promedio de días de hospitalización fue de 7 días. No se presentaron complicaciones intraoperatorias. Un caso presentó seroma de herida operatoria que requirió tratamiento quirúrgico. El tiempo de consolidación fue en promedio 14 semanas. CONCLUSIÓN: La artrodesis atlantoaxial con tornillos y amarras es una buena alternativa para el manejo de la inestabilidad C1-C2 en pacientes portadores de AR, consiguiendo buenos resultados clínicos e imagenológicos en un seguimiento a largo plazo.
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Bahadur R, Goyal T, Dhatt SS, Tripathy SK. Transarticular screw fixation for atlantoaxial instability - modified Magerl's technique in 38 patients. J Orthop Surg Res 2010; 5:87. [PMID: 21092173 PMCID: PMC2995783 DOI: 10.1186/1749-799x-5-87] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Accepted: 11/22/2010] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Symptomatic atlantoaxial instability needs stabilization of the atlantoaxial joint. Among the various techniques described in literature for the fixation of atlantoaxial joint, Magerl's technique of transarticular screw fixation remains the gold standard. Traditionally this technique combines placement of transarticular screws and posterior wiring construct. The aim of this study is to evaluate clinical and radiological outcomes in subjects of atlantoaxial instability who were operated using transarticular screws and iliac crest bone graft, without the use of sublaminar wiring (a modification of Magerl's technique). METHODS We evaluated retrospectively 38 subjects with atlantoaxial instability who were operated at our institute using transarticular screw fixation. The subjects were followed up for pain, fusion rates, neurological status and radiographic outcomes. Final outcome was graded both subjectively and objectively, using the scoring system given by Grob et al. RESULTS Instability in 34 subjects was secondary to trauma, in 3 due to rheumatoid arthritis and 1 had tuberculosis. Neurological deficit was present in 17 subjects. Most common presenting symptom was neck pain, present in 35 of the 38 subjects.Postoperatively residual neck and occipital pain was present in 8 subjects. Neurological deficit persisted in only 7 subjects. Vertebral artery injury was seen in 3 subjects. None of these subjects had any sign of neurological deficit or vertebral insufficiency. Three cases had nonunion. At the latest follow up, subjectively, 24 subjects had good result, 6 had fair and 8 had bad result. On objective grading, 24 had good result, 11 had fair and 3 had bad result. The mean follow up duration was 41 months. CONCLUSIONS Transarticular screw fixation is an excellent technique for fusion of the atlantoaxial complex. It provides highest fusion rates, and is particularly important in subjects at risk for nonunion. Omitting the posterior wiring construct that has been used along with the bone graft in the traditional Magerl' s technique achieves equally good fusion rates and is an important modification, thereby avoiding the complications of sublaminar wire passage.
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Affiliation(s)
- Raj Bahadur
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Government Medical College and Hospital, Chandigarh, India
| | - Tarun Goyal
- Dept of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Saravdeep S Dhatt
- Dept of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sujit K Tripathy
- Dept of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Ulm AJ, Quiroga M, Russo A, Russo VM, Graziano F, Velasquez A, Albanese E. Normal anatomical variations of the V₃ segment of the vertebral artery: surgical implications. J Neurosurg Spine 2010; 13:451-60. [PMID: 20887142 DOI: 10.3171/2010.4.spine09824] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors undertook this cadaveric and angiographic study to examine the microsurgical anatomy of the V₃ segment of the vertebral artery (VA) and its relationship to osseous landmarks. A detailed knowledge of these variations is important when performing common neurosurgical procedures such as the suboccipital craniotomy and the far-lateral approach and when placing atlantoaxial instrumentation. METHODS A total of 30 adult cadaveric specimens (59 sides) were studied using magnification × 3 to × 40 after perfusion of the arteries and veins with colored silicone. Seventy-three vertebral angiograms were also analyzed. The morphological detail of the V₃ segment was described and measured in both the cadavers and angiograms. Transarticular screws were placed into 2 cadavers and the relationship of the trajectory to the V₃ segment was analyzed. RESULTS The authors identified 4 sites along the V₃ segment that are anatomically the most likely to be injured during surgical approaches to the craniovertebral junction. In 35% of the cadaveric specimens the vertical portion of V₃ formed a posteriorly oriented loop that could be injured during surgical exposures of the dorsal surface of C-2. The mean distance from the midline to the most posteromedial edge of the loop was 25.6 ± 3.5 mm (range 20-35 mm) on the left side and 30.4 ± 3.8 mm (range 23-36 mm) on the right side. On lateral angiograms, this loop projected posteriorly, with a mean distance of 9.8 ± 3.5 mm (range 0-15.7 mm) on the right side and 11.7 ± 1.2 mm (range 10-13.6 mm) on the left side. The horizontal segment of V₃ can be injured when exposing the lower lateral occipital bone and when the C-1 arch is exposed. The mean distance from the inferior border of the occipital bone to the superior surface of the horizontal segment of V₃ was 6 ± 2.8 mm on the right side and 5.6 ± 2.3 mm on the left. In 12% of cases the authors found no space between the horizontal portion of V₃ and the occipital bone. The medial edge of the horizontal segment of V₃ was located 23 ± 5.5 mm (range 10-30 mm) from the midline on the right side and 24 ± 5.7 mm (range 15-32 mm) on the left side. The transition between the V₂-V₃ segments after exiting the C-2 vertebral foramen is the most likely site of injury when placing C1-2 transarticular screws or C-2 pars screws. CONCLUSIONS The normal variation of the V₃ segment of the VA has been described with quantitative measurements. An awareness of the anatomical variations and the relationships to the surrounding bony anatomy will aid in reducing VA injury during suboccipital approaches, exposure of the dorsal surfaces of C-1 and C-2, and when placing atlantoaxial spinal instrumentation.
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Affiliation(s)
- Arthur J Ulm
- Louisiana State University, School of Medicine, Louisiana State University Department of Neurosurgery, Health Sciences Center, 2020 Gravier Street, 336A, New Orleans, Louisiana 70112, USA.
