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PubMed1999

A novel endoscopic approach to anterior odontoid screw fixation: technical note.

Techniques for operative management for type II odontoid fractures have continuously been refined with anterior odontoid screw arthrodesis having a clear advantage in maintaining normal motion. We have refined the technique of odontoid screw fixation further with the introduction of an endoscopic approach developed by the senior author. The necks of two partially embalmed cadavers were slightly extended under fluoroscopic guidance to simulate a reduced, anteriorly displaced type II fracture. Using a guide wire, graduated plastic sheath and endoscopic guidance, a solid 45 mm bone screw was passed through the odontoid with the aid of biplanar fluoroscopy. There were no apparent complications and no damage to surrounding vital structures. Anterior screw fixation of the odontoid is an established technique that provides adequate fixation, but the procedure can be technically demanding secondary to awkward tissue retraction. We present a percutaneous technique that obviates the need for tissue retraction while achieving an excellent result with only a modicum of effort.

Arthroscopy↗
PubMed1987

Early posterior acrylic fixation of traumatic odontoid fractures.

Nine cases of traumatic odontoid fractures had, as a primary treatment, a posterior surgical fixation (C1 + C2 + C3) by means of acrylate, without waiting for the unpredictable results of external systems of immobilisation. No immediate or late (follow-up: six months to seven yrs) neurological complications occurred. Solid union took place in all the cases but one. Two cases of wound infection were recorded. All the patients were actively mobilised on the second postoperative day without external immobilisation.

Acrylates↗
PubMed2003

Trunk asymmetry and facial symmetry in young adults.

The aim of the present study was to detect possible associations between trunk and cervical asymmetry and facial symmetry. Frontal cephalograms prepared in the natural head position, representing 79 subjects (40 males, 39 females) with mild to moderate trunk asymmetry, were analyzed separately for thoracic humps, lumbar prominences, and cervical inclination by discriminating two groups: right-sided-dominant and left-sided-dominant. The differences between the groups were analyzed using an unpaired 2-group t test. The results showed that location of the thoracic humps and inclination of the cervical spine was predominantly right-sided, while the location of lumbar prominence was predominantly left-sided. Craniofacial morphological variables of the head and face were nearly equal for right-sided and left-sided thoracic humps and lumbar prominences, showing that moderate trunk asymmetry does not affect facial symmetry. Further, it was found that frontal head position in relation to the true vertical (VER/ORB) is stable in that the angle between the supraorbital and vertical lines is constantly maintained close to 90 degrees regardless of moderate trunk asymmetry, indicating that visual perception control is most important in orienting the head in frontal plane. Maintenance of the head position takes place by cervical spine adaptation.

Adaptation, Physiological↗
PubMed1995

Transoral surgery: some lessons learned.

The experience gained over the last decade has provided some further understanding of the rare, but potentially fatal problems associated with pathology at the craniovertebral junction. Some original concepts of the disease in the area have been challenged; new evidence has been provided to explain our alternative theories. The transoral procedure as a surgical tool is now well established. It is, however, technically demanding, and requires careful anatomical study and 'hands-on' workshop training before the novice will be competent.

Arnold-Chiari Malformation↗
PubMed1996

Morquio syndrome: a rehabilitation perspective.

Morquio Syndrome (mucopolysaccharidosis type IV A) is a rare inherited connective tissue disorder characterized by skeletal dysplasia, restrictive pulmonary disease and normal intelligence. Tetraplegia secondary to subluxation of C1 over C2 because of odontoid dysplasia is a common occurrence in these patients but there are limited descriptions regarding their specific physiatric management. Two patients (aged 20 and 17 years) were admitted to a pediatric rehabilitation facility after cervical spine stabilization following recurrent tetraplegia (C4 ASIA C and C4 ASIA D). Following surgery, patients were ventilator dependent and aphonic. One patient was successfully weaned off the ventilator to nocturnal BiPAP, while the other was able to tolerate three hours of ventilator free time despite being ventilator dependent for ten years. At discharge, both patients showed significant improvement in mobility, self care skills and communication abilities. Functional independence was encouraged through use of various assistive devices for mobility, activities of daily living (ADL) and communication. Group counseling and peer support were extremely helpful in their adjustment to disability. Physiatric intervention is essential and requires understanding of the unique impairments encountered by tetraplegics with Morquio Syndrome.

Activities of Daily Living↗
PubMed2005

Whiplash-associated disorders impairment rating: neck disability index score according to severity of MRI findings of ligaments and membranes in the upper cervical spine.

