Cervical Spine Instability Research Articles

The Shikani Optical Stylet as an Alternative to Awake Fiberoptic Intubation in Patients at Risk of Secondary Cervical Spine Injury: A Randomized Controlled Trial.

Conventional intubation of the trachea and consequent prone positioning of anesthetized patients with cervical spine instability may result in secondary neurological injury. Historically, flexible fiberoptics used to be the chief choice for patients presenting with cervical spine instability surgery with difficult airway. Recently, the rigid optical stylets have shown promise in assisting difficult intubations. The aim of the present study was to compare the efficacy of Shikani optical stylet (SOS) with the flexible fiberscope for awake intubation in patients with cervical spine instability. In total, 60 adult patients diagnosed with cervical instability or at risk of secondary cervical injury, who were planned for awake intubation and/or self-positioning prone, were registered in this study and were randomly categorized into 2 equal groups (30 patients each), a fiberoptic group and an SOS group, followed by assessment of coughing and gagging during intubation, time to successful intubation, number of attempts for successful intubation, and hemodynamic parameters. As regards time to successful intubation, statistically significant differences were detected between the 2 studied groups, with the fiberoptic group having significantly longer intubation time than the Shikani group, whereas no statistically significant differences were recorded between the 2 groups with regard to the first-attempt success, the mean heart rate value, the mean arterial blood pressure, coughing, and occurrence of complications. This study validates the efficacy of both SOS and flexible fiberoptic bronchoscope for awake oral intubation in patients with cervical spine instability. SOS has been found to be more effective in reducing time to intubation.

Biallelic B3GALT6 mutations cause spondylodysplastic Ehlers-Danlos syndrome.

Proteoglycans are among the most abundant and structurally complex biomacromolecules and play critical roles in connective tissues. They are composed of a core protein onto which glycosaminoglycan (GAG) side chains are attached via a linker region. Biallelic mutations in B3GALT6, encoding one of the linker region glycosyltransferases, are known to cause either spondyloepimetaphyseal dysplasia (SEMD) or a severe pleiotropic form of Ehlers-Danlos syndromes (EDS). This study provides clinical, molecular and biochemical data on 12 patients with biallelic B3GALT6 mutations. Notably, all patients have features of both EDS and SEMD. In addition, some patients have severe and potential life-threatening complications such as aortic dilatation and aneurysm, cervical spine instability and respiratory insufficiency. Whole-exome sequencing, next generation panel sequencing and direct sequencing identified biallelic B3GALT6 mutations in all patients. We show that these mutations reduce the amount of β3GalT6 protein and lead to a complete loss of galactosyltransferase activity. In turn, this leads to deficient GAG synthesis, and ultrastructural abnormalities in collagen fibril organization. In conclusion, this study redefines the phenotype associated with B3GALT6 mutations on the basis of clinical, molecular and biochemical data in 12 patients, and provides an in-depth assessment of β3GalT6 activity and GAG synthesis to better understand this rare condition.

Criteria to Screen for Traumatic Cervical Spine Instability: A Consensus of Chiropractic Radiologists

ObjectiveThe purpose of this study was to establish consensus on a radiographic definition for cervical instability for routine use in chiropractic patients who sustain trauma to the cervical spine. MethodWe conducted a modified Delphi study with a panel of chiropractic radiologists. Panelists were asked to rate potential screening criteria for traumatic cervical spine instability when assessing cervical spine radiographs. Items rated as important for inclusion by at least 60% of participants in round 1 were submitted for a second round of voting in round 2. Items rated for inclusion by at least 75% of the participants in round 2 were used to create the consensus-based list of screening criteria. Participants were asked to vote and reach agreement on the final screening criteria list in round 3. ResultsTwenty-nine chiropractic radiologists participated in round 1. After 3 rounds of survey, 85% of participants approved the final consensus-based list of criteria for traumatic cervical spine instability screening, including 6 clinical signs and symptoms and 5 radiographic criteria. Participants agreed that the presence of 1 or more of these clinical signs and symptoms and/or 1 or more of the 5 radiographic criteria on routine static radiographic studies suggests cervical instability. ConclusionThe consensus-based radiographic definition of traumatic cervical spine instability includes 6 clinical signs and symptoms and 5 radiographic criteria that doctors of chiropractic should apply to their patients who sustain trauma to the cervical spine.