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Study of the anatomical variations of vertebral artery in C2 vertebra with magnetic resonance imaging and its application in the C1-C2 transarticular screw fixation. Spine (Phila Pa 1976) 2010; 35:1136-43. [PMID: 20118834 DOI: 10.1097/brs.0b013e3181bb4f21] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Use of magnetic resonance imaging (MRI) with Constructive Interference in Steady State (CISS) sequence and isometric voxels to demonstrate the anatomic variations of vertebral artery in C2 vertebra. OBJECTIVES To determine the transarticular screw trajectory on CISS MRI and to identify patients with anatomic variations of vertebral artery in C2 vertebra. SUMMARY OF BACKGROUND DATA Atlantoaxial transarticular screw fixation has been reported to be biomechanically superior to other posterior techniques for atlantoaxial arthrodesis. Vertebral artery injury can be associated with catastrophic sequelae. Anatomic variation of vertebral artery is well recognized and computed tomography scan is the traditional preoperative assessment. However, no report has evaluated the use of MRI in preoperative assessment for the screw trajectories and the anatomic variation of vertebral artery. METHODS The 3-dimensional (3D) CISS MRI with isometric voxels was performed in 30 local Chinese patients. The 3D reconstruction images were created to determine the proposed screw trajectories and their relationship with the vertebral arteries. RESULTS In 12 patients (40%), the vertebral arteries were lying within the screw trajectories prohibiting transarticular screw fixation on at least one side. Bilateral variations with high risk of vertebral artery injuries were found in 6 patients. The remaining 6 patients had unilateral variations prohibiting the insertion of transarticular screws on one side. CONCLUSION The 3D CISS MRI with isometric voxels is a safe and simple imaging technique to outline the vertebral arteries in C2. Reconstruction images are easily created and undistorted. It is one of the useful imaging in preoperative planning of transarticular screw fixation and determination of anatomy of vertebral artery.
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Abstract
Abstract
BACKGROUND
Transarticular screw (TAS) fixation is our preferred method for stable internal fixation of the atlantoaxial joint because of its excellent outcomes, versatility, and cost-effectiveness.
OBJECTIVE
In this article, we update our series of patients who have undergone TAS fixation, with attention to surgical technique, planning, complication avoidance, and anatomic suitability.
METHODS
We retrospectively reviewed 269 patients (150 women, 119 men; average age, 52.9 years; age range, 17–90 years) who underwent placement of at least 1 TAS. In total, 491 TASs were placed for stabilization necessitated by various pathologic conditions. The mean follow-up period was 15.7 months (range, 0–106 months).
RESULTS
Fusion was achieved in 99% of 198 patients monitored until fusion or nonunion requiring revision, or for 2 years. Forty-five patients had a complication, for a rate of 16.7%. Five early patients had vertebral artery injuries, 1 of which was bilateral and fatal. No recent patients had vertebral artery injuries. Other complications did not result in neurologic morbidity. Review of all atlantoaxial fusions by the senior author (R.I.A.) revealed that the TAS fixation technique could be successfully applied in 86.7% of sides considered. The main reasons for inapplicability were anatomic (recognized on preoperative planning) in 77% and abandonment secondary to concern about possible vertebral artery injury on the first side attempted in 13.8%.
CONCLUSION
The placement of TASs is safe and effective for stabilizing the atlantoaxial articulation. Refinements in technique, such as 3-dimensional stereotactic workstation for trajectory planning, have reduced the rate of serious complications. Clinical outcomes are excellent, with nearly 100% of patients achieving stable bony union.
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Affiliation(s)
- Michael A. Finn
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Abstract
STUDY DESIGN Case report and clinical discussion. OBJECTIVE We report a rare case of delayed onset of cerebral infarction caused by an embolism after cervical pedicle screw (CPS) fixation. SUMMARY OF BACKGROUND DATA CPS has a risk of vertebral artery (VA) injury. CPSs sometimes breach the transverse foramen without rupture of the VA. Most breaches are not considered harmful. METHODS We present a case in a 71-year-old man who underwent an operation for CPS fixation and laminoplasty for cervical spondylomyelopathy. He presented symptoms of hemiparesis 3 days after the operation. The left C4 pedicle screw was proven to breach the transverse foramen. An angiogram showed a thrombus cranial to the screw. RESULTS The patient underwent anticoagulation therapy without removal of screw. After 2 weeks, the thrombus had disappeared. Subsequently, the pedicle screws were removed. At final follow-up, the patient complained of a grade 4/5 hemiparesis, facial nerve palsy, and hearing loss in his left ear. CONCLUSION To our knowledge, this is the first case report of delayed onset of cerebral infarction caused by an embolism after CPS fixation. When a CPS perforates the transverse foramen, even if no apparent VA injury occurs during the operation, the surgeon must take care not to risk cerebral infarction because of an embolism.
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30
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Wait SD, Ponce FA, Colle KO, Parry PV, Sonntag VK. IMPORTANCE OF THE C1 ANTERIOR TUBERCLE DEPTH AND LATERAL MASS GEOMETRY WHEN PLACING C1 LATERAL MASS SCREWS. Neurosurgery 2009; 65:952-6; discussion 956-7. [DOI: 10.1227/01.neu.0000350156.20774.ac] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Prieto R, Pascual JM, Gutiérrez R, Santos E. Recovery from paraplegia after the treatment of spinal dural arteriovenous fistula: case report and review of the literature. Acta Neurochir (Wien) 2009; 151:1385-97. [PMID: 19618103 DOI: 10.1007/s00701-009-0439-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 06/11/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND Spinal dural arteriovenous fistula (SDAVF) is a rare and enigmatic disease. Functional outcome is particularly uncertain for the small group of patients that are unable to stand at the time of diagnosis (grade 5 gait disturbance on the Aminoff-Logue scale, ALS). The objective of this study is to examine the final functional outcome of patients with SDAVF in grade 5 gait ALS before treatment. METHODS We conducted a PubMed search using the keyword "spinal dural arteriovenous fistula." A review of the clinical series and single well-detailed case reports of SDAVF gathered 106 patients with grade 5 gait ALS on the initial examination. Additionally, we report the case of a 56-year-old man presenting acute paraplegia and urinary retention on admission who had complained of sporadic motor and sphincter disturbances for 1 year. Spine T2-weighted MR imaging showed a central hyperintensity within the spinal cord, and the angiography demonstrated a T-11 SDAVF. Interruption of the fistula was performed through an urgent one-level laminectomy. RESULTS Grade 5 gait ALS was present in 25% of the patients with SDAVF included in the clinical series. Latest follow-up showed that gait disturbance improved in 73% of patients after treatment, although less than 6% became grade 1 gait ALS. Micturition disturbances improved in 39%. Exploration of our patient showed improvement to grade 1 gait ALS 1 year after the surgical treatment. CONCLUSION Interruption of SDAVF in paraplegic patients may improve the final functional gait outcome in some cases. No complete recovery (grade 0 gait ALS) was achieved after treatment. Micturition disturbances had a worse prognosis than motor deficits.
