Supplementation of Screw-Rod C1-C2 Fixation With Posterior Arch Femoral Head Allograft Strut.

BACKGROUND: Numerous C1-C2 fixation techniques exist for the treatment of atlantoaxial instability. Limitations of screw-rod and sublaminar wiring techniques include C2 nerve root sacrifice and dural injury, respectively. We present a novel technique that utilizes a femoral head allograft cut with a keyhole that rests posteriorly on the arches of C1 and C2 and straddles the C2 spinous process, secured by sutures. OBJECTIVE: To offer increased fusion across C1-C2 without the passage of sublaminar wiring or interarticular arthrodesis. METHODS: A total of 6 patients with atlantoaxial instability underwent C1-C2 fixation using our method from 2015 to 2016. After placement of a C1-C2 screw/rod construct, a cadaveric frozen femoral head allograft was cut into a half-dome with a keyhole and placed over the already decorticated dorsal C1 arch and C2 spinous process. Notches were created in the graft and sutures were placed in the notches and around the rods to secure it firmly in place. RESULTS: The femoral head's shape allowed for creation of a graft that provides excellent surface area for fusion across C1-C2. There were no intraoperative complications, including dural tears. Postoperatively, no patients had sensorimotor deficits, pain, or occipital neuralgia. 5 patients demonstrated clinical resolution of symptoms by 3 mo and radiographic (computed tomography) evidence of fusion at 1 yr. One patient had good follow-up at 1 mo but died due to complications of Alzheimer disease. CONCLUSION: The posterior arch femoral head allograft strut technique with securing sutures is a viable option for supplementing screw-rod fixation in the treatment of complex atlantoaxial instability.

Relationship between craniocervical orientation and center of force of occlusion in adults.

OBJECTIVE: Clinical observation and anecdotal reports suggest changes can occur to dental occlusion following intervention with the National Upper Cervical Chiropractic Association (NUCCA) procedure. This case controlled study discerned if occlusion changes are measurable using a dental force plate (T-Scan®) following an adjustment to the craniocervical junction (CCJ). METHODS: A degree of case control was established by active patients being assessed twice prior to and following intervention. Before-after intervention assessment included posture evaluation and dental occlusion (T-Scan®). RESULTS: Findings suggest that changes in posture and occlusion can be observed after the NUCCA chiropractic procedure. Not all patients demonstrated a more balanced contact pattern following the adjustment, indicating a need for further investigation. DISCUSSION: These findings may suggest interconnectivity between the CCJ and an individual's occlusal contacts and support the need for further integration between chiropractors and dentists seeking to co-manage temporomandibular joint disorders.

Closed manual reduction maneuver of atlantoaxial rotatory dislocation in pediatric age.

PURPOSE: The purposes of this study were to characterize the clinical and radiological features of type 1 and type 2 atlantoaxial rotatory dislocations (AARD) and to evaluate the outcome of the manual reduction maneuver for these types of dislocations in pediatric patients. METHODS: This study considered 12 pediatric patients with AARD who were treated between January 2003 and March 2013. The diagnosis was established by clinical findings and 3D-CT. All of the patients were treated by closed manual reduction and then a cervical orthosis was performed. All of the patients were followed up at regular intervals. RESULTS: The causes of the AARD were trauma (91.67 %) and infection (8.33 %). The time between onset of symptoms and admission to the hospital ranged from 16 days to 6 months. In radiological evaluation, the mean rotational angulation of the patients was 30.58°. The 3D-CT examination showed that six patients (50 %) had type 1 dislocation and six patients (50 %) had type 2 dislocation. All of the patients were treated by closed manual reduction and then a cervical orthosis was performed. For 11 patients (91.67 %), dislocation was successfully reducted and maintained. One patient (8.33 %) underwent surgery, following recurrence of the second closed reduction maneuver. CONCLUSION: This preceding treatment method has successfully produced a fast and recurrence-free alignment on all except one of our patients. This technique can be a useful treatment alternative in carefully selected AARD cases. Future research is encouraged to improve decision making in the application of this treatment method and provide additional validation of the current findings.

