Cervical Spine Instability Research Articles

Progression of cervical instabilities in patients with rheumatoid arthritis 5.7 years after their first lower limb arthroplasty

We reviewed 101 rheumatoid arthritis (RA) patients who had undergone their first lower limb arthroplasty between 1990 and 2002. None of the patients had received immunosuppressant or biological drugs. Preoperative and follow-up cervical spine radiographs had been performed (more than 2 years after the arthroplasty). Cervical spine instabilities were found in 62 and 82 patients, and a posterior atlantodental interval (PADI) of <14 mm was present in 20 and 22 patients in the respective radiographs. The presence of cervical spine instabilities and PADI <14 mm were correlated with a higher modified Lansbury index (LI) both preoperatively and at final follow-up. Patients with no cervical spine instability throughout the follow-up had a lower average LI. Patients with atlantoaxial subluxation (AAS), vertical subluxation (VS), and subaxial subluxation (SAS) had more joint arthroplasties at final follow-up compared with other patients. The percentage of patients with single and multiple cervical instabilities increased at final follow-up. The incidence of cervical spine instabilities in RA patients requiring a lower limb arthroplasty is extremely high, with progression of these instabilities after the procedure. There is a correlation between the severity of RA activity in peripheral joints and the severity of cervical spine instabilities.

Fiberoptic intubation through a laryngeal mask airway as a management of difficult airwary due to the fusion of the entire cervical spine - A report of two cases -.

Patients with cervical spine instability and limited range of motion are challenge to anesthesiologists. It is important to consider alternatetive methods for securing the airway while maintaining neutral position and minimizing neck motion, because these patients are at increased risk for tracheal intubation failure and neurologic injury during airway management or position change. We experienced two cases that patients had cervical spine instability and severe limited range of motion due to the fusion of the entire cervical spine. One patient was a 6-year-old girl weighing 12.7 kg and had Klippel-Feil syndrome with Arnold-Chiari malformation, the other was a 24-year-old female weighing 31 kg and had juvenile rheumatoid arthritis. We successfully performed the intubation by using the fiberoptic intubation though a laryngeal mask airway in these two cases.

Airway management in the patient with potential cervical spine instability: Continuing Professional Development

Airway management in the patient with potential cervical spine instability: Continuing Professional Development

Complications of cervical pedicle screw fixation for nontraumatic lesions: a multicenter study of 84 patients

The cervical pedicle screw (PS) provides strong stabilization but poses a potential risk to the neurovascular system, which may be catastrophic. In particular, vertebrae with degenerative changes complicate the process of screw insertion, and PS misplacement and subsequent complications are more frequent. The purpose of this study was to evaluate the peri- and postoperative complications of PS fixation for nontraumatic lesions and to determine the risk factors of each complication. Eighty-four patients who underwent cervical PS fixation for nontraumatic lesions were independently reviewed to identify associated complications. The mean age of the patients was 60.1 years, and the mean follow-up period was 4.1 years (range 6-168 months). Pedicle screw malpositioning was classified on postoperative CT scans as Grade I (< 50% of the screw outside the pedicle) or Grade II (≥ 50% of the screw outside the pedicle). Risk factors of each complication were evaluated using a multivariate analysis. Three hundred ninety cervical PSs and 24 lateral mass screws were inserted. The incidence of PS misplacement was 19.5% (76 screws); in terms of malpositioning, 60 screws (15.4%) were classified as Grade I and 16 (4.1%) as Grade II. In total, 33 complications were observed. These included postoperative neurological complications in 11 patients in whom there was no evidence of screw misplacement (C-5 palsy in 10 and C-7 palsy in 1), implant failure in 11 patients (screw loosening in 5, broken screws in 4, and loss of reduction in 2), complications directly attributable to screw insertion in 5 patients (nerve root injury by PS in 3 and vertebral artery injury in 2), and other complications in 6 patients (pseudarthrosis in 2, infection in 1, transient dyspnea in 1, transient dysphagia in 1, and adjacent-segment degeneration in 1). The multivariate analysis showed that a primary diagnosis of cerebral palsy was a risk factor for postoperative implant failure (HR 10.91, p = 0.03) and that the presence of preoperative cervical spinal instability was a risk factor for both Grade I and Grade II screw misplacement (RR 2.12, p = 0.03), while there were no statistically significant risk factors for postoperative neurological complications in the absence of evidence of screw misplacement or complications directly attributable to screw insertion. In the present study, misplacement of cervical PSs and associated complications occurred more often than in previous studies. The rates of screw-related neurovascular complications and neurological deterioration unrelated to PSs were high. Insertion of a PS for nontraumatic lesions is surgically more challenging than that for trauma; consequently, experienced surgeons should use PS fixation for nontraumatic cervical lesions only after thorough preoperative evaluation of each patient's cervical anatomy and after considering the risk factors specified in the present study.

