Surgical treatment for rheumatoid neck arthritis bilateral occipitospinal fusion with plate fixation

The results of surgical treatment of 12 patients with rheumatoid cervical spine arthritis were reviewed. The Ranawat classification was as follows: 5 with Ranawat IIIB, 1 Ranawat IIIA and 6 Ranawat II. Decompression and fusion using autogenous iliac bone graft and double occipitospinal plate fixation was carried out on 11 of these patients; the remaining patient underwent upper cervical spine fusion using screw and wire fixation. The main indication for surgery was neurological deterioration. In three cases previous surgery had been carried out on the cervical spine. The results were assessed at a mean follow-up of 26.1 months. According to Frankel's grading the neurological recovery in patients with neurological compression was one grade. There was clinical and radiological evidence of fusion in all these patients. The following complications required further surgery: acute postoperative epidural hematoma (one patient) screw loosening (one patient) CONCLUSION: Fusion of the occiput and lateral mass of the involved cervical spine using a plate on each side provides a relatively stable fixation in patients with rheumatoid arthritis of the cervical spine. Laminectomy and adequate decompression of the neural elements can be carried out without compromising spinal stability. There is a relatively high complication rate associated with surgery for rheumatoid neck and the patient needs to be informed.     

Mid-term results of computer-assisted cervical reconstruction for rheumatoid cervical spines

Study design

A retrospective single-center study.

Summary and background

We routinely have used C1–C2 transarticular and cervical pedicle screw fixations to reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions. However, there is little data on mid-term results of surgical reconstruction for rheumatoid cervical disorders, particularly, cervical pedicle screw fixation.

Objectives

The purpose of this study was to evaluate the mid-term surgical results of computer-assisted cervical reconstruction for such lesions.

Methods

Seventeen subjects (4 men, 13 women; mean age, 61 ± 9 years) with RA cervical lesions who underwent C1–C2 transarticular screw fixation or occipitocervical fixation, with at least 5 years follow-up were studied. A frameless, stereotactic, optoelectronic, CT-based image-guidance system, was used for correct screw placement. Variables including the Japanese Orthopaedic Association (JOA) score, Ranawat class, EuroQol (EQ-5D), atlantodental interval, and Ranawat values before, and at 2 and 5 years after surgery, were evaluated. Furthermore, screw perforation rates were evaluated.

Results

The lesions included atlantoaxial subluxation (AAS, n = 6), AAS + vertical subluxation (VS, n = 7), and AAS + VS + subaxial subluxation (n = 4). There was significant neurological improvement at 2 years after surgery, as evidenced by the JOA scores, Ranawat class, and the EQ-5D utility weight. However, at 5 years after surgery, there was a deterioration of this improvement. The Ranawat values before, and at 2 and 5 years after surgery, were not significantly different. Major screw perforation rate was 2.1 %. No neural and vascular complications associated with screw insertion were observed.

Conclusions

Subjects with rheumatoid cervical lesions who underwent C1–C2 transarticular screw fixation or occipitocervical fixation using a pedicle screw had significantly improved clinical parameters at 2 years after surgery. However, there was a deterioration of this improvement at 5 years post surgery.     

Occipitocervical stabilization for myelopathy in patients with rheumatoid arthritis. Implications of not bone-grafting

