Severe Cord Compression Research Articles

Cervical epidural hematoma: a case series highlighting uncommon causes

BackgroundCervical epidural hematoma (CEH) is a rare but potentially devastating condition, characterized by the accumulation of blood within the epidural space of the cervical spine, leading to spinal cord compression (Perron AD, Huff JS. Spinal cord disorders. In: Marx JA, et al. editors. Rosen’s emergency medicine: concepts and clinical practice. 8th ed. Philadelphia: Saunders; 2013. pp. 1419–27.); (Raasck K, Habis AA, Aoude A, Simoes L, Barros F, Reindl R. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043. https://doi.org/10.1038/scsandc.2016.43.); (Ryo Yamamoto M, Ito H, Shimuzu K, Wakabayashi H, Oyama. Two cases of cervical epidural hematoma presenting with left-sided hemiplegia and requiring surgical drainage. Cureus. 2022;14(4):e23915. https://doi.org/10.7759/cureus.23915.). While trauma and iatrogenic causes are well-documented, cases attributed to neck strain and acupuncture are uncommon. (Raasck K, Habis AA, Aoude A, Simoes L, Barros F, Reindl R. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043. https://doi.org/10.1038/scsandc.2016.43.); (Shiraishi S, Goto I, Kuroiwa Y, Nishio S, Kinoshita K. Spinal cord injury as a complication of an acupuncture. Neurology. 1979;29(8):1188–90. https://doi.org/10.1212/wnl.29.8.1188.) Here, we present two cases of CEH secondary to these unusual aetiologies. Both cases highlight the importance of considering uncommon causes of CEH to ensure early recognition and prompt treatment.Case presentationsCase 1 is an 81-year-old lady who presented with left hemiparesis and paraesthesia following a fall with neck strain. Magnetic resonance imaging (MRI) of cervical spine revealed left C3-C7 epidural haematoma with severe cord compression. In Case 2, a 35-year-old gentleman experienced sudden onset numbness and weakness in all limbs just 10 minutes after receiving acupuncture. MRI showed an epidural hematoma at the C2-C4 levels. Both patients underwent immediate surgical decompression and had significant recovery.ConclusionAlthough CEH is a rare occurrence, it can potentially be a neurosurgical emergency. Physicians must remain cognizant of the diverse aetiologies associated with CEH and the necessity for early recognition and immediate treatment.

Anaesthetic Management for a Dilated Cardiomyopathy Patient, Scheduled for Lumbar Spine Surgery

Background: Dilated cardiomyopathy (DCM) is characterized by dilatation and impaired contraction of left or both ventricles. Diagnostic criteria are left ventricular ejection fraction less than 40% or fractional shortening less than 25%. Perioperative anesthetic management of these patients are very challenging for anesthesiologists and intensive care team. Case presentation: A 55-year-old female, presented with complaints of severe low-back ache with bilateral lower limb involvement without involvement of bladder and bowel. Severe cord compression at the L4-5 level and severe lumbar canal stenosis were detected by magnetic resonance imaging. Echocardiography showed that the left ventricle (LV) had global hypokinesia, with an ejection fraction of 25% to 30%. The planed surgical procedures were L4 lumbar laminectomy and L4-5 microdiscectomy. Conclusion: Continuous monitoring and control of hemodynamic parameters as well as central venous pressure guided fluid therapy is the cornerstone in improving outcome in patients with dilated cardiomyopathy for non-cardiac surgery.

Surgical Outcomes of Extensive Dome-Like Laminoplasty Using En Bloc Resection of C2 Inner Lamina for Patients With Severe Cord Compression Behind C2 Body.

