Reconstruction Of Cervical Spine Research Articles

Antibiotic-impregnated polymethylmethacrylate as an anterior biomechanical device for the treatment of cervical discitis and vertebral osteomyelitis: technical report of two cases

To evaluate the feasibility of this novel surgical approach for treatment of cervical discitis and vertebral osteomyelitis. This is a report of two patients who underwent anterior cervical decompression for discitis and vertebral osteomyelitis (DVO) with cervical spine reconstruction with polymethylmethacrylate impregnated with antibiotics (AI-PMMA). Both patients had successful procedures that were followed by 6 weeks of intravenous antibiotics. Stabilization and eradication of infection was achieved with clinical and radiographic stabilization seen in both. Follow-up is greater than 18 months and both patients remain off antibiotics. The described technique using AI-PMMA offers immediate structural stability and local delivery of high concentration of antibiotics. Use in two patients has demonstrated a cost effective, long-term biomechanically stable construct and infection control.

Expandable titanium cages for anterior column cervical reconstruction and their effect on sagittal profile: a review of 48 cases

Expandable cervical cages have been utilised successfully to reconstruct the cervical spine for various conditions. However, to date there are only limited data on their influence on cervical sagittal profile. In this retrospective study, we present our experience with performing anterior cervical corpectomy in one or two levels using expandable titanium cages in order to achieve stable reconstruction and restoration of cervical lordosis. A case series of data from 48 consecutive patients (20 men, 28 women; mean age 61 years) operated upon in a 5-year-period is retrospectively reviewed. Standard anterior single- or two-level cervical corpectomy, fusion and spinal reconstruction were performed, including placement of an expandable titanium cage and an anterior cervical plate. The mean follow-up was 23 months (range, 8-42 months). Outcome was measured by clinical examinations and visual analogue scale (VAS) scale; myelopathy was classified according the Nurick grading system. Radiographic analysis comprised several parameters, including segmental Cobb angle, cervical lordosis, subsidence ratio and sagittal cage angle. Computed tomography was done 1 and 2 years after surgery; cervical spine radiographs were obtained 3, 6, 12 and 24 months after surgery. In 38 patients (79 %) osseous fusion or stability of construct could be demonstrated in the 2-year follow up examination. The mean restoration of segmental Cobb angle as well as cervical lordosis amounted to 7.6° and 5.4° respectively, both being statistically significant. Furthermore, a profound correction (10° or more) of the sagittal cervical curve was shown in 15 patients. Regarding the restoration of the physiological sagittal cervical profile, expandable cervical cages seem to be efficient and easy to use for cervical spine reconstruction after anterior corpectomy. Donor-site-related complications are avoided, fast and strong reconstruction of the anterior column is provided, resulting in satisfactory fusion rates after 2 years.

Evaluation of clinical results and quality of life after surgical reconstruction for rheumatoid cervical spine

Background contextThe EuroQol (EQ-5D) is a widely used comprehensive measure of health-related quality of life. There has been no study that has evaluated the health-related quality of life before and after the surgical reconstruction of rheumatoid arthritis (RA) cervical spine lesions using EQ-5D. PurposeThe present study aimed to evaluate the improvement of quality of life before and after surgical reconstruction of rheumatoid cervical spine using EQ-5D, and the surgical outcomes of cervical spine affected by RA. Study designA retrospective study of the patients who underwent surgical reconstruction of cervical disorders in RA. Patient sampleTwenty-five patients (seven men, 18 women, mean age 62.2 years) who underwent surgical reconstruction of cervical disorders in RA were enrolled. Outcome measuresJapanese Orthopaedic Association (JOA) score and EQ-5D. MethodsClinical symptoms were evaluated before surgery and at 2 years after surgery by measuring the JOA score. We also investigated health-related quality of life before surgery and outcome at 2 years after surgery using the EQ-5D questionnaire. ResultsMean observation period was 46.3 months. Mean JOA score significantly improved from 9.1±4.5 points before surgery to 12.4±2.8 at the 2 years after surgery (p=.0001). All the EQ-5D data were improved at the 2 years after surgery, compared with the data before surgery; especially, pain (p=.005), usual activity (p=.005), mobility (p=.008), and anxiety/depression (p=.02) were significantly improved. Utility weight was 0.37±0.27 before surgery and 0.56±0.26 at the 2 years after surgery, showing significant improvement at the 2 years after surgery compared to before surgery (p=.002). ConclusionsThe surgical reconstruction of rheumatoid cervical spine has been demonstrated to improve patients' health-related quality of life.