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Affiliation(s)
- Ruth Prieto
- Department of Neurosurgery, Clinico San Carlos University Hospital, 28040 Madrid, Spain.
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Higashino K, Sairyo K, Katoh S, Nakano S, Enishi T, Yasui N. The effect of rheumatoid arthritis on the anatomy of the female cervical spine. ACTA ACUST UNITED AC 2009; 91:1058-63. [DOI: 10.1302/0301-620x.91b8.22300] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The effect of rheumatoid arthritis on the anatomy of the cervical spine has not been clearly documented. We studied 129 female patients, 90 with rheumatoid arthritis and 39 with other pathologies (the control group). There were 21 patients in the control group with a diagnosis of cervical spondylotic myelopathy, and 18 with ossification of the posterior longitudinal ligament. All had plain lateral radiographs taken of the cervical spine as well as a reconstructed CT scan. The axial diameter of the width of the pedicle, the thickness of the lateral mass, the height of the isthmus and internal height were measured. The transverse diameter of the transverse foramen (d1) and that of the spinal canal (d2) were measured, and the ratio d1/d2 calculated. The width of the pedicles and the thickness of the lateral masses were significantly less in patients with rheumatoid arthritis than in those with other pathologies. The area of the transverse foramina in patients with rheumatoid arthritis was significantly greater than that in the other patients. The ratio of d1 to d2 was not significantly different. A high-riding vertebral artery was noted in 33.9% of the patients with rheumatoid arthritis and in 7.7% of those with other pathologies. This difference was statistically significant. In the rheumatoid group there was a significant correlation between isthmus height and vertical subluxation and between internal height and vertical subluxation.
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Affiliation(s)
- K. Higashino
- Department of Orthopedics, School of Medicine The University of Tokushima, 3-18-15 Kuramoto, Tokushima 770-8503, Japan
| | - K. Sairyo
- Department of Orthopedics, School of Medicine The University of Tokushima, 3-18-15 Kuramoto, Tokushima 770-8503, Japan
| | - S. Katoh
- Department of Orthopedics, School of Medicine The University of Tokushima, 3-18-15 Kuramoto, Tokushima 770-8503, Japan
| | - S. Nakano
- Department of Orthopedics, School of Medicine The University of Tokushima, 3-18-15 Kuramoto, Tokushima 770-8503, Japan
| | - T. Enishi
- Department of Orthopedics, School of Medicine The University of Tokushima, 3-18-15 Kuramoto, Tokushima 770-8503, Japan
| | - N. Yasui
- Department of Orthopedics, School of Medicine The University of Tokushima, 3-18-15 Kuramoto, Tokushima 770-8503, Japan
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A novel computer-assisted drill guide template for placement of C2 laminar screws. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18:1379-85. [PMID: 19517142 DOI: 10.1007/s00586-009-1051-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 04/09/2009] [Accepted: 05/17/2009] [Indexed: 10/20/2022]
Abstract
The present method of C2 laminar screw placement relies on anatomical landmarks for screw placement. Placement of C2 laminar screws using drill template has not been described in the literature. The authors reported on their experience with placement of C2 laminar screws using a novel computer-assisted drill guide template in nine patients undergoing posterior occipito-cervical fusion. CT scan of C2 vertebrae was performed. 3D model of C2 vertebrae was reconstructed by software MIMICS 10.01. The 3D vertebral model was then exported in STL format, and opened in a workstation running software UG imageware12.0 for determining the optimal laminar screw size and orientation. A virtual navigational template was established according to the laminar anatomic trait. The physical vertebrae and navigational template were manufactured using rapid prototyping. The navigational template was sterilized and used intraoperative to assist the placement of laminar screw. Overall, 19 C2 laminar screws were placed and the accuracy of screw placement was confirmed with postoperative X-ray and CT scanning. There were not complications of related screws insertion. Average follow-up was 9 months (range 4-13 months), 77.8% of the patients exhibited improvement in their myelopathic symptoms; in 22.2% the symptoms were unchanged. Postoperative computed tomographic (CT) scanning was available for allowing the evaluation of placement of thirteen C2 laminar screws, all of which were in good position with no spinal canal violation. This study shows a patient-specific template technique that is easy to use, can simplify the surgical act and generates highly accurate C2 laminar screw placement. Advantages of this technology over traditional techniques include planning of the screw trajectory is done completely in the presurgical period as well as the ability to size the screw to the patient's anatomy.