A retrospective, single-center study. The aim of this study is to evaluate the efficacy and safety of a newly developed extensive dome-like laminoplasty using en bloc resection of the C2 inner lamina in patients with severe cord compression behind the C2 body. A surgery for severe cord compression behind C2 body is challenging for spinal surgeons. To date, there has been no established solution for severe cord compression behind the C2 body. Patients with severe cord compression behind the C2 body who underwent posterior surgery consecutively were enrolled. Extensive dome-like laminoplasty that was newly developed was performed to remove en bloc removal of the C2 inner lamina were performed. Preoperative and postoperative canal diameters behind the C2 and mean removed area of the C2 inner lamina were measured using MRI and CT scan. Clinical and radiographic parameters were assessed preoperative and postoperative periods. In addition, perioperative complications were analyzed. A total of 36 patients underwent extensive dome-like laminoplasty and their diagnoses were ossification of the posterior longitudinal ligament (OPLL, 66.7%) and congenital stenosis with spondylosis (33.3%). The mean canal diameter behind the C2 increased from 9.85 (2.28) mm preoperatively to 19.91 (3.93) mm at the last follow-up ( P <0.001). Clinically, neck and arm visual analog scale, Japanese Orthopaedic Association score, and neck disability index significantly improved at postoperative 1 month ( P <0.05), and the scores were maintained until the last follow-up. No meaningful radiographic changes occurred after the surgeries. During the procedures, there were no particular complications, but one patient showed deteriorated myelopathic symptoms and underwent additional C1-C2 decompressive surgery. After extensive dome-like laminoplasty, surgical outcomes are satisfactory, and complications are rare. This technique may be a viable option for patients with severe cord compression behind the C2 body. Level IV.

Endoscopic endonasal approach for resection of odontoid process, decompression of the cervicomedullary junction spinal cord, and resection of pannus.

Odontoid pannus is an abnormal collection of degenerative or inflammatory tissue on the C1-dens joint that can result in severe spinal cord compression myelopathy. Treatment options vary depending on severity and etiology. In cases of severe cord compression, surgical management could be either through a purely posterior approach or in combination with an anterior decompression via endoscopic endonasal approach (EEA). This case presents a 77-year-old female who underwent posterior cervical fixation for odontoid pannus causing dramatic cervical myelopathy who failed to improve over a 6-month period and required anterior transodontoid pannus resection and decompression via EEA. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23176.

Definition, Frequency and Risk Factors for Intra-Operative Spinal Cord Injury: A Knowledge Synthesis.

Mixed-methods approach. Intra-operative spinal cord injury (ISCI) is a devastating complication of spinal surgery. Presently, a uniform definition for ISCI does not exist. Consequently, the reported frequency of ISCI and important risk factors vary in the existing literature. To address these gaps in knowledge, a mixed-methods knowledge synthesis was undertaken. A scoping review was conducted to review the definitions used for ISCI and to ascertain the frequency of ISCI. The definition of ISCI underwent formal review, revision and voting by the Guidelines Development Group (GDG). A systematic review of the literature was conducted to determine the risk factors for ISCI. Based on this systematic review and GDG input, a table was created to summarize the factors deemed to increase the risk for ISCI. All reviews were done according to PRISMA standards and were registered on PROSPERO. The frequency of ISCI ranged from 0 to 61%. Older age, male sex, cardiovascular disease including hypertension, severe myelopathy, blood loss, requirement for osteotomy, coronal deformity angular ratio, and curve magnitude were associated with an increased risk of ISCI. Better pre-operative neurological status and use of intra-operative neuromonitoring (IONM) were associated with a decreased risk of ISCI. The risk factors for ISCI included a rigid thoracic curve with high deformity angular ratio, revision congenital deformity with significant cord compression and myelopathy, extrinsic intradural or extradural lesions with cord compression and myelopathy, intramedullary spinal cord tumor, unstable spine fractures (bilateral facet dislocation and disc herniation), extension distraction injury with ankylosing spondylitis, ossification of posterior longitudinal ligament (OPLL) with severe cord compression, and moderate to severe myelopathy. ISCI has been defined as "a new or worsening neurological deficit attributable to spinal cord dysfunction during spine surgery that is diagnosed intra-operatively via neurophysiologic monitoring or by an intraoperative wake-up test, or immediately post-operatively based on clinical assessment". This paper defines clinical and imaging factors which increase the risk for ISCI and that could assist clinicians in decision making.

Ventro-Lateral Meningioma of the Cervico-Thoracic Junction: 2-Dimensional Operative Video.

