Superior Cervical Spine Research Articles

Speech and Swallowing Outcomes of Surgically Managed Cervical Chordoma: A Case Series.

Cervical chordoma is a rare, low-grade primary bone tumor occurring in the axial skeleton. Due to challenges in surgical exposure caused by anatomic location, patients may experience dysfunction in speech and swallowing. The objective of this study was to characterize speech and swallowing outcomes for patients undergoing surgical resection of cervical chordoma. Moreover, we detail in-depth two cases with similar initial presentations to compare prognostic factors and management strategies. Eleven patients with histologically confirmed cervical chordoma treated between 1993 and 2020 were included in this retrospective case series. Outcomes measured included overall survival, disease-free survival, need for enteral feeds, as well as results of modified barium swallow study (MBSS) and fiberoptic laryngoscopy. The mean age at diagnosis was 55.9 years. The patient population was 81.8% male. Mean survival after diagnosis was 96 months. Four (36.4%) patients required post-operative MBSS and demonstrated aspiration. All four of these patients presented with tumors in the superior cervical spine and received surgeries utilizing anterior approaches. Of the four, 2 required enteral feeds long-term. Four (36.4%) patients endorsed dysphonia. One patient developed post-operative right vocal fold paresis. The remaining three patients experienced stable dysphonia pre- and post-operatively. Additionally, three (27%) patients required tracheostomy placement, two of which remained in place long-term. Dysphagia is a common side effect of cervical chordoma resection. It is associated with the use of an anterior approach during resection and with tumors located in the superior cervical spine. Patients with postoperative dysphagia should receive early multidisciplinary swallow rehabilitation. 4 Laryngoscope, 134:3706-3712, 2024.

Prevalence of cervical postural alterations in oculomotor disturbances: a Brazilian cohort study

The literature suggests that maintaining correct posture depends on a balance between orientation and balance, which is linked to the reflex relationship between the oculomotor system and the superior cervical spine. Any disruption to this relationship can cause postural deviation, as the posture is dependent on head balance and eye horizontality. This study aimed to investigate the prevalence of cervical posture alterations, such as head tilt, rotation, and protrusion, scapular waist changes, scoliosis, kyphosis, and lumbar hyperlordosis, in patients with oculomotor disturbances, including convergent, divergent, and vertical squint, and convergence insufficiency. The study evaluated 24 patients aged between 4 and 39 years old, both male and female, through ocular motility and postural examination. The results showed that all patients with oculomotor disturbances also had postural imbalances, and the percentage of alterations in the posture segments was high. Therefore, oculomotor disturbances can cause postural imbalance, leading to orthopedic and facial asymmetry. The study concluded that patients with oculomotor disturbances should be evaluated to determine the compensatory positions they adopt and set a better visual performance that does not alter their appearance in the long term.

Traction load, tong position, and head support significantly influence cervical spine loading during traction.

Some cervical dislocation injuries may be acutely treated with traction via Gardner-Wells tongs, which are attached to the skull via two pins. While a variety of techniques have been proposed and utilized in the literature and clinical practice to use the tongs, these techniques have not been methodically studied to confirm how they transmit loads to the cervical spine. The current study investigated the mechanical effect of different traction techniques in a laboratory setting. A 50th male Hybrid anthropomorphic test device was used as a human surrogate to represent an average male in height and weight was modified to represent a patient with a unilateral facet dislocation injury. Electronic sensors at the atlanto-occipital joint recorded the loading delivered to the superior cervical spine by traction loading. Combinations of the following variables were evaluated as traction loads were progressively increased to one-third of body weight: tong pin position in the skull (anterior-posterior and superior-inferior to the recommended neutral position), traction cable angle in the sagittal plane (elevated, horizontal, declined), and presence or absence of an occipital support. Analysis of the cervical axial traction loads showed that the only significant predictor of cervical tension was the magnitude of the traction load. Anterior-posterior changes in the pin positions in the skull significantly influenced the cervical flexion-extension moment and anterior-posterior (AP) shear. The data show that a combined cervical tension, flexion moment, and anterior shear force can be achieved with posteriorly biased pins and a bolster behind the head. Increasing the angle of traction cable increased the cervical flexion moment and anterior shear force. The following variables should be carefully considered when applying cervical traction since they significantly affect cervical loading: magnitude of the hanging traction load, anterior-posterior pin position, use of an occipital bolster, and traction load angle.

