Stabilization Of Cervical Spine Research Articles

Percutaneous cervical nucleoplasty and percutaneous cervical discectomy treatments of the contained cervical disc herniation

There were no studies in literature to compare the clinical outcomes of percutaneous nucleoplasty (PCN) and percutaneous cervical discectomy (PCD) in contained cervical disc herniation. A retrospective of patients with symptomatic contained cervical disc herniated were operated on with PCN and PCD from June 2003 to July 2005. Two-hundred and four patients initially fulfilled the study criteria, and 28 patients were lost in follow-up. The patients were categorized into different groups depending on the procedure by PCN (81 cases) or PCD (95 cases). The clinical outcomes, pain reduction, and segment stability were recorded during this study. Puncture of the needle into the disc space was accurately performed under C-arm fluoroscopy guidance in all cases and no intraoperative deaths were reported in our study. At the end, 176 cases had follow-up and 28 cases were lost, and the follow-up rate was 88.0% (81/92) in the PCN group and 84.8% (95/112) in the PCD group. The follow-up time ranged from 16 to 48 months (average 29 months), and on an average of 28.86 ± 4.52 months on PCN and 8.42 ± 3.21 months on PCD (t = -0.24, P = 0.81, >0.05). The operation time averages of PCN and PCD are 4.67 ± 1.16 and 11.95 ± 1.80, respectively (P < 0.01). The pain index improved from 7.12 ± 1.13 to 2.74 ± 0.89 (t = 27.03, P = 0.0000, <0.001) in PCN patients and from 7.18 ± 1.09 to 2.71 ± 0.91 (t = 29.57, P = 0.0000, <0.001) in PCD patients. Clinical results of PCN were excellent in 31 cases, good 32 cases, fair 13 cases, and poor 5 cases; for PCD, the results were 33, 42, 12, and 7 cases, respectively, and 1 in discitis. Good and excellent was 78.4% (77.8% in PCN and 79.5% in PCD, P > 0.05). There was one case of PCN that had the partial Perc-D SpineWand broken in the disc space, cannot be moved by the percutaneous cervical discectomy, and remained there itself. One of the cases had discitis in this study after PCD. Patient presented with neck pain and associated radicular pain and numbness in the left upper-limb after 8 days of PCD. There were no instable cases after procedures of PCN and PCD. There were no significant difference in stability of preoperatively and postoperatively between PCN and PCD (P > 0.05). PCN and PCD treatments of contained cervical disc herniation show good outcomes and there was no difference in the stability of cervical spine. PCN and PCD are safe, minimally invasive, and no differences were observed between the methods in clinical outcome.

Intra-operative computer navigation guided cervical pedicle screw insertion in thirty-three complex cervical spine deformities

Background:Cervical pedicle screw fixation is challenging due to the small osseous morphometrics and the close proximity of neurovascular elements. Computer navigation has been reported to improve the accuracy of pedicle screw placement. There are very few studies assessing its efficacy in the presence of deformity. Also cervical pedicle screw insertion in children has not been described before. We evaluated the safety and accuracy of Iso-C 3D-navigated pedicle screws in the deformed cervical spine.Materials and Methods:Thirty-three patients including 15 children formed the study group. One hundred and forty-five cervical pedicle screws were inserted using Iso-C 3D-based computer navigation in patients undergoing cervical spine stabilization for craniovertebral junction anomalies, cervico-thoracic deformities and cervical instabilities due to trauma, post-surgery and degenerative disorders. The accuracy and containment of screw placement was assessed from postoperative computerized tomography scans.Results:One hundred and thirty (89.7%) screws were well contained inside the pedicles. Nine (6.1%) Type A and six (4.2%) Type B pedicle breaches were observed. In 136 levels, the screws were inserted in the classical description of pedicle screw application and in nine deformed vertebra, the screws were inserted in a non-classical fashion, taking purchase of the best bone stock. None of them had a critical breach. No patient had any neurovascular complications.Conclusion:Iso-C navigation improves the safety and accuracy of pedicle screw insertion and is not only successful in achieving secure pedicle fixation but also in identifying the best available bone stock for three-column bone fixation in altered anatomy. The advantages conferred by cervical pedicle screws can be extended to the pediatric population also.

The impact of fusion on adjacent levels in cervical spine injuries: Is it really important?