Airway management in the presence of cervical spine instability: A cross-sectional survey of the members of the Indian Society of Neuroanaesthesiology and Critical Care.

Background and Aims:There is a paucity of clinical practice guidelines for the ideal approach to airway management in patients with cervical spine instability (CSI). The aim of this survey was to evaluate preferences, perceptions and practices regarding airway management in patients with CSI among neuroanaesthesiologists practicing in India.Methods:A 25-item questionnaire was circulated for cross-sectional survey to 378 members of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) by E-mail. We sent four reminders and again submitted our survey to non-responders during the 2017 annual ISNACC meeting. Apart from demographic information, the survey captured preferred methods of intubation and airway management for patients with CSI and their justification. Regression analysis was used to identify factors associated with the use of indirect technique for intubation.Results:Only 122 out of the 378 anaesthesiologists responded to our survey. Most respondents were senior consultants, working in training hospitals, and performed ≥25 intubations per year for CSI patients. The majority of neuroanaesthesiologists (78.7%; n = 96) preferred indirect techniques for elective intubation. However, 45 anaesthesiologists (36.9%) preferred indirect techniques for emergency intubation. In an adjusted analysis, preference for patients to be conscious during intubation was significantly associated with the use of indirect techniques (odds ratio = 3.79; confidence interval = 1.52–9.49, P < 0.01).Conclusions:Among ISNACC members, indirect techniques are preferred for elective intubation of patients with CSI, while direct laryngoscopy is preferred for emergency intubation.

Functional outcome of cervical spine locking plate fixation in traumatic quadriplegics

Introduction: The cervical spine column is extremely vulnerable to injury due to its specific facet joint articulation. The most serious complication quadriplegia occurs in almost 40to50% of cases. Surgery is indicated if signs of instability, significant dislocation or neurological deficit are present. Over the last 15 years, the anterior approach has become the gold standard. Aim of Study: To evaluate the functional, clinical and radiographic results of traumatic cervical spine instability which were treated surgically using Cervical Spine Locking Plate (CSLP) fixation and anterior interbody fusion with tricortical iliac crest bone graft.Materials and Methods: This is a prospective and retrospective study 23 Patients who attended the Orthopaedics casualty Medical College Kozhikode, with traumatic quadriplegia due to lower cervical spine injury who were treated with anterior cervical locking plate during a period of 2 years from June 2010 onwards were studied. The outcome of the treatment was compared in terms of relief of symptoms, neurological recovery, clinical and radiological stability and improvement of rehabilitation. The cases were followed up for 2 years from the beginning of the treatment.Analysis and Results: The following observations were made from this study. The youngest patient in the study was 16 and the oldest 65 years. The most common level of injury in this study was C5-C6 (11 patients), Only 9 patients were treated within 72 hours. Neurological recovery was evaluated by preoperative and postoperative FRANKEL and ASIA scores. All patients were densely quadriplegic before surgery, 6 patients had no change in neurology and expired in postoperative period. Excellent neurological recovery was seen in only minimal number of patients. In the postoperative period, for functional outcome measurement, patients were evaluated using modified ODOMS criteria. Out of all the patients, 13 had good fusion status. Conclusion: The ideal management of traumatic cervical spine instability in lower cervical spine injury is anterior stabilization with cervical spine locking plate. The surgery related complications are relatively very less, and the survived patients had significant improvement in their neurological and functional status All the patients had good radiological fusion and no complications in union.

Clinical effect of clivo-axial angle in posterior approach for patients with unstable upper cervical spine