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C1 pedicle screws versus C1 lateral mass screws: comparisons of pullout strengths and biomechanical stabilities. Spine (Phila Pa 1976) 2009; 34:371-7. [PMID: 19214096 DOI: 10.1097/brs.0b013e318193a21b] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN In vitro biomechanical study. OBJECTIVE To compare the pullout strengths and the biomechanical stabilities afforded by C1 lateral mass screws and C1 pedicle screws using bicortical and unicortical fixation techniques. SUMMARY OF BACKGROUND DATA Posterior screw fixation techniques in the atlas including C1 lateral mass screw and C1 pedicle screw. The shortcomings of C1 lateral mass screw technique and potential risks of bicortical fixation method were recently described; C1 pedicle screw technique with unicortical fixation might overcome these anatomic and clinical drawbacks. However, it is unknown whether the biomechanical characteristics of unicortical C1 pedicle screw are comparable with that of bicortical C1 lateral mass screw. METHODS.: Bicortical or unicortical C1 pedicle screws and C1 lateral mass screws were inserted into 12 adult fresh human C1 specimens. Pullout strength was evaluated using a material testing machine. The construct's stability of bicortical C1 lateral mass screws or unicortical C1 pedicle screws incorporating unicortical C2 pedicle screws was compared with bilateral transarticular screws using another 6 fresh cervical cadaver spines. Pullout strength and biomechanical stability differences were compared statistically. RESULTS Bicortical C1 pedicle screws provided the biggest pullout strength (1757.0 +/- 318.7 N) of all 4 methods, whereas unicortical C1 lateral mass screws provided the weakest(794.5 +/- 314.8 N). However, there were no statistically significant differences between bicortical C1 lateral mass screws (1243.8 +/- 350.0 N) and unicortical C1 pedicle screws (1192.5 +/- 172.6 N). Furthermore, there was no statistically significant difference of biomechanical construct stability between unicortical C1 pedicle screw-rod constructs and bicortical C1 lateral mass screw-rod constructs. CONCLUSION C1 pedicle screws are stiffer than C1 lateral mass screws. Unicortical C1 pedicle screw provided the same pullout resistance and three-dimensional stability as bicortical C1 lateral mass fixation. Although lateral mass screw placement into C1 requires bicortical purchase, pedicle screw insertion into the atlas only requires unicortical fixation.
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Abstract
STUDY DESIGN A retrospective comparative study on the morphologic characteristics of the axis in patients with or without rheumatoid arthritis (RA). OBJECTIVE To compare the morphologic risk of vertebral artery (VA) injury during atlantoaxial transarticular screw fixation between patients with or without RA. SUMMARY OF BACKGROUND DATA VA injury is a potentially serious complication during atlantoaxial transarticular screw fixation. Although this operation is frequently performed on RA patients, there have been few comparative studies on the morphologic risk of VA injury between RA and non-RA patients. METHODS A total of 107 three-dimensional computed tomography images of the cervical spine including the C1-C2 complex were evaluated. Forty-seven RA patients and 60 non-RA patients were included in the study. The maximum atlantoaxial transarticular screw diameter (MSD) that could be inserted without breaching the cortex was measured 3-dimensionally using a computer- assisted navigation system. A high-riding-VA carrier was defined as a patient with either MSD of 4 mm or less. In RA patients, the space available for the spinal cord in flexion (SAC in flexion), duration of disease, RA stage, and type of disease were examined. RESULTS In the RA group, 45 of 94 MSDs (47.9%) were 4 mm or less, and 33 of 47 patients (70.2%) were high-riding-VA carriers. In the non-RA group, 11 of 120 MSDs (9.2%) were 4 mm or less, and 9 of 60 (15.0%) patients were high-riding-VA carriers. MSD, C3 A-P diameter, and the ratio of MSD to C3 A-P diameter were significantly smaller in the RA group than in the non-RA group. Multiple logistic regression analysis showed that SAC in flexion was a significant risk factor for a high-riding-VA carrier in the RA group. CONCLUSION RA was a significant risk factor for the presence of a high-riding VA. When performing atlantoaxial transarticular screw fixation, particularly on RA patients, thorough preoperative evaluation of the bony architecture is of great importance to avoid inadvertent VA injury.
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Cyr SJ, Currier BL, Eck JC, Foy A, Chen Q, Larson DR, Yaszemski MJ, An KN. Fixation strength of unicortical versus bicortical C1-C2 transarticular screws. Spine J 2008; 8:661-5. [PMID: 17526435 DOI: 10.1016/j.spinee.2007.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 02/07/2007] [Accepted: 02/08/2007] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The internal carotid artery and hypoglossal nerve lie over the anterior aspect of the lateral mass of the atlas and are at risk from bicortical C1-C2 transarticular screws. This has led to the recommendation for unicortical screws if the neurovascular structures are in close proximity to the proposed exit point. No data are available on strength of unicortical versus bicortical C1-C2 transarticular screws. PURPOSE To compare the biomechanical pullout strength of unicortical versus bicortical C1-C2 transarticular screws in a cadaveric model. STUDY DESIGN Biomechanical study. METHODS Fifteen cervical spine specimens underwent axial pullout testing. A unicortical C1-C2 transarticular screw was placed on one side with a contralateral bicortical screw. Data were analyzed to reveal any significant differences in strength. RESULTS Mean pullout strength for the bicortical C1-C2 transarticular screws was 1,048.8 (+/-360.1) N versus 939.2 (+/-360.6) for unicortical screws (p=.22). There was no significant difference in the pullout strength of unicortical and bicortical screws. CONCLUSIONS In cases with satisfactory bone quality, it appears reasonable to use unicortical screws to avoid the risk of neurovascular injury from penetrating the anterior cortex of C1.
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Affiliation(s)
- Steven J Cyr
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Miyata M, Neo M, Ito H, Yoshida M, Fujibayashi S, Nakamura T. Rheumatoid arthritis as a risk factor for a narrow C-2 pedicle: 3D analysis of the C-2 pedicle screw trajectory. J Neurosurg Spine 2008; 9:17-21. [DOI: 10.3171/spi/2008/9/7/017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Vertebral artery (VA) injury is a potentially serious complication of C-2 pedicle screw (PS) fixation. Although this surgery is frequently performed in patients with rheumatoid arthritis (RA), few studies have compared the risk of VA injury in patients with and without RA. In this study, the authors compare the morphological risk of VA injury relating to C-2 PS fixation in patients with and without RA.
Methods
A total of 110 3D CT images of the cervical spine including the axis were evaluated. Fifty patients with RA and 60 patients without RA were included in the study. The maximum PS diameter (MPSD) that could be used at C-2 without breaching the cortex was measured in 3D using a computer-assisted navigation system. A narrow-pedicle carrier was defined as a patient with an MPSD of 4 mm or less.
Results
In the RA group, 42 of 100 MPSDs were ≤ 4 mm, and 30 of 50 patients (60%) were narrow-pedicle carriers. In the non-RA group, 10 of 120 MPSDs (8%) were ≤ 4 mm, and 8 of 60 (13%) patients were narrow-pedicle carriers. The MPSD, the anteroposterior (AP) diameter of C-3, and the ratio of MPSD to the AP diameter of C-3 were significantly smaller in the RA group than in the non-RA group. Multiple logistic regression analysis showed that RA and narrow C-3 AP diameter were significant risk factors for a narrow-pedicle carrier.