Reconstruction of the Subaxial Cervical Spine Using Pedicle Screw Instrumentation

Review article. To review the indications, detailed techniques, and complications of cervical pedicle screw fixation procedure. Although screw insertion into the cervical pedicles has been considered too risky for the neurovascular structures except C2 and C7, biomechanical studies revealed a superior stabilizing effect of pedicle screw fixation in the cervical spine to other fixation procedures including lateral mass screw fixation. In addition, several investigators reported superior reconstructive results of unstable cervical spine. A literature review and review of the authors' experience in the treatment of the patients with unstable cervical spine and/or cervical spinal deformities using cervical pedicle screw fixation procedure. Pedicle screw fixation is biomechanically most reliable for reconstruction of the cervical spine in various kinds of disorders. Previously reported articles revealed that pedicle screw fixation is useful for reconstruction of unstable cervical spine and correction of cervical deformities. Neurovascular complication by this procedure cannot be completely eliminated; however, it can be minimized by sufficient preoperative imaging studies and strict control of screw placement during surgery. Modern technology of computer navigation system and newly developing aiming devices can be expected to increase the accuracy of screw placement. Pedicle screw provides excellent 3-dimensional fixations and is a useful procedure for reconstruction of the cervical spine in various kinds of disorders. Possible neurovascular complication can be minimized by sufficient preoperative imaging studies and strict control of screw placement during surgery.

Surgery for Failed Cervical Spine Reconstruction

Review article. To review the indications, operative strategy, and complications of revision cervical spine reconstruction. With many surgeons expanding their indications for cervical spine surgery, the number of patients being treated operatively has increased. Unfortunately, the number of patients requiring revision procedures is also increasing, but very little literature exists reviewing changes in the indications or operative planning for revision reconstruction. Narrative and review of the literature. In addition to the well-accepted indications for primary cervical spine surgery (radiculopathy, myelopathy, instability, and tumor), we have used the following indications for revision surgery: pseudarthrosis, adjacent segment degeneration, inadequate decompression, iatrogenic instability, and deformity. Our surgical goal for pseudarthrosis is obviously to obtain a fusion, which can usually be performed with an approach not done previously. Our surgical goals for instability and deformity are more complex, with a focus on decompression of any neurologic compression, correction of deformity, and stability. Revision cervical spine reconstruction is safe and effective if performed for the appropriate indications and with proper planning.

Cervical Spine Reconstruction in Cases of Compromised Bone Quality

( b r a s s m m a p b p t D d r C i B d T he prevalence of patients suffering from end-stage renal disease has increased in the United States (3). With the increasing availability of hemodialysis treatment, these atients are living longer but continue to suffer from the econdary complications of the illness. Renal osteodystrophy ROD) and hemodialysis-associated destructive spondyloarhropathy (DSA) are two related but distinct syndromes. ROD s a direct result of secondary (and rarely primary) hyperparahyroidism and is characterized by alternating areas of subhondral bone resorption, osteomalacia, and osteosclerosis 5). When these bony changes occur in the spine, they do so arallel to the vertebral end plates, creating alternating bands f lucency and sclerosis. The classic radiographic finding of rugger jersey spine” is a reflection of this pattern on lateral pine radiographs, as the alternating bands mimic the design f English rugby jerseys (4, 9, 17). The related phenomenon of emodialysis-associated destructive spondyloarthropathy DSA) was first described by Kuntz (7) in 1984. Kuntz’s group iscovered crystal deposition in the discs and vertebral bodies f patients undergoing long-term hemodialysis for chronic enal failure. This crystal was classified as beta-2-microglobuin ( 2M), a protein that is filtered by the healthy glomerulus, but cannot be filtered by dialysis filters due to its large size. Therefore, dialysis patients may have serum levels of 2M 50 to 60 times normal, resulting in deposition in not only the spine, but also the tendons leading to carpal tunnel syndrome and in the heart causing cardiomyopathy (5). DSA has a similar radiographic appearance to ROD in the spine, with the typical lack of osteophytic change (4). In addition to the compressive and destabilizing lesions that may result from ROD and DSA, surgeons must be aware of the high incidence of comorbidities (6), such as hypertension, diabetes, and coronary artery disease, when caring for patients with end-stage renal dis-