Objective To investigate the clinical effect of clivo-axial angle(CAA)in the posterior approach for patients with unstable upper cervical spine. Methods Twenty-one patients with unstable upper cervical spine treated with posterior approach surgery from October 2014 to March 2016 were included in this study, and the patients were divided into the decompression group (11 cases) and the non-decompression group (10 cases) according to whether the intraoperative decompression was included.The clivo-axial angle(CAA) were measured by mobile three-dimensional before and after the surgery in order to estimate the reduction of spinal cord compression effect after the posterior cervical surgery combined with the reduction, fixation and bone graft fusion, then to guide the restoration.CT was used to measure the CAA and MR was used to measure the cervico-medullary angle (CMA) before operation and 3 months after operation.Japanese Orthopedic Association (JOA) scores was used to evaluate the neurological function 6 months after operation. Results All patients were followed up for 6-12 months.CMA ((156.3±3.6°) vs.(155.9±2.7°)) and CAA ( (154.3±5.1°) vs.(151.3±4.7°)) of the decompression group and the non-decompression group at 3 months after surgery were improved significantly compared with those collected before the surgery (CMA: (131.5±0.6°) vs.(131.1±0.5°); CAA: (133.2±1.7°) vs.(132.4±1.2°)), the differences were statistically significant (CMA: t=-21.81, P=0.00 vs.t=-28.54, P=0.00; CAA: t=-12.44, P=0.00 vs.t=-11.68, P=0.00). After operation, CAA ((152.3±1.3) vs.(132.6±1.5)) was significantly improved, compared with that before reduction ((131.1±1.9) vs.(132.4±1.5°)) (t=-30.09, P=0.00 vs.t=-35.93, P=0.00). JOA scores of the two groups at 6 months after operation ((9.8±1.3) points vs.(10.3±1.7) points) were significantly lower than those before the surgery ((7.1±0.7) points vs.(7.6±1.1) points), the differences were statistically significant (t=6.01, P=0.00 vs.t=4.36, P=0.00). No complications such as fixed failure, infection, spinal cord injury and vertebral artery injury were found in all patients. Conclusion For patients with upper cervical spine instability, the usage of intraoperative three-dimensional C arm scanning in CAA measurement to determine the effect of spinal cord compression can guide the reduction, simple and feasible, the clinical effect is satisfactory. Key words: Upper Cervical Spine; Instability; Clivo-axial Angle

Upper Cervical Fusion in Children With Spondyloepiphyseal Dysplasia Congenita.

Paraplegia or death secondary to upper cervical spine instability and spinal cord compression are known consequences of spondyloepiphyseal dysplasia congenita (SEDC). Stabilization and occasionally decompression of the upper cervical spine are indicated to treat upper cervical instability and stenosis. The purpose of this study was to report the results of upper cervical spine fusion in children with SEDC who had upper cervical instability. Twenty children (17 females and 3 males) with SEDC who underwent upper cervical spine fusion at a mean age of 72 months were retrospectively analyzed. Three of these children were under the age of 2. Fifteen children had posterior instrumentation and fusion whereas 5 children had posterior in situ fusion without use of any implant. Thirteen of 20 children had iliac crest autograft. Radiographic and clinical results were reported. The average follow-up period was 8 years and 8 months. All children with instrumentation achieved fusion. Three of 5 children who had no instrumentation had nonunion (1 child had a stable nonunion and did not need revision; 1 had a single noninstrumented revision and ended up with a stable nonunion without further intervention; and the third one had a noninstrumented revision and had to have a second, instrumented, revision to achieve fusion). Six children had thoracolumbar scoliosis or kyphoscoliosis which required surgical management.No postoperative neurological deficits were observed. Two of the 3 children with a preoperative neurological deficit showed full recovery and the third one remained unchanged. Pseudarthrosis is the main complication for the noninstrumented group. Distal junctional instability after successful fusion is seen at long-term follow-up (average=6 y) for 13% of patients in instrumented group. Instrumentation and iliac bone grafting results in 100% upper cervical fusion for SEDC children who demonstrated instability before surgery. Level IV-therapeutic.

POSTERIOR INSTRUMENTATION OF THE CERVICAL SPINE IN CHILDREN: LITERATURE REVIEW

The paper presents a review of the current literature on instrumental fixation of the pediatric cervical spine and technical features of the application of described techniques in children. The posterior instrumental fixation of the cervical spine provides stability and increases fusion rates in children with cervical spine deformities or instability, and allows intraoperative reduction of vertebral displacements. A number of morphological and clinical studies proved the possibility of implantation of modern metal constructs in children. Given the small size of bone structures in children, each case requires careful preoperative planning, proper intraoperative positioning and strict adherence to surgical techniques.

Cervical spine instability in the course of rheumatoid arthritis - imaging methods.