Clinical guidelines for diagnosing and managing ocular manifestations in children with mucopolysaccharidosis

The mucopolysaccharidoses (MPS) are a group of rare lysosomal storage disorders characterized by the accumulation of glycosaminoglycans in several tissues and organs. This accumulation results in an array of clinical manifestations and premature death in severe cases. Ocular problems are very common in children with MPS and may involve the cornea, sclera, trabecular meshwork, retina, optic nerve and also the posterior visual pathways. The aims of this study are to give an overview of ocular problems in MPS and to provide clinical guidelines for paediatric ophthalmologists for early diagnosis and management of ocular manifestations in children with MPS. Diagnostic problems may arise in children with severe corneal clouding, hampering visualization of the fundus. Intraocular pressures may be falsely high, even leading to suspicion and unnecessary pressure-lowering treatment. Simple interventions such as the use of prescription glasses or photochromatic glasses can considerably improve quality of life in children with MPS.

Translaminar screws of the axis—an alternative technique for rigid screw fixation in upper cervical spine instability

C2 pedicle screws or transarticular atlantoaxial screws are technically demanding and carry an increased risk of vertebral artery injury. In up to 20% of cases, pedicle and transarticular screw placement is not possible due to a high-riding vertebral artery or very small C2 pedicles in addition to other anatomical variations. Translaminar screws have been reported to rigidly capture posterior elements of C2 and therefore appear to be a suitable alternative. We present our first experiences and clinical results with this new method in two neurosurgical spine centers. Twenty-seven adult patients were treated between 2007 and 2010 in two neurosurgical spine departments with C2 translaminar screw fixation for upper cervical spine instability of various origins (e.g., trauma, tumor, dens pseudarthrosis). Eight patients were men and 19 were women. Mean age was 68.9years. In most cases, translaminar screws were used because of contraindications for pedicle or transarticular screws as a salvage technique. All patients were clinically assessed and had CT scans postoperatively to verify correct screw placement. Follow-up was performed with reexamination on an ambulatory basis. Mean follow-up was 7.6months for all patients. In 27 patients, 52 translaminar screws were placed. There were no intraoperative complications. Postoperatively, we identified four screw malpositions using a new accuracy grading scale. One screw had to be revised because of violation of the spinal canal >4mm. None of the patients had additional neurological deficits postoperatively, and all showed stable cervical conditions at follow-up. Two patients died due to causes not associated with the stabilization technique. The fusion rate for patients with C1/C2 fixation is 92.9%. Translaminar screws can be used at least as an additional technique for cases of upper cervical spine instability when pedicle screw placement is contraindicated or not possible. The current data suggest comparable biomechanical stability and fusion rates of translaminar screws to other well-known posterior fixation procedures. In addition, translaminar screw placement is technically less demanding and reduces the risk of vertebral artery injury.

