Comparative analysis of patient-reported outcomes in myelopathy and myeloradiculopathy: a Quality Outcomes Database study.

OBJECTIVE: Myelopathy in the cervical spine can present with diverse symptoms, many of which can be debilitating for patients. Patients with radiculopathy symptoms demonstrate added complexity because of the overlapping symptoms and treatment considerations. The authors sought to assess outcomes in patients with myelopathy presenting with or without concurrent radiculopathy. METHODS: The Quality Outcomes Database, a prospectively collected multi-institutional database, was used to analyze demographic, clinical, and surgical variables of patients presenting with myelopathy or myeloradiculopathy as a result of degenerative pathology. Outcome measures included arm (VAS-arm) and neck (VAS-neck) visual analog scale (VAS) scores, modified Japanese Orthopaedic Association (mJOA) scale score, EuroQol VAS (EQ-VAS) score, and Neck Disability Index (NDI) at 3, 12, and 24 months compared with baseline. RESULTS: A total of 1015 patients were included in the study: 289 patients with myelopathy alone (M0), 239 with myeloradiculopathy but no arm pain (MRAP-), and 487 patients with myeloradiculopathy and arm pain (MRAP+). M0 patients were older than the myeloradiculopathy cohorts combined (M0 64.2 vs MRAP- + MRAP+ 59.5 years, p < 0.001), whereas MRAP+ patients had higher BMI and a greater incidence of current smoking compared with the other cohorts. There were more anterior approaches used in in MRAP+ patients and more posterior approaches used in M0 patients. In severely myelopathic patients (mJOA scale score ≤ 10), posterior approaches were used more often for M0 (p < 0.0001) and MRAP+ (p < 0.0001) patients. Patients with myelopathy and myeloradiculopathy both exhibited significant improvement at 1 and 2 years across all outcome domains. The amount of improvement did not vary based on surgical approach. In comparing cohort outcomes, postoperative outcome differences were associated with patient-reported scores at baseline. CONCLUSIONS: Patients with myelopathy and those with myeloradiculopathy demonstrated significant and similar improvement in arm and neck pain scores, myelopathy, disability, and quality of life at 3 months that was sustained at 1- and 2-year follow-up intervals. More radicular symptoms and arm pain increased the likelihood of a surgeon choosing an anterior approach, whereas more severe myelopathy increased the likelihood of approaching posteriorly. Surgical approach itself was not an independent predictor of outcome.

The impact of serum albumin levels on postoperative complications in lumbar and cervical spine surgery: an analysis of the Michigan Spine Surgery Improvement Collaborative registry.

OBJECTIVE: Patients with serum albumin levels < 3.5 g/dL are considered malnourished, but there is a paucity of data regarding the outcomes of patients with albumin levels > 3.5 g/dL. The objective of this study was to evaluate the effect of albumin on postoperative outcome in patients undergoing elective cervical and lumbar spine procedures. METHODS: The Michigan Spine Surgery Improvement Collaborative database was queried for lumbar and cervical fusion surgeries between January 2020 and December 2022. Patients were grouped by preoperative serum albumin levels: < 3.5 g/dL, 3.5-3.7 g/dL, 3.8-4.0 g/dL, and > 4.0 g/dL. Primary outcomes included urinary retention, ileus, dysphagia, surgical site infection (SSI), readmission within 30 and 90 days, return to the operating room, and length of stay (LOS) ≥ 4 days. Multivariate analysis was conducted to adjust for potential confounders. RESULTS: This study included 15,629 lumbar cases and 6889 cervical cases. Within the lumbar cohort, an albumin level of 3.5-3.7 g/dL was associated with an increased risk of readmission at 30 days (p = 0.048) and 90 days (p = 0.005) and an LOS ≥ 4 days (p < 0.001). An albumin level of 3.8-4.0 g/dL was associated with an increased risk of an LOS ≥ 4 days (p < 0.001). Within the cervical cohort, an albumin level of 3.5-3.7 g/dL was associated with an increased risk of SSI (p = 0.023), readmission at 30 days (p < 0.002) and 90 days (p < 0.001), return to the operating room (p = 0.002), and an LOS ≥ 4 days (p < 0.001). An albumin level of 3.8-4.0 g/dL was associated with an increased risk of readmission at 30 days (p = 0.012) and 90 days (p = 0.001) and an LOS ≥ 4 days (p < 0.001). CONCLUSIONS: This study maintains that patients with hypoalbunemia undergoing spine surgery are at risk for postoperative adverse events. However, there also exist significant associations between borderline serum albumin levels of 3.5-4.0 g/dL and increased risk of postoperative adverse events.