Meningiomas are one of the most common intradural extramedullary tumors.1 Symptoms often arise from cord compression, with gross total resection leading to the most optimal patient outcomes.2,3 Utilization of intraoperative neurophysiological monitoring can increase patient safety through real-time assessment of neural structures and reduce postoperative neurologic complications.4 In this video, we describe the operative techniques for the resection of a meningioma located at the cervico-thoracic junction. A 43-year-old female patient presented with 6 months of bilateral leg numbness and gait disturbances. MRI of the cervical spine demonstrated a cervical thoracic ventral meningioma causing severe cord compression from the bottom of the C6 lamina to the top of the T1 lamina. Surgical resection with intraoperative neuromonitoring with somatosensory-evoked potentials, motor-evoked potentials, and free-running electromyography was recommended. A partial C6-T1 laminectomy was routinely performed, and the dura was opened using a paramedian approach to allow for maximal tumor visualization. The tumor was carefully dissected and debulked, achieving gross total resection. Postoperatively, the patient experienced improvements in preoperative symptoms with no perioperative complications, and the final pathology confirmed the intradural lesion was a meningioma. This video illustrates the surgical technique and management of a spinal meningioma at the cervico-thoracic junction. Patient consent was obtained for their participation in this surgical video.

Non-Traumatic Cervical Disc Herniation Presented as Sudden Paralysis of the Limbs: Two Case Reports

We report two uncommon cases of non-traumatic, acute cervical disc herniation presented with sudden paralysis of the limbs. First, a 61-year-old man presented with sudden quadriplegia while resting on the bed 2 hr ago. He had motor weakness of grade 3 in the upper arms and grade 0 in the lower legs. Magnetic resonance imaging (MRI) of the cervical spine showed severe spinal cord compression caused by huge soft central disc herniation at the C6-7 level. After surgery, the paralysis of the upper arms improved, but the paralysis of the lower legs and sphincter functions did not improve. Second, a 65-year-old woman presented with acute right hemiparesis just after waking up in the morning 3 hr ago. She had motor weakness of grade 3 of the right upper arm and grade 2 of the right lower leg. MRI of the cervical spine showed severe cord compression by the right-sided, superiorly migrated soft disc herniation at the C6-7 level. After surgery, she recovered completely and could walk independently.

Severe Spine Cord Compression By Plasmacytoma/Multiple Myeloma, Series of Cases

Severe Spine Cord Compression By Plasmacytoma/Multiple Myeloma, Series of Cases

Pedicle subtraction metallectomy with complex posterior reconstruction for fixed cervicothoracic kyphosis: illustrative case.

Iatrogenic cervical deformity is a devastating complication that can result from a well-intended operation but a poor understanding of the individual biomechanics of a patient's spine. Patient factors, such as bone fragility, high T1 slope, and undiagnosed myopathies often play a role in perpetuating a deformity despite an otherwise successful surgery. This imbalance can lead to significant morbidity and a decreased quality of life. A 55-year-old male presented to the authors' clinic with a chin-to-chest deformity and cervical myelopathy. He previously had an anterior C2-T2 fixation and a posterior C1-T6 instrumented fusion. He subsequently developed screw pullout at multiple levels, so the original surgeon removed all of the posterior hardware. The T1 cage (original corpectomy) severely subsided into the body of T2, generating an angular kyphosis that eventually developed a rigid osseous circumferential union at the cervicothoracic junction with severe cord compression. An anterior approach was not feasible; therefore, a 3-column osteotomy/fusion in the upper thoracic spine was planned whereby 1 of the T2 screws would need to be removed from a posterior approach for the reduction to take place. This case highlights the devastating effect of a hardware complication leading to a fixed cervical spine deformity and the complex decision making involved to safely correct the challenging deformity and restore function.

Endoscopic Transoral Odontoidectomy of Craniovertebral Junction Rheumatoid Arthritis With the Help of Real-Time Fluoroscopy and Intraoperative Computed Tomography.