Manipulation based on Fryette’s Laws increases heart rate variability and muscle flexibility in subjects with headache

Background: The sympathetic nervous system has a direct connection with the cervical spine, through the cervical ganglia, in the superior cervical ganglion; therefore the manipulation of the superior cervical spine could result on modifications of the heart rate variability (HRV). Objective: To evaluate the immediate effect of the manipulation based on the Fryette’s laws of the superior cervical spinal (SCS) on HRV and posterior chain flexibility (PCF) in subjects with headache. Methods/Design: Twelve volunteers of both genders (23.8 ± 2.8 years), who had complaints of headache, participated in the study. Before and immediately after the HRV assessment, PCF was measured with the assistance of Wells and Dillon’s Bench test. For this the volunteer remained seated with the spine erect, lower limbs extended and feet resting on the bench. Then it was requested maximum flexion of the trunk and measured with a ruler the achieved distance. The HRV was obtained by the cardiofrequencymeter Polar RS800cx and captured for continuous fifteen minutes with the volunteer resting in supine position. At five minutes of collection, with the volunteer in the same position, the SCS manipulation technique (Fryette’s Laws) was performed bilaterally. The HRV assessment was performed in the time domain by the RMSSD index of RR intervals (Matlab For Windows version 6.1) in two different moments: before and after the manipulation. Statistical analysis consisted of the Kolmogorov-Smirnov test and paired t-test for comparison of pre and post manipulation variables (p<0.05). Results: There was a significant increase (p = 0.004) in the RMSSD index after the manipulation (from 42.58 ± 24.52 ms before the manipulation to 51.25 ± 27.55 ms ten minutes after manipulation). The PCF also increased significantly (p = 0.03) after the SCS manipulation (from 17.65 ± 11.9 cm to 21.40 ± 13.8 cm). Conclusions: The manipulation of SCS increased the HRV through the increase of the RMSSD index indicating a predominance of parasympathetic activity, and improved the PCF of the studied volunteers, also reduced signs and symptoms of headache.

Use of a tubular retractor for transoral odontoidectomy of upper cervical epidural phlegmon extraction and abscess drainage

Anterior epidural abscess of the superior cervical cord with odontoid osteomyelitis is a rare but potentially devastating condition due to the potential for severe and irreversible neurological injury. Early and aggressive neurosurgical intervention and medical management is usually indicated in cases with symptomatic spinal cord compression and may be associated with superior clinical outcomes. Access to the craniovertebral junction for decompression of the upper cervical cord is complicated by the proximity of critical anatomical structures. The transoral approach is considered to be the standard for treating lesions of the odontoid and anterior epidural space of the superior cervical spine. The use of a tubular retractor for procedures of the craniovertebral junction has been described for several approaches to this region but its use has yet to be described for the transoral approach in a live patient. This report describes the novel use of a tubular retractor for cervicomedullary decompression via transoral odontoidectomy for abscess drainage and phlegmon resection in a patient with progressive cervical myelopathy. The tubular retractor serves to retract the pharyngeal wall flaps and expose the anterior arch of C1, odontoid, and inferior clivus. This variation of the transoral approach eliminates the need for stay sutures for these purposes and may be used for lesions of the odontoid and anterior epidural space of the superior cervical spine.

Feasibility of Screw Placement in the Occipital Condyle of Chinese Patients for Occipitocervical Arthrodesis: A Cadaveric Study.

The feasibility of computed tomography (CT) and two-dimensional (2D) reconstruction-guided screw placement in the occipital condyle (OC) of Chinese patients was investigated. Twenty (40 OCs) fresh cadaveric specimens with intact superior cervical spine and occipital bones were placed in the prone position. Simulated screw placement was achieved by placing 4.0 mm diameter virtual screws with the help of the 2D reconstruction CT scan image technology. Maximal screw length, angulation in the sagittal and transverse planes, and medial and cranial base OC entry points were determined and recorded. Actual screw placement was achieved by similar placement; actual position and angulation were determined by postoperative CT scanning. Screws were successfully inserted in 36 of 40 (90%) OCs. Four ruptures of the medial OC wall were on the left side. Actual screw placement did not damage the hypoglossal canal, and no screws pierced the medial or lateral OC walls. Females displayed significantly smaller left and right maximum screw lengths than males (p < 0.05); no other significant gender differences were noted. The results can feasibly accommodate 4-mm OC screws for OA treatment. As in other populations, OC shape and size is smaller in females and varies in Chinese individuals, necessitating individualized imaging for good outcomes.

Craniocervical posture and hyoid bone position in children with mild and moderate asthma and mouth breathing