Cervical spine is affected in more than a half of patients with rheumatoid arthritis (RA). Depending on the degree of damage to the individual joints and ligaments RA-related cervical spine instability takes the form of atlanto-axial subluxation, subaxial subluxation or cranial settling. In the advanced cases spinal stenosis can occur as well as spinal cord injuries with typical neurological symptoms. The identification of patients with cervical spine instability before the occurrence of neurological complications still constitutes a diagnostic challenge.The article presents the methods of cervical spine imaging with the use of plain radiographs, magnetic resonance imaging (MRI) and computed tomography (CT). We discuss the advantages and disadvantages associated with each method and the possibility of its application in the diagnosis of cervical spine instability in RA. The knowledge of the above mentioned issues is indispensable to select an appropriate time for surgical intervention.

Surgical management of cervical spine deformity in chondrodysplasia punctata.

OBJECTIVE Chondrodysplasia punctata (CDP), a rare skeletal dysplasia, can lead to cervical spine instability and deformity. However, an optimal neurosurgical intervention has yet to be established. Thus, a retrospective study was conducted to assess the efficacy of various surgical interventions for children with CDP. METHODS The authors retrospectively reviewed 9 cases of CDP in which cervical decompression with or without posterior fusion was performed between April 2007 and May 2016. Patient demographics, preoperative clinical conditions, radiographic findings, surgical procedures, and the postoperative course were analyzed in detail. RESULTS A total of 12 operations were carried out in 9 patients (8 male, 1 female) during the study period. The patients' ages at the initial surgery ranged from 2 months to 2 years. Seven of the children had CDPX1, 1 had CDPX2, and 1 had tibia-metacarpal type CDP (CDP-TM). The lesion occurred at the craniovertebral junction (CVJ) in 7 cases and involved a subaxial deformity in 2 cases. The initial surgery was C-1 laminectomy with occipitocervical fusion (OCF) followed by halo external fixation in 5 cases, OCF alone in 1 case, and C-1 laminectomy alone in 3 cases. Three children required additional surgery. In one of these cases, a staged operation was required because the patient's head was too small to attach a halo ring at the time of the initial procedure (C-1 laminectomy). In another case, OCF was performed 11 months after C-1 laminectomy because of intramedullary signal change on serial MRI, although the child remained asymptomatic. In the third case, additional posterior fusion was performed 17 months after an initial laminectomy and OCF due to newly developed cervical dislocation caudal to the original fusion. This last patient required a third operation 9 months after the second because of deep wound infection. Surgery improved the motor function of all 7 children with CDPX1, but 3 children who had already suffered respiratory failure preoperatively required continued respiratory support. At the time of this report, 7 of the 9 children were alive and in stable condition. One child died due to restrictive respiratory insufficiency, and another died in an accident unrelated to CDP. CONCLUSIONS Surgical decompression with or without fusion for CVJ and subaxial cervical lesions in infants and toddlers with CDP generally saves lives and increases the likelihood of motor function recovery. However, in this case series the patients' preoperative condition had a strong effect on postoperative respiratory function. The surgery was not straightforward, and a second operation was required in some cases. Nevertheless, the findings indicate that early surgical intervention for CDP with cervical involvement is feasible, suggesting that the role of neurosurgery should be reevaluated.

Factors That Predict Risk of Cervical Instability in Rheumatoid Arthritis Patients.

Retrospective data analysis. To identify factors affecting the atlantodental interval, the Ranawat value, and subaxial translation after rheumatoid arthritis (RA) diagnosis. In addition, factors predictive for cervical spine instability (CSI) development after RA diagnosis were examined. Development of CSI affects the prognosis and mortality of RA patients. Previous studies described that obesity is associated with reduced radiographic joint damage in RA patients. We hypothesized that body mass index (BMI) is also associated with radiographic cervical damage in RA patients. Cervical radiographs were taken at full flexion, neutral position, and full extension to measure the geometric length of the anterior atlantodental interval, the Ranawat value, and subaxial translation. These values were entered into multivariable linear regression analysis based on potential associated factors. Hazard ratios were calculated to identify independent factors predictive of CSI. Of the patients diagnosed with RA between January 2005 and August 2015, 1611 who underwent at least one cervical radiograph were included. After adjusting for sex, age, BMI category, CSI, rheumatoid factor, and RA medication, multivariate analysis revealed that the risk of atlantoaxial subluxation in the underweight and normal BMI groups was about 1.6-fold (hazard ratio, 1.63; 95% CI, 1.10-2.43; P = 0.015) and 1.7-fold higher, respectively, than that in the obese group, and that the risk of vertical subluxation was about 2.5-fold (hazard ratio, 2.52; 95% CI, 1.32-4.83; P = 0.005) higher in the underweight group than in the obese group. We also found that the rheumatoid factor positivity was a predictive risk factor for CSI development. We identified risk factors predictive for CSI occurrence after RA diagnosis through cervical radiograph assessment. We found that BMI was an independent predictor for development of CSI. Further large-scale prospective studies are required to confirm these findings. 3.

