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PubMed1998

Anatomy and pathology of the aging spine.

The vertebral column is a complicated anatomical structure which is composed of the intervertebral discs and the vertebrae. Both components develop special degenerative changes and morphologic features during life. This paper first reviews the anatomical fundamentals and then describes the morphological features of the aging intervertebral disc and the subsequent osseous changes of the vertebral bodies and the zygapophyseal joints. The aging intervertebral disc is characterised by processes which are labeled as intervertebral chondrosis and intervertebral osteochondrosis. Often these processes are combined with typical dislocations of intervertebral disc tissue in an anterior or dorsolateral direction. The well known Schmorl's nodules must also be mentioned in this context. Furthermore calcification and ossification of the intervertebral disc tissue can take place. More severe processes lead to osseous changes of the vertebral bodies. In particular, an osteophytosis of the vertebral bodies can be established. These sturdy osteophytes are able to stiffen the vertebral column. Furthermore the arthrotic changes of the zygapophyseal joints are delineated in this paper. The special appearances of these changes are discussed according to the different and specialised regions of the vertebral column. The advanced degenerative changes of the zygapophyseal and uncovertebral joints of the cervical spine are of essential clinical interest because the compression of the vertebral artery or the narrowing of the intervertebral foramina by these processes may cause severe neurological symptoms. The arthrotic changes of the medial atlantoaxial joint, which lead to the crowned odontoid, and the pseudospondylolisthesis (so called M. Junghanns) of the lumbar spine must also be mentioned. It is the aim of this paper, not only to explain and review the degenerative changes, but to illustrate the anatomy and pathology of the aging spine on the basis of macerated osseous specimens in order to make radiological investigations and pictures more understandable and clear.

Aged↗
PubMed1999

Anesthetic care for the child with Morquio syndrome: general versus regional anesthesia.

Morquio syndrome is a subtype of the mucopolysaccharidoses (MPS IV) characterized by the intracellular accumulation of keratin sulfate. Anesthetic issues related to the primary disease process include infiltration of tissues with keratin sulfate leading to distortion of upper airway anatomy with difficult or impossible endotracheal intubation, infiltration of the cervical spine with odontoid hypoplasia placing these patients at risk for atlanto-axial subluxation and quadriparesis, as well as alterations in cardiorespiratory function. Two children with Morquio syndrome who required anesthetic care during lower extremity orthopedic procedures are presented. The anesthetic implications of Morquio syndrome are reviewed. General anesthesia was used in one case, whereas continuous spinal anesthesia, which was used in the second case, is reported for the first time in a child with mucopolysaccharidoses.

Anesthesia, General↗
PubMed1991

Fractures of the spine in diffuse idiopathic skeletal hyperostosis.

Fractures of the spine in diffuse idiopathic skeletal hyperostosis (DISH) have rarely been reported. Only four cases could be found in the world literature. Eight new cases with nine fractures are reported in this study. The critical features are the frequent delays in diagnosis (three of eight patients) and the high rate of immediate and delayed neurologic deficit (seven of eight patients). Two fracture patterns occurred in this group. The first type occurred through the midportion of an ankylosed segment of the spine and involved the vertebral body (five fractures). The second type occurred at the top or bottom of a fused segment (four fractures). The latter were disk disruptions or odontoid fractures. This is a marked difference from spinal fractures in ankylosing spondylitis, in which the majority are transdiskal fractures. The difference can be explained on the basis of the different pathology of these two disease processes. Careful evaluation of patients with DISH who sustain trauma is critical. Treatment of this rare injury should be early stabilization of the spine to avoid complications of nonunion, deformity, neurologic injury, and death.

Aged↗
PubMed2006

Management of recalcitrant osteoarthritis of the atlanto-axial joint.