Cervical Intradural Fungal Infection Masquerading as a Meningioma in an Immunocompetent Patient: A Case report and Systematic Review.

BACKGROUND: Intradural spinal fungal infection is a rare phenomenon that can carry a significant increase in morbidity and mortality. In this systematic review and case report presentation of a 75-year-old male with an intradural cervical mass that was diagnosed as a fungal infection intraoperatively. The objective of this paper is to analyze and report on intradural spinal fungal infections in immunocompetent patients. METHOD: We performed a systematic literature review following the PRISMA protocol for studies of intradural fungal infections published in the past 25 years. Original articles with a description of treatment outcomes of such patients were included. RESULTS: 8 studies were included in this review with the addition of the present case. There were 5 males and 4 females with the average age of patients was 45.6-year-old (range 24-75). Aspergillus and Candida species being the most isolated fungal organism. The origin of the lesions was identified and iatrogenic in four cases. Most patients underwent decompressive laminectomy with biopsy, abscess drainage, or resection of the identified lesion. There were two instances of cervical lesions, but most of the lesions were in the thoracic and lumbar spine. Half of the cases reported symptoms improvement, but two patients died from the infection or complications from the infections. CONCLUSION: Intradural fungal infections are rare with only ten total cases reported in the past 25 years. Nonetheless, they can be associated with significant mortality and morbidity. Thus, the timeline from presentation to intervention should be evaluated and determined carefully.

Biportal Endoscopic Resection of Intradural Meningioma in the Cervical Spine: A Case Report.

Cervical intradural meningioma are rare central nervous system neoplasms. Surgical resection is the primary treatment due to the tumor's benign nature and clear demarcation from the spinal cord, although the posterior surgical approach can result in complications such as neurological deficits and cerebrospinal fluid leaks. We present a case of a 78-year-old woman with progressive clumsiness, gait disturbance, and weakness. She was diagnosed with an intradural extramedullary meningioma at the C2 to C3 level through magnetic resonance imaging. The tumor was excised using a cervical biportal endoscopic spine surgery approach, a minimally invasive technique that utilizes 2 small portals for endoscope and instrument access. The procedure, performed under general anesthesia, involved a hemilaminectomy and partial laminectomy to access and remove the tumor. Postoperative assessments indicated significant neurological recovery, with the patient regaining independent mobility and fine motor skills. Follow-up magnetic resonance images at 18 months confirmed the absence of tumor recurrence. This case demonstrates the efficacy of cervical biportal endoscopic spine surgery in managing high cervical intradural tumors, highlighting its potential for reducing surgical complications and promoting rapid patient recovery.

Cervical spine spondylodiscitis due to neglected esophageal perforation after a dilation procedure 30 years after a laringectomy and radiotherapy. Report of a case and review of literature.

Current treatment of cervical spine spondylodiscitis generally involves a radical surgical debridement and stable reconstruction together with antibiotic therapy until complete healing. But this classical approach could be difficult for patients who have been treated previously for an esophageal carcinoma and received radiotherapy. We present a case of a 75-year-old male who underwent an esophageal dilation procedure and developed afterward a spondylodiscitis with epidural abscess due to a neglected esophageal perforation. Blood cultures were positive for Peptostreptococcus. Cervical spondylodiscitis and epidural abscess are extremely rare complications of esophageal dilations. Successful treatment without debridement was achieved by performing a posterior fixation without decompression associated with antibiotic therapy for 8 weeks. The present case highlights that spondylodiscitis and epidural abscess may be treated in selected cases where the anterior neck is unapproachable and with a recognized pathogen by a posterior approach fixation without debridement, in association to specific antibiotic therapy.