Airway management in the patient with potential cervical spine instability: Continuing Professional Development

Securing the airway of a patient with a potentially unstable cervical spine (C-spine) is a complex and challenging task. The objective of this continuing professional development module is to review the current knowledge essential for airway management in the face of potential C-spine instability and, at the same time, to underline areas of uncertainty and limitations in the literature. In low-risk patients-defined by strict criteria derived from large multicentre studies-the C-spine can be considered stable or "cleared" without imaging. In all other patients, at least a thin-section computed tomographic examination of the spine from the occiput to T1 should be obtained, including sagittal and coronal multiplanar reconstructed images. Until the C-spine is cleared, it should be immobilized in the neutral position using a rigid cervical collar, sandbags, tape, and a backboard. During airway management, the anterior part of the cervical collar should be removed, and manual in-line stabilization should be applied. Some airway techniques, such as fibreoptic bronchoscopy and the Trachlight(®), have been shown to induce less C-spine movement than direct laryngoscopy; however, the impact of such airway management on outcome is uncertain. Adequate airway management in the patient with potential C-spine injury demands an understanding of C-spine anatomy, the criteria required to clear the C-spine, and the indications, techniques, and pitfalls of C-spine immobilization. When choosing an airway technique, minimization of C-spine motion should be considered, but the method of choice should also incorporate the broader clinical context.

C1–2 instability from os odontoideum mimicking intramedullary spinal cord tumor

Os odontoideum is a common cause of atlantoaxial instability in the pediatric population. The authors present the cases of 2 patients whose initial clinical presentation and MR imaging findings were suggestive of an intramedullary neoplasm, but whose ultimate diagnosis was determined to be cervical spine instability and cord injury due to os odontoideum.

Stable reconstruction using halo vest for unstable upper cervical spine and occipitocervical instability

Upper cervical or occipitocervical disorders such as rheumatoid arthritis present as atlantoaxial subluxation, vertical subluxation of the axis, and subaxial subluxation, which produce myelopathy and severe pain. In such cases, occipitocervical reconstruction surgery may be indicated, and several reports have described reduction of subluxation by fixing the halo vest before this surgery. The purpose of this study was to evaluate the efficacy of using the halo vest before the surgery for unstable upper cervical spine and for occipitocervical instability. Twenty-eight patients (9 men and 19 women; mean age, 61.8 years at surgery) who presented with atlantoaxial or occipitocervical fusion were studied. In all cases, the halo vest was fixed in the conscious condition, and subluxation was reduced before the surgery. The mean follow-up period was 45 months. Roentgenologic measurement and clinical evaluation were performed before the surgery and at the final follow-up. Using the halo vest resulted in significant reductions in the atlantodental interval, the space available for the spinal cord, and the Ranawat value (p < 0.05), and these were maintained until the final follow-up. The mean Japanese Orthopedic Association score significantly improved from 9.5 before surgery to 12.2 at the final follow-up (p = 0.01). Nineteen cases (68%) improved by more than 1 grade by Ranawat's classification after surgery and 16 cases (57%) maintained the same at the follow-up visit. Conscious preoperative reduction using the halo vest for occipitocervical disorders is a useful and safe technique.

A New Algorithm for Pediatric Airway Management Using the Intubating Laryngeal Airway

Objective: 1) Evaluate the use of the intubating laryngeal airway (ILA) in providing safe endotracheal intubations in pediatric patients with difficult airways. 2) Present a management algorithm using direct laryngoscopy, rigid bronchoscopy, and the ILA for evaluating and securing the airway in pediatric patients with difficult airways. Method: The medical records of patients in whom the ILA was used to secure the airway from January 2009 to January 2011 were reviewed. We documented the circumstances necessitating airway management, success of the ILA, airway evaluation findings, and medical conditions contributing to the difficult airway. Results: A total of 50 patients had an ILA placed for airway management. Nine out of 50 (18%) were performed emergently. The median age was 59.8 months (range, 0.3-244.1 months), and the median weight was 19.0 kg (range, 2.6-86 kg). Four cases (8%) were unanticipated difficult airways, and 46 out of 50 (92%) were anticipated difficult airways. Comorbid conditions included craniofacial syndromes (n = 36), cervical spine instability or immobility (n = 9), and airway hemorrhage (n = 3). A total of 48 out of 50 (96%) patients were intubated on the first attempt through the ILA. In 2 patients intubation required a second attempt. The overall success rate using the ILA to secure the airway was 100%. Conclusion: ILA is safe and effective in pediatric patients with a difficult airway as a conduit for tracheal intubation. Our proposed algorithm for difficult pediatric airway provides a safe means for anesthesiologists and otolaryngolgists to evaluate and secure the airway in these patients.

