Trends in orthopaedic surgery for spondyloarthritis: outcomes from a National Hospitalised Patient Registry (MBDS) over a 17-year period (1999-2015).TREND-EspA study.

OBJECTIVE: To assess the incidence of orthopaedic surgery (OS) (including total hip arthroplasty (THA), total knee arthroplasty, upper limb arthroplasty, arthrodesis and spinal surgery) and associated trends in patients with spondyloarthritis (SpA) over a long period (17 years). METHODS: An observational, retrospective, population-based, serial cross-sectional study was conducted. All hospital admissions of patients with SpA reported between 1999 and 2015 were analysed, and a control group was selected and matched by age, sex and year of admission. Incidence rates for OS (and subtypes) were calculated. Generalised linear models were used to analyse trends; unconditional logistic regression models were used to calculate crude and adjusted ORs (aORs) with the aim of evaluating the association between OS and SpA. RESULTS: The study database contained data on 214 280 hospital admissions (SpA/non-SpA 1:1 ratio). In the SpA cohort, 5 382 admissions (5.02%) had undergone OS compared with 3 533 in the non-SpA cohort (3.29%) (AOR 1.64; 95% CI 1.57 to 1.72). OS rates increased for both cohorts (+4.92% per year vs +8.41%). The trend in OS, THA, arthrodesis and spinal surgery decreased or stabilised in patients under age 60 in the SpA cohort, while the non-SpA cohort remained stable. In the SpA cohort, the mean age was 53.68 years (SD 13.65) in 1999, increasing to 62.76 years (SD 12.74) in 2015. In the non-SpA cohort, the mean age remained stable at around 63 years. CONCLUSIONS: A 9-year difference in the age of patients undergoing OS was observed in patients with SpA. The incidence of OS, THA and arthrodesis decreased in patients under age 60, and the incidence of spinal surgery decreased in patients under age 40. Our findings suggest that these patients are increasingly able to defer surgical interventions.

Radiofrequency facet joint denervation efficiency based on the severity of spondylarthrosis and in osteoporotic vertebral compression fractures. A retrospective study.

OBJECTIVES: Radiofrequency denervation of the facet joints is performed via a well-established method. Its primary, direct indication is a positive response to a nerve block injection (MBB). Our study aimed to find other, effective but indirect indication signs through the retrospective analysis of our patients treated earlier. PATIENTS AND METHODS: In our institute between 1 January, 2008 and 31 December, 2017 facet joint denervation has been performed in more than 2000 cases, and we included 529 patients in our retrospective study. We had separate groups for vertebral compression fractures and for spondylarthrosis of different severity (Grade 1; 2-3; 4), thus we assessed the postoperative condition of these patients using Visual Analoge Scale (VAS). The efficacy of the intervention was examined in every groups separately according to symptoms and previous spine surgeries. RESULTS: In view of our results, chronic lumbago and dorsalgia that are attributable to osteoporotic vertebral compression fracture are obvious indications if they do not respond to conservative therapy, as 76.8% of such patients remained asymptomatic for minimum 6 months (p = 0,000). Another indication is Grade 2 or 3 chronic spondylarthrosis without radicular involvement, since these groups reported a 51.4% success rate (asymptomatic for minimum 6 months) (p = 0,015). Long term pain relief is obviously impaired by the presence of radicular compression, as we were not able to decrease the pain of 97% of such patients. Our findings also suggest that the vast majority of those who have previously undergone spine surgery cannot benefit from the intervention. CONCLUSION: Based on this study, facet joint denervation can serve as an effective therapy supplement in a properly selected group of patients who do not respond to oral NSAIDs, exercise and physiotherapy. By this procedure we found we can reach long term benefit in the groups of osteoporotic vertebral fracture patients and patients with moderate spondylarthrosis. According to our results and the literature datas the properly patient selection for the indication of the RF ablation can be as effective as the controversial diagnostic nerve block injections.

Factors Associated With Opioid Use in Presurgical Knee, Hip, and Spine Osteoarthritis Patients.