Objective Although the literature on degenerative disease of the cervical spine contains numerous articles studying the changes on levels adjacent to a fusion, there exist very few such studies concerning cervical spine stabilization for trauma. Methods Over a 16-year period (1989–2005), one hundred and twelve patients underwent stabilization of the lower cervical spine (C3–T1) for subaxial cervical spine injuries, either with an anterior or posterior procedure, or both. Eighty-one patients with adequate follow-up were included in the study and 3 groups were identified: Group A, consisting of 8 patients who underwent anterior stabilization and developed Adjacent Level Ossification Development (ALOD), Group B, comprising 53 patients who were anteriorly plated but who did not develop ALOD and Group C, comprising 20 patients who received posterior stabilization. Results Eight out of 61 patients (13.1%) who were anteriorly operated developed ALOD in 11 adjacent levels (Group A). Severe (grade 3) ossification was noted in 6/8 patients at the cranial adjacent level, and in 2/8 patients at the caudal one. Three out of 8 patients presented with early ALOD at 3, 4 and 18 months respectively. Despite the radiographic abnormalities showing ossification, all the patients had an uncomplicated course without symptoms. All the radiographs of Group B and Group C patients demonstrated grade 0 ossification for both the cranial and caudal adjacent levels. Conclusion Adjacent-level ossification in cervical spine injuries may appear very early in the postoperative period and it can have a different course than in the degenerative disc disease population, at least in some patients. The first cephalad level adjacent to a fusion appears to be at greater risk. However, even when ALOD is evident radiographically, it very rarely produces any symptoms.

Reviewer’s comment concerning “Anterior cervical pedicle screw and plate fixation using fluoroscope-assisted pedicle axis view imaging: a preliminary report of a new cervical reconstruction technique” by Y. Yukawa et al.: DOI:10.1007/s00586-009-0949-1

Methods for the stabilization of the cervical spine improved enormously in the last two decades as also improved all other spinal fixations. This was possible on one side through the technology and the development of better screw fixation systems having stronger bone purchase and angle stable linkage despite variable insertion angles. On the other side, the recognition of the pedicle as the strongest element for screw anchorage has been demonstrated also in the cervical spine. All these improved implants combined with interbody or reconstruction cages having different size and shape have allowed always more complex cervical spine reconstruction surgeries. In this article the authors report on a new fixation technique of the cervical spine where pedicle screw anchorage is performed through an anterior approach. Screw insertion into the pedicles is performed using fluoroscopy guided technique. Cervical spine stabilization consists in an unilateral plate/screw system. This study demonstrates the technique is feasible when performed by extremely skilled surgeons. Major neurological complications with screw misplacement are evident and could be partially reduced using computer-assisted navigation system. Due to these dangers, the indications for this technique must remain extremely limited to those very rare cases where the traditional anterior or/and posterior stabilization systems cannot be applied and to those spine centers with sufficient experience in complex cervical spine reconstruction surgery. Dante G. Marchesi MD

Posterior Fusion in Patients with Trauma, Instability, and Tumor of the Cervical Spine.

Trauma, instabilities and tumors of the cervical spine are treated with established methods of surgery. Therefore, anterior fusion is considered to be a standardized procedure for the lower cervical spine, while posterior and anterior instrumentation facilitates stabilization of the upper cervical spine. However, special situations that particularly require posterior instrumentation in traumatic lesions, tumor or other kinds of instabilities arise again and again. Neurological deficit symptoms, bone quality and related diseases fundamentally lead to a decision of posterior access and fusion. Different pathologies and corresponding reasons for posterior surgical interventions on the cervical spine are described in this paper and discussed using the current literature.