The medical records and radiographs of 17 patients with recalcitrant pain secondary to C1-C2 osteoarthritis were independently reviewed. All patients were treated by the senior author (K.D.R.). Initial treatment included physical therapy, nonsteroidal anti-inflammatory drugs, and soft collar immobilization. If non-responsive, patients were referred to a single radiologist for injection of the involved C1-C2 joint(s). If symptoms persisted, then transarticular screw fixation and Magerl wire fixation with structural iliac crest bone graft was performed. Postoperatively, all patients were placed in a soft collar. Postoperative anteroposterior (AP), lateral, flexion/extension, and open-mouthed odontoid radiographs were taken at 6 weeks, 3 months, and 1 year. Three independent observers assessed all radiographs for fusion. Fusion was noted by radiographic evidence of bridging bony trabeculae across the C1-C2 joint and/or bridging bone from the posterior arch of C1 to the C2 spinous process. Patient satisfaction improved significantly whether they were treated by corticosteroid injection or surgically.

Adrenal Cortex Hormones↗
PubMed1997

Management guidelines for participation in collision activities with congenital, developmental, or postinjury lesions involving the cervical spine.

OBJECTIVE: Conditions involving the cervical spine in athletes requiring a management decision are numerous. This report presents appropriate guidelines for return to collision activities in those with congenital, developmental, or postinjury lesions. DATA SOURCES: Information was compiled from > 1,200 cervical spine lesions documented by the National Football Head and Neck Injury Registry and an extensive literature review. DATA SYNTHESIS: Available data as well as a clinical understanding of injury mechanisms have resulted in the development of reasonable management guidelines. Each of the congenital, developmental, and posttraumatic conditions presented are determined to present either no contraindication, relative contraindication, or an absolute contraindication to sport participation on the basis of a variety of parameters. Conditions included in the discussion are odontoid anomalies; spina bifida occulta; atlanto-occipital fusion; Klippel-Feil anomalies; cervical canal stenosis; spear tackler's spine; traumatic conditions of the upper, middle, and lower cervical spine, including ligamentous injuries and fractures; intervertebral disc injuries; and postcervical spine fusion. CONCLUSION: The proposed guidelines should be used in the decision-making process in conjunction with other such factors as the age, experience, ability of the individual, level of participation, and position played, as well as the attitude and desires of the athlete and his or her parents following an informed discussion of the problem with particular regard to potential risk.

Athletic Injuries↗
PubMed1997

Suggested management guidelines for participation in collision activities with congenital, developmental, or postinjury lesions involving the cervical spine.

Many conditions involving the cervical spine in the athlete require a management decision. The purpose of this paper is to present appropriate guidelines for return to collision activities in those with congenital, developmental, or post-injury lesions. Information compiled from over 1200 cervical spine lesions documented by the National Football Head & Neck Injury Registry, an extensive literature review, as well as an understanding of injury mechanisms have resulted in reasonable management guidelines. Each of the congenital, developmental, and post-traumatic conditions presented are determined to present either no contraindication, relative contraindication, or an absolute contraindication on the basis of a variety of parameters. Conditions included in the discussion are: odontoid anomalies; spina bifida occulta; atlanto-occipital fusion; Klipple-Feil anomalies; cervical canal stenosis; spear tackler's spine; and traumatic conditions of the upper, middle, and lower cervical spine, including ligamentous injuries and fractures, intervertebral disc injuries, and post-cervical spine fusion. Emphasized is the fact that the proposed guidelines should be used in the decision-making process in conjuction with other factors such as the age, experience, ability of the individual, level of participation, position played, as well as the attitude and desires of the athlete and his parents after an informed discussion of the problem with particular regard to potential risk.

Athletic Injuries↗
PubMed1992

Somatosensory and brainstem auditory evoked potential in congenital craniovertebral anomaly; effect of surgical management.