OBJECTIVE: To evaluate rates of prescription opioid use among patients with presurgical knee, hip, and spine osteoarthritis (OA) and associations between use and sociodemographic and health status characteristics. METHODS: Participants were patients with presurgical, end-stage OA of the knee (n = 77), hip (n = 459), and spine (n = 168). Data were collected on current use of opioids and other pain medications, as well as measures of sociodemographic and health status variables and depression and pain (0-10 numeric rating scale). Rates of opioid use were calculated by sex, age, and surgical site. Multivariable logistic regression was used to examine associations between opioid use (sometimes/daily versus never) and other study variables. RESULTS: The mean age of participants was 65.6 years; 55.5% were women, 15% of patients reported "sometimes" using opioids, and 15% reported "daily use." Use of opioids was highest among patients with spine OA (40%) and similar among patients with knee and hip OA (28% and 30%, respectively). Younger women (ages <65 years) reported the greatest use of opioids overall, particularly among patients with spine OA. From multivariable logistic regression, greater likelihood of opioid use was significantly associated with spine OA (versus knee OA), obesity, being a current or former smoker, higher symptomatic joint count, greater depressive symptoms, greater pain, and current use of other prescription pain medication. CONCLUSION: Nearly one-third of patients with presurgical OA used prescription opioid medication. Given the questionable efficacy of opioids in OA and risk of adverse effects, higher opioid use among younger individuals and those with depressive symptoms is of concern and warrants further investigation.

Incidence and risk factors for adjacent segment degeneration following occipitoaxial fusion for atlantoaxial instability in non-rheumatoid arthritis.

PURPOSE: To investigate the incidence and risk factors for adjacent segment degeneration (ASD) following occipitoaxial fusion (OAF) for atlantoaxial instability (AAI) in non-rheumatoid arthritis (RA). METHODS: The study group comprised 41 patients without RA who underwent OAF due to AAI. Fifteen patients with postoperative ASD after OAF were classified as the ASD group, and the other 26 patients without postoperative ASD were included in the non-ASD group. There were 12 men and 3 women with a mean age of 43.52 years in the ASD group, and 19 men and 7 women with a mean age of 45.31 years in the non-ASD group. The mean follow-up period was 6.1 and 5.9 years in the ASD group and non-ASD group, respectively. Clinical outcomes and plain radiographs were retrospectively reviewed and compared between the two groups. RESULTS: The difference between pre- and postoperative O-C2 angles in the non-ASD group was significantly greater than that in the ASD group. The C2-7 angles changed significantly between the pre- and postoperative periods. It was suggested that the small O-C2 angle and large C2-7 angle observed in the early postoperative period were risk factors for the development of ASD. We also demonstrated a high incidence of subaxial subluxation (SAS) and swan neck deformity in the ASD group (27 versus 3.8% and 20 versus 0%, respectively). CONCLUSION: Under-correction of the O-C2 angle is likely to cause malalignment of the cervical spine, resulting in the development of postoperative ASD, SAS, and swan neck deformity.

2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis.

To update and integrate the recommendations for ankylosing spondylitis and the recommendations for the use of tumour necrosis factor inhibitors (TNFi) in axial spondyloarthritis (axSpA) into one set applicable to the full spectrum of patients with axSpA. Following the latest version of the European League Against Rheumatism (EULAR) Standardised Operating Procedures, two systematic literature reviews first collected the evidence regarding all treatment options (pharmacological and non-pharmacological) that were published since 2009. After a discussion of the results in the steering group and presentation to the task force, overarching principles and recommendations were formulated, and consensus was obtained by informal voting. A total of 5 overarching principles and 13 recommendations were agreed on. The first three recommendations deal with personalised medicine including treatment target and monitoring. Recommendation 4 covers non-pharmacological management. Recommendation 5 describes the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice drug treatment. Recommendations 6-8 define the rather modest role of analgesics, and disprove glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for axSpA patents with predominant axial involvement. Recommendation 9 refers to biological DMARDs (bDMARDs) including TNFi and IL-17 inhibitors (IL-17i) for patients with high disease activity despite the use (or intolerance/contraindication) of at least two NSAIDs. In addition, they should either have an elevated C reactive protein and/or definite inflammation on MRI and/or radiographic evidence of sacroiliitis. Current practice is to start with a TNFi. Switching to another TNFi or an IL-17i is recommended in case TNFi fails (recommendation 10). Tapering, but not stopping a bDMARD, can be considered in patients in sustained remission (recommendation 11). The final two recommendations (12, 13) deal with surgery and spinal fractures. The 2016 Assessment of SpondyloArthritis international Society-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.