The influence of age, sex, and posture on the measurement of atlantodental interval in a normal population.

OBJECTIVE: The atlantodental interval (ADI) is used in assessing atlantoaxial stability. This measurement may potentially be affected by several features encountered during patient examination. This study examined the influence of 3 features: age, sex, and posture, on the measurement of ADI in a normal population. METHODS: The ADI was measured sequentially on 269 lateral cervical radiographs of adults with no demonstrated bony injury. Images were stratified by age and sex with equal representation in each age group. A further 25 asymptomatic adults were assessed for posture using craniovertebral angle measured from digital lateral photographs. The ADI was then measured from a lateral radiograph. The data were examined for correlation between age, craniovertebral angle, and ADI using Spearman rank correlation. The ADI of age groups was compared by Kruskal-Wallis test. The relationship between ADI and sex was examined using Wilcoxon rank sum test. Interaction between age and sex was explored using an interaction term in regression analysis. RESULTS: The ADI decreased with age, median measurements reducing from 2.07 to 0.85 mm across age groups (P < .01). No significant relationship was demonstrated between ADI and sex. No significant interaction was demonstrated between age and sex. Measurements of craniovertebral angle did not correlate with ADI (ρ = 0.03, P = .90). CONCLUSION: The magnitude of ADI decreases with advancing age. Age should be considered a modifying factor when interpreting measurement of ADI, particularly in consideration of potential minor instabilities. Patient sex does not appear to influence ADI, either independently or in interaction with age. Craniocervical posture variation does not influence ADI in an asymptomatic adult population.

Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases.

OBJECTIVE: This study presents the outcomes of patients with idiopathic degenerative and posttraumatic atlantoaxial osteoarthritis who were treated with upper cervical manipulation in combination with mobilization device therapy. CLINICAL FEATURES: A retrospective case review of 10 patients who were diagnosed with either degenerative or posttraumatic atlantoaxial arthritis based on histories, clinical symptoms, physical examination, and radiographic presentations was conducted at a multidisciplinary integrated clinic that used both chiropractic and orthopedic services. All 10 patients selected for this series were treated with a combination of upper cervical manipulation and mechanical mobilization device therapy. Outcome measures were collected at baseline and at the end of the treatment period. Assessments were measured using patients' self-report of pain using a numeric pain scale (NPS), physical examination, and radiologic changes. Average premanipulative NPS was 8.6 (range, 7-10), which was improved to a mean NPS of 2.6 (range, 0-7) at posttreatment follow-up. Mean rotation of C1-C2 at the end of treatment was improved from 28° (±3.1) to 52° (±4.5). Restoration of joint space was observed in 6 patients. Overall clinical improvement was described as "good" or "excellent" in about 80% of patients. Clinical improvements in pain and range of motion were seen in 80% and 90% of patients, respectively. CONCLUSION: Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients.

Brain stem compression and atlantoaxial instability secondary to chronic rheumatoid arthritis in a 67-year-old female.