BACKGROUND: Approximately 0.9 percent of the white adult population of the United States and 1.1 percent of the adult population in Europe are affected by seropositive rheumatoid arthritis. As many as 10 percent of those patients may need an operation for atlantoaxial subluxation. Severe instability, especially when associated with vertical subluxation of the odontoid process, can result in progressive cervical myelopathy. Typically, occipitocervical fixation has been performed for these patients with use of autograft bone to achieve long-term stability through a solid fusion. Harvesting the bone graft increases the operative risk to the patient and may result in increased morbidity. In our experience, patients who have had no clear radiographic evidence of fusion following use of occipitocervical instrumentation seemed to have done as well as those who have had obvious fusion. One assumption is that the clinical improvement might be attributable simply to stabilization of the joint rather than to osseous fusion. A longitudinal study was performed on patients with rheumatoid arthritis who required an operation because of craniocervical or upper cervical instability. METHODS: The results of clinical, radiographic, functional, and self-evaluations were studied to determine the efficacy of treatment and to compare the outcomes of bone-grafting with those of procedures done without bone-grafting in a group of 150 patients who underwent posterior occipitocervical stabilization with use of a contoured metal implant (a Ransford loop) that was affixed by sublaminar wires. Internal fixation was performed in 120 patients without bone-grafting and in thirty patients with use of autogenous bone-grafting. Preoperatively, 23 percent (thirty-five) of the 150 patients had mild neurological involvement (class II, according to the system of Ranawat et al.), 45 percent (sixty-eight) had objective findings of weakness and long-tract signs but were able to walk (class III-A), and 29 percent (forty-three) were quadriparetic and unable to walk (class III-B). The age of the patients at the time of the operation ranged from twelve to eighty-three years (mean, sixty-two years). RESULTS: There were significant improvements in postoperative Ranawat classes at all time-periods (range, p < 0.00005 to p = 0.0066) and in patient ratings of neck pain (range, p < 0.00005 to p = 0.0044) compared with preoperative scores. With the numbers available, there were no significant differences between the patients managed with a graft and those managed without grafting with respect to survival after the operation, Ranawat class, head or neck-pain rating, presence of subaxial abnormalities, radiographic craniovertebral motion, or vertical subluxation. Overall mortality at one month was 10 percent (fifteen of 150), although this value varied directly with the degree of preoperative disability. A second cervical spine operation was required in 11 percent (sixteen) of the 150 patients. CONCLUSIONS: While patients who have rheumatoid disease with anterior atlantoaxial subluxation should be treated with posterior atlantoaxial arthrodesis with use of bone-grafting and internal fixation, we believe that those who present with vertical instability and multi-level involvement can be treated with posterior occipitocervical stabilization with use of a contoured occipitocervical loop and sublaminar wire fixation without bone-grafting. Furthermore, we believe that the use of preoperative traction, bone cement, or a postoperative halo vest is unnecessary. Avoiding the harvesting of autogenous bone for grafting reduced the morbidity of this operation without compromising the outcome in these already sick patients.     

Results of a longer than 10-year follow-Up of patients with rheumatoid arthritis treated by occipitocervical fusion

STUDY DESIGN: Evaluation of results a longer than 10-year follow-up of patients with upper cervical lesions due to rheumatoid arthritis who underwent occipitocervical fusion. OBJECTIVE: To determine the final outcome of patients with upper cervical lesions due to rheumatoid arthritis treated by occipitocervical fusion. SUMMARY OF BACKGROUND DATA: There are few studies reporting the final outcome of patients with rheumatoid arthritis treated by occipitocervical fusion and observed for longer than 10 years. METHODS: The subjects were 16 patients with rheumatoid arthritis with myelopathy who underwent occipitocervical fusion with a rectangular rod more than 10 years ago. All 16 patients had irreducible atlantoaxial dislocation, and 11 also had vertical dislocation of the axis. All patients had preoperative nuchal pain, and were classified into Class II (two patients), Class IIIA (nine patients), and class IIIB (five patients) according to Ranawat's preoperative neurologic classification. RESULTS: The atlas-dens interval remained the same as immediately after surgery. Vertical dislocation returned to the preoperative condition, despite successful surgical correction. Preoperative occipital pain disappeared or was reduced in all cases. Myelopathy improved in 12 of the 16 patients (75%) by more than one class in the Ranawat preoperative neurologic classification. Survival rate at 10 years after surgery was 38%; mean age at death was 70.7 years. The postoperative periods during which patients could walk by themselves ranged from 6 months to 13 years (mean, 7.5 years). CONCLUSIONS: Occipitocervical fusion for patients with rheumatoid arthritis is useful for decreasing nuchal pain, reducing myelopathy, and improving prognosis.     