Hematopoietic and mesenchymal stem cells: a promising new therapy for spondyloarthritis?

In the last years, a considerable progress has been made in the treatment of spondyloarthritides. Nonetheless, there remain a considerable number of patients who are unresponsive to all current therapies. Since the late 1990s, numerous trials have investigated the use of stem cell transplantation as a new approach for the treatment of autoimmune disease, particularly with hematopoietic stem cell transplantation. More recently, the research has focused on mesenchymal stem cell application due to their low immunogenicity and immunomodulatory properties. In this article, we summarize available data on hematopoietic stem cell and mesenchymal stem cell use for the treatment of spondyloarthritides and discuss the data gaps and possible research agenda in this area.

The Surgical Treatment Principles of Atlantoaxial Instability Focusing on Rheumatoid Arthritis.

OBJECT: This retrospective review was conducted to determine the surgical treatment principle for rheumatoid arthritis (RA) patients with atlantoaxial instability (AAI). METHODS: Thirteen patients with AAI, including 5 RA patients, received preoperative computed tomography- (CT-) based image-guided navigation system (IGS) in C1 lateral mass-C2 pedicle screw-rod system fixation (LC1-PC2 fixation). These 13 patients were analyzed for 52 screws inserted into C1 and C2. We defined these patients as non-RA group (8 patients, 32 screws) and RA group (5 patients, 20 screws). The neurological status for RA group was evaluated using the Ranawat classification. The causes of AAI, surgical indications, complications, surgical method revolution, and CT-based navigation application are discussed. RESULTS: None of the 13 patients expressed neurological function deterioration. The non-RA group screw accuracy was 100%. In the RA group, 1 RA patient developed left C2 screw loosening at 1(+) months after operation due to screw malposition. The screw accuracy for this group was 95%. CONCLUSIONS: Higher intraoperative surgical complication rate was described in RA patients. Preoperative CT-based IGS in LC1-PC2 fixation can provide good neurological function and screw accuracy results. However, for higher screw accuracy in RA patients, intraoperative CT-based IGS application may be considered.

[The Anterior "Triple-/Quadruple" Technique for C1/C2 Trauma in the Elderly: First Experience with 16 Patients]. / Die ventrale "Triple-/Quadruple"-Schraubenosteosynthese für die traumatische C1-C2-Kombinationsverletzung des geriatrischen Patienten: erste operative Erfahrungen mit 16 Patienten.

