Journal of Craniovertebral Junction and Spine最新文献

Introduction: The options for the management of type II odontoid fractures in young patients include anterior screw fixation, posterior spinal fusion, or halo-vest immobilization (HVI). However, there is a recent trend away from nonoperative management and an increase in primary operative stabilization across several centers. Hence, our study aims to compare the functional and radiological outcomes of type II odontoid fractures in young patients managed with HVI and surgery.

Materials and methods: A retrospective analysis of 70 patients with type II odontoid fracture who were managed in our institution with a mean age of 47 years was included in our study. The clinical details included the Neck Disability Index (NDI), Visual Analog Scale (VAS) for neck pain, and S-Range of Movement (ROM)-Neck score. Radiological details included union status, atlanto-dens interval, amount of displacement and angulation, and transverse ligament injury. Both the clinical and radiological parameters were compared between the patients who underwent HVI (n = 28) and surgery (n = 42).

Results: The mean ± standard deviation follow-up duration was 4.2 ± 2.5 years in the HVI group and 3.8 ± 2.7 years in the surgery group. Of the clinical parameters, the S-ROM-Neck score was significantly better in the HVI group than in the surgery group (P < 0.001). The length of hospitalization was much shorter in the HVI group (P < 0.001). There were no differences in NDI, VAS for neck pain, and other radiological parameters.

Conclusion: For type II odontoid fractures in young patients, HVI had better clinical outcomes compared to the surgery and should be considered the first line of management.

Background: There are still no consensus criteria on how to select the lower instrumented vertebra (LIV) for growing rods (GRs) at index surgery. The aim was to evaluate whether the criteria used for adolescent idiopathic scoliosis fusion adapts to early-onset scoliosis (EOS).

Materials and methods: Retrospective analysis of prospectively collected data in a consecutive cohort of patients with EOS treated with GR, expanding from index surgery to 2 years after graduation. The LIV was analyzed regarding its relation to the stable vertebra (SV), substantially touched vertebra (STV), and non-substantially touched vertebra (NSTV). Failure of LIV selection was considered when revision surgery with distal add-on was needed during follow-up.

Results: A total of 13 patients met the inclusion criteria. The mean chronological age was 9.16 years (at index surgery), 12.9 years (at graduation), and 14.9 years (at final follow-up). The most frequent LIV at index surgery was L4 in four cases, closely followed by L2 and L3 with three cases each at the index surgery. The designation of SV, STV, and non-STV (NSTV) was based on standard anteroposterior radiographs. There were six cases where the LIV at growth rod insertion was the SV. Three of these did not require revision of the LIV at graduation. The remaining three which required revision required addition of one level. There were six cases in which the LIV was higher than the SV. Four of these were one level higher, i.e., STV, and two of these NSTV. Those which were at STV did not require revision of the LIV at graduation. Of the two where the initial LIV was NSTV, one required revision down to four levels below, while the other required extension by one level.

Conclusions: For EOS, whenever an SV or STV was chosen, the incidence of revision of LIV was about 30%. The revision required was a distal add-on by one level. If the LIV was any higher than STV, the revision required a distal add-on to more than one level. Choosing a STV or SV as the distal foundation for the construct of EOS correction possibly leads to lesser rates of add-on phenomenon.

Background: Thoracolumbar spine fractures are the most common fracture in the whole spine. Their treatment is often surgical and the posterior approach is the most frequently realized. The aim of this study is to evaluate the clinical recovery and the radiological alignment improvement in thoracolumbar spine patient's trauma operated through posterior approach.

Materials and methods: Retrospective study of 104 thoracolumbar trauma patients operated via posterior approach in our neurosurgery department between 2018 and 2023. Demographic data, clinical, radiological, and surgical characteristics, and outcome were evaluated for each patient.

Results: One hundred and four patients were selected; there were 73 males and 31 females with a mean age of 40.94 years. Most of the patients had no significant medical history and were directly transferred from emergency department. Poly trauma was observed in nearly half of the patients. The most common mechanism of injury was fall from height and secondly road traffic accident. At admission, 70% of patients were classified American Spinal Injury Association (ASIA) E, 12.5% ASIA A, and 17.5% had incomplete neurological deficit. Radiological investigations showed that most fractures are located in the thoracolumbar junction (53.85%) followed by lumbar location (36.55%) and thoracic region (9.6%). Most fractures are classified type A (AO classification) with predominance of subtype A3 and A4, frequently located in the thoracolumbar and lumbar region. All patients were operated through posterior approach with pedicle screw fixation and only 36% had in addition posterior decompression. The mean postoperative hospital stay was 5.4 days. The rate of postoperative complications was 2.9%. At the last follow-up, improvement of incomplete neurological deficit was seen in 80% of cases, and a statistically significant correction of the regional kyphosis angle was observed at the thoracolumbar junction.