OBJECTIVE: This case study describes a patient with long-standing rheumatoid arthritis of the cervical spine who presented with significant bone destruction, gross joint derangement, and a potentially life-threatening complication, basilar invagination with brain stem compression. The pathophysiology, clinical presentation, imaging, and surgical management are discussed. CLINICAL FEATURES: A 67-year-old female presented to a chiropractic clinic with chronic neck pain of 30 years of duration complicated by rheumatoid arthritis. Her neck pain had recently exacerbated and was radiating into her trapezius muscle and shoulders. She also reported a recent onset of mild dysphagia. The patient was referred to a neurosurgeon for consultation and management. INTERVENTION AND OUTCOME: Computed tomography and magnetic resonance imaging of the cervical spine demonstrated significant bone destruction, gross joint derangement, and basilar invagination. There was moderate stenosis of the foramen magnum secondary to basilar invagination with significant brain stem compression. The patient underwent surgical stabilization fusion from the occiput to T2 using a posterior approach. Her pain severity was lessened after surgery, and the dysphagia had not progressed suggesting stabilization of brain stem compression. CONCLUSION: Patients with long-standing rheumatoid arthritis of the cervical spine often present with chronic neck pain. Cervical spine instability may arise from rheumatoid osteolysis and is also secondary to horizontal or vertical subluxation of the atlantoaxial and occipitoatlantal regions, respectively. High-velocity, low-amplitude manipulation of the upper cervical spine is an absolute contraindication in cases of atlantoaxial instability. A timely diagnosis and favorable surgical outcome provided relief from a potentially life-threatening disorder. This case exemplifies the clinical caution necessary for managing patients with chronic cervical spine pain complicated by rheumatoid arthritis.

Association of methylenetetrahydrofolate reductase genetic polymorphisms with atlantoaxial dislocation.

OBJECT: Genetic mechanisms of atlantoaxial dislocation (AAD) have not previously been elucidated. The authors studied association of polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene, which encodes enzymes of the folate pathway (implicated in causation of neural tube defects [NTDs]), in patients with AAD. METHODS: Molecular analysis of MTHFR polymorphisms (677C-->T, cytosine to thymine and, 1298A-->C, adenine to cytosine, substitutions) was carried out using polymerase chain reaction and restriction enzyme digestion in 75 consecutive patients with AAD and in their reducible (nine patients, 12%) and irreducible (66 patients, 88%) subgroups. Controls were 60 age- and sex-matched patients of the same ethnicity. Comparisons of genotype and allele frequencies were performed using a chi-square test (with significance at p < 0.05). RESULTS: The CT genotype frequency of MTHFR 677C-->T polymorphism was significantly increased in the full group of patients with AAD (odds ratio [OR] 3.00, 95% confidence interval [CI] 1.28-7.14, p = 0.005) as well as in the irreducible subgroup (OR 2.81, 95% CI 1.17-6.86, p = 0.01). The frequency of T alleles was also higher in the AAD group (25.3%) than in controls (15%). The comparison of the combined frequency of CT and TT genotypes with the frequency of the CC genotype again showed significant association in AAD (OR 2.63, 95% CI 1.98-5.90, p = 0.009) and the irreducible (OR 2.5, 95% CI 1.1-5.74, p = 0.016) subgroup. There was, however, no significant association of MTHFR 1298A-->C polymorphism with AAD. CONCLUSIONS: Both MTHFR 677C-->T polymorphism and higher T allele frequency have significant associations with AAD, especially the irreducible variety. Perhaps adequate supplementation of periconceptional folic acid to circumvent effects of this missense mutation (as is done for prevention of NTDs) would reduce the incidence of AAD.

Iatrogenic pyogenic osteomyelitis of C-1 and C-2 treated with transoral decompression and delayed posterior occipitocervical arthrodesis. Case report.

The authors describe a case of osteomyelitis of the craniocervical junction caused by iatrogenic infection of the spine during corticosteroid injection therapy. This 58-year-old diabetic man presented with acute exacerbation of neck pain that had began 4 months prior to admission. He did not experience the associated fever, chills, or sweats, but he did notice transient weakness in the right upper extremity. A computed tomography (CT) scan of the cervical spine demonstrated a destructive process involving the odontoid and the left occipitocervical and atlantoaxial joints that was not present on a CT obtained 2 months earlier, just before trigger-point and left-sided C1-2 facet joint corticosteroid injections. A diagnosis of staphylococcal osteomyelitis was made, and initial treatment with external immobilization and appropriate antibiotic therapy failed to control radiographically demonstrated and clinical progression. The patient was successfully treated using staged anterior decompression and posterior instrumented fusion with prolonged antibiotic therapy. To the authors' knowledge this case is the first reported instance of iatrogenic pyogenic osteomyelitis of the craniocervical junction successfully treated with anterior decompression and delayed posterior arthrodesis.