寰枢椎椎弓根螺钉内固定术治疗儿童寰枢椎脱位的初步报告

目的:探讨寰枢椎椎弓根螺钉内固定手术治疗儿童寰枢椎脱位的可操作性和近期疗效。方法:2005年9月~2011年3月对16例儿童寰枢椎脱位患者采用寰枢椎椎弓根螺钉内固定术治疗,男9例,女7例;年龄5～13岁,平均9.1岁。均有枕颈部疼痛、颈部僵硬;3例有高位颈脊髓病表现,ASIA分级:D级2例,C级1例。术前均行颈椎正侧位及过伸过屈位X线片、CT和MRI检查,均诊断为寰枢椎脱位,其中寰椎横韧带断裂1例,寰枢椎骨折脱位1例,先天性齿状突畸形12例,寰枢椎固定旋转半脱位2例;颈脊髓受压5例。寰椎后弓(椎弓根)高度2.5~3.8mm,平均3.0mm;寰齿前间隙6~14mm,平均9mm。术前常规行牵引1~2周复位,完全复位7例,部分复位5例,不能复位4例。术中采用"寰椎椎弓根显露置钉法",在直视下行C1、C2置钉,复位固定,植骨融合。随访患者症状和神经功能改善情况,定期行颈椎X线片及CT复查,了解内固定及植骨融合情况。结果:16例均行双侧寰枢椎椎弓根螺钉内固定,手术过程顺利,64枚螺钉均成功置入,复位固定满意,无术中、术后神经和血管并发症。术中出血150~650ml,平均300ml;手术时间100~190min,平均130min。12例随访12~72个月,平均28.5个月,术后3~6个月寰枢椎均骨性融合;末次随访时,颈枕症状明显改善,3例术前有脊髓功能损害者均好转,2例术前ASIA分级D级者恢复到E级,1例术前ASIA分级C级者恢复到D级;未发现螺钉松动、断钉和寰枢椎再移位现象,未发现曲轴现象。结论:采用"寰椎椎弓根显露置钉法"行寰椎椎弓根螺钉内固定可操作性强,置钉安全性高;寰枢椎椎弓根螺钉内固定治疗儿童寰枢椎脱位的近期疗效满意。     

Upper cervical spine surgery in rheumatoid arthritis: retrospective study of 30 patients followed for two years or more after Cotrel-Dubousset instrumentation

PURPOSE: To evaluate the efficacy of upper cervical spine surgery in symptomatic atlantoaxial instability due to rheumatoid arthritis (RA). MATERIAL AND METHODS: Thirty RA patients (29 women and one man) with a mean age of 56 years were studied retrospectively. Symptomatic forward slippage of the atlas on the axis with a synovial pannus surrounding the odontoid and magnetic resonance imaging evidence of spinal cord compression was present in all 30 patients; 18 patients had vertical translocation of the odontoid and 14 had basilar invagination. Surgery, performed between 1991 and 1997, consisted of occipitocervical fusion in 18 patients and atlantoaxial fusion in 12. Cotrel-Dubousset instrumentation was performed in all 30 patients. RESULTS: Mean follow-up was four and a half years. All patients were satisfied with the procedure and exhibited marked functional gains and objective neurological improvement (by one class in the Ranawat scheme). Stable fusion was documented in all 30 patients. CONCLUSION: Cervical instrumentation and bone grafting seems to provide functional and neurological gains in carefully selected RA patients with atlantoaxial instability and spinal cord compression. Long term follow-up suggests that the benefits are sustained and that morbidity is low.     

Cervifix内固定系统在枕颈融合术中的应用

目的 介绍Cervifix枕颈内固定系统在枕颈融合术中的应用并评价其疗效。方法 对6例由新鲜创伤和25例由陈旧性创伤、先天畸形、类风湿引起的枕颈失稳病例，采用Cervifix系统进行枕颈融合术；随访手术效果。结果 全部病例得到随访，随访时间9～37个月。3l例均获得骨性融合。内固定无松动，移位和断裂等并发症。脊髓神经功能有不同程度恢复。l例在术中发现有椎动脉损伤，术后无相关症状出现。所有病例未出现与内固定有关的神经脊髓损伤和脑脊液漏等并发症。结论 Cervifix系统固定可靠，器械安装方便，手术操作虽有一定难度，但仍是目前枕颈融合内固定的较好方法：     

枕颈融合治疗创伤性上颈椎不稳疗效观察

目的 介绍Cervifix枕颈内固定系统及同种异体骨板在枕颈融合术中的应用并评价其疗效。方法 对22例新鲜创伤和5例陈1日性创伤引起的枕颈不稳病例，采用Cervifix系统内固定，同种异体骨板植骨融合，随访手术效果。结果 全部病例获得随访，随访时间6～42个月，平均18．4个月。全部患者均在术后6个月内取得骨性融合。有脊髓压迫症状者，神经功能均有不同程度的恢复。全部病例未出现脑脊液漏及椎动脉损伤现象。亦无术后出现脊髓压迫症状加重病例。结论 Cervifix系统固定可靠，器械安装方便，是枕颈融合内固定较好的方法；同种异体骨板具有良好的生物相容性、生物力学性能和诱导成骨作用，是一种较好的枕颈部植骨融合材料。     