Computed Tomographic Scan for Head Injury Patients: Any Justification for Adapting Routine Cranio-Cervical Examination Irrespective of Clinical Severity?

Background and Objective: This study aimed to assess the prevalence of concomitant cervical spine and head injury at our University Teaching Hospital in Nigeria and attempted to justify examining patients' head and cervical spine using computed tomography (CT) scan at presentation irrespective of the head injury severity by clinical assessment using Glasgow Coma Scale (GCS). Patients and Methods: All eligible patients, 1-80 years of age who presented with head injuries in the accident and emergency (A&E) unit during the study period, were included if they satisfied the inclusion criteria. Post-resuscitation GCS was assessed clinically, and head and cervical spine injury (CSI) were observed radiologically on cranio-cervical CT scan for all patients. The presence of cervical spine fractures, subluxation or dislocation was considered a confirmation of CSI. Results: There were 143 patients with head injuries studied; 90.2% of them were males. The mean age of the patients was 28.87 ± 15.93 years. The most common cause of injury was road traffic accidents in 110 (76.90%). The prevalence of CSI was 11.2%. Majority of the patients with CSI in this study (56.25%) had a mild head injury, 25% had a moderate head injury, and 18.75% had a severe head injury. The lower cervical spine was the most frequently injured segment in this study, involving 10 patients. Multi-level cervical vertebral body fractures of C3 to C6 were the most common form of CSI in this segment. Conclusion: The prevalence of concomitant cervical spine and head injury was significant in this study. This was confirmed among study subjects with a clinical diagnosis of mild-to-moderate head injury as compared with moderate-to-severe head injury. Therefore, all patients who sustained a head injury irrespective of severity are required to have a complete and rapid evaluation of the cervical spine.

Correlation Between Radiological Changes of the Temporomandibular Joint and Upper Cervical Vertebrae in Degenerative Joint Disease: A Cone-Beam Computed Tomography-Based Analytical Study.

Objectives This study was conducted to assess the radiological changes of the temporomandibular joint (TMJ) and cervical vertebrae individually and their correlation in degenerative joint disease (DJD) using a cone-beam computed tomography (CBCT)-based approach. Methodology The study employed a cross-sectional, analytical retrospective design, analyzing one-year data. CBCT scans of 60 patients (120 TMJs) were assessed for degenerative changes using standardized imaging parameters. Eligibility criteria included full field-of-view CBCT scans, excluding those with craniofacial anomalies or prior orthodontic treatment. Radiological assessments of TMJs and cervical vertebrae were conducted by experienced radiologists using the Anjos Pontual method and novel grading system (TMJ Spine Degenerative Severity Index). Results The study included 60 CBCT scans (120 joints), with 31.7% males and 68.3% females. Participants were predominantly aged 31-60 years (58.3%). DJD findings for the right TMJ showed grade 1 changes in 55.0% and grade 2 in 31.7%, while the left TMJ had 46.7% grade 1 and 35.0% grade 2 changes. A strong positive correlation (0.704) was found between bilateral TMJ and cervical vertebrae changes. Age correlated significantly with TMJ alterations but not with cervical vertebrae changes. Conclusion This study demonstrated that there exists a positive association between the radiological changes of TMJ and cervical vertebrae in DJD with age, which can be detected in mild stage of severity on CBCT and can be of use in clinical correlation and application of optimal interventions ensuring better prognosis.

Successful Non-operative Management of Unstable Jefferson Fracture With Transverse Atlantal Ligament Injury (Dickman Type I and IIb) in a Pediatric Patient: A Case Report.