Surgical treatment strategy for cervical spine fracture

Objective To review anterior approach, posterior approach and one-stage combined anterior-posterior approach in surgical treatment of cervical spine fracture in terms of clinical outcomes. Methods From January 2004 to January 2008, 151 patients with cervical spine fractures who had been treated in our department were reviewed. The anterior approach was used for 87 cases in disckectomy, sub-total resection of cervical vertebra and decompression, fusion, and titanium plating; the posterior approach was used for 49 cases in laminectomy of cervical vertebra for decompression, reduction, lateral mass fixation with plate and pedicle screws; the combined anterior-posterior approach was used for 15 cases. By ASIA criteria, the spinal injury was rated as degree A in 51 cases, degree B in 40, degree C in 28, degree D in 24 and degree E in 8. Results All patients were followed up for 6 months to 4 years(average, 12.5 months) . Healing was delayed in 2 cases. Reduction and restoration of the stability of cervical spine were satisfactory, and bone fusion was achieved. All patients had recovery of nerve function, though to different extents. At the last follow-up, the spinal injury was rated, by ASIA scores, as degree A in 30 cases, degree B in 24, degree C in 31, degree D in 40 and degree E in 26. The anterior and posterior surgical approaches had better ASIA scores than combined anterior-posterior approach. Conclusions It is important to choose an appropriate approach according to the type of cervical fracture. The anterior, posterior or combined ante-rior-posterior approach should be chosen mainly according to 2 aspects: the compression site of cervical spinal cord and the residual post-traumatic stability of cervical spine. Key words: Cervical vertebrae; Fracture fixation, internal; Surgical approach

The excision and reconstruction technique of atlantoaxial tumors.

Objective To summarize the techniques for atlantoaxial tumors exposure and radical excision, and to evaluate the clinical effects of internal fixation by special formed titanium mesh in upper cervical spine stability reconstruction after atlantoaxial tumors resection. Methods From Mar. 2005 to Aug. 2007, 6 patients (3 males, 3 famales)with atlantoaxial tumors were treated in our hospital, including 4 cases with chordoma,1 case with bone giant cell tumor, 1 case with bone fibrous hyperplasia. Vertebral body and lateral mass or posterior structure were involved in these 6 patients. All the paitents underwent total vertebra resection according to free operating principle by anterior submandibular carotid triangle approach firstly and posterior occipito-cervical approach secondly, and were fixed internally by special formed titanium mesh anteriorly and occipito-cervieal fixation posteriorly, Halo-vest fixed externally. All patients were fol-lowed up for 6-16 months. Results One case underwent C12 resection, 2 cases for C23, 3 cases for C2. Op-eration time was 7.2 hours in average, bleeding volume was 2400 ml in average. Local pain and neurological symptoms of all patients were improved or resolved. No complications of blood vessel and nerve injury. Tu-mor focus recurred in 1 case with chordoma 1 year after operation. All patients had good head position and occipito-cervical stability, no internal fixation failure happened. Conclusion Tumor resection beyond the capsule of lesion according to free operating principle can obtain good clinical results. Internal fixa-tion by special formed titanium mesh with occipito-cervical fixation and Halo-vest external fixation assisted, can improve safety in operation, reestablish stability effectively after tumor resction in the upper cervical spine, and provide immediate stabilization, which has the advantages in easy manipulation, early function ex-ercises, is a good method for stability reconstruction of upper cervical spine. Key words: Atlas; Axis; Neoplasms; Treatment ouwome

Lateral radiological evaluation of transarticular screw placement in the lower cervical spine

This study assessed the ideal district of lateral radiograph in evaluation of transarticular screw placement in the lower cervical spine. To assess the ideal zone of lateral radiographs in determining the safe or hazardous locations of the screw tips during transarticular screw implantation in the lower cervical spine. Transarticular screw in the lower cervical spine had been used as an alternative technique to achieve posterior cervical spine stability. Injury to the spinal nerves caused by transarticular screws which are too long must be identified quickly to minimize the neurologic complication. No previous radiological study regarding evaluation of the transarticular screw placement using lateral radiographs has been reported. Twelve cervical spines were removed from embalmed cadavers. Four transarticular screw placements with Dalcanto's technique under direct visualization, including placement of the screw tip staying the ventral cortex, 2, 4 and 6 mm over-penetration of the ventral cortex, were performed on each specimen. Following each placement, a lateral radiograph was taken. Each vertebral body was divided vertically into four equal zones, and another equal zone posterior to the posterior border of the vertebral body was defined as Zone pre-1. The numbers of screw tips seen in each zone were quantified for each placement. Partitions of chi (2) method was used to evaluate the ideal zone on lateral radiograph for transarticular screw insertion. At C34 and C45, no significant difference was found between Zone pre-1 and Zone 1 (chi(2) = 0.18, P > 0.50), while there was significant difference between Zones 1 and 2 (chi(2) = 73.6, P < 0.005), as well as Zones 2 and 3 (chi(2) = 13.2, P < 0.005). At C56 and C67, No significant difference was found between Zones 2 and 3 (chi(2) = 0.25, P > 0.50), while there was significant difference between Zone pre-1 and Zone 1 (chi(2) = 66.2, P < 0.005), as well as Zones 1 and 2 (chi(2) = 10.5, P < 0.005). Ideal screw tip positions on lateral radiograph for transarticular screw by Dalcanto's technique should be in Zone 1 at C34 and C45, in Zone pre-1 at C56 and C67. If the screw tip was in Zones 3 and 4, the safe rate will be decreased significantly and it might be too deep and be dangerous.