枕颈部后路手术翻修的原因和对策

目的 :研究和总结枕颈部后路手术翻修的原因并寻求对策。方法 :回顾性研究12例患者 ,男 9例 ,女 3例 ,年龄 2 6～ 69岁 ,平均 47岁 ,对再手术入院病人的症状及X线片进行分析 ,据此分别采用不同的翻修手术。临床症状有局部疼痛、四肢麻木无力、行走不稳等。翻修术采用枕颈部寰椎后弓切除或枕骨大孔扩大减压、取髂骨块行枕颈植骨或C1～ 2 弓间植骨、枕颈部内固定或C1～ 2 间固定。翻修后平均随访 18个月。结果 :翻修的原因包括 ,枕颈融合植骨块吸收 ( 4例 ) ,C1～ 2 植骨块不融合、假关节形成致C1～ 2 不稳 ( 3例 ) ,枕颈部脊髓压迫未减压 ( 2例 ) ,减压不全残余压迫( 2例 ) ,枕颈部内固定松动断裂致枕颈不稳 ( 1例 )。其中因植骨融合失败致再次手术翻修占 5 8.3 % ,未减压或减压不全 3 3 .3 % ,内固定断裂或松动 8.3 %。翻修术后 5例症状缓解 ,6例症状减轻 ,1例改善不明显。结论 :目前枕颈部手术失败的原因主要是植骨不融合或植骨块吸收 ,其次是减压不全 ,第 3位的原因是内固定失败。因此应强调植骨区和植骨块的去皮质和术后的必要制动 ,以及彻底病灶减压。     

Congenital Reducible Atlantoaxial Dislocation: Classification and Surgical Considerations

Summary.  Background: Reducible atlanto-axial dislocation (AAD) may cause severe motor and respiratory compromise due to recurrent spinal cord and/or brain stem impingement. To the best of the authors' knowledge, this is the first study concentrating on the classification, the protocol of the surgical management and the outcome of congenital, reducible AAD.  Methods: 109 patients with congenital, reducible AAD underwent posterior stabilization. Their preoperative disability was graded as: I (n=11, 10.09%) no functional disability (a history of minor trauma led to quadriparesis that subsequently improved); II (n=31, 28.44%) independent for activities of daily living with minor disability; III (n=42, 38.53%) partially dependent on others for their daily needs; and, IV (n=25, 22.93%) totally dependent. They were classified into 4 groups depending upon their association with: a normal odontoid and posterior arch of atlas (n=27); a dysplastic odontoid and normal posterior arch (n=25); an assimilated posterior arch (n=49); and, Arnold Chiari malformation type I (n=8). Nine patients with a dysplastic odontoid had a “hypermobile” AAD with an unrestricted backward and forward movement of the axis relative to the atlas in flexion as well as in extension of the neck, respectively.  The surgical procedures included Brooks' (n=12) or modified Brooks' C1–2 fusion (n=39); Goel's C1–2 fusion (3); Ransford's contoured rod fusion (n=7); Jain's occipitocervical fusion (n=47); and, transoral decompression and Jain's occipitocervical fusion (n=1). There were 6 peri-operative mortalities in the series.  Findings: At follow-up (ranging from 3 months to 6 years; n=86), 64 patients had shown improvement by one grade or more; 8 patients, who had a history of transient quadriparesis but were without neurological deficits at presentation, remained in grade I; 11 had achieved stabilization of neurological functions; while 3 had deteriorated despite adequate radiological reduction of AAD and fusion of the construct. A follow-up of 6 months or more was available in 79 of these 86 patients, in whom a dynamic intrathecal CT scan showed a good osseous union.  Interpretation: The patients with congenital reducible AAD, depending on their surgical management, may be classified into four groups. Some patients with a dysplastic odontoid have a “hypermobile” AAD and require special care during intubation, positioning and stabilization. An assimilated posterior arch is often associated with asymmetrical lateral occipito-C1–C2 joint synostosis rendering transarticular screw placement difficult. The various causes of failure of constructs are discussed. Published online October 31, 2002 Correspondence: Dr. Vijendra K. Jain, MCh, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India.     