Rheumatoid arthritis (RA) involvement in the craniovertebral junction (CVJ) is a rare condition after antirheumatoid medications, nevertheless still exists. Neurological deterioration of the patient makes surgery inevitable. Seventy-seven years old man without antirheumatoid treatment presented with progressive neurological deterioration and CVJ involvement of RA with severe cord compression with myelomalacia. The patient underwent endoscopic transoral odontoidectomy with real-time fluoroscopy and intraoperative computed tomography. Even though radiological improvement has been achieved the patient died because of pulmonary complications. Rheumatoid arthritis of CVJ is a life-threatening medical condition. Surgical procedures will be safer by using endoscopy and intraoperative radiological imaging techniques.

Are Functional Gains Durable After Decompressive Surgery for Cervical Myelopathy?: Commentary on an article by Victor Hin Ting Yick, MBBS, et al.: "Neurological Survivorship Following Surgery for Degenerative Cervical Myelopathy. A Longitudinal Study on 195 Patients".

Commentary In degenerative cervical myelopathy, spine surgeons generally accept the concept that patients will show clinically meaningful improvement after spinal cord decompression. At a minimum, the spine literature and common sense support the notion that cord decompression will at least halt ongoing neurological deterioration. Surgeons may debate the best method of decompression (anterior or posterior) and whether decompression with fusion is necessary, but there is little dissension with regard to the need for a surgical procedure in the setting of moderate to severe myelopathy1. The extent to which early neurological improvement after the surgical treatment of degenerative cervical myelopathy is sustained in the long term is unknown. Using the concept of neurological survivorship and Kaplan-Meier curves, Yick et al. demonstrate that, although most patients improve after decompressive surgery, not all of these good early results are durable. The authors found that as many as 17.9% of patients will see a recurrent decline in neurological function by 10 years, and most of these patients who underwent failed treatment (74.3%) underwent a revision surgical procedure. Given the published high reoperation rates in cervical spine surgery, these results in degenerative cervical myelopathy are not particularly surprising. In a recent minimum 10-year follow-up of anterior cervical fusion in 159 patients, Buttermann reported a 31% reoperation rate2. In the current study, Yick et al. confirm what smaller, short-term studies have suggested: improvement after decompression for degenerative cervical myelopathy is fleeting in many patients and reoperation is common. Such knowledge is valuable when counseling patients both before and after the surgical procedure. In addition to describing the neurological survivorship of these patients, Yick et al. drilled down on the risk factors for failure. Some of these significant risk factors are patient-specific and are not controllable by the surgeon. These factors include renal failure and spinal cord signal change on T2-weighted magnetic resonance imaging sequences. A cord signal change, associated with cellular changes in the cord secondary to severe cord compression, is often irreversible3 and, as seen in the current study, is associated with ongoing declines in neurological function. Other significant risk factors are modifiable. Surgeons can use these factors to modify their surgical management of cervical myelopathy and, hopefully, improve future neurological survivorship. First, and most importantly, surgeons should not be performing suture laminoplasty. Patients treated with this technique had the worst neurological survivorship (31.2%) and tended to experience treatment failure early after the surgical procedure. Second, patients with ossification of the posterior longitudinal ligament did best when decompression was combined with fusion. Surgeons should give strong consideration to including fusion in patients with ossification of the posterior longitudinal ligament to improve outcomes. Conversely, surgeons might consider avoidance of fusion in younger patients with cervical compressive myelopathy. The top risk factor for late neurological decline was adjacent-level stenosis, proximal or distal to a fusion construct. In these patients, perhaps a posterior decompression without fusion or a laminoplasty with plating will result in better neurological survivorship. Yick et al. should be commended for their efforts to publish longer-term neurological outcomes for this complex group of patients. The strengths of the study include a large cohort of 195 patients and a mean follow-up of 76 months. The weaknesses of the study include a retrospective design with many patients (49) excluded because of incomplete follow-up. Furthermore, many of the included patients (37) had a follow-up period shorter than 2 years. Nevertheless, Yick et al. identify important predictive factors for neurological survivorship after surgical treatment of degenerative cervical myelopathy and give surgeons specific pearls to help with surgical planning. A long-term prospective study with a minimum 10-year follow-up is still necessary to define optimal surgical approaches for degenerative cervical myelopathy.