INTRODUCTION: In geriatric patients the management of odontoid type II fractures is complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2) with an increased lever arm. Furthermore, a few of the odontoid fractures are accompanied by an atlas fracture resulting in the "atlantoaxial unhappy triad". Posterior C1/C2 spondylodesis with bilateral Magerl screws and C1 hooks is a strong biomechanical construct, however, the posterior approach is associated with several drawbacks such as increased risk of infection and increased blood loss. In contrast, the anterior bilateral C1/C2 transarticular screw fixation with additional odontoid screw fixation is also a known technique. Advantages of the anterior approach are shorter surgery time, lower intraoperative blood loss and lower risk of infection. MATERIALS AND METHODS: In this retrospective study, all geriatric patients with an atlantoaxial arthritis and odontoid or combined atlantoaxial fracture treated at our institution between 01/2012 and 12/2014 with an anterior screw fixation were included. Following closed reduction, the surgical management was performed over a standard right anterior approach. At the end of surgery, operation time and blood loss were documented. During the hospital stay radiological follow-up of the upper cervical spine were performed to analyse the screw position. We also report the length of stay on intensive care unit, the hospital course and demographic data of the patients. Follow-up was planned after 6 weeks, 6, 12 and 18 months. During follow-up COMI evaluation and X-rays of the cervical spine were made. RESULTS AND CONCLUSION: This study included 16 patients who underwent surgery for C1-C2 lesions. There were 9 females and 7 males. Median age at the time of operation was 76 years. At the time of surgery, fractures were classified as follows: 8 patients showed an "atlantoaxial unhappy triad", 8 patients had a type II odontoid fracture complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2). Average time for operative treatment was 100 ± 36.35 minutes with a median intraoperative fluoroscopy time of 161 seconds. The intraoperative blood loss was minimal (45 ± 22.80 ml). Length of stay was documented with 10 (± 4.60) days whereby the patients spent on average 0.8 days in the intensive care unit postoperatively. No serious morbidities, such as esophageal perforation, carotid artery laceration, neurological deterioration, and airway obstruction were reported. All cases of transient dysphagia resolved gradually and spontaneously without therapy. In 4 cases (25 %) we detected a penetration of the atlantooccipital joint without functional impairment. In one case we have seen an implant failure. The technique of anterior screw fixation of odontoid and bilateral transarticular C1-C2 anterior screw fixation provides a fast surgery without higher morbidity. Based on our findings, this technique and its feasibility is an alternative to known posterior C1/C2 spondylodesis in the elderly.

[The influence of laser therapy on selected functional parameters of patients with spondyloarthrosis of the lower section of the spine]. / Wplyw laseroterapii na wybrane parametry czynnosciowe u chorych ze zmianami zwyrodnieniowymi dolnego odcinka kregoslupa.

UNLABELLED: Spondyloarthrosis is a quickly growing disease in highly civilized communities. It is one of the most frequent causes for movement limitations and is listed as the main reason for the incapacitation for work among people of the working age. The following symptoms can be observed in patients with spondyloarthrosis: pain, limited spine mobility, increased muscle tone. Chronic pain and the associated limitation of movement underlie the quest for an effective therapy. Using laser therapy as part of physical therapy prompts research into the effectiveness of the measure in patients with spondyloarthrosis. The aim of this study was to evaluate the effectiveness of laser therapy on spondyloarthrosis of the lumbar spine. MATERIAL AND METHODS: 60 patients suffering from chronic low back pain, diagnosed with a lumbar disc herniation with no nerve root symptoms, received laser therapy (820 nm, 400 mW, 6-12 J/cm2. Every patient underwent examinations before and after rehabilitation. Subjective pain assessment was carried out using a modified Laitinen questionnaire and visual analogue scale of pain intensity. Spine mobility was evaluated using Schober's test and the fingertip-to-floor-test. The obtained results were subject to a statistical analysis. RESULTS: Laser therapy was effective in the therapy of lumbar disc herniation. The results of the analysis showed that the intensity and frequency of pain decreased, as well as the use of painkillers. A vast improvement in global spine mobility and lumbosacral flexion and extension could be observed, too. CONCLUSIONS: The study showed a slight analgesic effect and a substantial increase in spine mobility through laser biostimulation.

US trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis.