Occipitocervical fusion. Indications, technique, and long-term results in thirteen patients

Thirteen patients who underwent occipitocervical fusion that was performed using the same operative technique were followed for an average of 3.6 years (range, two to seven years). The indications for surgery were occipitocervical instability, neurological deficit, or intractable pain that was not responsive to non-operative treatment. Of the thirteen patients, eight had rheumatoid arthritis, two had atlanto-axial osteomyelitis, and one patient each had trauma, ankylosing spondylitis, and atlanto-occipital osteoarthritis. At follow-up, all of the thirteen patients had a solid arthrodesis and relief of severe pain in the neck. Of the ten patients who had had myelopathy preoperatively, all improved, but of four patients who had been unable to walk preoperatively because of severe motor involvement, only one was considered to be able to walk. Of the thirteen patients, ten had a satisfactory result. Occipitocervical arthrodesis using iliac grafts and the wiring technique that is described herein achieves immediate stable fixation, allowing early mobilization with a successful arthrodesis, and it should be undertaken before severe myelopathy occurs in patients who have instability of the cervical spine. The operation may optimize the patient's chances of neurological recovery.     

陈旧性寰枢椎脱位与枕颈不稳的手术治疗

目的　观察两种内固定方法治疗陈旧性寰枢椎脱位与不稳的疗效。方法　自 1992—2 0 0 0年收治 36例陈旧性寰枢椎脱位与枕颈不稳的患者 ,年龄 12～ 6 1岁 ,平均 38岁 ;病程 1个月～ 8年 ,平均 16个月。 2 2例颅骨牵引复位或基本复位的 ,用 Gallie法寰枢椎固定 ,C1～ 2 髂骨植骨。 9例牵引未复位和 5例枕颈区畸形的 ,用 Ransford环固定 ,枕颈区减压 (C0 ～ C2 )和枕颈植骨融合。结果　 1例术后 4天死亡 ,35例随访 3个月～ 4年。寰枢椎固定 2 2例中 2 1例获骨性融合 ,2例复位不满意 ,其中 1例植骨不愈合。Ransford法 13例有 12例骨性融合 ,1例植骨块断裂未愈合 ,但内固定无松动。术后神经功能明显改善。结论　颅骨牵引复位的陈旧性寰枢椎脱位 ,Gallie法寰枢椎固定疗满意。 Ransford环固定对枕颈区减压和枕颈融合能提供可靠的固定作用。     

Spinal fractures in patients with Diffuse idiopathic skeletal hyperostosis:A nationwide multi-institution survey

BackgroundDiffuse idiopathic skeletal hyperostosis (DISH) increases the spine's susceptibility to unstable fractures that can cause neurological deterioration. However, the detail of injury is still unclear. A nationwide multicenter retrospective study was conducted to assess the clinical characteristics and radiographic features of spinal fractures in patients with DISH.MethodsPatients were eligible for this study if they 1) had DISH, defined as flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies, and 2) had an injury in the ankylosing spine. This study included 285 patients with DISH (221 males, 64 females; mean age 75.2 ± 9.5 years).ResultsThe major cause of injury was falling from a standing or sitting position; this affected 146 patients (51.2%). Diagnosis of the fracture was delayed in 115 patients (40.4%). Later neurological deterioration by one or more Frankel grade was seen in 87 patients (30.5%). The following factors were significantly associated with neurological deficits: delayed diagnosis (p = 0.033), injury of the posterior column (p = 0.021), and the presence of ossification of the posterior longitudinal ligament (OPLL) (p < 0.001). The majority of patients (n = 241, 84.6%) were treated surgically, most commonly by conventional open posterior fixation (n = 199, 69.8%). Neurological improvement was seen in 20.0% of the conservatively treated patients, and in 47.0% of the patients treated surgically.ConclusionsMinor trauma could cause spinal fractures in DISH patients. Delayed diagnosis, injury of the posterior column, and the presence of OPLL were significantly associated with neurological deterioration. Patients with neurological deficits or unstable fractures should be treated by fixation surgery.     