Do Modic changes affect cervical sagittal alignment and motion in symptomatic patients?

The cervical segmental instability often occurs simultaneously withModicchanges (MCs). However, it is unknown whether there is a relation between the two diseases. The aim of this study was to evaluate therelationshipbetween MCsand cervical segmental instability, cervical curvature and range of motion (ROM) in thecervicalspine. Atotalof 464patients withneck pain or cervical neurologic symptoms who underwent imaging examination were analyzed retrospectively. Based on MRI imaging cervical MCs were diagnosed, and patients were divided into with or without MCs groups. The cervical curvature and range of motion were measured. We compared the incidence of cervical instability, cervical curvature and ROM between the two group patients and their relationships with MCs were studied. Logistic regression was used to study the risk factors associated with MCs. MCs were observed in 94 of 464 patients and 122 of total 2320 cervical segments and were most frequent at C5-6 segment. Theincidence of the cervical instability was significantly higher in patients with MCs than those without MCs at cervical level C3-7. In addition, cervical curvature and ROM in patients with MCs were less than those without MCs. Logistic regressionanalysis showed that the occurrence of cervical spine instability, less cervical curvature and ROM were risk factors forMCs. Patients with MCs were prone to have cervical instability at the same cervical level and may have a higher possibility of less cervical curvature and ROM.

X-RAY SCAN EXAMINATION AS A QUALIFICATION TO PRACTICE JUDO–THE CERVICAL SPINE INSTABILITY AMONG CHILDREN

BackgroundJudo is a martial art focused on the use of grasping the neck with the high risk of the cervical spine injury. Therefore on examination which qualifies to practicing judo,...

Down Syndrome child in the Intensive care unit

Down syndrome is the most common chromosomal abnormality in newborns, with a high incidence in Chile. This condition presents unique physiological aspects that should be known, which can affect the child during their stay in an Intensive Care Unit, beyond the neonatal period This review is focused on the respiratory, cardiovascular, infectious and neurological disorders. Anesthetic management and postoperative analgesia considerations, weaning from mechanical ventilation, cervical spine instability and prognosis of the critically ill child with Down syndrome are also analyzed. The evaluation of these conditions should be performed when the patient is admitted to the intensive care unit. The purpose of this update is to update the knowledge of the diagnosis and treatment of potential complications of children with Down syndrome during their stay in the unit of critical patient.

A patient with cervical spinal canal stenosis and anterior glenohumeral joint instability who experienced pain when undressing

A patient with cervical spinal canal stenosis and anterior glenohumeral joint instability who experienced pain when undressing

GlideScope versus McCoy laryngoscope: Intubation profile for cervically unstable patients in critical care setting

BackgroundEndotracheal intubation for cervically unstable patients remains a challenging procedure. We compared the utility of a relatively new promising airway tool “GlideScope” (GL) with the routinely used McCoy laryngoscope in our critical care unit.MethodsForty intubated patients with suspected or proved cervical spine injury who were scheduled for replacing a conventional endotracheal tube (ETT) by ETT with subglottic suction facility were enrolled in this randomized controlled trial. Patients were randomly intubated using either GL “G group” or McCoy laryngoscope “M group”. The first attempt was performed by anesthetic residents inexperienced in using both scopes. In case of failure, a second attempt was done by a consultant anesthetist using these tools masterly. If these two attempts failed to intubate the trachea, a third one was attempted using a fiberoscope by the same consultant anesthetist. We compared the intubation profiles of both scopes.ResultsThere was a higher success rate of primary intubation attempts among the G group population (85% versus 55% in the M group “P value 0.03”). Moreover, all secondary intubation attempts succeeded in intubating the trachea. The mean time for primary intubation attempts was statistically longer in the M group (27.6 ± 2.7 S versus 19.8 ± 5.2 S in the G group “P value < 0.001”). However, there was no statistical difference as regards the mean time of intubation among the study population during the secondary intubation attempts. The Cormack and Lehane score and the percentage of required optimization maneuvers were significantly higher in the M group for both attempts.ConclusionIn critical care setting, GL is an excellent primary intubating tool for patients with potential cervical spine instability even if being performed by inexperienced users.