Conclusion: The posterior approach with pedicle screw fixation is an effective technique for the treatment of thoracolumbar fracture, leading to a good clinical recovery and radiological satisfactory alignment in most of cases with low rate of complications.

Introduction: Traumatic atlantoaxial joint (AAJ) vertical distraction injuries lie on a spectrum of injury involving the craniocervical junction. Isolated injuries can be unstable, requiring surgical stabilization, a highly morbid procedure given C1-C2 joint's primary role in cervical spine rotation. Previous authors established normative C1-C2 lateral mass values to evaluate for vertical AAJ distraction injuries. However, these studies focus on bilateral AAJ injury, with no data on unilateral or incomplete AAJ injuries. Clinical decision-making regarding these partial injuries is fraught with uncertainty, especially given the possibility of delayed instability. As a result, this study seeks to characterize injury patterns and clinical courses of patients with incomplete or unilateral AAJ injuries.

Methods: After receiving Institutional Review Board approval, all magnetic resonance imaging (MRI) and computed tomography (CT) radiology reads from January 1, 2006, to August 1, 2021, at our Level I Trauma Center were queried for the following terms: edema, disruption, avulsion, tear, distraction, or subluxation and transverse ligament, AAJ, or C1-C2 joint, resulting in 2779 patients. Inclusion criteria consisted of age greater than 18 years old, history of recent traumatic injury, and radiographic evidence of unilateral AAJ distraction on CT, defined by a unilateral lateral mass index (LMI) >2.6 mm. MRI scans were classified based on the extent of soft-tissue injury. Demographic data and clinical outcomes were obtained by chart review and summarized using descriptive statistics.

Results: Five patients comprised this study: 3 males and 2 females with an average age of 51 years. Four patients were injured by motor vehicle accident and 1 due to fall from standing height. Three patients had concomitant orthopedic extremity fractures requiring operative fixation. The average LMI of the involved joint was 4.2 mm versus 2.0 in the contralateral joint. On MRI, 3 patients exhibited bilateral AAJ effusions. No patients demonstrated complete injury of associated ligaments. All patients were treated conservatively with a rigid cervical collar. No patients demonstrated late instability at an average radiographic follow-up of 876 days.

Conclusion: Unilateral or incomplete AAJ vertical distraction injuries lie on a spectrum of injury involving the craniocervical junction and more specifically the C1-C2 articulation. MRI is essential to evaluate the ligamentous stabilizers of the craniocervical junction prior to any treatment decisions, but in the absence of an unstable ligamentous injury, incomplete or unilateral vertical distraction injuries can be safely managed conservatively. This study is one of few to examine unilateral ligamentous injury between the atlas and axis of the spine. This study shows that in the absence of injury instability, these injuries can successfully be

Background: Pedicle screw augmentation with polymethylmethacrylate (PMMA) is a technique used to reduce the risk of pedicle screw pullout, loss of screw fixation, and implant failure in patients at high risk of mechanical complications.

Study design: This was a retrospective observational study.

Objective: The objective of this study was to describe a modification of the classic augmentation technique of conventional pedicular screw instrumentation in spinal surgery.

Methods: A retrospective analysis was performed on 47 patients over the age of 65 years who underwent spinal surgery using the proposed cement augmentation technique and were followed for 2 years. High-viscosity cement was injected into tapped vertebral pedicles, followed by the insertion of traditional pedicle screws. Patient selection was based on detailed preoperative clinical and imaging evaluations. Outcomes measured included the rate of complications, particularly cement leakage (CL), and the occurrence of neurological or vascular deficits.

Results: A total of 47 patients were treated with 700 conventional screws. A total of 26/700 screws (3.71%) showed CL. According to the modified Yeom classification for CL, 9/700 (0.71%) were type S, 9/700 (0.71%) were type B, and 8/700 (0.57%) were type I; there were no neurological or vascular complications. There were no mechanical complications at 2 years.

Conclusions: This modified augmentation technique for conventional pedicle screws is an alternative for spinal instrumentation in elderly patients with a low incidence of clinically significant complications and also reduces procedure time by facilitating pedicle screw placement.

Background and objectives: Ponticulus posticus (PP), also known as arcuate foramen or Kimmerle's anomaly, is an atlas (C1) bone anomaly in the form of a bone bridge. This study aims to determine the prevalence of PP in two hospitals in Surabaya, Indonesia, and to determine the risk factors for PP and its impact on the thickness of the C1 lamina.

Materials and methods: We conducted a retrospective analysis using a total sampling technique of computed tomography scan results from 121 patients at Dr. Soetomo Surabaya Hospital's and Mitra Keluarga Surabaya Hospital's Department of Neurosurgery. The study included patients aged 18 and aging who met the inclusion criteria. We assessed the relationship between C1 morphological characteristics and PP prevalence, with particular focus on laminar thickness measurements.