Surgical treatment of nonunited fractures of the odontoid process, with special reference to occipitocervical fusion for unreducible atlantoaxial subluxation or instability

Fifty-seven consecutive patients treated surgically for nonunited fractures of the odontoid process were reviewed. All patients presented late, exhibiting neurological deficits subsequent to nonunion. Delay in presentation was between ¶6 and 120 months (mean 32 months) after the original injury, due to missed diagnosis or inappropriate management. Seven patients who were reduced in traction underwent a Gallie atlantoaxial fusion. In the remaining 50 patients who were unreducible, an occipitocervical arthrodesis was performed. They were followed up for a minimum of 2 years, except one who died from postoperative respiratory failure. All patients obtained a solid bony union, including two in whom nonunion occurred following atlantoaxial fusion, and occipitocervical fusion was added as a rescue. Thirty-eight patients achieved excellent neurological recovery, nine still had some disability, five retained their neurological deficits and two reported a deterioration. In two patients, a recurrence in a traumatic episode was experienced long after a resolution. Our findings demonstrate that occipitocervical arthrodesis is preferable for unreducible subluxation or instability of atlantoaxial articulation in nonunion of odontoid fractures.     

Spinal instability in ankylosing spondylitis

Background:

Unstable spinal lesions in patients with ankylosing spondylitis are common and have a high incidence of associated neurological deficit. The evolution and presentation of these lesions is unclear and the management strategies can be confusing. We present retrospective analysis of the cases of ankylosing spondylitis developing spinal instability either due to spondylodiscitis or fractures for mechanisms of injury, presentations, management strategies and outcome.

Materials and Methods:

In a retrospective analysis of 16 cases of ankylosing spondylitis, treated surgically for unstable spinal lesions over a period of 12 years (1995-2007); 87.5% (n=14) patients had low energy (no obvious/trivial) trauma while 12.5% (n=2) patients sustained high energy trauma. The most common presentation was pain associated with neurological deficit. The surgical indications included neurological deficit, chronic pain due to instability and progressive deformity. All patients were treated surgically with anterior surgery in 18.8% (n=3) patients, posterior in 56.2% (n=9) patients and combined approach in 25% (n=4) patients. Instrumented fusion was carried out in 87.5% (n=14) patients. Average surgical duration was 3.84 (Range 2-7.5) hours, blood loss 765.6 (± 472.5) ml and follow-up 54.5 (Range 18-54) months. The patients were evaluated for pain score, Frankel neurological grading, deformity progression and radiological fusion. One patient died of medical complications a week following surgery.

Results:

Intra-operative adverse events like dural tears and inadequate deformity correction occurred in 18.7% (n=3) patients (Cases 6, 7 and 8) which could be managed conservatively. There was a significant improvement in the Visual analogue score for pain from a pre-surgical median of 8 to post-surgical median of 2 (P=0.001), while the neurological status improved in 90% (n=9) patients among those with preoperative neurological deficit who could be followed-up (n =10). Frankel grading improved from C to E in 31.25% (n=5) patients, D to E in 12.5% (n=2) and B to D in 12.5% (n=2), while it remained unchanged in the remaining - E in 31.25% (n=5), B in 6.25% (n=1) and D in 6.25% (n=1). Fusion occurred in 11 (68.7%) patients, while 12.5% (n=2) had pseudoarthrosis and 12.5% (n=2) patients had evidence of inadequate fusion. 68.7% (n=11) patients regained their pre-injury functional status, with no spine related complaints and 25% (n=4) patients had complaints like chronic back pain and deformity progression. In one patient (6.2%) who died of medical complications a week following surgery, the neurological function remained unchanged (Frankel grade D). Persistent back pain attributed to inadequate fusion/ pseudoarthrosis could be managed conservatively in 12.5% (n=2) patients. Progression of deformity and pain secondary to pseudoarthrosis, requiring revision surgery was noted in one patient (6.2%). One patient (6.2%) had no neurological recovery following the surgery and continued to have nonfunctional neurological status.

Conclusion:

In ankylosing spondylitis, the diagnosis of unstable spinal lesions needs high index of suspicion and extensive radiological evaluation Surgery is indicated if neurological deficit, two/three column injury, significant pain and progressive deformity are present. Long segment instrumentation and fusion is ideal.     