The effects of bite line deviation on lateral cervical radiographs when upper cervical joint dysfunction exists: a pilot study.

PURPOSE: To demonstrate the impact of inconsistent bite line positioning during pre and post lateral cervical radiographic examinations and to suggest certain additional imaging studies if the bite line cannot be consistently maintained. METHODS: Radiographic measurements of relative flexion and extension in the atlantal-occipital (AO) and atlantal-axial (AA) joints were taken from neutral lateral cervical and cervical flexion and extension radiographs of 20 subjects. RESULTS: The average relative AO flexion was -0.9 degrees and 12.0 degrees of extension, while the average relative AA flexion and extension values were 8.5 degrees and 2.8 degrees, respectively. In addition, 12 (60%) of the 20 subjects exhibited paradoxical motion at the AO joint during cervical flexion. Of these 12 subjects, 10 also displayed excessive relative AO extension (beyond 7.5 degrees ). CONCLUSIONS: If a bite line deviation exists in pre and post lateral cervical radiographic examinations, dynamic cervical flexion and extension radiographs should be taken to calculate the maximum tolerances in the upper cervical spinal joints. If these tolerances are exceeded, the measurement of the cervical lordosis from the back of the second cervical vertebra and seventh cervical vertebra may be altered, thus incorporating the possibility of a 20.3% measurement error on the post lateral cervical radiograph.

Clinical study on manipulative treatment of derangement of the atlantoaxial joint.

The derangement of the atlantoaxial joint is one of main cervical sources of dizziness and headache, which were based on the observation on the anatomy of the upper cervical vertebrae, analysis of X-ray film of the atlantoaxial joint, and the manipulative treatment in 35 patients with cervical spondylosis. The clinical diagnosis of derangement consists of: dizziness, headache, prominence and tenderness on one side of the affected vertebra, deviation of the dens for 1 mm-4 mm on the open-mouth X-ray film, abnormal movement of the atlantoaxial joint on head-rotated open-mouth X-ray film. An accurate and delicate adjustment is the most effective treatment.

Diagnostic value on signs of subluxation of cervical vertebrae with radiological examination.

OBJECTIVE: To investigate the relationship between radiographic signs of subluxation in the cervical vertebrae and their clinical diagnostic value. DESIGN: Controlled, clinical study. SETTING: Institute of Clinical Anatomy and Biomechanics and NanFang Hospital of the First Military Medical University, Guangzhou, China. SUBJECTS: Eighty-seven subjects with cervicodynia and 21 asymptomatic volunteers. INTERVENTIONS: Radiological signs of subluxation from anteroposterior, lateral, open-mouth and dynamic radiographs of the cervical vertebrae of the subjects were measured and analyzed. MAIN OUTCOME MEASURES: The right and left odontoid lateral mass interspace, divergence of the spinous processes, sign of double contour and position of odontoid process were studied. RESULTS: The bilateral odontoid lateral mass interspaces were asymmetrical in most cases, and the divergence of spinous processes, sign of double contour and position of odontoid process were also common. Cervical vertebrae C5, C4 and C6 showed no special variations. CONCLUSION: There was little evidence to support the contention that signs of subluxation in the cervical vertebrae are of diagnostic significance. Subluxation should be defined in two ways: as a purely roentgenological diagnosis and as a combination of roentgenological signs with clinical signs.

Chiropractic correction of atlantoaxial rotatory fixation.