Clinical features and evoked potential recordings were analysed in 32 patients with congenital atlantoaxial dislocation before and after surgery. Seven patients (group 1) had atlantoaxial dislocation, while 22 patients had associated basilar invagination (group 2). In both groups, pyramidal tract signs, posterior column signs, wasting of the upper limbs, and abnormality of somatosensory evoked potentials (SSEP) were similar. Conversely, lower cranial nerve involvement and abnormal brainstem auditory evoked potentials (BAEP) were significantly more in patients with basilar invagination (p less than 0.05). All seven patients in group 1 and 17 patients in group 2 were operated upon. Clinical and electrophysiological deterioration were significant in patients with basilar invagination (group 2), following posterior fixation compared with group 1. Among the patients in group 2, who clinically deteriorated following posterior fixation, seven had transoral excision of odontoid and six of them improved both clinically and electrophysiologically. Two patients in group 2 had odontoid excision before posterior fixation, and in both the evoked potentials improved postoperatively. In group 1 the patient's BAEP remained unaffected following posterior fixation, however, in group 2, eight patients over 53% showed improvement in brainstem function following posterior fixation. This study shows the value of evoked potentials in congenital atlantoaxial dislocation, and rationalizes the surgical procedure in these patients. In patients with basilar invagination, odontoid excision is the preferred first stage procedure.

Atlanto-Axial Joint↗
PubMed2005

A biomechanical study of unilateral posterior atlantoaxial transarticular screw fixation.

The purpose of this study was to investigate the fixation of C1-C2 instability with the use of a unilateral screw. Transarticular screw placement across C1-C2 may be contra-indicated in up to 20% of specimens on at least one side because of anatomic variations or other pathological processes. Hence the current study looks into unilateral screw fixation of C1- C2 instability. Eight cervical spine specimens, C1 through C5, were harvested from fresh human cadavers (4 male and 4 female) of average age 67 years (54-80). C1 and C2-C5 vertebrae were potted to allow motion only at the C1-C2 articulation. Cutting the transverse ligament on both sides of the odontoid and the tectorial membrane destabilized the specimens. Transarticular screw fixation of C1-C2 was performed in a manner similar to the technique described by Magerl. The stability was tested after fixation with one transarticular screw together with a posterior graft and wire. Placement of the screw was randomized, resulting in half the specimens receiving screws on the right side and the remaining half on the left side. The stiffness of the C1-C2 articulation was tested in rotation, lateral bending, flexion, and anterior translation in random order. The rotational stiffness was 1.44 +/- 0.44 N-m/deg, while lateral bending stiffness values were 2.33 +/- 1.14 N-m/mm (right bending) and 2.81 +/- 1.36 N-m/mm (left bending). The stiffness value in flexion was 0.813 +/- 0.189 N-m/mm and in translation 67.1 +/- 25.1 N/m. It was found that stability after unilateral transarticular screw fixation was less than that previously reported after bilateral transarticular screw fixation, but similar to that found with modified Brooks posterior wiring, which has been shown to provide better stability than other posterior wiring methods, and fusion rates of 96% have been reported. We concluded that C1-C2 unilateral posterior transarticular screw fixation with supplemental posterior graft and wiring would confer adequate stability in cases where bilateral screw placement is contraindicated.

Aged↗
PubMed1984

Respiratory arrest following posteriorly displaced odontoid fractures. Case reports and review of the literature.

Posterior displacement of the odontoid after fracture occurs much less frequently than does anterior displacement. Experience with four patients suggests that anatomic reduction may not be possible and prolonged attempts to gain reduction are not advisable. Those cases should be managed with early application of a halo vest. A rotating frame should be avoided. The potential for respiratory arrest, at least in the older individual, is great and can be precipitated even by a change of position in the process of turning on the rotating frame. The mechanism of the respiratory failure is obscure.

Accidents, Home↗
PubMed1996

[Clinico-radiologic correlations in common neck pain].