Predictive Risk Factors of Cervical Spine Instabilities in Rheumatoid Arthritis: A Prospective Multicenter Over 10-Year Cohort Study.

A prospective multicenter cohort study for more than 10 years of outpatients with rheumatoid arthritis (RA). To identify predictive risk factors of cervical spine instabilities, which may induce compression myelopathy in patients with RA. Many reports described the natural course of cervical spine involvement in RA. Only a few studies, however, conducted comprehensive evaluation of its prognostic factors. Cervical spine instability was radiographically defined as atlantoaxial subluxation with the atlantodental interval greater than 3 mm, vertical subluxation (VS) with the Ranawat value less than 13 mm, and subaxial subluxation with irreducible translation of 2 mm or higher. The "severe" category of instability was defined as atlantoaxial subluxation with the atlantodental interval of 10 mm or lower, vertical subluxation with the Ranawat value of 10 mm or higher, and subaxial subluxation with translation of 4 mm or higher or at multiple levels. Of 503 "definite" or "classical" patients with RA without baseline "severe" instability, 143 were prospectively followed throughout for more than 10 years. The Cox proportional hazards regression analysis was performed to determine predictors for the development of "severe" instabilities. To exclude biases from the low follow-up rate, similar assessments were performed in 223 patients followed for more than 5 years from baseline. The incidence of cervical spine instabilities and "severe" instabilities significantly increased during more than 10 years in both 143 and 223 cohorts (all P < 0.01). Multivariable Cox proportional hazards models found that baseline mutilating changes (hazard ratio [HR]=19.15, 95% confidence interval [95% CI] = 3.96-92.58, P < 0.01), corticosteroid administration (HR = 4.00, 95% CI = 1.76-9.11, P < 0.01), and previous joint surgery (HR = 1.99, 95% CI = 1.01-3.93, P = 0.048) correlated with the progression to "severe" instability in 143 cases and also in 223 cases (HR = 8.12, 95% CI = 2.22-29.64, P < 0.01; HR = 3.31, 95% CI = 1.68-6.53, P < 0.01; and HR = 2.07, 95% CI = 1.16-3.69, P = 0.014, respectively). Established mutilating changes, concomitant corticosteroid treatment, and previous joint surgery are relatively robust indicators for a poor prognosis of the cervical spine in patients with RA, based on the consistency in more than 10-year analysis of two different settings. 3.

Cervical spine injuries in civilian victims of explosions: Should cervical collars be used?

Semirigid cervical collars (SRCCs) are routinely applied to victims of explosions as part of the prehospital trauma protocols. Previous studies have shown that the use of SRCC in penetrating injuries is not justified because of the scarcity of unstable cervical spine injuries and the risk of obscuring other neck injuries. Explosion can inflict injuries by fragments penetration, blast injury, blunt force, and burns. The purpose of the study was to determine the occurrence of cervical spine instability without irreversible neurologic deficit and other potentially life-threatening nonskeletal neck injuries among victims of explosions. The potential benefits and risks of SRCC application in explosion-related injuries were evaluated. This is a retrospective cohort study of all explosion civilian victims admitted to Israeli hospitals during the years 1998 to 2010. Data collection was based on the Israeli national trauma registry and the hospital records and included demographic, clinical, and radiologic details of all patients with documented cervical spine injuries. The cohort included 2,267 patients. All of them were secondary to terrorist attacks. SRCC was applied to all the patients at the scene. Nineteen patients (0.83%) had cervical spine fractures. Nine patients (0.088%) had unstable cervical spine injury. All but one had irreversible neurologic deficit on admission. A total of 151 patients (6.6%) had potentially life-threatening penetrating nonskeletal neck injuries. Unstable cervical spine injuries secondary to explosion are extremely rare. The majority of unstable cervical spine fractures were secondary to penetrating injuries, with irreversible neurologic deficits on admission. The application of SRCC did not seem to be of any benefit in these patients and might pose a risk of obscuring other neck injuries. We recommend that SRCC will not be used in the prehospital management of victims of explosions. Prognostic/epidemiologic study, level III.