OBJECTIVE: To discuss the diagnosis, management and possible mechanism of atlantoaxial rotatory fixation. CLINICAL FEATURES: An 11-yr-old girl with significant head tilt of 7 months' duration sought chiropractic evaluation. Her history included indirect head and neck trauma from a motor vehicle accident and prior manipulative and therapeutic treatment. There was minimal muscular hypertonicity, except for the sternocleidomastoid muscle on the side opposite head tilt. The head seemed to be locked in a classic "cock robin" position. Radiological examination revealed asymmetry of the atlanto-odontoid interval, suggesting occipital-atlantoaxial joint dysfunction. A diagnosis of atlantoaxial rotatory fixation was made. INTERVENTION AND OUTCOME: Treatment included vectored/linear, upper cervical, high-velocity, low-amplitude chiropractic manipulation of the atlas vertebra, mobilizing manipulation and stretching exercises. Complete resolution occurred. CONCLUSION: This single case study suggests that chiropractic manipulation may be a viable treatment option for atlantoaxial rotatory fixation. Further investigation into manipulation as a treatment should be pursued.

Upper cervical instability: fact or fiction?

OBJECTIVES: The purpose of this review is to examine the internal validity of the standardized clinical stability tests for the upper cervical spine in relation to symptomatology. Whether radiology can confirm the clinical diagnosis is also examined. The importance of radiology in this situation, the pathogenesis and the prevalence of atlanto-axial hypermobility and the clinical symptomatology are discussed. DATA SOURCES: A literature search from January 1984 to March 1995. We consulted the CD-ROM Medline with the keywords "atlanto-axial instability," "atlanto-axial dislocation," "hypermobility," "cervical spine" and "atlanto-axial joint." Ninety-six Dutch, French, German, and English publications were selected. The Documentation Centre of the Institute for Research and Postgraduate Education Physiotherapy (SWSF) was consulted with the keywords: atlanto-axial joint, upper cervical spine, segmental examination, interobserver-reliability, intraobserver-reliability, interobserver variation, intraobserver variation, manual therapy, examination, diagnostics. Finally, recent developments and views published during this study were added. RESULTS: There seems to be no correlation between the amount of hypermobility or subluxation and the presence of clinical signs or neurological signs. The clinical signs can vary from relatively diffuse complaints, no symptoms and signs to serious ones. Radiology does not seem to be a reliable diagnostic mechanism in relation to upper-cervical instability. Conventional X-rays fail to give adequate information about atlanto-axial stability. CT-scan and MRI can visualize much more because of the direct sagittal projection but neither is an absolute standard. Furthermore, in relation to upper-cervical hypermobility, the validity of radiology is under debate. CONCLUSION: There is no correlation between the measure of hypermobility and the presence of clinical symptoms. Also, the validity of the upper-cervical stability tests is questionable. In diagnostics, every radiological examination measures anatomical and morphological variables, not functional variables. Despite this, CT and MRI should be preferred in diagnostics over conventional functional radiology.

A comparative study of two methods for obtaining the anteroposterior open mouth cervical view.

OBJECTIVE: To compare two methods of obtaining the anteroposterior (AP) open mouth view. DESIGN: Radiological evaluation of the occiput-C1/C1-C2 structures, as visualized on radiographs obtained using two different radiographic position set-ups. SETTING: The Anglo-European College of Chiropractic Clinic. PATIENTS: A total of 60 patients. Each method used on 30 patients. CRITERIA ASSESSED: Visualization of: (a) occiput-C1 joints, (b) atlantoaxial joints, (c) lateral masses C1 and (d) odontoid process. RESULTS: The visualization of the occiput-C1 joints was increased almost 100% using method 2. The atlantoaxial joints were seen in 7% more cases using method 2 and the lateral masses were seen in 10% more cases. The only structure seen more consistently using method 1 was the odontoid process, which was seen in 7% more cases using that method. CONCLUSION: This study shows that there is an easier and more consistent method of obtaining the AP open mouth view than that traditionally used in many institutions.

Os odontoideum: chronic neck pain after car accident; failure of two posterior atlantoaxial arthrodeses--medicolegal issues in the occupational setting.