Treatment of physeal fractures in children]

The aim of the study was to determine final clinical and radiological results of epiphyseal fractures treated in our hospital. Thirty-five patients were included in the study (6 girls and 29 boys) aged from 5 to 17 years (mean 12.1 years). Follow up ranged from 2 to 20 years. According to Salter and Harris classification system 15 patients had type I and 20 had type II fracture. According to the Neer-Horowitz classification system of the proximal end of humerus one patient had grade III and three had grade IV fracture. Physeal fractures included: proximal end of humerus (n = 4), distal end of radius (n = 16) (with coexistent distal end of ulna fractures in 6 cases), distal end of femur (n = 4), distal end of tibia (n = 3) and distal end fibula (n = 8). Six patients were treated with open reduction and K-wire fixation, three with skeletal traction and cast, one with closed reduction and K-wire fixation and twenty five with closed reduction and cast. Neurovascular deficit was noted in any of our patients at admission and after reduction. During follow-up we did not notice physeal arrest, changes in limbs axis or limb shortening in any of our patients. All our patients had good clinical results. In 2 cases in early postoperative follow-up limitation of shoulder abduction after physeal fracture of proximal humerus was observed. Restoration of proper anatomical conditions is conducive to restore function of growth plate. Kirschner wire fixation did not increase the risk of growth arrest. Physeal injuries at the end of growth did not cause limb axis changes.     

Transoral atlantoaxial reduction plate internal fixation for the treatment of irreducible atlantoaxial dislocation: a 2‐ to 4‐year follow‐up

Objective: To evaluate the mid‐term outcomes of transoral atlantoaxial reduction plate (TARP) internal fixation for the treatment of irreducible atlantoaxial dislocation. Methods: From April 2003 to April 2005, 31 patients with irreducible atlantoaxial dislocation were treated with TARP internal fixation. The average age was 37.9 years (range, 15–69 years). The subjective symptoms, objective signs, and neurological function of the patients were assessed. Radiography and magnetic resonance imaging (MRI) were performed and the results analyzed according to the Symon and Lavender clinical standard, Japanese Orthopaedic Association (JOA) score for spinal cord function and imaging standard for spinal cord decompression. Results: Complete or almost complete anatomical reduction was obtained in all 31 patients. No screw‐loosening or atlantoaxial redislocation was found in 29 cases. According to the Symon and Lavender clinical standard, 14 cases had recovered completely, 7 to mild, 6 to moderate, and 4 to severe type by final follow‐up, compared to the preoperative classifications of 4 as moderate, 15 as severe, and 12 as extra severe type. The outcome for 26 patients was evaluated as excellent and in 5 as adequate. The average postoperative improvement in spinal cord function was 73.3% and of decompression of the cervical cord 92.6%. The only complication was loosening of screws in two cases with senile osteoporosis. One case underwent TARP revision surgery and the other posterior occipitocervical internal fixation. Both of them were eventually cured. Conclusion: The TARP operation is a good choice for patients with irreducible atlantoaxial dislocation and has valuable clinical application.     

Sleep apnea in rheumatoid arthritis patients with occipitocervical lesions: the prevalence and associated radiographic features

Since sleep apnea is a risk factor for high mortality of rheumatoid arthritis (RA) patients, this study examined the prevalence in RA patients with occipitocervical lesions, and the associated radiographic features. Twenty-nine RA patients requiring surgery for progressive myelopathy due to occipitocervical lesions (3 males, 26 females, average age 65 years) were preoperatively evaluated. Twenty-three (79%) had sleep apnea defined as apnea–hypopnea index >5 events per hour measured by a portable monitoring device, and all of them were classified as the obstructive type. Among gender, age, bone mass index (BMI), and radiographic parameters related to occipitocervical lesions: atlantodental interval (ADI), cervical angles (O/C1, C1/2, and C2/6), and cervical lengths (O–C2 and O–C6), the ADI and cervical lengths were shown to be significantly associated with the presence of sleep apnea by parametric statistical analysis. Since there were positive correlations between the ADI and cervical lengths by Pearson’s test, we performed a multivariate logistic regression analysis after adjustment for confounding factors and found that small ADI was the principle parameter associated with sleep apnea. We therefore conclude that the prevalence of sleep apnea is higher than that in a general RA population that was reported previously, and believe that occipitocervical lesions are an independent risk factor for this condition. Small ADI and short neck, secondary to the vertical translocation by RA, may cause obstructive sleep apnea, probably through mechanical or neurological collapse of the upper airway.     