Conclusions
Rheumatoid arthritis is a significant risk factor for a narrow C-2 pedicle. When performing PS placement at C-2, particularly in patients with RA, thorough preoperative evaluation of the bone architecture is very important for avoiding inadvertent injury to the VA.
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Treatment of upper cervical spine involvement in rheumatoid arthritis patients. Mod Rheumatol 2008; 18:327-35. [PMID: 18414784 DOI: 10.1007/s10165-008-0059-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 02/12/2008] [Indexed: 10/22/2022]
Abstract
The cervical spine, especially the upper cervical spine, is a common focus of destruction by rheumatoid arthritis (RA). Because of its potentially debilitating and life-threatening sequelae, cervical spine involvement remains a priority in the diagnosis and treatment of RA. Many studies show that early surgical intervention gives a more satisfactory outcome. Surgery aims to establish spinal stability and to prevent neurological deterioration and injury to the spinal cord, leading to improved neurological function. The recent sophisticated screw-rod-plate technique allows one to obtain a solid fixation of the upper cervical spine with a high possibility of bone union even in RA patients. Although surgery of the occipitoatlantoaxial region is a challenge with many possibilities of serious complications, recent advances in the surgical technique, complete understanding of the anatomy, and precise preoperative evaluation have decreased complication rates. Early consultation with a specialized spine surgeon is mandatory once cervical involvement is suspected in an RA patient because once the patient becomes myelopathic, the rate of long-term mortality increases and the chance of neurological recovery decreases.
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Hoh DJ, Maya M, Jung A, Ponrartana S, Lauryssen CL. Anatomical relationship of the internal carotid artery to C-1: clinical implications for screw fixation of the atlas. J Neurosurg Spine 2008; 8:335-40. [DOI: 10.3171/spi/2008/8/4/335] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Various C1–2 instrumentation techniques have been developed to treat atlantoaxial instability. Screw fixation of C1–2 poses a risk of injury to the vertebral artery and internal carotid artery (ICA). Injury to the ICA caused by C-1 screws is extremely rare, but has been described. To characterize this risk, the authors studied the anatomical relationship of the ICA to the lateral mass of C-1.
Methods
The authors studied 100 patients who had undergone computed tomography scanning and magnetic resonance imaging of the neck to assess the position of the ICA in association with the C-1 lateral mass. Each ICA was classified into 1 of the following 4 zones: Zone 1 (medial to lateral mass), Zone 2 (medial half of lateral mass), Zone 3 (lateral half of lateral mass), and Zone 4 (lateral to lateral mass). For patients with an ICA ventral to the lateral mass, the shortest distance between the ICA and lateral mass was measured to determine the margin of error with an overpenetrated bicortical screw.
Results
Of the 100 patients, 58% had a left ICA in Zones 2 and 3 with a mean distance from the anterior cortex of 3.5 ± 1.5 mm (± standard deviation), and 74% had a right ICA in Zones 2 and 3 with a mean distance from the anterior cortex of 3.9 ± 1.6 mm. Both ICAs anterior to the lateral mass were noted in 47% of patients, and 84% had ≥ 1 ICA anterior to the lateral mass. When the ICA was anterior to the lateral mass, it was more commonly in the lateral half (left ICA in 91% and right ICA in 92%). The left ICA was in Zone 1 in 1% and Zone 4 in 41%. The right ICA was in Zone 1 in 1% and Zone 4 in 25%.
Conclusions
A high percentage of patients demonstrate an ICA directly ventral to the C-1 lateral mass, which poses a risk of ICA injury caused by an overpenetrated bicortical screw.
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Affiliation(s)
- Daniel J. Hoh
- 1Department of Neurological Surgery, University of Southern California
| | - Marcel Maya
- 2Department of Neuroradiology, Cedars–Sinai Medical Center, Los Angeles; and
| | - Alexander Jung
- 2Department of Neuroradiology, Cedars–Sinai Medical Center, Los Angeles; and
| | - Skorn Ponrartana
- 2Department of Neuroradiology, Cedars–Sinai Medical Center, Los Angeles; and
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Abstract
STUDY DESIGN Retrospective survey. OBJECTIVE To clarify the present incidence and management of iatrogenic vertebral artery injury (VAI) during cervical spine surgery. SUMMARY OF BACKGROUND DATA VAI is a rare complication of cervical spine surgery, but it may be catastrophic. Anterior cervical decompression (ACD) and posterior atlantoaxial transarticular screw fixation (Magerl fixation) have been the main causes, with reported incidences of 0.3% to 0.5% and 0% to 8.2%, respectively. Popular new surgical techniques, such as cervical pedicle screw or C1 lateral mass screw fixation, also entail the potential risk of VAI. METHODS A questionnaire was sent to our affiliated hospitals requesting information regarding iatrogenic VAI during cervical spine surgery. RESULTS Seven spine surgeon groups and 25 general orthopedist groups responded to the questionnaire, with a response rate of 89%. The overall incidence of VAI was 0.14% (8 cases among 5641 cervical spine surgeries). The incidence in anterior cervical decompression procedures was 0.18% and that in Magerl fixation was 1.3%. Inexperienced surgeons tended to commit VAI more frequently. One case of VAI during C1 lateral mass screw fixation was included, whereas there was no case of VAI caused by cervical pedicle screw fixation. In the case of "VAI in the screw hole," hemostasis was obtained by tamponade or screw insertion, whereas "VAI in the open space" sometimes caused uncontrollable bleeding, in which embolization eventually stopped the bleeding. There were no deaths or apparent neurologic sequelae. CONCLUSION The incidence of VAI during cervical spine surgery from this survey was similar to or slightly less than that in the literature. Tamponade was effective in many cases, but prompt consultation with an endovascular team is recommended if the bleeding is uncontrollable. Preoperative careful evaluation of the vertebral artery seems to be most important to prevent iatrogenic VAI and to avoid postoperative neurologic sequelae.