Manual C-Spine Stabilization and Difficult Intubation

Previous studies of the effect of manual in-line stabilization of the cervical spine on direct laryngoscopy have relied on surrogate markers of intubation difficulty, such as laryngoscopic grade of view and requisite lifting force (JW Emerg Med Feb 13 2009 and JW Emerg Med Mar 14 2008). In the current study, investigators measured actual intubation success at a …

Aneurysmal Bone Cyst

Case report. To present 2 cases of aneurysmal bone cyst in the cervical spine of children who were aggressively treated with resection, fusion, and stabilization with hardware to achieve complete cure and future stability. Aneurysmal bone cyst is a rapidly expanding and destructive bone lesion of unknown etiology. Current approaches to treatment include surgical en bloc excision, complete curettage, selective arterial embolization, radiotherapy, and intralesional injection with a sclerosing agent. Fusion and stabilization with instrumentation have often been avoided in children due to concerns over instability following future axial skeleton growth. The authors present 2 case reports of aneurysmal bone cyst in the cervical spine of children, both demonstrating deeply involved lesions with extensive bone destruction. Both were treated aggressively with resection, fusion, and stabilization with instrumentation. Additionally, the relevant background literature is briefly discussed. Both patients had an uncomplicated postoperative course. At 36- and 18-month follow-up, both patients have no cervical spine instability or recurrence of tumor. Treatment of aneurysmal bone cyst in the cervical spine is challenging when it occurs in close proximity to neural and vascular structures. Future stability of the cervical spine is a concern, especially when there is significant involvement of the vertebral body and posterior elements. At 36- and 18-month follow-up, the surgical approach to aneurysmal bone cyst presented here provided these patients with complete curative treatment and preservation of cervical spine stability.

Microsurgical treatment of tumors in cervical spinal canal

Objective To report effects of microsurgical treatment for tumors in cervical spinal canal. Methods A total of 32 cases of tumors in cervical spinal canal had received microneurosurgery through a posternmedial approach. 22 cases had received reconstruction of cervical spinal canal stability. Results A total tumor resection was performed in 26 cases (81.25%),a subtotal tumor resection was conducted in 6 cases(18.75%). A cemplete recovery was achieved in 23 cases(71.88%), an improvement of symptoms was achieved in 6 cases(18.75%), and no improvement in 3 cases(9.38%), no death was encountered. Follow up observations were carded out in 30 cases for 3 months to 3 years. MRI examinatious 3 months after operation in 26 cases found no residual or recurrent tumor,recurrence was seen in 3cases of astrocytoma, 1 case was invariable. X-ray radiography in 26 cases showed good vertebral stability ,spinal deformation was found in 4 eases. Conclusion Microsurgery in early period play a key role in treatment of cervical spinal tumors. Reconstruction of spinal canal stability is important to patients. Key words: Cervical vertebra; Spinal tumor; Reconstruction; Microsurgery; Stability

Biomechanical Differences Between Transfacet and Lateral Mass Screw-Rod Constructs for Multilevel Posterior Cervical Spine Stabilization