This report presents the case of a Jefferson fracture (posterior arch fracture) associated with an unstable avulsion fracture and substance injury of the transverse atlantal ligament (Dickman type I and IIb) in an eight-year-old male child. The patient was managed conservatively with external immobilization using a halo vest and a sternal occipital mandibular immobilizer (SOMI) brace and subsequently made a full recovery. Computed tomography (CT) and dynamic cervical spine radiographs at the final follow-up demonstrated solid reattachment of the avulsed bony fragment of the transverse atlantal ligament and no instability at the C1/2 level. This case report adds to the literature on the optimal non-operative management of the rare pediatric unstable C1-C2 trauma.

Craniovertebral Junction Deformity Diagnosed by Computed Tomography: A Case Report.

Craniovertebral junction (CVJ) deformities, including basilar invagination and atlanto-occipital assimilation, present significant challenges in diagnosis and management due to their complex nature and impact on neurological function. We report a case of a 28-year-old female who experienced neck pain, weakness, tingling in the upper limbs, restricted neck movements, occipital headaches, and intermittent dizziness. These symptoms progressively worsened over six months, markedly affecting her quality of life. Neurological examination revealed reduced motor power in the upper limbs and a diminished bicipital tendon reflex, while other assessments remained normal. Cervical spine CT imaging was done which revealed basilar invagination and atlanto-occipital assimilation. This case underscores the importance of recognizing and managing CVJ deformities, highlighting the need for a multidisciplinary approach to address anatomical and associated neurological symptoms. Early and accurate diagnosis and a tailored treatment strategy are crucial for improving patient outcomes.

Development, calibration and validation of impact-specific cervical spine models: A novel approach using hybrid multibody and finite-element methods.

BACKGROUND AND OBJECTIVE: Spinal cord injuries can have a severe impact on athletes' or patients' lives. High axial impact scenarios like tackling and scrummaging can cause hyperflexion and buckling of the cervical spine, which is often connected with bilateral facet dislocation. Typically, finite-element (FE) or musculoskeletal models are applied to investigate these scenarios, however, they have the drawbacks of high computational cost and lack of soft tissue information, respectively. Moreover, material properties of the involved tissues are commonly tested in quasi-static conditions, which do not accurately capture the mechanical behavior during impact scenarios. Thus, the aim of this study was to develop, calibrate and validate an approach for the creation of impact-specific hybrid, rigid body - finite-element spine models for high-dynamic axial impact scenarios. METHODS: Five porcine cervical spine models were used to replicate in-vitro experiments to calibrate stiffness and damping parameters of the intervertebral joints by matching the kinematics of the in-vitro with the in-silico experiments. Afterwards, a five-fold cross-validation was conducted. Additionally, the von Mises stress of the lumped FE-discs was investigated during impact. RESULTS: The results of the calibration and validation of our hybrid approach agree well with the in-vitro experiments. The stress maps of the lumped FE-discs showed that the highest stress of the most superior lumped disc was located anterior while the remaining lumped discs had their maximum in the posterior portion. CONCLUSION: Our hybrid method demonstrated the importance of impact-specific modeling. Overall, our hybrid modeling approach enhances the possibilities of identifying spine injury mechanisms by facilitating dynamic, impact-specific computational models.

[Transport of severely injured trauma patients in an ambulance with and without a rigid neck orthosis: comparative biomechanical measurements]. / Transport von schwer verletzten Traumapatienten im Rettungswagen mit und ohne starre Halsorthese: vergleichende biomechanische Messungen.