Cervical Spine Instability following Resection of Benign Intradural Extramedullary Tumours in Children

Background: Benign intradural extramedullary (IDEM) tumours in children are usually neural sheath derivatives or are dura based. Total resection of these benign tumours is the primary surgical goal. A management issue related to their occurrence in the growing paediatric spine is a higher propensity for the development of postlaminectomy kyphosis, especially in the upper cervical spine, than what is seen in adults. Methods: A retrospective study was performed on 22 patients to analyse the incidence, presentation and management of postoperative kyphotic deformities in children who underwent laminotomy and tumour excision for benign cervical IDEM tumours. Results: The incidence of postoperative kyphosis was 13%. All these patients underwent subsequent posterior fusion following reduction of the deformity with good results. Conclusion: Following excision of cervical intradural lesions, paediatric patients need to be followed up regularly to rule out the development of postsurgical deformities especially in the upper cervical spine region. Various biomechanical, surgical and tumour-related factors which influence the development of deformities are reviewed.

Occipitocervicothoracic stabilization in pediatric patients

Although rarely encountered, pediatric patients with severe cervical spine deformities and instability may occasionally require occipitocervicothoracic instrumentation and fusion. This case series reports the experience of 4 pediatric centers in managing this condition. Occipitocervical fixation is the treatment of choice for craniocervical instability that is symptomatic or threatens neurological function. In children, the most common distal fixation level with modern techniques is C-2. Treated patients maintain a significant amount of neck motion due to the flexibility of the subaxial cervical spine. Distal fixation to the thoracic spine has been reported in adult case series. This procedure is to be avoided due to the morbidity of complete loss of head and neck motion. Unfortunately, in rare cases, the pathological condition or highly aberrant anatomy may require occipitocervical constructs to include the thoracic spine. The authors identified 13 patients who underwent occipitocervicothoracic fixation. Demographic, radiological, and clinical data were gathered through retrospective review of patient records from 4 institutions. Patients ranged from 1 to 14 years of age. There were 7 girls and 6 boys. Diagnoses included Klippel-Feil, Larsen, Morquio, and VATER syndromes as well as postlaminectomy kyphosis and severe skeletal dysplasia. Four patients were neurologically intact and 9 had myelopathy. Five children were treated with preoperative traction prior to instrumentation; 5 underwent both anterior and posterior spinal reconstruction. Two patients underwent instrumentation beyond the thoracic spine. Allograft was used anteriorly, and autologous rib grafts were used in the majority for posterior arthrodesis. Follow-up ranged from 0 to 43 months. Computed tomography confirmed fusion in 9 patients; the remaining patients were lost to follow-up or had not undergone repeat imaging at the time of writing. Patients with myelopathy either improved or stabilized. One child had mild postoperative unilateral upper-extremity weakness, and a second child died due to a tracheostomy infection. All patients had severe movement restriction as expected. Occipitocervicothoracic stabilization may be employed to stabilize and reconstruct complex pediatric spinal deformities. Neurological function can be maintained or improved. The long-term morbidity of loss of cervical motion remains to be elucidated.