OBJECTIVE: Although rates of arthroplasty have increased dramatically, rates among patients with rheumatoid arthritis (RA) are reported to be decreasing. It is not known if this is also the case among patients with other inflammatory arthritides. This study was undertaken to evaluate rates of arthroplasty due to RA, juvenile idiopathic arthritis (JIA), spondyloarthritis (SpA), and a composite group of patients with inflammatory arthritides (IA), compared to arthroplasty rates among patients without inflammatory or autoimmune conditions. METHODS: Administrative discharge databases (State Inpatient Databases of the Healthcare Cost and Utilization Project, New York Department of Health Statewide Planning and Research Cooperative System, California Statewide Health Planning and Development) were used to compare rates of knee, hip, and shoulder arthroplasty occurring from 1991 to 2005. RESULTS: Of 2,839,325 arthroplasties in 1991-2005, 2.7% were performed in patients with IA. The rate of arthroplasty for noninflammatory conditions doubled (124.5 per 100,000 persons in 1991 versus 247.5 per 100,000 persons in 2005), while the rate for IA remained stable at 5.1 per 100,000. Rates of arthroplasty for RA decreased slightly (4.6 per 100,000 versus 4.5 per 100,000) and those for JIA decreased by nearly 50% (0.22 per 100,000 versus 0.13 per 100,000), but the rate of arthroplasty for SpA increased by nearly 50% (0.22 per 100,000 versus 0.31 per 100,000). Age at the time of arthroplasty increased for patients with RA (mean ± SD 63.4 ± 12.7 years versus 64.9 ± 12.8 years), JIA (30.9 ± 12.2 years versus 36.7 ± 14.9 years), and SpA (54.3 ± 16.1 years versus 60.4 ± 13.9 years). However, the mean age at the time of arthroplasty among non-IA cases decreased (71.5 ± 11.8 years versus 69.0 ± 12.0 years). CONCLUSION: This population-based study is the first to show that arthroplasty rates have decreased significantly among patients with JIA and minimally among patients with RA, and have increased among patients with SpA. The increased age at the time of arthroplasty among patients with JIA and SpA suggests that these patients are increasingly able to defer surgical interventions. Further research is needed to assess the ongoing effect of biologic agents on the need for arthroplasties in patients with IA.

Back pain in patients with degenerative spine disease and intradural spinal tumor: what to treat? when to treat?

BACKGROUND: Back pain is common in industrialized countries and one of the most frequent causes of work incapacity. Successful treatment is, therefore, not only important for improving the symptoms and the quality of life of these patients but also for socioeconomic reasons. Back pain is frequently caused by degenerative spine disease. Intradural spinal tumors are rare with an annual incidence of 2-4/1,00,000 and are mostly associated with neurological deficits and radicular and nocturnal pain. Back pain is not commonly described as a concomitant symptom, such that in patients with both a tumor and degenerative spine disease, any back pain is typically attributed to the degeneration rather than the tumor. OBJECTIVE: The aim of the present retrospective investigation was to study and analyze the impact of microsurgery on back/neck pain in patients with intradural spinal tumor in the presence of degenerative spinal disease in adjacent spinal segments. METHODS: Fifty-eight consecutive patients underwent microsurgical, intradural tumor surgery using a standardized protocol assisted by multimodal intraoperative neuromonitoring. Clinical symptoms, complications and surgery characteristics were documented. Standardized questionnaires were used to measure outcome from the surgeon's and the patient's perspectives (Spine Tango Registry and Core Outcome Measures Index). Follow-up included clinical and neuroradiological examinations 6 weeks, 3 months and 1 year postoperatively. RESULTS: Back/neck pain as a leading symptom and coexisting degenerative spine disease was present in 27/58 (47 %) of the tumor patients, and these comprised to group under study. Patients underwent tumor surgery only, without addressing the degenerative spinal disease. Remission rate after tumor removal was 85 %. There were no major surgical complications. Back/neck pain as the leading symptom was eradicated in 67 % of patients. There were 7 % of patients who required further invasive therapy for their degenerative spinal disease. CONCLUSIONS: Intradural spinal tumor surgery improves back/neck pain in patients with coexisting severe degenerative spinal disease. Intradural spinal tumors seem to be the only cause of back/neck pain more often than appreciated. In these patients suffering from both pathologies, there is a higher risk of surgical overtreatment than undertreatment. Therefore, elaborate clinical and radiological examinations should be performed preoperatively and the indication for stabilization/fusion should be discussed carefully in patients foreseen for first time intradural tumor surgery.

Cardiovascular risk in the rheumatic disease patient undergoing orthopedic surgery.