BACKGROUND: The actual significance of prehospital immobilization of the cervical spine in severely injured trauma patients remains unclear. In view of possible negative implications, such as an increase in intracranial pressure due to the application of a rigid cervical spine orthosis, the long-term use must be critically questioned. Further studies are required to justify the long-term use of a rigid cervical spine orthosis in the prehospital setting. OBJECTIVE: Comparative measurements of the mobility of the cervical spine during immobilization using a vacuum mattress with or without the additional application of a rigid cervical spine orthosis after positioning on the stretcher were carried out. MATERIAL AND METHODS: Biomechanical measurements of the movement of the cervical spine were carried out by attaching inertial measurement units to a test person during the loading and unloading process in a modern ambulance and during the journey along a predefined parkour. The test person on whom the measurements were carried out was immobilized on a vacuum mattress with the option of lateral fixation of the head and chin and forehead strap on an electrohydraulic stretcher. The complete standard monitoring was set up to simulate as realistic a transport of a severely injured patient as possible. A total of 30 test runs were realized. In one half of the tests, the cervical spine was additionally immobilized using a rigid orthosis and in the other half a cervical spine orthosis was not used. For each of the 30 tests, the angles, axial rotation, lateral bending and flexion/extension as well as the first and second derivatives were considered for loading, transport and unloading and the parameters mean deviation from the zero position, size of the swept angle range and maximum were calculated for each test run. RESULTS: Statistically significant differences were only found for some biomechanical parameters in the sagittal plane (flexion and extension). No significant differences were found for the measured parameters in the other directions of movement (axial rotation, lateral flexion). In general, only very small angular deflections were measured both in the tests with the cervical spine orthosis and without the cervical spine orthosis (on average in the range of 1-2° for axial rotation and flexion/extension and up to 3° for lateral flexion). CONCLUSION: If immobilization is carried out correctly using a vacuum mattress with the option of lateral stabilization of the head and chin and a forehead strap on an electrohydraulic stretcher with a loading system, there are no relevant advantages with respect to the restriction of movement of the cervical spine by the additional use of a rigid cervical spine orthosis for the loading and unloading process or during the transport in a modern ambulance. It could therefore be advantageous to remove the rigid cervical spine orthosis initially applied for the rescue of the patient at the scene after the patient has been positioned on the vacuum mattress and stretcher to avoid potential negative effects of the rigid cervical spine orthosis for the period of transportation to the hospital.

Novel MRI signs of the atlantodental space in patients with atlantoaxial dislocation.

OBJECTIVES: The type of atlantodental space tissue in patients with atlantoaxial dislocation (AAD) can help doctors understand the possibility of reduction before surgery. However, relevant research on this topic is lacking. In this study, we aimed to summarise the atlantodental space classification of patients with AAD using magnetic resonance imaging (MRI) and explore their clinical characteristics. MATERIALS AND METHODS: Preoperative 3T cervical MR images of patients who underwent posterior reduction and fixation surgery for non-traumatic AAD between 1 September 2012 and 31 July 2023 were collected. Two radiologists read and recorded the MRI results based on the standard protocol. The kappa value was used to evaluate intra- and inter-observer agreements. The patient's age, sex, body mass index, clinical symptoms, Japanese Orthopaedic Association (JOA) score, and visual analogue scale information were obtained from medical records. RESULTS: A total of 135 patients with AAD (mean age, 51.3 ± 14.0 years, 52 men) were included in the analysis. The inter-observer agreement between the two readers was 0.818 (P < 0.0001). The intra-observer consistencies were 0.882 (P < 0.0001) and 0.896 (P < 0.0001). Patients with inflexible tissue signs exhibit more irreducible in hyperextension position, and their range of motion of ADI is smaller. These patients were older and had a higher incidence of abnormal spinal cord signals and JOA scores. CONCLUSIONS: Novel MRI signs exhibited high inter- and intra-observer consistency and were associated with patient age, abnormal spinal cord signals, reducibility, range of motion of ADI, and symptoms.

Pediatric C-spine Clearance by CT: A Retrospective Cohort Study.

BACKGROUND: Pediatric cervical spinal injury (CSI) remains a significant concern following blunt trauma, with mortality rates as high as 48%. Current protocols involve cervical immobilization and clearance through multidetector computed tomography (MDCT) scans, followed by magnetic resonance imaging (MRI) or clinical examination. However, prolonged collar use poses risks, necessitating timely clearance. This study assessed the efficacy of MDCT in pediatric CSI clearance. METHODS: A retrospective cohort study, spanning January 2019 to January 2023, included pediatric patients under 18 undergoing cervical CT scans. RESULTS: MDCT sensitivity was evaluated, with 13.8% positive scans, detecting clinically significant injuries. MRI identified no additional injuries, affirming MDCT reliability. The average clearance time was 24.9 hours, impacting hospitalization durations. Mortality unrelated to CSI was excluded. CONCLUSION: These results align with recent studies advocating cervical collar removal based on negative MDCT, emphasizing its potential to decrease the time that patients remain in C-collars and expedite hospital courses, including therapy and discharge. The study encourages consideration of MDCT-based protocols for timely pediatric CSI clearance, promoting patient care efficiency and informed medical decision-making.