Indications for Use of Dynamic Four-dimensional Computed Tomography in Diagnosing Instability in Spinal Cervical Conditions

Introduction Cervical spinal instability is a pathological consequence of a variety of spine disorders such as trauma, malignancy and degenerative conditions. If left undiagnosed, cervical spinal instability can lead to compressive cervical myelopathy and devastating consequences such as quadriplegia and death. Although dynamic cervical X-ray is traditionally used to detect cervical instability, it provides only two static views and there is no gold standard in diagnosing such condition. Dynamic four-dimensional computed tomography (4DCT) is a non-invasive method that provides functional assessment of cervical motion in high resolution, throughout the entire range of motion. It has been previously shown to be clinically useful in assessing instability and impingement evaluation of the shoulder and finger joint. This is the first early case series utilizing dynamic 4DCT to assess cervical instability in various spinal pathologies. Material and Methods Six elderly patients who presented with neck pain and suspected instability in cervical spine from a major Australian academic hospital were included. In addition to routine imaging modalities, dynamic 4DCT of cervical spine was performed using a 320 × 0.5mm detector multislice-CT (Aquilion One, Toshiba Medical Systems, Japan) with consent. With gantry rotation speed of 275 milliseconds, scans were conducted without table motion with patients in the lateral-decubitus position, capturing approximately seven volume datasets per second. Patients were instructed to continuously move their necks between flexion and extension. Cine movie files were generated from the volume datasets. Results The mean age of the cohort was 69 years old. There was equal male:female ratio. All patients presented with neck pain. Two presented acutely after trauma: one with suspected ligamentous instability at C1/C2; the second presented after recurrent falls with suspected fracture of odontoid process. Four patients had neck pain of more than 6 months at presentation: one had severe rheumatoid arthritis with suspected C1/C2 instability; three patients had cervical spondylotic changes, with one having had a previous anterior cervical discectomy and fusion(ACDF). Before employing 4DCT, MRI and static CT of occipito-cervical regions were performed in five patients; dynamic X-ray of cervical spine at flexion and extension were performed in four patients. Interpretation of the imaging finding in all cases by neuroradiologist and neurosurgeon was found to be equivocal for stability. Dynamic 4DCT confidently ruled in or ruled out cervical spinal instability in all cases: one case was confirmed to have instability; five cases were confirmed to be stable. The one unstable case with severe cervical spondylosis was demonstrated on 4DCT to have instability at C3/C4 level and incomplete fusion from previous ACDF at C5/C6 level and a cervical stabilization procedure was offered. The remaining stable cases included all the trauma cases with a case of os odontoideum diagnosed on 4DCT. Conservative management was prescribed confidently Conclusion Dynamic 4DCT can be used to detect and confirm subtle cervical spinal instability (or lack thereof) with relative ease in various cervical spinal pathologies such as rheumatoid arthritis, cervical spondylosis, os odontoideum and trauma. We propose that dynamic 4DCT has an important role in detecting cervical spinal stability and further studies using this technique are warranted.

Airway management for cervical spine surgery.

Cervical spine surgery is one of the most commonly performed spine surgeries in the United States, and 90% of the cases are related to degenerative cervical spine disease (the rest to cervical spine trauma and/or instability). The airway management for cervical spine surgery represents a crucial step in the anesthetic management to avoid injury to the cervical cord. The crux for upper airway management for cervical spine surgery is maintaining the neck in a neutral position with minimal neck movement during endotracheal intubation. Therefore, the conventional direct laryngoscopy (DL) can be unsuitable for securing the upper airway in cervical spine surgery, especially in cases of cervical spine instability and myelopathy. This review discusses the most recent evidence-based facts of the main advantages and limitations of different techniques available for upper airway management for cervical spine surgery.