Anterior construction after resection for axis tumors through the sub mandible approach

Objective To investigate procedure and therapeutic effect of resection and reconstruction for axis tumors through the sub mandible approach. Methods Between December 2004 to June 2010,17 patients with axis neoplasm underwent tumor resection and antero-posterior reconstruction through the combined the sub mandible-inner sternocleidomastoid muscle (SMIS) approach and posterior approach. Tumor lesions involved C2 in 11 cases, C2-3 in 4, C2-4 in 2. Eight cases involved vertebral body, and 9 involved both vertebral body and element. Fourteen primary lesions including 4 giant cell tumors, 4 plasmocytomas, 2 chordomas, 2 eosinophilic granulomas, 1 hemangiopericytomas and 1 lymphoma, and 3 metastatic lesions were involved in this study. Three types of reconstruction in upper cervical spine including titanium mesh plus vertically placed titanium plate, titanium mesh plus obliquely placed titanium plate and trimmed titanium mesh alone, were adopted after anterior tumor resection, and then posterior tumor resection and reconstruction were performed. Results All patients experienced pain relief and neurological improvement after surgery. Except for one incidence of screw pull-out which was corrected by a revision surgery, solid fusion was achieved in all patients. A follow-up period of 6 months to 6 years was available for this study. One patient died of cerebral infarction 9 months postoperative. Two patients with chordoma relapsed 13 months and18 months postoperative, respectively, of whom one died of high plegia and respiratory failure, and the other was alive with disease. Two patients with metastasis died of multiple remote metastases 12 months and 18 months postoperative, respectively. Conclusion Through the SMIS apporach, a satisfactory exposure can be obtained for axis tumor resection and reconstruction. Anterior reconstruction of upper cervical spine after tumor resection can be achieved with internal fixation system of cervical spine, which can improve intraopera-tive safety. The combined anterior reconstruction and posterior occipito-cervcial fixation can provide immediate stability, and benefit maintaining stability of upper cervical spine. Key words: Axis; Neoplasms; Surgical procedures, operative

Vascularized Free Fibula for Cervical Spine Reconstruction following Complicated Retropharyngeal Abscess

Vascularized Free Fibula for Cervical Spine Reconstruction following Complicated Retropharyngeal Abscess

Total subaxial reconstruction

Certain cervical spinal conditions require decompression and reconstruction of the entire subaxial cervical spine. There are limited data concerning the clinical details and outcomes of patients treated in this manner. The object of this study was to describe the specific technique employed to perform a total subaxial reconstruction and review the postoperative outcomes following surgery. The author performed a review of data prospectively collected in 27 consecutive patients undergoing complete anterior decompression and reconstruction of the anterior cervical spine and followed by posterior instrumented arthrodesis with or without decompression. There were 16 men and 11 women whose mean age was 59 years (range 35-86 years). The minimum follow-up was 12 months and the mean follow-up period for all patients was 26 months. One patient underwent C2-7 surgery, and in all others the procedure crossed the cervicothoracic junction. Following surgery patients remained intubated for an average of 3.3 days (range 1-22 days). The mean hospital length of stay was 11 days (range 3-45 days). One patient died 6 weeks following an uneventful surgery. Pneumonia developed in 5 patients, 1 patient experienced a minor pulmonary embolism, and 2 patients had posterior wound infections. No patient was neurologically worse following surgery. A single patient presented with a C-8 radiculopathy 6 weeks after surgery. At final follow-up no patient complained of dysphagia when specifically questioned about this potential problem. In all patients solid fusions developed at each treated levels. Preoperatively the mean sagittal Cobb angle was 15.4° (kyphosis) and the postoperative mean angle was -10.9° (lordosis) representing a total average correction of over 25° (p < 0.0001). The mean preoperative Neck Disability Index was 27.6; this score decreased to 15.5 (p = 0.0008) postoperatively. The mean pre- and postoperative visual analog scale neck pain scores were 6.0 and 2.1, respectively (p = 0.0004), and mean visual analog scale arm pain scores decreased by 3.7 following surgery (p = 0.001). Based on Odom criteria, the author found that 8 patients had an excellent outcome and 14 patients a good outcome. There were 4 patients in whom the outcome was judged to be fair and the single death was recorded as a poor outcome. The mean preoperative Nurick score was 2.68. Postoperatively the group improved to an average score of 1.5; the difference between the 2 was statistically significant (p = 0.002). Segmental anterior decompression and reconstruction of the entire subaxial cervical spine, combined with an instrumented posterolateral fusion, can be performed with acceptable morbidity and is of significant benefit in selected patients.