Early Occipitocervical Fusion Surgery in a Rare Clinical Encounter of Non-traumatic Atlantooccipital Subluxation (AOS) in Down Syndrome (Trisomy 21).

Subluxation of the atlantooccipital joint in patients with underlying Down syndrome is an extremely rare orthopedic condition. The condition can pose life-threatening risks if not promptly diagnosed and treated in the early stage. Yet, there have been documented cases of survival following atlantooccipital subluxation or dislocation. Atlantooccipital subluxation (AOS) is usually identified during screening in children with Down syndrome for atlantoaxial subluxation (AAS). Therefore, careful evaluation of the atlantooccipital joint from radiographs is also essential. It is crucial to emphasize the clinical significance of AOS. Here the authors present the case of a fifteen-year-old girl with underlying Down syndrome (trisomy 21) who survived a sudden onset of non-traumatic atlantooccipital subluxation with spinal cord compression. There are only a few cases were reported in patients with Down syndrome (trisomy 21) and only two cases with surgically treated atlantooccipital (C0C1) subluxation have been reported. This case is of particular interest as it represents the first reported case of atlantooccipital (C0C1) subluxation with spinal cord compression in Down syndrome that underwent occipitocervical fusion surgery during the acute presentation, resulting in significant neurological recovery. Her neurology symptoms and physical functions showed remarkable improvement post-surgery, and she is doing well at the one-year follow-up in the clinic. Early surgery during acute presentation in this case resulted in good surgical outcomes and improved patient quality of life.

Inaugural cervical spinal location of gout: A case report.

Gout is a crystalline arthropathy associated with prolonged body overload with uric acid. The most common sites are the distal joints of the lower limbs and the spine is rare. We report a case of gout with an initial cervical location of spondylodiscitis with epiduritis in a 62-year-old patient.

Percutaneous dilational tracheostomy following anterior cervical spine fixation - a retrospective propensity-matched cohort study.

PURPOSE: In patients with traumatic, infectious, degenerative, and neoplastic surgical indications in the cervical spine, commonly the anterior approach is used. Often these patients require a tracheostomy necessary due to prolonged mechanical ventilation. The limited spinal mobility and proximity to the surgical site of anterior cervical spine fixation (ACSF) could pose an increased risk for complications of percutaneous dilational tracheostomy (PDT.) Importantly, PDT might raise wound infection rates of the cervical spine approach. The aim of this study is to prove safety of PDT after ACSF. METHODS: We performed a retrospective, single-center study comparing patients with and without ACSF who underwent Ciaglia-single step PDT. After propensity score matching using logistic regression, we compared intra- and postprocedural complication rates. Furthermore, surgical site infections were evaluated. Putensen's definitions of complications and Clavien-Dindo's classification were used. RESULTS: A total of 1175 patients underwent PDT between 2009 and 2021. Fifty-seven patients underwent PDT following ACSF and were matched to fifty-seven patients without ACSF. The mean interval between ACSF and PDT was 11.3 days. The overall complication rate was 19.3% in the ACSF group and 21.1% in the non-ACSF group. The mean follow-up was 388 days (± 791) in the ACSF group and 424 days (± 819) in the non-ACSF group. Life-threatening complications (Clavien-Dindo IV to V) were found in 1.8% of ACSF patients and 3.5% of non-ACSF patients. There were no significant differences in complication rates. No surgical site infection of the anterior spine access was detected. CONCLUSION: PDT is a feasible and safe procedure in patients after ACSF. Complication rates are comparable to patients without ACSF. Surgical site infections of ACSF are very rare.

Structural allograft versus Polyetheretherketone cage in Anterior Cervical Discectomy and Fusion: A Meta-analysis.