Solution for the Problem of Difficult Respiratory Tract in Planned Orthopaedic Surgery

Methods to solve the situation of difficult intubation in planned orthopaedic surgery are presented. Total number of 101 patients with problematic conventional tracheal intubation due to various orthopaedic pathology (Bekhterev's disease, abnormality of development or posttraumatic instability of cervical spine, etc.) was studied. In 49 patients tracheal intubation was performed using laryngeal mask LMA C-Trach with videovisualization (main group), in 52 patients - using fiberoptic bronchoscope (control group). The results achieved showed high efficacy of LMA C-Trach technology for solving difficult intubation problem. Application of laryngeal mask was successfully performed even in patients with Hallo-apparatus fixed cervical spine. Unlike fiber bronchoscope insertion placing of laryngeal mask was atraumatic in relation to stomatopharynx and enabled to perform adequate pulmonary ventilation till tracheal intubation. Videovisualization ensured accurate localization of trachea and its intubation with atraumatic reinforced tube under visual control. Only in 2 patients use of that technology failed and it was related to the bleeding from tonsils after multiple unsuccessful attempts of trachea intubation using direct laryngoscopy. Above described technique is not only a highly effective method for solving the problem of difficult intubation but decreases psychologic strain of the anesthesiologic team.

Comparative Analysis of Cervical Spine Management in a Subset of Severe Traumatic Brain Injury Cases Using Computer Simulation

BackgroundNo randomized control trial to date has studied the use of cervical spine management strategies in cases of severe traumatic brain injury (TBI) at risk for cervical spine instability solely due to damaged ligaments. A computer algorithm is used to decide between four cervical spine management strategies. A model assumption is that the emergency room evaluation shows no spinal deficit and a computerized tomogram of the cervical spine excludes the possibility of fracture of cervical vertebrae. The study's goal is to determine cervical spine management strategies that maximize brain injury functional survival while minimizing quadriplegia.Methods/FindingsThe severity of TBI is categorized as unstable, high risk and stable based on intracranial hypertension, hypoxemia, hypotension, early ventilator associated pneumonia, admission Glasgow Coma Scale (GCS) and age. Complications resulting from cervical spine management are simulated using three decision trees. Each case starts with an amount of primary and secondary brain injury and ends as a functional survivor, severely brain injured, quadriplegic or dead. Cervical spine instability is studied with one-way and two-way sensitivity analyses providing rankings of cervical spine management strategies for probabilities of management complications based on QALYs. Early collar removal received more QALYs than the alternative strategies in most arrangements of these comparisons. A limitation of the model is the absence of testing against an independent data set.ConclusionsWhen clinical logic and components of cervical spine management are systematically altered, changes that improve health outcomes are identified. In the absence of controlled clinical studies, the results of this comparative computer assessment show that early collar removal is preferred over a wide range of realistic inputs for this subset of traumatic brain injury. Future research is needed on identifying factors in projecting awakening from coma and the role of delirium in these cases.

Clipping of a Cerebral Aneurysm in a Patient With Loeys-Dietz Syndrome: Case Report

his is the first case report of clipping a cerebral aneurysm in a patient with Loeys-Dietz syndrome (LDS). LDS is a newly described autosomal dominant connective tissue disease with systemic vascular involvement. Unique to this syndrome is the development of aneurysms at a young age with the propensity of dissection or rupture at a stage that is earlier than when surgical intervention is typically indicated. We describe the nuances in intraoperative and postoperative management. A 31-year-old woman who recently received a diagnosis of with LDS type II presented to neurosurgical attention for management of an unruptured right ophthalmic artery aneurysm. The patient underwent a right pterional craniotomy for clipping of the aneurysm, with lumbar drain placement before the procedure. Papaverine had to be used several times to counteract vasospasm of the vessels during arachnoid dissection. Because of vascular reactivity, temporary clipping was not used, and the aneurysm was clipped successfully. LDS is a newly described disorder that warrants awareness in the neurosurgical community because of its association with intracerebral aneurysms as well as craniosynostosis (19%), scoliosis (20%), cervical spine instability (7%), hydrocephalus, and Arnold-Chiari malformation. When clipping aneurysms in these patients, the surgeon should be aware of the potential for severe vascular reactivity during dissection and avoid temporary clipping when possible. Avoidance of lumbar drainage intraoperatively reduces the risk of intracranial hypotension after removal.

