Preoperative Skull Traction, Anterior Debridement, Bone Grafting, and Internal Fixation for Cervical Tuberculosis with Severe Kyphosis.

OBJECTIVE: Cervical tuberculosis (CTB) readily causes local kyphosis, and its surgical strategy remains controversial. Although some previous studies suggested that the anterior approach could effectively treat CTB, patients in these studies only suffered mild to moderate kyphosis. Therefore, little is known about whether the anterior approach can achieve satisfactory outcomes in CTB patients with severe kyphosis. This study was performed to evaluate the safety and efficacy of preoperative skull traction combined with anterior surgery for the treatment of CTB patients with a severe kyphosis angle of more than 35°. METHODS: In this retrospective study, we enrolled 31 CTB patients with severe kyphosis who underwent preoperative skull traction combined with anterior surgery from April 2015 to January 2021. Patients were followed up for at least 2 years. Clinical data, such as operative time, blood loss, and postoperative hospital stay, were collected. The clinical outcomes included American Spinal Injury Association (ASIA) spinal cord injury grade, Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, and related complications. The radiological outcomes included the Cobb angle of cervical kyphosis at each time point and the bony fusion state. Clinical efficacy was evaluated by paired Student's t-test, Mann-Whitney U-test, and others. RESULTS: Six patients had involvement of one vertebra, 21 had involvement of two vertebrae, and four had involvement of three vertebrae. The most common level of vertebral involvement was C4-5, whereas the most common apical vertebra of kyphosis was C4. The mean kyphosis angle was 46.1° ± 7.7° preoperatively, and the flexibility on dynamic extension-flexion X-rays and cervical MRI was 17.5% ± 7.8% and 43.6% ± 11.0%, respectively (p = 0.000). The kyphosis angle significantly decreased to 13.2° ± 3.2° after skull traction, and it further corrected to -6.1° ± 4.3° after surgery, which was well maintained at the final follow-up with a mean Cobb angle of -5.4° ± 3.9°. The VAS and JOA scores showed significant improvement after surgery. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels normalized at 3 months after surgery. All patients achieved solid bone fusion, and no complications related to the instrumentation or recurrence were observed. CONCLUSION: Preoperative skull traction combined with anterior debridement, autologous iliac bone grafting, and internal plate fixation can be an effective and safe surgical method for the treatment of cervical tuberculosis with severe kyphosis. Skull traction can improve the safety and success rate of subsequent anterior corrective surgery.

Comparative study of halo-vest reduction and skull traction reduction in the treatment of cervical fracture dislocation in patients with ankylosing spondylitis.

Background: This study aimed to investigate the safety and efficacy of the halo-vest in the treatment of cervical fracture in patients with ankylosing spondylitis (AS) and kyphosis. Methods: From May 2017 to May 2021, 36 patients with cervical fractures with AS and thoracic kyphosis were included in this study. The patients with cervical spine fractures with AS underwent preoperative reduction by halo-vest or skull tractions. Instrumentation internal fixation and fusion surgery were then performed. The level of cervical fractures, the operative duration, blood loss, and treatment outcomes were investigated preoperatively and postoperatively. Results: A total of 25 cases were included in the halo-vest group and 11 cases were included in the skull tractions group. The intraoperative blood loss and the surgery duration were significantly less in the halo-vest group than in the skull traction group. A comparison of American Spinal Injury Association scores at admission and final follow-up showed that the neurological function of patients improved in both groups. All patients had reached solid bony fusion during the follow-up. Conclusion: This study presented a unique approach to use halo-vest treatment fixation of unstable cervical fracture in patients with AS. The patient should also have early surgical stabilization with a halo-vest to correct spinal deformity and avoid worsening of neurological status.

Rare improperly treated traumatic vertical atlantoaxial dislocation: A case report and literature review.