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Claybrooks R, Kayanja M, Milks R, Benzel E. Atlantoaxial fusion: a biomechanical analysis of two C1-C2 fusion techniques. Spine J 2007; 7:682-8. [PMID: 17434809 DOI: 10.1016/j.spinee.2006.08.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2005] [Revised: 07/26/2006] [Accepted: 08/03/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND CONTEXT Different atlantoaxial fusion techniques are used for instability. Transarticular screws are biomechanically superior to wiring techniques and equivalent to C1 lateral mass to C2 pedicle (C1LM-C2P) fixation. Recently, C1 lateral mass to C2 laminar (C1LM-C2L) fixation has been shown to have flexibility similar to C1LM-C2P fixation in flexion, extension, lateral bending, and axial rotation. PURPOSE Compare the stiffness of C1LM-C2P with C1LM-C2L screw rod fixation. STUDY DESIGN In vitro biomechanical study. OUTCOME MEASURES Stiffness in flexion/extension, lateral bending, axial rotation, and anterior-posterior (AP) translation. METHODS Eight fresh-frozen human cadaveric cervical spines (C1-C3) were tested intact and, after a type II odontoid fracture, were instrumented and tested with two fixation constructs: C1LM-C2P screws and C1LM-C2L screws. The testing involved flexion, extension, lateral bending, AP translation, and axial rotation. Stiffness was measured and compared with a repeated-measures analysis. RESULTS C1LM-C2P was significantly stiffer than the intact in AP translation (p<.001), lateral bending (p=.001), and axial rotation (p=.002) and equivalent in flexion/extension (p=.09). C1LM-C2L was significantly stiffer than the intact in AP translation (p<.01) and axial rotation (p<.004) and equivalent in lateral bending (p<.71) and flexion/extension (p=.22). C1LM-C2P was stiffer than C1LM-C2L in right/left lateral bending (p<.001) and axial rotation (p=.009) and equivalent in AP translation (p=.06) and flexion/extension (p=.74). CONCLUSION C1LM-C2P fixation is equivalent to C1LM-C2L fixation in flexion/extension and AP translation and superior in lateral bending and axial rotation.
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Gunnarsson T, Massicotte EM, Govender PV, Raja Rampersaud Y, Fehlings MG. The use of C1 lateral mass screws in complex cervical spine surgery: indications, techniques, and outcome in a prospective consecutive series of 25 cases. ACTA ACUST UNITED AC 2007; 20:308-16. [PMID: 17538356 DOI: 10.1097/01.bsd.0000211291.21766.4d] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Direct C1 lateral mass/C2 pars or pedicle screw fixation has been recently proposed as an alternative method to C1-C2 transarticular screw fixation. Although this method seems attractive, there are currently limited clinical data on the use of this technique for multilevel fixation including complex craniocervical reconstructions. The objectives of this study were to assess the safety and the clinical/radiographic outcomes in patients undergoing cervical spine surgery using C1 lateral mass screws (C1-LMS). METHODS A prospectively accrued database was reviewed to determine initial presentation, etiology, operations, complications, and clinical/radiologic outcomes. RESULTS Twenty-five patients with a mean age of 56 underwent fixation with C1-LMS. Mean follow-up was 12 months. The indications for using C1-LMS instead of C1-C2 transarticular screws were: unfavorable bony or vascular anatomy, tumor destruction, thoracic kyphosis or cervical hyperlordosis, inability to reduce the C1-C2 dislocation intraoperatively and or surgeon preference. Satisfactory stability was achieved in all cases with no neurologic or vascular complications. In one case, the C1 screws breached the medial cortex. Three patients developed transient postoperative C2 neuralgia. One patient had an extended stay in ICU due to respiratory issues. CONCLUSIONS On the basis of our experience, proficiency with the use of C1-LMS screw fixation greatly enhances the ability to manage complex atlantoaxial or craniocervical pathologies with low morbidity. This technique should be considered an excellent adjunct or alternative to transarticular screw fixation.
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Affiliation(s)
- Thorsteinn Gunnarsson
- Division of Neurosurgery, Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, University of Toronto, Toronto, Canada
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Abstract
Abstract
INSTABILITY OF THE atlantoaxial complex may result from inflammatory, traumatic, congenital, neoplastic, or degenerative disorders and often requires surgical stabilization. Initial dorsal wiring techniques allow safe fixation but require rigid external immobilization and have been associated with high fusion failure rates. Rigid screw fixation techniques including transarticular screw fixation and C1–C2 rod-cantilever fixation offer higher fusion rates and less need for rigid immobilization but are more technically demanding. C1–C2 fixation using crossing C2 laminar screws offers rigid fixation but without the technical demands of C2 pars placement. The history and techniques of dorsal fixation of the atlantoaxial complex are reviewed, and the success rates and complications of each are discussed.
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Affiliation(s)
- Jose A Menendez
- Department of Neurological Surgery, Washington University, School of Medicine, St. Louis, Missouri 63110, USA
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Cassinelli EH, Lee M, Skalak A, Ahn NU, Wright NM. Anatomic considerations for the placement of C2 laminar screws. Spine (Phila Pa 1976) 2006; 31:2767-71. [PMID: 17108826 DOI: 10.1097/01.brs.0000245869.85276.f4] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaveric study. OBJECTIVE To study the applicability of C2 laminar screw placement in the general adult population and to provide useful guidelines for their safe placement. SUMMARY OF BACKGROUND DATA Laminar screws for fixation into the second cervical vertebra are becoming an increasingly used technique since they eliminate the risk of vertebral artery injury. Although it is being used clinically, there are no published data that describe the anatomic considerations and potential limitations of this technique in the general population. METHODS The C2 vertebrae of 420 adult specimens were studied. Laminar thickness, spinolaminar angle, and the length from the spinolaminar junction to the contralateral lamina/lateral mass junction were measured. Statistical analysis was performed using unpaired Student t tests and regression analysis (P < 0.05). RESULTS Mean laminar thickness was 5.77 +/- 1.31 mm; 70.6% of specimens had a laminar thickness > or =5 mm; 92.6% had a thickness > or =4.0 mm. The spinolaminar angle was 48.59 degrees +/- 5.42 degrees. The mean screw length that could be used was 2.46 +/- 0.23 cm. More than 99% of specimens had an estimated screw length of at least 20 mm. Gender had a significant effect on all of the measurements studied, but race, height, and weight did not. CONCLUSION The majority of specimens can safely accept placement of a laminar screw. This study establishes anatomic guidelines to allow for accurate screw selection and insertion. Preoperative planning is essential for safe screw placement via this technique.