OBJECTIVE: To present the case of a woman with previously asymptomatic os odontoideum (OO) who developed chronic neck pain after a car accident. CLINICAL FEATURES: A 32-yr-old woman developed slight constant neck pain following a car accident. Radiographs revealed OO with 12-mm atlantoaxial subluxation on neck flexion. There was no spinal cord compression clinically or on magnetic resonance imaging. INTERVENTION AND OUTCOME: Posterior atlantoaxial arthrodesis was performed twice but the bone graft resorbed for no apparent reason. The patient was treated with analgesics, physiotherapy and a Philadelphia collar to prevent accidental spinal cord compression. CONCLUSION: OO patients may remain asymptomatic if "space available for cord" is sufficient. Even low velocity rotational injury can precipitate chronic neck pain in adults with OO. Posterior atlantoaxial arthrodesis can fail inexplicably even under the best circumstances. Medicolegal issues in the occupational setting are discussed.

[Therapy of functional disorders of the craniovertebral joints in vestibular diseases]. / Zur Therapie funktioneller Kopfgelenksstörungen bei Vestibularisaffektionen.

Cervicogenic vertigo is caused by functional disorders of the craniovertebral joints. Improvement of vertigonous symptoms by chiropractic treatment was often described. The therapeutic effect of chiropractic treatment in 28 patients with vertigo and purely functional disorders of the upper cervical spine or with a combination of functional disorders of the upper cervical spine and the labyrinth was evaluated. Improvement of vertigonous symptoms on patients with purely functional disorders of the craniovertebral joints as well as on patients with combined functional disorders of the craniovertebral joints and labyrinth could be seen. Two of the 28 patients showed persistent relief of symptoms and normalisation of cervical motility whereas the vestibular deficit persisted. One patient with persistent vestibular dysfunction showed recurrent malfunction of the upper cervical spine and vertigo. In our opinion chiropractic treatment is mandatory for the therapy of patients with vestibular affections and functional disorders of the craniovertebral joints.

Atlantoaxial anomalies with particular emphasis on os odontoideum.

Anomalies of the atlantoaxial articulation are discussed with emphasis on os odontoideum. Normal and abnormal embryological and anatomical characteristics are described, as is their relevance upon stability of the upper cervical segments. This paper further discusses and reviews theories pertaining to the congenital and acquired forms of os odontoideum and a case report is presented. Some conclusions are drawn from the presented case report.

Brucellosis: a rare cause of the unstable spine.

Brucellosis infection in humans is very rare in the United States. Occasional cases are identified primarily in individuals who have been exposed to an animal's raw dairy products. Presented is a rare case of human brucellosis involving the cervical spine. Of interest is how the case unfolds, reminding the practitioner of the need for thorough clinical practice. A review of clinical features and findings is offered.

[Palmer-Sandberg-Gutmann chiropractic diagnosis of the atlanto-occipital joint from the conventional medical and radiologic viewpoints]. / Die chiropraktische Kopfgelenksdiagnostik nach Palmer-Sandberg-Gutmann aus schulmedizinisch-radiologischer Sicht.

There can be no lateral displacement of the atlas (massae laterales) in relation to the condyles, because this is impossible from an anatomical point of view, neither "angular" (atlas A rule) nor "non-angular" (atlas B rule) in the sense of the "hole-in-one (HIO)" diagnostic method evolved by the U.S. chiropractor Palmer. The course of the condyle baseline is not altered by a lateral displacement of the atlas in relation to the condyles, but by a tilting rotation of the condyles in respect of the atlas. Rotatory movements will result, among other phenomena, in a change of the course of the condyle and atlas baseline due to projection-produced changes in the region of the atlanto-occipital and atlas-axis joints. Last but not least, the course of the condyle and atlas baseline is also influenced by other functional parameters, another important parameter being an asymmetrically constructed joint.