Patients with spontaneous neck pain, headache, dizziness and/or pain to the upper limbs are frequently observed. Common cervicodynia, due to the involvement of arthromuscular structures of the cervical spine, was diagnosed in the patients with these symptoms in the absence of trauma or neurologic signs. The authors investigated the clinical-radiologic correlation in a series of 130 symptomatic patients and considered it a metameric disorder. The frequent association of many radiographic signs at the same level often prevents single radiographic signs from being assessed individually; therefore, the authors selected some patients with just one radiographic change per functional unit, to assess its relationship with clinical symptoms. The patients underwent anteroposterior, lateral and functional (flexion-extension) radiographs of the cervical spine. Vertebral rotation, detected on antero-posterior views as a spinous process deviation, was the most frequent isolated sign (79/130 cases) per metameric level, with strong clinical correlation (70/79 cases). Vertebral rotation was probably due to unilateral muscular stiffness. Other single radiologic signs per functional unit with strong clinical correlation follow: atloaxial rotation (13/130 with clinical-radiologic agreement of 12/13), functional blockage (13/130 with clinical-radiologic agreement of 11/13), angular flexion (21/130 with clinical-radiologic agreement of 19/21) and overall disc space thinning (12/130 with clinical-radiologic agreement of 10/12). Atloaxial rotation is represented as an asymmetry of the spaces between the odontoid and the lateral masses of the atlas; functional blockage consists of insufficient or lacking physiological width of the occipito-atlantoid or interspinous space in functional tests. Angular flexion consists of a single flexion angle of the cervical spine in functional tests; two or more angles indicate normal flexion of the cervical spine. This study confirmed the poorer clinical impact of degenerative changes, mostly interapophyseal arthrosis, than of other radiologic signs. Interapophyseal arthrosis alone was isolated in single functional units in 46/130 patients, mostly at C7-D1, with clinical-radiologic agreement in 19/46 patients. Clinical-radiologic correlation proved the high diagnostic value of anteroposterior, lateral and functional radiographs of the cervical spine in common cervicodynia, which make them a valuable tool for the clinician.

Adolescent↗
PubMed2004

Neck-tongue syndrome.

OBJECTIVE: To discuss a case of neck-tongue syndrome (NTS) affecting a dancer/figure skater, review literature summarizing the pathogenesis and treatment, and offer new categorization of neck-tongue syndrome. CLINICAL FEATURES: A 24-year-old female dancer/skater sought treatment for recurrent episodes of right-sided upper neck pain with associated ipsilateral numbness of her tongue following brisk active rotation. Radiographs revealed a narrowing of the left para-odontoid space. Physical examination revealed a mildly painful restriction in rotation at C1-2 with no apparent muscular hypertonicity. INTERVENTION AND OUTCOME: The patient had sought chiropractic treatment for this condition several times since she was 8 years old. Diversified chiropractic adjustments were applied to restrictions throughout the cervical spine as determined by the clinician. No other interventions were employed. The patient experienced significant improvement in frequency and intensity of the neck and tongue symptoms following spinal manipulative therapy applied to her cervical spine. CONCLUSIONS: There are 2 categories of NTS: complicated NTS due to the presence of an underlying disease process (inflammatory or degenerative) and uncomplicated NTS (idiopathic or trauma-related). This case report is of uncomplicated NTS that responded favorably to spinal manipulative therapy directed at the cervical spine. In the absence of upper cervical instability, spinal manipulative therapy appears to be beneficial and should be considered in all cases of uncomplicated NTS.

Adult↗
PubMed2001

Spontaneous craniocervical osseous fusion resulting from cervical dystonia. Case report.

The authors report on a 31-year-old man with spontaneous craniocervical osseous fusion secondary to cervical dystonia (CD). After an 8-year history of severe CD, the patient developed a fixed rotation of his head to the right. Three-dimensional computerized tomography reconstructions revealed rotation and fixation of the occiput and C-1 relative to C-2, which was similar to that seen in atlantoaxial rotatory fixation. There was abnormal ossification of the odontoid facet joints and ligaments. Additional ossification was observed in the cervical soft tissue bridging the lateral mass of C-1 and the occiput. The patient underwent partial myectomy of the dystonic left sternocleidomastoid muscle and selective posterior ramisectomy of the right posterior neck muscles; postoperatively he experienced relief of his neck pain. In patients with CD refractory to conservative treatment, the appropriate timing of surgical treatment is important.

Adult↗
PubMed1995

The role of frameless stereotactic techniques in the treatment of pediatric CNS lesions.