Plasmocitoma/multiple myeloma with severe cord compression: Case reports

Abstract Introduction: Multiple myeloma (MM) is generally located in the bone marrow (BM) and is associated with a wide spectrum of clinical, laboratory, and radiological findings.[1] Conversely, solitary plasmacytoma (SP) is characterized by a single mass of clonal plasma cells, with no or minimal BM plasmacytosis and with no other symptoms than those derived from the primary lesion.[2] The cases with spine involvement and spine cord suffering from compression always were very complicated and challenging. Materials and Methods: We describe two cases of SP and MM with severe spine cord compression treated surgically with an indication to address the compression and stabilization of the affected segments with subsequent treatment in hematology and oncology. Results: In both cases, the surgery was a success, the patient with SP survived 3 years and 1 month, and the patient with MM survived 1 year and 3 months. Conclusion: The outcomes of surgical interventions for these patients with spine cord compression and spinal instability due to MM and plasmacytoma of the spine were improved with neurological function following surgery and no instrumentation failure.

Transdural Approach for Resection of Craniovertebral Junction Cysts: Case Series.

Craniovertebral junction (CVJ) cysts, including retro-odontoid pseudotumors, are challenging pathologies to treat and manage effectively. Surgical intervention is indicated when these lesions result in progressive myelopathy, intractable pain, or instability. To present a case series of older patients who underwent successful resection retro-odontoid lesions using transdural approach. A single-center, retrospective observation study of older patients who underwent transdural resection of CVJ cysts at a single institution was performed. Summary demographic information, clinical presentation, perioperative and intraoperative imaging, and Nurick scores were collected and analyzed. Eight patients were included (mean age [±SD] 75.88 ± 9.09 years). All patients presented with retro-odontoid lesions resulting in severe cervical stenosis, cord compression, and myelopathy. The mean duration of surgery was 226 ± 83.7 minutes. The average intraoperative blood loss was 181.2 cc. The average hospital stay was 4.5 days ± 1.3 (range, 3-7 days). The average follow-up time was 12.5 ± 9.5 months. No intraoperative complications were encountered. The Nurick classification score for myelopathy improved at the final postoperative examination (2.38 ± 1.06 vs 1 ± 1.07). Three patients demonstrated a pre-existing deformity prompting an instrumented fusion. Both computed tomography and MRI evidence of complete regression of retro-odontoid cyst were noted in all patients on the final follow-up. Posterior cervical transdural approach for ventral lesions at the CVJ is a safe and effective means of treating older patients with progressive myelopathy. This technique provides immediate spinal cord decompression while limiting neurological complications commonly associated with open or endoscopic anterior transpharyngeal approaches.

A Practical Classification System for Acute Cervical Spinal Cord Injury Based on a Three-Phased Modified Delphi Process From the AOSpine Spinal Cord Injury Knowledge Forum.

A modified Delphi study. To assess current practice patterns in the management of cervical spinal cord injury (SCI) and develop a simplified, practical classification system which offers ease of use in the acute setting, incorporates modern diagnostic tools and provides utility in determining treatment strategies for cervical SCI. A three-phase modified Delphi procedure was performed between April 2020 and December 2021. During the first phase, members of the AOSpine SCI Knowledge forum proposed variables of importance for classifying and treating cervical SCI. The second phase involved an international survey of spine surgeons gauging practices surrounding the role and timing of surgery for cervical SCI and opinions regarding factors which most influence these practices. For the third phase, information obtained from phases 1 and 2 were used to draft a new classification system. 396 surgeons responded to the survey. Neurological status, spinal stability and cord compression were the most important variables influencing decisions surrounding the role and timing of surgery. The majority (>50%) of respondents preferred to perform surgery within 24hours post-SCI in clinical scenarios in which there was instability, severe cord compression or severe neurology. Situations in which <50% of respondents were inclined to operate early included: SCI with mild neurological impairments, with cord compression but without instability (with or without medical comorbidities), and SCI without cord compression or instability. Spinal stability, cord compression and neurological status are the most important variables influencing surgeons' practices surrounding the surgical management of cervical SCI. Based on these results, a simplified classification system for acute cervical SCI has been proposed.