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Affiliation(s)
- Ezequiel H Cassinelli
- Spine Institute, Department of Orthopaedic Surgery, University Hospitals of Cleveland, Case School of Medicine, Cleveland, OH 44106, USA.
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Kuroki H, Rengachary SS, Goel VK, Holekamp SA, Pitkänen V, Ebraheim NA. Biomechanical comparison of two stabilization techniques of the atlantoaxial joints: transarticular screw fixation versus screw and rod fixation. Neurosurgery 2006; 56:151-9; discussion 151-9. [PMID: 15799804 DOI: 10.1227/01.neu.0000144838.01478.35] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2004] [Accepted: 08/23/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To compare the biomechanical stability imparted to the C1 and C2 vertebrae by either transarticular screw fixation (TSF) or screw and rod fixation (SRF) techniques in a cadaver model. METHODS Ten fresh ligamentous human cervical spine specimens were harvested from cadavers. The specimens were tested sequentially in the intact state, after injury and stabilization (unilateral left side and bilateral), and after fatiguing to 5000 cycles (0.5 Hz) at +/-1.0 N.m of flexion and extension. The specimens were stabilized by use of TSF in 5 spines or SRF in the other 5 spines. The data were converted to angular displacements, and the stabilized cases were compared with intact states for evaluating the efficacies of the two techniques in stabilizing the C1-C2 segments. RESULTS In the TSF group, the unilateral fixation using one screw imparted a significant stability in only the axial rotation mode. The unilateral procedure in the SRF group was effective in stabilization in all modes except in extension. The bilateral procedure in both of the groups was effective across the C1-C2 segment. However, the SRF group afforded higher stability than the corresponding TSF group in the flexion and extension modes. The degree of stability did not change after fatigue compared with the prefatigue data. CONCLUSION In general, a surgeon should undertake a bilateral fixation to achieve sufficient stability across the atlantoaxial complex, and either technique will provide satisfactory results, although the SRF technique may be better in the flexion and extension modes. One should use the SRF procedure while trying to achieve stability with a unilateral system.
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Affiliation(s)
- Hiroshi Kuroki
- Department of Orthopedic Surgery, University of Miyazaki, Faculty of Medicine, Miyazaki, Japan.
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Chung SS, Lee CS, Chung HW, Kang CS. CT analysis of the axis for transarticular screw fixation of rheumatoid atlantoaxial instability. Skeletal Radiol 2006; 35:679-83. [PMID: 16802148 DOI: 10.1007/s00256-006-0155-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Revised: 04/06/2006] [Accepted: 04/26/2006] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the morphological characteristics of the axis of rheumatoid arthritis (RA) patients with atlantoaxial instability and to determine, by means of sagittal reconstructed computed tomography (CT), the suitability for atlantoaxial transarticular screw fixation. DESIGN AND PATIENTS Twenty-seven patients, who had undergone reconstructed cervical spine CT scanning preoperatively and posterior atlantoaxial arthrodesis for atlantoaxial instability, were identified from a database for inclusion in this study. The isthmus height and internal height of the lateral mass of the axis were measured using digital imaging software. RESULTS The mean isthmus height and internal height of the lateral mass of the axis in RA patients (n=14) were significantly lower than in non-RA patients (n=13) (P<0.01). A high-riding vertebral artery (VA) was present in 54% (15 joints, 9 patients) of the 28 atlantoaxial joints in the RA group and in 12% (3 joints, 2 patients) of the 26 atlantoaxial joints in the non-RA group (P<0.01). CONCLUSIONS In RA patients, the axis showed more extensive thinning of the isthmus and lateral mass than in non-RA patients. A precise preoperative evaluation of screw trajectory using reconstruction CT imaging may be useful in atlantoaxial transarticular fixation, particularly for RA patients with atlantoaxial instability.
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Affiliation(s)
- Sung Soo Chung
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 135-710, South Korea
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Hauck EF, Nauta HJW. Spontaneous spinal epidural arteriovenous fistulae in neurofibromatosis type-1. ACTA ACUST UNITED AC 2006; 66:215-21. [PMID: 16876638 DOI: 10.1016/j.surneu.2006.01.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Accepted: 12/29/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND NF-1 is one of the most common autosomal-dominantly inherited genetic disorders with an incidence of approximately 1:3500. We report a case and review the literature to characterize spontaneous spinal AVF that occur in neurofibromatosis (NF-1). CASE REPORT A 51-year-old woman presented with NF-1 and progressive radiculomyelopathy. Angiography revealed an AVF terminating in a giant intraspinal epidural varix extending paraspinally through the C3/4 neural foramen. Trapping of the AVF attempted 18 years earlier prevented endovascular access for embolization, and vigorous bleeding made direct surgical resection impossible. Therefore, as palliation, arterial feeding collaterals were occluded, and surgically exposed tortuous veins were packed with coils. Laminectomies and partial resection of the epidural varix resulted in subtotal occlusion with clinical improvement. CONCLUSION The spinal AVF associated with NF-1 appears to show dominant venous drainage to the intraspinal extradural and paraspinal venous plexus without evidence of intradural drainage. The vertebral artery is typically the origin of the fistula. A giant venous varix and numerous collateral feeders to the vertebral artery may give an AVM-like appearance. Clinically, the fistulae produce a syndromic triad including symptoms of NF-1, progressive radiculomyelopathy, and a bruit. Treatment is direct attack on the fistula by either surgery or embolization. If, however, a direct approach cannot be chosen, occlusion of feeding vessels combined with laminectomies can result in long-term symptomatic improvement.
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Affiliation(s)
- Erik F Hauck
- Division of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555-0517, USA.