In vitro biomechanical investigation using human cadaveric cervical spines. Evaluate differences in biomechanical stability between typical lateral mass screw + rod constructs compared to transfacet screw fixation with and without rods. Lateral mass screw + rod constructs have reported efficacious arthrodesis rates/quality but risk damaging the lateral neurovascular structures. Transfacet screw fixation has been studied in the lumbar spine, but little data exists regarding its potential utility in the cervical spine. Sixteen human cadaveric cervical spines were stripped of soft tissue leaving the occiput and ligamentous structures intact. Spines were randomized to lateral mass or transfacet groups (n = 8/group). Spines were prepared in typical surgical fashion and instrumented with the appropriate devices. In the case of the transfacet constructs, the occiput was left intact to simulate the potential surgical difficulty of screw insertion. The transfacet screw group was initially instrumented with rods. Once instrumented (C3-C6) for each group, spines were further dissected to isolate the instrumented levels. End vertebral bodies were rigidly fixed and constructs biomechanically tested in flexion/extension, lateral bending, and axial torsion between +/-2 Nm. After testing for the transfacet screw + rod group, rods were removed and spines retested. All instrumentation was then removed and spines tested in their destabilized state as would occur with surgical preparation. Stiffness data were calculated for each test direction for all groups. Raw and normalized data were each compared across techniques with a 1-way ANOVA (P < 0.05). The transfacet screw groups (with and without rods) were found to have statistically similar biomechanical stability to lateral mass screw + rod constructs for each test direction. Transfacet screws (without rods) were found to have similar biomechanical stability compared to typical lateral mass screw + rod constructs. However, transfacet fixation eliminates the risk to the neurovascular structures and lowers the overall implant profile.

Comparison of Macintosh, Truview EVO2®, Glidescope®, and Airwayscope® laryngoscope use in patients with cervical spine immobilization

BackgroundThe purpose of this study was to evaluate the effectiveness of the Pentax AWS®, Glidescope®, and the Truview EVO2®, in comparison with the Macintosh laryngoscope, when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization. MethodsOne hundred and twenty consenting patients presenting for surgery requiring tracheal intubation were randomly assigned to undergo intubation using a Macintosh (n=30), Glidescope® (n=30), Truview EVO2® (n=30), or AWS® (n=30) laryngoscope. All patients were intubated by one of the three anaesthetists experienced in the use of each laryngoscope. ResultsThe Glidescope®, AWS®, and Truview EVO2® each reduced the intubation difficulty score (IDS), improved the Cormack and Lehane glottic view, and reduced the need for optimization manoeuvres, compared with the Macintosh. The mean IDS was significantly lower with the Glidescope® and AWS® compared with the Truview EVO2® device, and the IDS was lowest with the AWS®. The duration of tracheal intubation attempts was significantly shorter with the Macintosh compared with the other devices. There were no differences in success rates between the devices tested. The AWS® produced the least haemodynamic stimulation. ConclusionsThe Glidescope® and AWS® laryngoscopes required more time but reduced intubation difficulty and improved glottic view over the Macintosh laryngoscope more than the Truview EVO2® laryngoscope when used in patients undergoing cervical spine immobilization.

Significance of Laminar Screw Fixation in the Subaxial Cervical Spine

We retrospectively reviewed 11 patients who underwent laminar screw fixation in the subaxial cervical spine. In 4 patients, laminar screws were inserted for posterior cervical arthrodesis, and in 7 patients it was used for fixation of the open laminae during laminoplasty. In this study, the author describes the technique and surgical results of translaminar screw placement in the subaxial cervical spine. The use of laminar screws for fixation of the second cervical vertebra and upper thoracic vertebrae has been introduced as an important technique in spinal surgery because they can avoid injury to adjacent neurovascular structures. However, there have been no reports of translaminar screw use in the subaxial spine including C7. In this study, we describe the use of translaminar screws for fixation of the subaxial cervical spine in cases of degenerative or traumatic spine disease. Between June 2006 and March 2007, 34 translaminar screws were placed in 11 patients to treat trauma or degenerative disease: 6 at C7, 6 at C6, 7 at C5, 7 at C4, 7 at C3, and 1 at T1. There were 6 women and 5 men. The ages ranged from 23 to 87 years with a mean age of 61.3 years. All patients were evaluated at 6 weeks, as well as at 3 and 6 months using flexion and extension lateral radiographs. Patients requiring fusion were also evaluated with computed tomography at 3 and 6 months to verify arthrodesis. The mean follow-up period was 5.7 months, at which time there was no significant complications from laminar screw placement, except for 2 asymptomatic breaches of the dorsal lamina cortex. Sound bone fusion was identified in cases where arthrodesis was the goal. No screw pullout or avulsion was identified in the laminoplasty cases. The translaminar screw method avoided damaging vascular structures, especially when the vertebral artery courses in the C7 transverse foramen, and it maintains solid stabilization of the subaxial cervical spine. This technique has 2 important advantages to currently used techniques: it is simpler and is not limited by the position of vascular structures. Therefore, it may be applicable to a wider number of patients, especially as it may be used in the subaxial cervical spine.