Introduction The objective of the present study was to assess the craniocervical posture and the positioning of the hyoid bone in children with asthma who are mouth breathers compared to non-asthma controls. Methods The study was conducted on 56 children, 28 of them with mild ( n = 15) and moderate ( n = 13) asthma (14 girls aged 10.79 ± 1.31 years and 14 boys aged 9.79 ± 1.12 years), matched for sex, height, weight and age with 28 non-asthma children who are not mouth breathers. The sample size was calculated considering a confidence interval of 95% and a prevalence of 4% of asthma in Latin America. Eighteen variables were analyzed in two radiographs (latero-lateral teleradiography and lateral cervical spine radiography), both obtained with the head in a natural position. The independent t-test was used to compare means values and the chi-square test to compare percentage values ( p < 0.05). Intraclass correlation coefficient (ICC) was used to verify reliability. Results The Craniovertebral Angle (CVA) was found to be significantly smaller in asthma than in control children (106.38 ± 7.66 vs. 111.21 ± 7.40, p = 0.02) and the frequency of asthma children with an absent or inverted hyoid triangle was found to be significantly higher compared to non-asthma children (36% vs. 7%, p = 0.0001). The values of the inclination angles of the superior cervical spine in relation to the horizontal plane were significantly higher in moderate than in mild asthma children (CVT/Hor: 85.10 ± 7.25 vs. 90.92 ± 6.69, p = 0.04 and C1/Hor: 80.93 ± 5.56 vs. 85.00 ± 4.20, p = 0.04). Conclusions These findings revealed that asthma children presented higher head extension and a higher frequency of changes in hyoid bone position compared to non-asthma children and that greater the asthma severity greater the extension of the upper cervical spine.

Minimum 2-year outcome of cervical laminoplasty with deep extensor muscle-preserving approach: impact on cervical spine function and quality of life

In this retrospective cohort study, two surgical methods of conventional open-door laminoplasty and deep extensor muscle-preserving laminoplasty were allocated for the treatment of cervical myelopathy, and were specifically compared in terms of axial pain, cervical spine function, and quality of life (QOL) with a minimum follow-up period of 2 years. Eighty-four patients were divided into two groups and received either a conventional open-door laminoplasty (CL group) or laminoplasty using a deep extensor muscle-preserving approach (MP group). The latter approach was performed by preserving multifidus and semispinalis cervicis attachments followed by open-door laminoplasty and re-suture of the bisected spinous processes at each decompression level. The average follow-up period was 38 months (25-53 months). The preoperative and follow-up evaluations included the original Japanese Orthopaedic Association (JOA) score, the new tentative JOA score including cervical spine function and QOL, and the visual analogue scale (VAS) of axial pain. Radiological analyses included cervical lordosis and flexion-extension range of motion (flex-ext ROM) (C2-7), and deep extensor muscle areas on MR axial images. The JOA recovery rates were statistically equivalent between two groups. The MP group demonstrated a statistically superior cervical spine function (84% vs 63%) and QOL (61% vs 45%) when compared to the CL group at final follow-up (P < 0.05). The average VAS scores at final follow-up were 2.3 and 4.9 in MP and CL groups (P < 0.05). The cervical lordosis and flex-ext ROM were statistically equivalent. The percent deep muscle area on MRI demonstrated a significant atrophy in CL group compared to that in MP group (56% vs 88%; P < 0.01). Laminoplasty employing the deep extensor muscle-preserving approach appeared to be effective in reducing the axial pain and deep muscle atrophy as well as improving cervical spine function and QOL when compared to conventional open-door laminoplasty.

Decompression of the brain stem and superior cervical spine for congenital / Acquired craniovertebral invagination: An interdisciplinary approach

A transoropharyngeal/transpalatal approach to the clivus and anterior cervical spine in association with a midline labiomandibular glossotomy has proved successful in the treatment of craniovertebral instability. Nine cases at this institution between 1978 and 1986 were retrospectively reviewed. A head-and-neck surgeon, along with a neurosurgeon and/or orthopedic surgeon collaborated on these procedures. The indications, methods, operative techniques, results and postoperative complications are presented.

The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression.

The transoral-transclival surgical approach is the most direct operative approach to pathology ventral to the brain stem and superior spinal cord. In selected patients, this approach is efficacious in the treatment of extradural compressive lesions from the cervicomedullary junction to the C-4 vertebra. The authors have used the transoral surgical approach in treating 53 patients with lesions compressing the ventral extradural brain stem or the cervical cord. The evaluation, management, and long-term outcome of these patients are described (median follow-up time 24 months). The operative morbidity rate in this series was 6%, and the operative mortality rate was zero. The authors review specific features of the transoral procedure, including methods of retraction, microsurgical techniques, and adjunctive measures to avoid cerebrospinal fluid fistulae, that contributed to these good results.

The transoral approach to the anterior superior cervical spine. A review of 29 cases.

The transoral surgical approach is the most direct operative approach to pathology ventral to the brain stem and superior spinal cord. This approach is useful in the treatment of extradural compressive cervicomedullary lesions in selected patients. Twenty-nine patients with ventral extradural brain stem or cervical cord compressive lesions who were treated via the transoral surgical approach are presented. Their evaluation, treatment, and long-term outcome will be reviewed (median follow-up, 24 months). Specific features of the transoral procedure, including intraoperative monitoring, methods of retraction, and microsurgical techniques that contributed to minimal operative morbidity (3%) and zero operative mortality, will be discussed.