A Hollow Cylindrical PMMA Strut for Cervical Spine Reconstruction After Cervical Multilevel Corpectomy

Between January 2002 and December 2005, a prospective study was performed with 14 patients. The patients had cervical diseases and received more than 1 segment anterior cervical corpectomies. We investigated the effectiveness of the hollow cylindrical polymethyl methacrylate (PMMA) strut with the autograft for fusion and reconstruction of the cervical spine after multiplelevel cervical corpectomy. We usually used the titanium mesh cage to reconstruct the cervical spine after cervical corpectomy. A significant number of poor outcomes were noted. Because the mesh cage is very hard, it sinks into the vertebral body without the cortex. It is also difficulty to assess the fusion status. A total of 14 patients (age range: 31 to 76 y) underwent anterior cervical corpectomy after fusion and reconstruction with cylindrical PMMA struts. Each patient was reinforced with anterior cervical plate fixation. Follow-up radiographic evaluation was comprised of plain lateral dynamic radiographs and computerized tomography (CT) scans. We evaluated the patients for cervical lordosis and vertebral body height on the basis of plain radiographs. The fusion status was evaluated with CT scans. Neurologic status was assessed preoperative and postoperatively using the Nurick's grading system. : The mean follow-up was 48.2 months (range: 28 to 70 mo). All patients showed spinal stability at 6 months follow-up on the basis of plain lateral dynamic radiograph results. Thirteen patients showed neurologic improvement with complete bony fusion in the 24-month reconstructed CT scans. There were no complications related to the hollow cylindrical PMMA strut. One patient had loosened screws and required a second operation. The cylindrical PMMA strut provides solid fusion and increased cervical lordosis and vertebral body height. There are few complications associated with the use of this strut, and neurologic recovery is satisfactory. The hollow cylindrical PMMA strut, combined with an anterior cervical plate, is a very successful surgical construct in these patients after long-segmental cervical corpectomy.

Surgical Management of Cervical Spondyloarthropathy in Hemodialysis Patients

Dialysis-related spondyloarthropathy is a rare cause of spinal deformity and cervical myelopathy. Optimal management of cervical spine spondyloarthropathy often requires circumferential reconstructive surgery, because affected patients typically have both the anterior column and the facet joints compromised. The occasional presence of noncontiguous or "skip lesions" adds an additional level of complexity to surgical management, because decompression and fusion in an isolated segment of neural compression can worsen spine deformity by applying increased stress to adjacent cervical spine segments. We report two cases of hemodialysis patients who presented with cervical myelopathy and initially had anterior cervical discectomy or corpectomy. Because symptoms recurred due to hardware failure, both patients required posterior spine fusion as well. In retrospect, because of the hardware failure, both of these patients might have benefited from a circumferential (combined anterior and posterior) cervical spine reconstruction as their initial treatment.

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

Anterior cervical pedicle screw and plate fixation using fluoroscope-assisted pedicle axis view imaging: a preliminary report of a new cervical reconstruction technique