Of snakes and babies: intrathoracic stomach and vertebral rachischisis. A serpentine-like syndrome?

Snakes have intrathoracic stomachs and rachischisis-like spinal vertebrae. These anomalies are rare in babies and have not been previously described in combination in the English medical literature. Here we present 2 cases of total intrathoracic stomach with a foreshortened esophagus, cervical spine rachischisis, and splenic anomalies in newborns. Both had 46, XX karyotypes. The first case was initially treated with mobilization of the stomach into the abdomen. However, at 18 months the stomach was found to have retracted back into the thorax. Subsequently, the patient received a Collis gastroplasty and G-tube. Two-year follow-up is available. The second case exhibited the abovementioned anomalies along with absence of toes 3 and 4 on the right foot, and cardiac anomalies not compatible with life. The parents chose to withdraw support. The encountered abnormalities may be explained by a first trimester mesenchymal insult and share some similarities with the VACTERL association. In our experience, mobilization of the stomach into the abdomen without elongation of the esophagus will fail. If tolerated, the management of the intrathoracic stomach should include preoperative intragastric feedings to allow time for gastric enlargement followed by a Collis gastroplasty. The management of cervical rachischisis requires assessment of cervical spine stability and cervical immobilization. As other life-threatening birth defects may be present, thorough evaluation should be completed before counseling the families of the treatment options available.

Orthopedic effects of internal fixation of cervical pedicle screw on cervical spondylotic myelopathy with cervical kyphosis

To evaluate the orthopedic effects of internal fixation of cervical pedicle screw on cervical spondylotic myelopathy with cervical kyphosis. Seventeen patients with cervical spondylotic myelopathy with cervical kyphosis with the Cobb's angle >10 degrees underwent internal fixation of cervical pedicle screw. The patients were followed up for 13. 8 months. The Cobb's angle of cervical kyphosis was measured before operation, one week after-operation, and upon the final follow up. The neural function and cervical spine stability were evaluated using Japanese Orthopedic Association (JOA) scoring system. The average preoperative Cobb's angle of cervical kyphosis was -16.1 degrees before operation, was -3.3 degrees one week after operation, and was -3.8 degrees at the final follow-up. Follow-up 6 months after operation and at the final follow up showed that the fused segments were stable. The JOA score improved by 5.2 +/- 1.6 (P < 0.05) with a mean JOA score improvement rate of 64. 3%. No neurovascular and instrumentation-related complications occurred. Internal fixation of cervical pedicle screw is effective and safe in treatment of cervical spondylotic myelopathy with cervical kyphosis.

Suitability of the noninvasive halo for cervical spine injuries: a retrospective analysis of outcomes

Background context Conventional halos (CHs) have been used since 1959 and have long been regarded as the standard for external stabilization of the injured cervical spine. Unfortunately, there use is associated with several significant complications including infection, pin loosening, dysphasia, dural and skull penetration, and pressure ulcers. Recently, a pinless noninvasive halo (NIH) (Seattle Systems/Trulife, Poulsbo, WA) was introduced with the goal of providing cervical spine stabilization and control approaching that of the CH in a less invasive fashion. The design of this orthosis could prove useful if it is found to produce the same outcomes with fewer complications than the CH. Purpose To review outcomes of patients fitted with the NIH to determine its suitability for treating cervical spine injuries. Study design Retrospective case series. Patient sample Consisted of 19 patients fitted with NIHs as inpatients and followed as outpatients at a university-based level-1 trauma center. Outcome measures Data on fracture alignment and healing as assessed by imaging, neurological status, treatment complications, and patient demographics were collected. Methods A retrospective chart review of patients treated for cervical trauma at a university-based level-1 trauma center by attending surgeons was performed. Subjects were identified for the study by reviewing inpatient fitting records of the Department of Orthotics and Prosthetics. Data regarding patient demographics, tobacco use, classification of injury, surgical treatment, total time in NIH, complications, fracture alignment, and neurological status were collected. Results Average time spent in the NIH was 79 days, all fractures successfully healed in acceptable alignment, and no neurologic deterioration was noted. Complications were limited to one case of occipital ulceration, two cases of noncompliance, (loosening straps), and one case of recurrent subluxation that was later resolved. Conclusions This study offers preliminary data to support a larger scale, randomized trial with long-term follow-up to compare the clinical efficacy of the NIH to that of CHs in patients with cervical spine trauma. Biomechanical studies of the stability of the cervical spine in the NIH, currently underway, will help to assess the suitability of the NIH as an alternative to CHs. The complications encountered do not preclude further investigation of this device and patient tolerance of this treatment has been satisfactory.