BACKGROUND: Because of the severity and fatal outcome of traumatic vertical atlantoaxial dislocation (AAD), most patients may die in the early post-traumatic period. The post-injury management of patients with vertical AAD has been rarely reported. Improper treatment may lead to disastrous outcome and further aggravate the neurologic symptoms. CASE PRESENTATION: This report describes the perioperative management and outcome of a rare improperly treated patient with traumatic vertical AAD. The severe pulmonary infection of this patient prevented further surgery for vertical AAD. After placement of a halo vest, combined with effective antibiotic drug treatment, the patient's pulmonary infection was brought under control. The patient underwent atlantoaxial fusion using C1 lateral mass screws and C2 pedicle screws with the assistance of the halo vest. A computed tomography scan at 1 year follow-up indicated that the bone graft was fused and the patient was able to walk independently. CONCLUSION: Skull traction is contraindicated in patients with traumatic vertical AAD. Application of a halo vest can be used for temporary fixation of the cervical spine and atlantoaxial fixation should be performed to maintain the stability of atlantoaxial articulation.

An Innovative Prone Position Using a Body-Shape Plaster Bed and Skull Traction for Posterior Cervical Spine Fracture Surgeries.

Background: An innovative prone cervical spine surgical position using a body-shape plaster bed with skull traction (BSPST) was compared with the traditional prone surgical position with horseshoe headrests. Methods: A total of 47 patients, undergoing posterior cervical spine surgery for cervical spine fracture, were retrospectively classified into two groups, the BSPST group (n = 24) and the traditional group (n = 23), and underwent a posterior instrumented fusion with or without decompression. Multiple indicators were used to evaluate the advantages of the BSPST compared with the traditional position. Results: All the operations went smoothly. The mean recovery rate was 56.30% in the BSPST group and 48.55% in the traditional group (p = 0.454), with no significant difference. The intraoperative blood loss (177.5 ml vs. 439.1 ml, p = 0.003) and the total incidence of complications (8.3 vs. 47.8%, p = 0.004) were significantly less in the BSPST group than in the traditional group. In addition, the BSPST position provided a greater comfort level for the operators and allowed convenient intraoperative radiography. Conclusions: This is the first study to describe a combined body-shape plaster bed and skull traction as an innovative cervical spine-prone surgical position that is simple, safe, and stable, intraoperative traction direction adjustable, reproducible, and economical for posterior cervical spine fracture surgery, and potentially other cervical and upper dorsal spine surgeries in the prone position. Additionally, this position provides the surgeons with a comfortable surgical field and can be easily achieved in most orthopedic operation rooms.

Surgical treatment of a complex craniocervical malformation combined with posterior cranial fossa teratoma: a case report and literature review.

BACKGROUND: Basilar invagination (BI) with atlantoaxial dislocation (AAD) is not uncommon in patients with scoliosis, Klippel-Feil syndrome (KFS), and other bone deformities. Cases with combinations of the abovementioned dislocations and deformities with posterior cranial fossa teratoma are rare in the clinic and difficult to handle. CASE PRESENTATION: This case presents a 34-year-old woman diagnosed with atlantoaxial dislocation and posterior cranial fossa mass. After two surgeries, the posterior cranial teratoma was completely removed with satisfactory atlantoaxial reduction. The postoperative 1-year follow-up examination showed that the bone graft fusion was successful, without remaining significant dysfunction. CONCLUSIONS: The surgical risk of irreducible atlantoaxial dislocation combined with posterior cranial fossa tumor is huge. Thus, it needs to be fully preoperatively evaluated and managed carefully in accordance with sound surgical principles.

Surgical treatment of atlantoaxial subluxation by intraoperative skull traction and C1-C2 fixation.

BACKGROUND: Atlantoaxial subluxation (AAS) is a not rare abnormality between the atlas (C1) and axis (C2). For AAS patients with persistent neck pain and neurologic symptoms, surgical intervention is a good choice. Nevertheless, there were still few reports about the use of intraoperative skull traction and different fixation methods in treatment of AAS. METHODS: From January 2012 to December 2018, a total of 86 cases were admitted to our hospital and diagnosed as AAS. All the patients received atlantoaxial reduction with the help of intraoperative skull traction and C1-C2 fixation. Clinical and radiological parameters were collected through chart review. RESULTS: There were 86 cases included in this study. The mean operative time was 153.9 ± 73.9 min, and the mean amount of intraoperative blood loss was 219.1 ± 195.6 ml. 81 patients underwent posterior reduction, internal fixation and fusion. 5 patients underwent anterior release, followed by posterior internal fixation and fusion. 82 patients got satisfactory postoperative outcomes while complications occurred in 4 patients. Significant neurologic improvement was observed in these patients. Bone fusion was achieved on the midline sagittal reconstructed CT images at the latest follow-up in all these patients except 1 case. All the patients were followed up for 34.84 ± 15.86 months at average (range 12-60 months). The mean ADI value was 7.55 ± 1.67 mm at average preoperatively, and improved to 4.03 ± 1.21 mm postoperatively, and to 4.21 ± 0.99 mm at the latest follow-up. The mean A-A angle was 15.48 ± 9.82 degrees at average preoperatively, and improved to 21.61 ± 10.43 degrees postoperatively, and to 19.73 ± 8.13 degrees at the latest follow-up. The mean A-A height was 35.61 ± 7.66 mm at average preoperatively, and improved to 40.08 ± 8.5 mm postoperatively, and to 38.83 ± 6.97 mm at the latest follow-up. There were complications in 4 patients, including pedicle misplacement, pedicle screw fracture, infection and one death. CONCLUSION: Intraoperative skull traction can effectively facilitate the surgical procedures for ASS caused by different etiologies. Further research will be needed to investigate the safety and effectiveness of this method in the future.