A Dorsal Epidural Herniated Disc Fragment Initially Presenting as Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that presents with neurological symptoms that can mimic other conditions. This mimicry can hide other important neurological diagnoses. Here, we present a rare case of thoracic myelopathy secondary to a sequestered dorsal epidural herniated disc fragment that initially presented with the classic findings of GBS.A 58-year-old female presented with progressing bilateral lower extremity weakness, paresthesias, and absent bilateral lower extremity deep tendon reflexes. Lumbar magnetic resonance imaging (MRI) findings were disproportionate to presentation, and lumbar puncture fluid analysis revealed clear, colorless fluid with albuminocytological dissociation. The patient was diagnosed with GBS and treated with a short course of intravenous steroids followed by intravenous immunoglobulin. The patient later developed new-onset ulnar distribution paresthesias, lower extremity spasticity, constipation, and urinary retention that caused a decline in functional progress. Further investigation prompted evaluation with cervical and thoracic MRIs, which revealed a left dorsal epidural lesion at the T9-T10 level causing severe cord compression. The patient was definitively treated with a T9-T10 laminectomy and excision of the offending lesion. Pathology revealed collagenous tissue with fibroblastic proliferation, consistent with a sequestered fragment of the herniated intervertebral disc. The patient was further treated with both acute and subacute rehabilitation. She was eventually discharged home and was able to ambulate independently with a walker.Dependency on positive albuminocytological dissociation in cases of potential GBS can lead to errors in diagnostic accuracy and delay appropriate treatment. Clinicians should remain mindful that GBS is a diagnosis of exclusion and MRI of the entire spine should be considered when the diagnosis of GBS is uncertain.

Spinal Cord Reperfusion Injury after Decompression of Severe Cord Compression: Critical Care Management

Spinal Cord Reperfusion Injury after Decompression of Severe Cord Compression: Critical Care Management

High thoracic disc herniation: a case-based discussion with a review of literature

Aim This article aims to describe a case of a 28-year-old male patient with progressively worsening of myelopathic symptoms owing to a large T4-5 thoracic disc herniation with severe cord compression. Background A 28-year-old male patient was referred to the clinic by a neurologist for worsening of bilateral lower extremity numbness, tingling, and progressive weakness over a period of few months with a clinical examination significant for severe myelopathy and imaging confirming a large thoracic disc herniation. Procedure T4-5 left hemilaminectomy and transfacet discectomy with unilateral right T4/T5 fixation and fusion were done. Outcomes The patient experienced delayed postoperative paraplegia that was reversible despite negative imaging studies, suggesting intraoperative incidental trauma to the cord or progressive postoperative cord edema. Scientific message Literature review of similar cases is presented as well as learning points from this challenging case. If the posterior approach is to be used, complete thorough decompression of the cord is advisable to minimize the risk of complications.

Minimal invasive fixation following with radiotherapy for radiosensitive unstable metastatic spine

BackgroundMinimally invasive surgery (MIS) has become a feasible option for patients with spinal metastasis, but the effectiveness of percutaneous pedicle screw fixation (PPSF) without decompression in patients with severe cord compression remains unknown. We compared PPSF without decompression with debulking surgery in patients with radiosensitive, unstable, metastatic thoracolumbar spinal cord compression. MethodsA retrospective study of surgically treated spinal metastasis and spinal cord compression patients was conducted between October 2014 and June 2019. Demographic and pre- and postoperative data were collected and compared between patients treated with minimally invasive percutaneous fixation and external beam radiotherapy (EBRT) (the PPSF group) and those treated with debulking surgery (the debulking group). ResultsWe included 50 patients in this study. The PPSF group had a significantly shorter operative time (143.56 ± 49.44 min vs. 181.47 ± 40.77 min; p < 0.01), significantly lower blood loss (116.67 ± 109.92 mL vs. 696.55 ± 519.43 mL; p < 0.01), and significantly shorter hospital stay (11.90 ± 9.69 vs. 25.35 ± 20.65; p < 0.01) than did the debulking group. No significant differences were observed between the groups in age, sex, spinal instability neoplastic score, ESCC, Tomita scores, numeric rating scale scores, American Spinal Injury Association Impairment Scale scores, survival rates, and complication rates. Postoperative neurologic function and decrease in pain were similar between the groups. ConclusionThe PPSF group had a shorter operation time, shorter length of hospital stay, and less blood loss than did the debulking group. PPSF followed by EBRT is pain relieving, relatively safe and appropriate as palliative therapy.