The surgical management of children with deep-seated lesions within the brain and skull base or with superficial lesions within functionally important regions of the brain is often challenging. In order to optimize the functional outcome of an affected child, it is essential not only to adequately treat the offending lesion, but also to minimize injury to the surrounding brain. In this study, we examined the applicability of a video-interactive frameless stereotactic system for intraoperative localization and treatment of a variety of pediatric central nervous system problems, including craniotomy for tumor (n = 14), vascular malformation (n = 3), or cortical resection for intractable epilepsy (n = 4); ventricular puncture for shunt insertion in a patient with slit ventricles (n = 2); transoral odontoid resection (n = 1); cannulation of a brainstem syrinx (n = 1); removal of a foreign body (n = 1); and posterior craniocervical decompression (n = 1). The efficacy of the system was judged on several criteria: (1) the accuracy of the targeting achieved; (2) whether the system facilitated treatment of the lesions of interest; and (3) whether neurologic function was preserved. In general, the accuracy of the system for target localization was within 2-4 mm when rigid head fixation was employed intraoperatively. In such cases, frameless stereotactic guidance was extremely helpful in providing rapid and reliable assistance with operative planning, which facilitated the treatment of a variety of lesions in critical areas of brain with minimal neurologic morbidity. Limitations of this technology and potential solutions to these shortcomings are discussed. We conclude that the application of frameless stereotaxis for intraoperative localization represents a major advance in the treatment of a variety of intracranial processes in children by providing a means for accurately directing the approach to and removal of a targeted lesion while minimizing injury to the surrounding brain.

Astrocytoma↗
PubMed2003

Are five-view plain films of the cervical spine unreliable? A prospective evaluation in blunt trauma patients with altered mental status.

OBJECTIVES: Clearing the cervical spine in a time-sensitive fashion is difficult. We hypothesized that admission computed tomographic scan of the occiput to T1 (CTS) with multiplanar reformatted images will replace five-view (odontoid, anteroposterior, lateral, and oblique) plain films of the cervical spine (CSX) in the initial evaluation of blunt trauma patients with altered mental status. METHODS: Between January and July 2001, all patients aged 16 years or older with altered mental status undergoing both CTS and CSX were prospectively entered into the study group. Attending physician interpretation defined the presence of cervical spine injury. Unstable fractures were defined as requiring surgical or halo stabilization. RESULTS: One thousand six patients met study criteria. One hundred sixteen patients had 172 cervical spine injuries (CSIs) (fracture and subluxation). CSX missed 90 of 172 (52.3%) CSIs in 65 of 172 (56.0%) patients. Anatomically, CSX failed to identify 14 of 15 occipital fractures (93.3%), 17 of 36 (47.2%) C1-3 fractures, and 59 of 121 (48.8%) C4-T1 CSIs. CSX failed to identify 5 of 29 (17.2%) patients with unstable CSIs. CTS failed to diagnose 3 of 172 (1.7%) CSIs that were stable (spinous process fractures at C6-7). Two patients exhibited spinal cord injury without radiologic abnormality missed by both modalities. CTS had a sensitivity of 97.4%, a specificity of 100%, a prevalence of 11.5%, a positive predictive value of 100%, and a negative predictive value of 99.7%. CSX had a sensitivity of 44.0%, a specificity of 100%, a prevalence of 11.5%, a positive predictive value of 100%, and a negative predictive value of 93.2%. CONCLUSION: CTS outperformed five-view CSX in a group of patients with altered mental status or distracting injuries. Five-view CSX failed to diagnose 52.3% of cervical spine fractures identified by CTS. Five-view CSX failed to diagnose five patients with unstable cervical fractures and failed to identify 93.3% of patients with occipital condyle fractures.

Adult↗
PubMed1989

Halo vest versus spinal fusion for cervical injury: evidence from an outcome study.