Posterior atlantoaxial dislocation without fracture or neurological symptoms treated by transoral-posterior approach surgery: a case report and literature review.

BACKGROUND: Atlantoaxial dislocation usually results from hyperextension trauma and is almost always accompanied by odontoid fracture and neurological symptoms. In most cases, patients with atlantoaxial dislocation die instantly. This is a rare report of posterior atlantoaxial dislocation without fracture and neurological symptoms effectively treated by transoral-posterior approach surgery, and only eleven similar cases have been previously reported. OBJECTIVE: To describe the very rare case of an adult posterior atlantoaxial dislocation patient without fracture who was neurologically treated using transoral-posterior approach surgery and to review the relevant literature. METHOD: A 52-year-old man riding a motorcycle was rear-ended by a car. Using X-ray, computed tomography (CT) scan and magnetic resonance imaging (MRI), he was diagnosed with posterior atlantoaxial dislocation without a related fracture or a significant change in spinal cord signal. Transoral-posterior approach surgery with sustained skull traction was used after failed closed reduction. RESULT: During a 6-month follow-up observation, the lateral cervical spine radiography and sagittal reconstructions of CT scans demonstrated no instability of the atlantoaxial complex. Few patients experience posterior atlantoaxial dislocation without a related fracture or spinal cord deficit. For a patient who experiences trauma with hyperextension, such as in rear-end collisions, X-ray, CT scan and MRI should be performed to ensure that this injury is diagnosed. It is necessary to perform surgery to recover atlantoaxial stability, even in the absence of fracture or neurological symptoms. CONCLUSION: Transoral-posterior approach surgery is a safe and effective way to manage irreducible posterior atlantoaxial dislocation.

Multicentre comparative study of Z-shape elevating-pulling reduction and skull traction reduction for treatment of lower cervical locked facets.

PURPOSE: The aim of this study was to assess the clinical efficacy and safety of Z-shape elevating-pulling reduction as compared to that of conventional skull traction in the treatment of lower cervical locked facet. METHODS: Patients with cervical locked facet (n = 63) were retrospectively enrolled from four medical centers and divided into two groups according to the pre-operative reduction method used: Z-shape elevating-pulling reduction (Z-shape elevating group; n = 20) or traditional skull traction reduction (skull traction group; n = 43). RESULTS: The success rates, efficacy of reduction, and safety were compared between the two groups. The success rates were significantly better in the Z-shape elevating group than in the skull traction group: 87.5% (7/8) vs. 35.3% (6/17) for unilateral locked facet reduction (P = 0.03) and 100% (12/12) vs. 69.2% (18/26) for bilateral locked facet reduction (P = 0.04). There was no obvious change in American Spinal Injury Association (ASIA) grade after the reduction in either group. Combined surgery was necessary in 5% in the Z-shape elevating group vs. 27.9% in the skull traction group. Imaging showed that the segment angle and horizontal displacement were significantly improved after surgery in both groups, with no significant difference between the groups. Follow-up with radiography showed good recovery of the cervical spine sequence; all internal fixation sites were stable, with no loosening, prolapse, or breakage of internal fixators. CONCLUSIONS: Halo vest-assisted Z-shape elevating-pulling reduction appears to be a simple, safe, and effective technique for pre-operative reduction of lower cervical locked facets.