The aim of this study was to explore whether reported pain and functional disability in whiplash-associated disorders (WAD) patients is associated with lesions to specific soft tissue structures in the upper cervical spine, as assessed by MRI. Pre-selected structures for MRI assessment included the alar ligaments, the transverse ligament, the tectorial and the posterior atlanto-occipital membranes. The questionnaire employed was a modification of the Oswestry Low Back Pain Index. It was comprised of ten single items related to pain and activity of daily living. Ninety-two whiplash patients and 30 control persons, randomly drawn, were included. WAD patients reported significantly more pain and functional disability than the controls, both for total score and each of the ten single items. In the WAD patients, MRI lesions to the alar ligaments showed the most consistent association to the reported pain and disability. Lesions to other structures often occurred in combination with lesions to the alar ligaments. Lesions to the transverse ligament and to the posterior atlanto-occipital membrane also appeared to be related to the NDI score, although the association was weaker than for the alar ligament. The disability score increased with increasing number of abnormal (grade 2-3) structures. These results indicate that symptoms and complaints among WAD patients can be linked with structural abnormalities in ligaments and membranes in the upper cervical spine, in particular the alar ligaments.

Activities of Daily Living↗
PubMed1985

Injuries to pathologically changed cervical vertebrae.

Three cases of fatal injuries to the upper cervical spinal cord and underlying cervical spine pathology are presented. It is stressed that the slightest suspicion concerning injuries to the upper part of the neck must lead not only to microscopic examination of the cervical spinal cord and medulla oblongata, but also to careful preparation (or maceration) of the upper cervical spine, in order not to overlook fractures or misinterpret old fractures and diseases as fresh fractures.

Accidents, Traffic↗
PubMed1990

Fatal high cervical spinal cord injury in an automobile accident complicating os odontoideum.

We report a case where spinal instability from incomplete fusion of the dens of C2 (os odontoideum) allowed anterior displacement of the skull and first cervical vertebra following right frontal impact against the A pillar in an automobile accident. Resultant crushing and laceration of the spinal cord occurred at the level of C1 and C2. Without either radiographic investigation or detailed examination of the spine, the fatal injury might have been overlooked and death attributed to acute alcoholic poisoning because the blood alcohol level was .613%.

Accidents, Traffic↗
PubMedDate not supplied

Diagnosis of a C-2 fracture during physiatric consultation: a case report.

Consultation in the acute care setting allows physiatrists to make significant contributions. In our case, a 90-year-old woman presented to the emergency room after falling down five stairs. Six view C-spine films taken at that time revealed no fracture. She was sent home on anti-inflammatory medication and was later admitted for gastritis. A repeat six-view C-spine series again revealed no fracture. Physiatry was then consulted to prescribe modalities and therapies for "cervical strain." On examination, the patient demonstrated severely decreased neck range of motion limited by pain, with pain radiating down her right arm. Physiatry recommended obtaining a C-spine magnetic resonance image to rule out occult fracture or herniated disc before proceeding with therapies. The magnetic resonance image revealed a complex C-2 fracture consisting of a Type III odontoid component. Computed tomographic scan was then performed to obtain a high-resolution assessment of the bony architecture. The computed tomographic scan revealed a high degree of comminution, including bilateral pedicle fractures and a fracture through the left transverse foramen of C-2. The patient was placed in a hard cervical collar and seen by a neurosurgeon. Had therapies been initiated before physiatric consultation, the patient could have experienced significant neurologic complications, including the possibility of becoming tetraplegic. This case demonstrates that physiatrists play a crucial role in the evaluation of acute care patients before the initiation of therapies. The authors will review pertinent history and the results of physical and diagnostic tests.

Accidental Falls↗
PubMed1992

Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation.

Odontoid fractures, especially unstable type II fractures have a poor prognosis in respect to healing. Therefore, operative stabilization (posterior fusion C1/2 or anterior screw fixation) has been suggested for the treatment of unstable type II and for some unstable type III fractures. Compared to posterior fusion C1/2, anterior screw fixation has proven to be effective; it has the advantage of leaving the motion segment C1/2 intact, therefore preserving at least some C1/2 rotation. However, in some instances, this method of stabilization is not indicated. In these cases, posterior fusion C1/2 is the treatment of choice. Primary posterior fusion C1/2 is indicated in (a) odontoid fracture associated with comminution of one or both atlanto-axial joints; (b) fracture of the odontoid associated with an unstable Jefferson fracture; (c) unstable type III odontoid fracture, when immobilization in a halo jacket or plaster cast is not suitable, as in elderly people or polytraumatized patients; (d) atypical type II fractures (comminuted or with oblique fracture in the frontal plane); (e) irreducible fracture dislocation C1/2, e.g., several-weeks-old fracture; (f) unstable type II or shallow and unstable type III odontoid fracture, when marked thoracic kyphosis is associated with limited extension of the cervical spine; (g) unstable type II or shallow type III odontoid fracture in elderly people with degenerative narrow spinal canal; (h) pathologic fracture of the odontoid. In all these instances, posterior fusion C1/2 is the treatment of choice. We prefer the transarticular screw fixation technique. Compared to other posterior fusion techniques, it has the advantage of increased stability and allows effective stabilization of C1/2 in a reduced position as well as immediate ambulation with minimal head support. This technique can also be performed when the posterior arch of the atlas is fractured or absent. Our experience of 12 acute odontoid fractures, managed by this technique, is presented. At follow-up, all C1/2 fusions were united in reduced position.