BACKGROUND: Polyetheretherketone (PEEK) cages and structural allografts (SAs) are commonly used in Anterior Cervical Discectomy and Fusion (ACDF), yet their postoperative results remain uncertain. This meta-analysis was conducted to determine whether there were any differences in outcomes between patients who received these two grafts in ACDF. METHODS: We comprehensively searched electronic databases up to August 2023. Observational studies or randomized controlled trials reported postoperative outcomes, including fusion, subsidence, reoperation rates, and patient-reported outcomes through the Neck Disability Index (NDI), the Visual Analog Scale (VAS) for neck and arm pain, and the Japanese Orthopedic Association (JOA)/modified JOA score following primary ACDF using SA or PEEK cage. The results are presented in odds ratios (ORs) or mean differences with corresponding 95% confidence intervals (CIs). RESULTS: Eleven studies were included, with 1213 patients (788 receiving SAs and 425 receiving PEEK cages). Patients having SA had significantly higher fusion (OR: 1.84, 95% CI: 1.27-2.67, p = 0.001) and lower subsidence (OR: 0.50, 95%CI: 0.30-0.86, p = 0.01) rates when compared with the PEEK cage. There was no difference in revision rate between SA or PEEK cage (p = 0.88). Two grafts demonstrated similar clinical improvements in NDI (p = 0.31), VAS for the neck (p = 0.77) and arm pain (p = 0.22), and JOA/mJOA score (p = 0.99). CONCLUSION: SA demonstrates better fusion and lower subsidence rates than the PEEK cage in ACDF. Nevertheless, these two cages resulted in equally successful postoperative clinical performances.

Anatomical Relationships of Internal Carotid Artery with Posterior Pharyngeal Wall and Upper Cervical Spine: Analysis of 238 Computed Tomography Angiograms.

OBJECTIVE: To evaluate internal carotid artery's (ICA) anatomical relationships with atlantoaxial joints and posterior pharyngeal wall and to illustrate ICA injury risk during transoral procedures to upper cervical spine. METHODS: Cervical spine computed tomography angiography (CTA) of 238 patients were retrospectively evaluated. Each ICA was classified into one of three zones: areas medial (Zone 1), anterior (Zone 2), or lateral (Zone 3) to the atlantoaxial joint. For an ICA in Zone 1, the shortest distances to the posterior pharyngeal wall and midsagittal plane were measured. For an ICA in Zone 2, the closest distances to the midsagittal plane and anterior cortex of the C1-2 complex were measured. RESULTS: Fifteen ICAs in Zone 1 were found in 12 (5%) patients, with three female patients having bilateral ICAs medial to the atlantoaxial joint. The incidence of ICA in Zone 1 was higher in females than in males. In cases of ICAs in Zone 2, the ICAs were close to the anterior cortex of C1-2 complex, with the shortest distance being 2.6±1.5 mm. A total of 39.9% of patients had bilateral ICAs in Zone 3. CONCLUSION: Transoral surgeries in the upper cervical spine carry potential ICA injury risk. They should be carefully deliberated in patients whose ICAs are in Zone 1. In cases of ICAs in Zone 2, meticulous subperiosteal stripping and gentle traction should be performed on the posterior pharyngeal wall. Preoperative identification of the course of ICAs is mandatory in patients undergoing transoral surgeries in the upper cervical spine.

Intradural extramedullary cervical cavernoma.

Background: Spinal cavernomas (SCs) account for about 5% of all spinal vascular malformations. Intradural SCs occur in just 3% of cases and are typically intramedullary. Case Description: A 58-year-old female presented with progressive left occipital neuralgia, left cervicobrachial neuralgia, and paresthesia of all four extremities. The magnetic resonance imaging (MRI) revealed an intradural extramedullary C2-C4 lesion causing significant spinal cord compression. Gross total tumor excision was accomplished through a midline laminectomy pathologically; the lesion proved to be a cavernoma. The postoperative follow-up MRI obtained 4 months postoperatively showed complete tumor resection. Conclusion: A 58-year-old female successfully underwent gross total excision of a C2-C4 intradural extramedullary SC.