Direct laryngoscopy and endotracheal intubation in the prone position following traumatic thoracic spine injury

Perioperative airway management in trauma victims presenting with penetrating thoracic spine injury poses a major challenge to the anesthesiologist. To avoid further neurological impairment it is essential to ensure maximal cervical and thoracic spine stability at the time of airway manipulation (e.g., direct laryngoscopy and endotracheal intubation). Airway management in the prone position additionally increases the incidence of cervical/thoracic spine injury, difficult ventilation, and difficult airway instrumentation. Although awake fiberoptic intubation of the trachea is considered the gold standard for airway instrumentation in patients with posterior thoracic/cervical trauma, this technique requires the patient's cooperation, special equipment, and extensive training, all of which might be difficult to accomplish in emergency situations. We herein present the first reported case of an adult trauma patient who underwent direct laryngoscopy and endotracheal intubation under general anesthesia in the prone position. Although the prone position is not the standard position for airway instrumentation with direct laryngoscopy and endotracheal intubation under general anesthesia, our experience indicates that this technique is possible (and relatively easy to perform) and might be considered in an emergency situation.

Comparative Biomechanical Study of Cervical Spine Stabilisation by Cage Alone, Cage with Plate, or Plate-Cage: A Porcine Model

To compare stability and subsidence associated with 3 types of cervical spine stabilisation. The C3 to C4 vertebrae of 28 Polish pigs were used. Pigs with intact vertebrae (group 1) underwent standard anterior cervical discectomy (group 2), followed by stabilisation using a cage alone (group 3), a cage with plate (group 4), or a plate-cage (group 5). Cervical spine stability and subsidence were compared in all 5 groups. Stability was significantly increased after stabilisation by a cage with plate or a plate-cage, but not by a cage alone. The difference between stabilisation by a cage with plate and a plate-cage was not significant. Subsidence was maximal after the cage-alone stabilisation (3.1 mm), being 1.6 mm after the cage-with-plate and plate-cage stabilisations. Additional plating as a supplement to anterior interbody cervical cage stabilisation significantly improves segmental stability and subsidence.

Delayed Migration of a Screw Into the Gastrointestinal Tract After Anterior Cervical Spine Plating

Case report and clinical discussion. To describe a rare case of spinal cervical screw migration into the gastrointestinal tract 11 years after surgery. Anterior cervical spine fusion and stabilization with plating is a well-established procedure for cervical myelopathy, cervical spinal trauma, and spinal infectious disease. Esophageal injury has been related to screw or plate extrusion. We present a 45-year-old white man suffering from severe quadriparesis and neck pain. Cervical spine magnetic resonance images showed spondylodiscitis and spinal fracture of C4 and C5 vertebral bodies. He underwent anterior surgical decompression consisting of C4 and C5 corpectomies and fusion with fibular allograft fixated with a cervical plate. The patient's neurologic examination gradually improved during his follow-up. The patient returned 11 years after cervical spine graft and plating, complaining of severe dysphagia and high fever. Radiographs of the cervical spine showed a screw back-out. Three days later, a new radiograph of the cervical spine revealed a progression of the screw's extrusion. In a new cervical spine radiograph, obtained immediately before surgical intervention, the displaced screw was no more visible. Abdominal radiograph showed the missed screw in the right lower abdominal quadrant. Barium meal swallowing test showed no leakage on the cervical area. At 6 months follow-up, the patient is in good condition and symptom free. In this case, the delayed esophageal perforation occurred 11 years after initial surgery: the rapid progression of the screw extrusion after initial pull-out (6 days) was documented by several radiographs and spontaneous closure of the fistula was achieved.