Anterior procedures in the cervical spine are feasible in cases having anterior aetiologies such as anterior neural compression and/or severe kyphosis. Halo vests or anterior plates are used concurrently for cases with long segmental fixation. Halo vests are bothersome and anterior plate fixation is not adequately durable. We developed a new anterior pedicle screw (APS) and plate fixation procedure that can be used with fluoroscope-assisted pedicle axis view imaging. Six patients (3 men and 3 women; mean age, 54 years) with anterior multisegmental aetiology were included in this study. Their original diagnoses comprised cervical myelopathy and/or radiculopathy (n = 4), posterior longitudinal ligament ossification (n = 1) and post-traumatic kyphosis (n = 1). All patients underwent anterior decompression and strut grafting with APS and plate fixation. Mean operative time was 192 min and average blood loss was 73 ml. Patients were permitted to ambulate the next day with a cervical collar. Local sagittal alignment was characterised by 3.5 degrees of kyphosis preoperatively, which improved to 6.8 degrees of lordosis postoperatively and 5.2 degrees of lordosis at final follow-up. Postoperative improvement and early bony union were observed in all cases. There was no serious complication except for two cases of dysphagia. Postoperative imaging demonstrated screw exposure in one screw, but no pedicle perforation. APS and plate fixation is useful in selected cases of multisegmental anterior reconstruction of cervical spine. However, the adequate familiarity and experience with both cervical pedicle screw fixation and the imaging technique used for visualising the pedicle during surgery are crucial for this procedure.

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

Anesthetic management of a child with Down’s Syndrome having atlanto axial instability

Down's syndrome is the most commonly encountered congenital anomaly in medical practice. These patients are of special concern to medical practice because of their associated problems with regard to respiratory, cardiovascular and other systemic problems. As these patients present for repeated surgeries like dental extraction, facial reconstruction and fixation of cervical spine, these patients pose challenges to the anesthesiologist because of their unique set of problems, namely atlantoaxial instability, small trachea, congenital heart disease and repeated chest infections due to lowered immunity. Their reactivity to inhalational anesthetics and atropine is variable. Here we present an interesting case report of a child with Down's syndrome who presented with atlantoaxial instability for MRI of cervical spine under general anesthesia.

S112 – Fibula C-Spine Reconstruction Following Retropharynx Abscess

Objectives 1) Understand the pathogenesis and epidemiology of retropharyngeal abscess. 2) Appreciate the diagnostic dillema and rapid progression of untreated deep neck space infections. 3) Recognize the significance of free vascularized tissue grafting in the acute post-infection setting of cervical osteomyelitis. Methods A 42-year-old man presented with rapidly progressive odynophagia, respiratory distress, and lower extremity muscle weakness. A large odontogenic retropharyngeal abc-scess had rapidly progressed to cervical osteomyelitis. Diagnostic imaging revealed C2-C6 level involvement. A review of the literature reveals the unusual progression of this case. Results Following drainage, debridement, and anterior as well as posterior stabilization, the patient underwent reconstruction. An early successful second-stage reconstruction was performed with vascularized free fibula graft. The patient did well postoperatively with resolution of paresis, pain, and airway compromise. Conclusions We present the first reported use of vascularized free fibula graft for anterior cervical spine reconstruction from a complicated odontogenic retropharyngeal abscess leading to cervical osteomyelitis. A review of the literature highlights the dangers of untreated deep neck space infections and the role of the reconstructive surgeon in their management.

The significance of hardware failure in anterior cervical plate fixation. Patients with 2- to 7-year follow-up.

In this retrospective study, the incidence of anterior cervical hardware failure was reviewed in 109 patients with degenerative disorders treated by one surgeon. To evaluate the risk of injury caused by hardware failure in anterior cervical spine reconstruction. Anterior plating is used for stabilization after cervical spine trauma and other conditions of instability. There has been a concern among surgeons about the risks involved when anterior cervical plating fails (fracturing or loosening of the construct). The series included placement of 70 nonconstrained plates and 39 constrained plates. The average length of follow-up was 43 months. Hardware failure was defined as any broken or loosened screw or plate, regardless of clinical significance. There were 32 Orozco (Synthes, Inc., Paoli, PA) failures, 5 cervical spine locking plate failures, and 2 Orion (Sofamor Danek USA, Inc., Memphis, TN) failures. There were no injuries to tracheoesophageal or neurovascular structures as a result of hardware implantation or failure. The incidence of prominent hardware that endangers tracheoesophageal structures is minimal. In most cases, careful and long-term follow-up can ensure that failed hardware has not progressed and can confirm that late failure has not occurred. Hardware failure should increase the surgeon's suspicion of a nonunion, but immediate removal of the failed hardware is rarely necessary. If reoperation is necessary for nonunion repair, kyphosis correction, or other secondary procedures, the hardware can be removed at that time. Constrained systems (cervical spine locking plate, Orion) had significantly (P2 = 7.65, P < 0.01) fewer failures than the nonconstrained Orozco system.