Results: The study found a prevalence of PP of 15.7%. The mean thickness of the posterior arch lamina with PP was 3.3 ± 0.95 mm on the right side and 3.4 ± 1.0 mm on the left side. Although these figures are not statistically significant, both were thinner than the lamina without PP. The study also found that the prevalence of PP increases with age, with a significant value of P < 0.001.

Conclusions: The average thickness of the posterior lamina arch containing PP has a smaller value but is not statistically significant. In this study, significant statistical results were obtained to suggest that the prevalence of PP increases with age (degenerative).

Study design: Literature review.

Objectives: Review prehabilitation techniques used for elective spine surgery to create a comprehensive list of recommendations.

Methods: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines by searching three electronic databases from 1997 to 2021. Pertinent literature reporting information on prehabilitation, applicable to spine surgery, was identified. Seventy studies were selected for further analysis. Findings from the literature were reinforced by practices employed by the authors.

Results: Preoperative smoking cessation should be achieved 3-4 weeks before elective spine surgery. Preoperative weight loss programs to reach a goal BMI <35 kg/m² may be a viable solution to minimize wound complications and surgical site infections. To minimize the negative impact of cardiopulmonary comorbidities, patients can enroll in an exercise program prior to surgery. Patients should abstain from alcohol before elective spine surgery. Patients with osteoporosis may benefit from supplementation with Vitamin D, calcium, and parathyroid hormone. Opioids should be weaned to complete cessation 6-8 weeks before surgery. Preoperative cognitive behavioral therapy (CBT) and education seem to be the most beneficial in reducing complications associated with psychiatric comorbidities. Patients should engage in a comprehensive prehabilitation regimen.

Conclusion: Targeting patient risk factors with personalized interventions can improve postoperative outcomes in patients undergoing elective spine surgery.

Study design: Retrospective review of a single institution cohort.

Objective: To assess the injury characteristics and outcomes in patients who suffered trauma to the cervical spine and vertebral artery injury (VAI).

Methods: This was a retrospective study of patients admitted to our trauma center with osseous or ligamentous cervical spine injury and VAI. Imaging findings were reviewed to classify the fracture types and fracture extension into transverse foramina was noted. Electronic medical records were reviewed to capture the mechanism of injury, discharge disposition, neurologic status, and mortality. Kaplan-Meier analysis was performed to determine the mean survival time and cumulative survival rate.

Results: Ultimately, 30 patients were included for the analysis. The mean age was 56 years old (range: 18-91 years). There were four major subgroups of cervical injuries: unilateral facet fractures (9 patients, 30%), occipital-cervical junction fractures (15 patients, 50%), translation or distraction injuries (3 patients, 10%), and injuries without extension into transverse foramina (20 patients, 67%). Left-sided VAIs were more common than right-sided (60% vs. 37%). Twelve patients (40%) initially presented with neurological symptoms. Nine patients (30%) died by final follow-up; the mean survival time for the cohort was 704.5 days (95% confidence interval: 440.1-968.9 days).

Conclusion: The laterality of facet fractures and fractures extending into the transverse foramina are associated with VAI sidedness. Various mechanisms may account for injury presentation, including rotation and hyperflexion. Given that patients may initially present without neurologic deficits, it is recommended that cervical trauma protocols integrate computed tomography angiography to reduce morbidity and mortality.

Introduction: The susceptibility of the thoracolumbar junction to injury is attributed mainly to the transition from a relatively rigid thoracic kyphosis to a more mobile lumbar lordosis that occurs at thoracic T11 to lumbar L2 level.

Materials and methods: We present our experience of management of 87 patients of single-level injury who presented with or without neurological deficit between March 2014 and October 2018. All adult patients (18-59 years) were included who were selected for management by single-level posterior transpedicular fixation and followed up for a minimum of 12 months.

Results: The male-to-female ratio in our study was 6.3:1 with a mean age of 32 years. Forty-eight percent were in the work-productive age group of 31-40 years. The L1 vertebra was the most commonly fractured (47%) followed by D12, L2, and D11 vertebra, respectively. Thoracolumbar injury classification severity score 6 was the most common score at presentation. More than 80% patients had some degree of neurological deficit on American Spinal Injuries Association grading with Grade C being the most common pattern of presentation of spinal cord neurological deficit. About 25% patients had some degree of neurological improvement at 12 months follow-up. Among them, 10% achieved an ambulatory status from a bed-ridden status signifying the importance of surgical management in appropriately selected patients.

Conclusions: Single-level transpedicular fixation can be offered to a group of selected patients for rehabilitative purposes. This is the largest study discussing only junctional thoracolumbar injuries and also outcomes in single-level posterior instrumentation.