The indications for surgical fusion, as opposed to halo fixation, in the management of cervical spine injury are still unclear. At St. Louis University Medical Center a conservative protocol has been adopted to treat almost all cervical spine fractures with halo fixation. To determine what factors have contributed to failure of halo fixation, the records and radiographs of all patients with cervical spine injuries who were treated at that institution between 1984 and 1986 were reviewed. During this interval, 124 patients were treated, consisting of 93 men and 31 women between 6 and 94 years old. Of these, 15 (12%) had cervical fusion without preoperative halo device application. This group included eight patients with old injuries and delayed diagnosis, three with nonreducible locked facets, and four with miscellaneous indications. The remaining 109 patients were treated with halo vests. Four died before completing the 3-month standard treatment. Of those completing the treatment, 48 had C1-2 level injuries and 57 had C3-T1 level injuries. Sixteen patients (15%) failed their halo treatments and required surgical fusion: eight while still in halo fixation and eight after they had completed treatment with a halo device. Failure of halo treatment was indicated by recurrent dislocation in 13 patients and increased neurological deficit in three. Thirteen of the patients who failed treatment had C3-T1 injuries and three had C1-2 injuries. Of 27 patients with odontoid fractures, only two (7.4%) failed halo fixation. There were no failures in 11 patients with hangman's fractures. Of the 57 patients with C3-T1 injuries, 13 (23%) failed treatment, nine of whom had locked or "perched" facets. The factors causing failure of halo fixation were analyzed. The overall success rate was 85%, suggesting that the halo vest can be used to treat most patients with cervical spine injuries. Under certain circumstances (in the presence of old injuries, difficult reduction, or locked or "perched" facets), surgery may be indicated to avoid unnecessary delay in definitive management.

Adolescent↗
PubMed2003

Osteogenesis imperfecta in childhood: MR imaging of basilar impression.

OBJECTIVE: To determine on radiographs the presence of Basilar Impression (BI) in children with Osteogenesis Imperfecta (OI). To confirm this sign and altered geometrical relationships of the craniocervical junction in course of time with magnetic resonance imaging (MRI). METHODS AND PATIENTS: In a cohort study of 130 patients with OI (OI type I: 85; OI type III: 21; OI type IV: 24) lateral radiographs of the skull and cervical spine were made in a standardised way. MRI scans were performed when BI was suspected based upon protrusion of the odontoid above Chamberlain's line. Intracranial abnormalities as well as the basal angle were described. Neurological examination was performed in patients with conclusive BI at MRI-scan. RESULTS AND DISCUSSION: In eight patients BI could be confirmed by MRI-scan. None of the children had or developed in time neurological symptoms or signs. Follow up of BI by MRI scans was done in seven patients (mean: 5 years; range: 2-6 years). No alteration of intracranial findings were seen at subsequent investigation, although in one child Chamberlain's line increased from 8 (first MRI) to 15 mm (last MRI). BI can be diagnosed by radiographs but in the extreme osteoporotic bone and altered anatomy of the craniocervical junction of children with OI MRI is preferable. As intracranial pathology can be demonstrated by MRI, also a relation can be laid to possible neurological symptoms and signs at clinical examination. CONCLUSION: In our cohort study no alteration of the intracranial contents was seen at subsequent MRI scans. Although anatomic deformations exist in BI, no neurological symptoms or signs were present in our study and no operative reconstruction had to be performed. Periodical MRI-scan has not been of influence on the clinical decision making process. At the moment we perform a MRI-scan if BI is suspected at lateral skull radiographs. The MRI images serve as reference findings to anticipate on possible future symptoms and signs of neurological deficit.

Adolescent↗
PubMed1997

Frameless stereotactic guidance for surgery of the upper cervical spine.

OBJECTIVE: The goal was to evaluate and describe the use of a frameless, computed tomography-guided, stereotactic technique in complex procedures involving the craniocervical junction. METHODS: Eleven procedures, including transoral odontoid resection, posterior atlantoaxial fusion with transarticular C1-C2 screw fixation, and spinal tumor resection, were performed in the preceding 26 months. In each case, frameless stereotaxy was used to plan the incision, to define resection margins, and to determine the appropriate orientation of instrumentation. RESULTS: There were no intraoperative complications noted. Each patient underwent adequate resection of the pathological lesion and satisfactory placement of instrumentation. The stereotactic system provided detailed anatomic visualization, which increased the confidence of the surgeon during the procedure. The system limited the need for extensive surgical exposure, reduced fluoroscopy time, and decreased the risk of neurovascular injury. CONCLUSION: Frameless stereotaxy provided the surgeon with intraoperative information regarding the extent of bone and soft tissue resection. It provided a multidimensional view of anatomic relationships in the operative field, which significantly increased surgical accuracy and safety.

Adult↗