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Rampersaud YR, Moro ERP, Neary MA, White K, Lewis SJ, Massicotte EM, Fehlings MG. Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine (Phila Pa 1976) 2006; 31:1503-10. [PMID: 16741462 DOI: 10.1097/01.brs.0000220652.39970.c2] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE To assess the incidence and clinical consequence of intraoperative adverse events from a wide variety of spinal surgical procedures. SUMMARY OF BACKGROUND DATA In this study, adverse events were defined as any unexpected or undesirable event(s) occurring as a result of spinal surgery. A complication was defined as a disease or disorder, which, as a consequence of a surgical procedure, will negatively affect the outcome of the patient. We hypothesized that most adverse events would not result in complications that would be normally flagged through traditional practice audit approaches. By defining the incidence and types of adverse events seen in a spine surgical practice, we hope to develop preventative approaches to enhance patient safety. METHODS All postoperative clinical sequelae (i.e., complications) were prospectively identified, classified as to type, and graded (0 [none] to IV [death]) in 700 consecutive patients who underwent spine surgery (excluding > 300-day surgery microdiscectomies) at a university center from January 2002 to June 2003. To confirm data accuracy and assess the clinical sequelae of any adverse events, the medical records of these 700 patients were reviewed. RESULTS The overall incidence of intraoperative adverse events was 14% (98/700). A total of 23 adverse events led to postoperative clinical sequelae for an overall intraoperative complication incidence of 3.2% (23/700). Specific adverse events included dural tears (n = 58), spinal instrumentation-related events (n = 12), blood loss exceeding 5000 mL (n = 10), anesthesia/medical (n = 4), suspected or actual vertebral artery injury (n = 3), approach-related events (n = 3), esophageal/pharyngeal injury (n = 2), and miscellaneous (n = 6). CONCLUSIONS Adverse events can frequently occur (14%) during spinal surgery, however, the majority (76.5%) are not associated with complications. Improved patient safety can only be maximized by independent practice audit and the development of prospective methods to record adverse event data so that enhanced, evidence-based, clinical protocols can be developed.
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Affiliation(s)
- Y Raja Rampersaud
- Division of Orthopaedic and Neurosurgery, Krembil Neuroscience Center, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Vascular injury is an uncommon, but not rare complication of spine surgery. The consequence of vascular injury may be quite devastating, but its incidence can be reduced by understanding the mechanisms of injury. Properly managing vascular injury can reduce mortality and morbidity of patients. A review of the literature was conducted to provide an update on the etiology and management of vascular injury and complication in neurosurgical spine surgery. The vascular injuries were categorized according to each surgical procedure responsible for the injury, i.e., anterior screw fixation of the odontoid fracture, anterior cervical spine surgery, posterior C1-2 arthrodesis, posterior cervical spine surgery, anterolateral approach for thoracolumbar spine fracture, posterior thoracic spine surgery, scoliosis surgery, anterior lumbar interbody fusion (ALIF), lumbar disc arthroplasty, lumbar discectomy, and posterior lumbar spine surgery. The incidence, mechanisms of injury, and reparative measures were discussed for each surgical procedure. Detailed coverage was especially given to vascular injury associated with ALIF, which may have been underestimated. The accumulation of anatomical knowledge and advanced imaging studies has made complex spine surgery safer and more reliable. It is not clear, however, whether the incidence of vascular injury has been reduced significantly in all procedures of spine surgery. Emerging new techniques, such as microendoscopic discectomy and lumbar disc arthroplasty, seem to be promising, but we need to keep in mind their safety issues, including vascular injury and complication.
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Affiliation(s)
- J Inamasu
- Department of Neurosurgery, University of South Florida College of Medicine, Tampa, 33606, USA.
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Yamazaki M, Koda M, Aramomi MA, Hashimoto M, Masaki Y, Okawa A. Anomalous vertebral artery at the extraosseous and intraosseous regions of the craniovertebral junction: analysis by three-dimensional computed tomography angiography. Spine (Phila Pa 1976) 2005; 30:2452-7. [PMID: 16261125 DOI: 10.1097/01.brs.0000184306.19870.a8] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study examined the extraosseous and intraosseous anomalies of vertebral arteries in patients who underwent surgery of the craniovertebral junction. OBJECTIVES To describe the usefulness of three-dimensional computed tomography angiography for evaluating vertebral artery anomalies before surgery. SUMMARY OF BACKGROUND DATA Previous studies using catheter angiograms have identified anomalous courses of the vertebral artery at the craniovertebral junction. Studies using computed tomography reconstruction also showed deviation of the vertebral artery groove at the C2 isthmus, demonstrating a risk of vertebral artery injury for C1-C2 transarticular screw placement. These analyses provided us with useful information for identifying anomalies of the vertebral artery, but they could not visualize the artery and its circumferential osseous tissue simultaneously, nor could they analyze the reciprocal anatomy of both tissues. METHODS Thirty-one consecutive patients who submitted to surgery at the craniovertebral junction were evaluated before surgery by three-dimensional computed tomography angiography. Eleven of the patients had congenital osseous anomalies at the craniovertebral junction including os odontoideum and ossiculum terminale. Anomalous vertebral arteries at the extraosseous region were visualized by three-dimensional reconstruction images, and the intraosseous deviation of the vertebral artery at the C2 isthmus was evaluated by multiplanar reconstruction images. RESULTS Extraosseous and/or intraosseous vertebral artery anomalies were detected in 9 cases. Eight of the 9 cases had osseous anomalies at the craniovertebral junction. Abnormal courses of the vertebral artery at the extraosseous region were detected in 4 cases: 2 had fenestration and 2 had persistent first intersegmental artery. Asymmetry of bilateral vertebral arteries was found in 5 cases: the right was dominant in 3 cases and the left in 2 cases. A high-riding vertebral artery at the C2 isthmus was detected in 5 cases. Based on these findings, we modified our surgical approach and the screw placement; consequently, no vertebral artery injury occurred. CONCLUSIONS In patients having osseous anomalies at the craniovertebral junction, the frequency of vertebral artery anomalies at the extraosseous and intraosseous regions is increased. With preoperative three-dimensional computed tomography angiography, we can precisely identify the anomalous vertebral artery and reduce the risk of intraoperative injury to the vertebral artery, in advance.
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Affiliation(s)
- Masashi Yamazaki
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.
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