Role of intraoperative Iso-C based navigation in challenging spine trauma

Background:

Pedicle screw fixation is the most preferred method of stabilizing unstable spinal fractures. Pedicle screw placement may be difficult in presence of fractured posterior elements, deformed spine, gross instability and spinal pathology. Challenging spine-fracture fixation is defined as the presence of one or more of the following: 1) obscured topographical landmarks as in ankylosing spondylitis, 2) fractures in occipitocervical or cervicothoracic regions and 3) preexisting altered spinal alignment. We report a series of pedicle screw insertion with guidance of navigation in difficult fixation problems..

Materials and Methods:

Fourteen patients [hangman''s fracture (n=3), odontoid fracture (n=4), C1C2 fracture (n=1) and spinal fracture with coexistent ankylosing spondylitis (n=6)] underwent posterior stabilization. Intraoperatively after surgical exposure, images were acquired by Iso-C 3D C-arm and transferred to navigation system. Instrumentation was performed with navigational assistance. Postoperatively, placements of pedicle screws were evaluated with radiographs and CT scan.

Results:

Sixty-seven pedicle screws (cervical, n=33; thoracic, n=6; lumbar, n=26; sacral n=2) and 15 lateral mass screws were inserted with navigation guidance. The average time of image data acquisition by Iso-C 3D C-arm and its transfer to workstation was 4 minutes (range, 2-6 minutes). Postoperative CT scan revealed ideal placement of screws in 63 pedicles (94%), grade 1 cortical breaches (<2 mm) in 3 pedicles (4.5%) and grade 2 cortical breach (2-4 mm) in one pedicle (1.5%). There were no neurovascular complications. Deep infection was encountered in one case, which settled with debridement.

Conclusions:

Intraoperative Iso-C 3D C-arm based navigation is a useful adjunct while stabilizing challenging spinal trauma, rendering feasibility, accuracy and safety of pedicle screw placement even in difficult situations.     

Treatment strategies and outcome in patients with non-tuberculous spinal epidural abscess--a review of 46 cases.

OBJECTIVES: Spinal epidural abscess (SEA) is a rare disease and its early detection and appropriate treatment is essential to prevent high morbidity and mortality. There are only few single-institution series who report their experiences with the microsurgical management of SEA and treatment strategies are discussed controversially. Within the last 15 years the authors have treated 46 patients with SEA. This comparatively high number of cases encouraged us to review our experiences with SEA focussing on the clinical presentation, microsurgical management and outcome. METHODS: Clinical charts of 46 cases with a spinal epidural abscess treated between 1990 and 2004 were reviewed. There were 30 men and 16 women, the age ranged between 32 and 86 years (mean: 57 years). The clinical mean follow-up was 8.5 months (range: 2-84). The clinical presentation and severity of neurological deficits were measured by the Frankel grading system on admission and on follow-up visit. RESULTS: The abscess was located in the cervical spine in 8, the thoracic spine in 17 and the lumbar spine in 21 patients. On admission 8 patients were in Frankel grade A, 7 in B, 15 in C, 8 in D and 8 in E. During follow-up 1 patient was in Frankel grade A, 1 in B, 5 in C, 13 in D and 24 in E. 37 patients underwent primary microsurgery with abscess drainage or removal of chronic granulomatous tissue. The clinical symptoms in 4 patients worsened shortly after the operation due to a compression fracture of the vertebral body (n=2) or progress of the abscess (n=2) making re-operation necessary. 9 patients with severe critical illness or without neurological deficits had primarily a CT-guided puncture for assessment of the causative organism. 3 of them needed additional surgical therapy within the hospital stay because of a new neurological deficit. All patients were immobilised and treated with antibiotics for at least 6 weeks. The mortality was 6.5%. As for complications we noted septicaemia (n=5), meningitis (n=1) and a transient malresorptive hydrocephalus (n=1). CONCLUSION: Early diagnosis, microsurgical therapy with appropriate antibiotic therapy and careful observation of patients are the keys to successful management of SEA. The goal of surgical treatment is to isolate the causative organism and to perform a decompression at the site of maximal cord compression in cases of neurological deterioration or severe pain. Instrumentation with primary fixation does not seem to be imperative. In cases of post-operative worsening, a fracture of additionally infected bony elements has to be considered and a stabilisation should be discussed on an individual basis.