Practice and outcomes of airway management in patients with cervical orthoses

Increasing evidence indicates an association of video laryngoscopy with the success rate of airway management in patients with neck immobilization. Nevertheless, clinical practice protocols for tracheal intubation in patients immobilized using various types of cervical orthoses and the outcomes remain unclear. We retrospectively assessed the tracheal intubation techniques selected for patients immobilized using cervical orthoses from 2015 to 2018. The endpoints were the intubation outcomes of the different techniques and the factors associated with the selection of the technique. We included 218 patients, 118 of whom wore halo vest braces (halo vest group) and 100 wore cervical collars (collar group). GlideScope video laryngoscopy (GVL) and fiberoptic bronchoscopy (FOB) were the initial intubation methods in 98 and 120 patients, respectively. GVL had a higher first-attempt success rate than did FOB in the collar group (p=0.002) but not in the halo vest group (p=0.522). GVL was associated with a lower risk of episodes of SaO2< 90% (adjusted relative risk [aRR], 0.11; 95% CI, 0.02-0.67; p=0.016) and shorter intubation time (aRR, -3.52; 95% CI, -4.79∼-2.25; p<0.001) in the collar group. However, in the halo vest group, more frequent requirement of a rescue technique (p=0.002) and necessity of patient awakening (p=0.001) was noted when GVL was used. Use of the halo vest brace and noting of severe cord compression were independent predictors of the initial selection of FOB. Caution should be exercised when using GVL for tracheal intubation in patients immobilized using halo vest braces.

Posterior Stabilization for Management of Neglected Odontoid Fractures

Background: Odontoid fractures are specific types of cervical fractures that show many challenges in their management. There are several types of Odontoid fractures with different modes of stability. There is no definite widely accepted way of management of Type II fractures among spine surgeons. There is a high rate of delayed or non-union of Odontoid fracture cases that are managed conservatively which may lead to dangerous complications. If non-union occurs, the patient should undergo surgical intervention as early as possible to avoid neurological deterioration. Objective: To demonstrate the value of intra-operative reduction and posterior stabilization of atlanto-axial junction in cases of non-union old Odontoid fractures and their outcome. The study was also to check for criteria associated with a favorable outcome and if posterior decompression will be associated with a better outcome. Patients and Methods: 12 patients of old neglected Odontoid fractures following conservative management and complicated by non-union were operated through intra-operative reduction with posterior stabilization and fixation of atlanto-axial junction at Al-Azhar University Hospitals during the period starting from June 2016 till the end of December 2019 using Screws and Rods. Intra-operative reduction under C-Arm X-ray and firm stabilization were aimed in all cases. Posterior cord decompression was an option in selected 4 patients with severe cord compression. Both intra-operative, post-operative radiological and clinical outcomes were assessed. Results: Good intra-operative reduction and alignment of fractured Odontoid process were obtained in all cases with use of 4 screws and 2 rods (2 screws and 1 rod on each side) in 11 cases and with using 2 screws and 1 rod (unilateral fixation) in one case. Good clinical outcome was obtained in all patients with improvement of pre-operative condition except in 3 patients where there were persistent pre-operative neurological deficits and without deterioration of pre-operative condition. Additional posterior cord decompression was associated with a better clinical outcome in 2 of 4 selected cases with severe cord compression. Conclusion: Good intra-operative reduction under C-Arm X-ray with posterior stabilization through atlanto-axial fixation using screws and rods is a reliable way of management of neglected type II Odontoid fractures complicated with non-union. Better results were obtained with less pre-operative neurological deficits and with absence of myelomalacia in MRI images. Additional posterior decompression may improve clinical outcome in cases of severe cord compression.