Cervical Spinal Cord, Root, and Bony Spine Injuries

The aim of this study was to characterize cervical cord, root, and bony spine claims in the American Society of Anesthesiologists Closed Claims database to formulate hypotheses regarding mechanisms of injury. All general anesthesia claims (1970-2007) in the Closed Claims database were searched to identify cervical injuries. Three independent teams, each consisting of an anesthesiologist and neurosurgeon, used a standardized review form to extract data from claim summaries and judge probable contributors to injury. Cervical injury claims (n = 48; mean ± SD age 47 ± 15 yr; 73% male) comprised less than 1% of all general anesthesia claims. When compared with other general anesthesia claims (19%), cervical injury claims were more often permanent and disabling (69%; P < 0.001). In addition, cord injuries (n = 37) were more severe than root and/or bony spine injuries (n = 10; P < 0.001), typically resulting in quadriplegia. Although anatomic abnormalities (e.g., cervical stenosis) were often present, cord injuries usually occurred in the absence of traumatic injury (81%) or cervical spine instability (76%). Cord injury occurred with cervical spine (65%) and noncervical spine (35%) procedures. Twenty-four percent of cord injuries were associated with the sitting position. Probable contributors to cord injury included anatomic abnormalities (81%), direct surgical complications (24% [38%, cervical spine procedures]), preprocedural symptomatic cord injury (19%), intraoperative head/neck position (19%), and airway management (11%). Most cervical cord injuries occurred in the absence of traumatic injury, instability, and airway difficulties. Cervical spine procedures and/or sitting procedures appear to predominate. In the absence of instability, cervical spondylosis was the most common factor associated with cord injury.

New Perioperative Cervical Injury

New Perioperative Cervical Injury

Défaut de fusion corporéo-pédiculaire bilatéral de C7

We expose the case of a 48-year-old woman suffering of a chronic bilateral C7 radiculalgy and bilateral C7 failure of fusion between pedicles and body. According to spine embryogenesis we bring three hypothesis to explain this failure of fusion. Then we show that bilateral C6–C7 foraminal compression can arise from local cervical spine instability due to C7 and disk development abnormalities. The treatment proposed is dissectomy bone graft and anterior osteosynthesis leading to clinical and radiological good results. The patient went back to work after three months.

Safety of Spinal Anesthesia in a Patient with Achondroplasia for Cesarean Section

Controversial reports exist regarding the administration of spinal anesthesia in achondroplastic dwarfs regarding safety, dose, drug choice, in obstetric patients. Bony characteristics such as vertebral anomalies, lordosis and lumbar scoliosis, limited mouth opening and cervical spine instability make the administration of anesthesia to these patients truly a challenge. Here we demonstrate that low dose meperidine and bupivacaine spinal anesthesia in an achondroplastic parturient for cesarean section, was administered successfully after careful evaluation, consideration of risks, and awareness of potential complications.

Diagnosing Cervical Spine Instability: Role of the Post-Computed Tomography Scan Out-of-Collar Lateral Radiograph

Cervical spine injuries may have devastating neurological consequences, which makes accurate diagnosis of injury a key part of the trauma evaluation. Imaging plays a significant role in making the diagnosis and guiding management. Current American College of Radiology Appropriateness Criteria guidelines recommend computed tomography (CT) of the cervical spine with multi-planar reformats as the highest-rated imaging examination for patients meeting clinical criteria, without subsequent need for further imaging with a negative scan in a neurologically intact and non-obtunded patient. Although CT is fast and accurate for evaluation of bony injury, it may overlook ligamentous injury. We report a case in which ligamentous instability was demonstrated as subluxation with an out-of-collar lateral radiograph after a CT scan showed no subluxation or fracture in a patient without neurological deficits. Our Radiology Department routinely performs an out-of-collar lateral radiograph after a negative CT scan, and this case suggests that there may be an important role for this practice. Magnetic resonance is the optimal study for soft tissue and ligamentous evaluation; however, a simple lateral out-of-collar radiograph after CT clearance, in an otherwise neurologically intact and non-obtunded patient, may be a quick and cost-effective means to assess for instability of the cervical spine.