Adult↗
PubMed1993

Anterior occipital cervical reconstruction with a free vascularized osteocutaneous graft: a case report.

Free vascularized osteocutaneous bone grafts are an unusual but effective method to reconstruct complex and extensive defects of skin and bone of the extremities due to trauma, tumor, or infections. Many recent publications support their utility in these situations. In distinction, little literature exists to document the use of free vascularized osteocutaneous flaps in the spine. This is likely due to the infrequent occurrence of concomitant skin and osseous defects that are not manageable by routine spinal and plastic surgical approaches. We recently managed a particularly challenging patient in whom six prior operations--three anterior and three posterior--to decompress and stabilize the occipital-cervical junction had failed. We used a free vascularized distal radius osteocutaneous flap for three purposes: to provide the patient with an optimal chance to obtain an extensive and critically important anterior occipital-cervical arthrodesis, to supply a stable soft tissue envelope for protection of a tenuous dural repair, and to reconstruct an atrophic and scarred posterior pharyngeal wall. We are unaware of any report to date that documents the use of a graft of this type in the spine. We wrote this brief article to document the indications for this operation, to illustrate the problems we encountered in this difficult reconstructive situation, and to report on the progress of our patient to date.

Adolescent↗
PubMed1993

Odontoid fractures in the elderly.

A review of 35 patients > 60 years of age with odontoid fractures showed that a type II injury (Anderson and D'Alonso) was the most common fracture pattern (82% of cases). On the basis of mechanism of injury and sex incidence, we deduced that osteopenia is a contributory factor in the occurrence of odontoid fractures. A fall in a domestic setting was the cause in 53%. The peg was posteriorly displaced in 88% of type II fractures, and primary union occurred in 23%. The incidence of concomitant spinal cord injury with type II fractures was higher in older patients than it was in those < 60 years of age. The outcome for these patients was largely determined by their neurological status at presentation. Myelopathy as a late complication of nonunion was not observed in nine patients with an average follow-up of 21 months. The data suggest that vigorous attempts to secure both primary union and a sound arthrodesis for non-union are questionable in the elderly except in unusual circumstances.

Aged↗
PubMed1994

One Herbert double-threaded compression screw fixation of displaced type II odontoid fractures.

Surgical treatment of type II odontoid fractures (OFs) has usually entailed C1-2 arthrodesis rather than fracture fixation. An alternative treatment of direct screw fixation is used to treat the fractures for preservation of atlantoaxial rotation. Type II OFs that cannot be completely reduced by close means are generally believed to be a contraindication for anterior screw fixation. Seven patients (group I) with displaced type II OFs that could be completely reduced were treated with fracture fixation by one 4.5-mm double-threaded compression screw and five patients (group II) with displaced type II OFs that could only be partially reduced were treated with fracture fixation by one 3.0-mm double-threaded compression screw. All patients had a minimum of 1-year follow-up. No major complications occurred. No loss of reduction occurred in group I patients. Group II patients had an average loss of reduction of 0.8 mm anterior displacement and 5 degrees anterior angulation. The overall rate of fracture union was 100%, and fracture resolution averaged 4.1 months. Ten patients had a normal range of cervical rotation, and there was no difference in preservation of cervical rotation between the two groups. Our results suggest that close reduction and compressive osteosynthesis by one double-threaded compression screw is an optimal method of treatment for displaced type II OFs that can be completely reduced and for some cases that can only be partially reduced. A 100% rate of fracture union and preservation of cervical rotation are the major advantages of this method. However, significant complications have been reported by other investigators. (ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2001

Surgical therapy for dialysis-related spondyloarthropathy: review of 30 cases.

Surgical therapy for dialysis-related spondyloarthropathy was investigated regarding its spinal manifestation. Between August 1985 and May 1998, 31 operations were performed on 16 male and 14 female patients; of these, 17 had cervical and 13 had lumbar spinal disorders. The average patient age was 59 years. The average period of hemodialysis was 14.8 years. Twenty-eight of 30 patients had cystic bone lesions and 24 had carpal tunnel syndrome. Four major postoperative complications occurred: death from paralysis and respiratory distress, severe kyphosis from the collapse of the grafted bone, deep infection from instrumentation, and wire breakage and bone fusion failure. Postoperative results with an average follow-up period of 2.7 years were good in 19 cases (63%), fair in 8 cases (27%), and poor in 3 cases (10%). As yet, surgical intervention for dialysis-related spondyloarthropathy is still regarded as a noncurative treatment; furthermore, the anterior approach to the cervical spine has a high risk for postoperative complications.

Aged↗