A hallmark of the rheumatic diseases, including systemic lupus erythematosis, spondyloarthritis, and rheumatoid arthritis, has been sustained inflammation, which typically targets the joint and may lead to joint destruction. Inflammation also plays a role in atherosclerotic cardiovascular disease, which is highly prevalent in patients with rheumatic diseases. Total joint arthroplasty, considered an intermediate cardiac risk procedure by the American College of Cardiology, maintains an important role in the management of rheumatic disease patients who progress to end-stage joints. The purpose of this article is to discuss the role of inflammation in cardiovascular disease, the prevalence of cardiovascular disease in patients with systemic rheumatic diseases, and the role of cardiovascular risk assessment when these patients undergo total joint arthroplasty.

Transarticular screw fixation of C1-2 for the treatment of arthropathy-associated occipital neuralgia.

Two patients with occipital neuralgia due to severe arthropathy of the C1-2 facet joint were treated using atlantoaxial fusion with transarticular screws without decompression of the C-2 nerve root. Both patients experienced immediate postoperative relief of occipital neuralgia. The resultant motion elimination at C1-2 eradicated not only the movement-evoked pain, but also the paroxysms of true occipital neuralgia occurring at rest. A possible pathophysiological explanation for this improvement is presented in the context of the ignition theory of neuralgic pain. This represents the first report of C1-2 transarticular screw fixation for the treatment of arthropathy-associated occipital neuralgia.

Rheumatoid arthritis of the craniovertebral junction.

BACKGROUND: Rheumatoid arthritis (RA) is the most common inflammatory disease involving the spine. It has a predilection for involving the craniocervical spine. Despite widespread involvement of the cervical spine with RA, few patients need surgery. The 3 major spinal manifestations of RA in the cervical spine are basilar invagination, atlantoaxial instability, and subaxial subluxations. Surgical management of RA involving the craniovertebral junction remains a challenge despite a decline in severe cases and an improvement in surgical techniques. METHODS: We conducted an exhaustive review of English-language publications discussing RA involving the craniovertebral junction. We paid special attention to publications detailing modern surgical management of these conditions. In addition, we outline our own surgical experience with such patients. RESULTS: We discuss alternative surgical methods for treating basilar invagination, atlantoaxial instability, and concurrent subaxial subluxations. We detail our surgical technique for transoral odontoidectomy, occipital cervical fusion, and atlantoaxial fusion. We detail the use of spinal surgical navigation in both of these procedures. CONCLUSION: Surgical management of RA remains a challenging field. There clearly has been a decrease in cases of mutilating RA involving the craniovertebral junction. Surgical techniques for managing these conditions have steadily improved.

Comparison of magnetic resonance imaging and computed tomography in predicting facet arthrosis in the cervical spine.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine the ability of magnetic resonance imaging (MRI) and computed tomography (CT) to predict the presence of cervical facet arthrosis. SUMMARY OF BACKGROUND DATA: In the Food and Drug Administration Investigational Device Exemption trials of cervical disc arthroplasty (CDA), the presence of facet arthrosis on CT was a contraindication to the insertion of a CDA. Most surgeons routinely obtain an MRI, but not necessarily a CT before performing surgery in the cervical spine. We sought to determine if the MRI alone is adequate to assess for the presence of facet arthrosis. METHODS: Three experienced spine surgeons retrospectively evaluated CT scans and MRIs of the same patients, obtained within 30 days of each other in a blinded, random fashion. Reviewers graded each of the MRI and CT scan as normal or abnormal on 3 separate occasions and if the facet was abnormal, each reviewer graded the degree of arthrosis. The radiologist's evaluation for each study was compared with our results. RESULTS: Of 594 facets analyzed, 43.1% were categorized as normal on CT, and of those, MRI concordance was only 63.7% with moderate/substantial intermethod agreement. Furthermore, MRI was concordant only 15.9% of the time in patients with ankylosed facet joints on CT. CT inter-rater reliability showed substantial agreement for diagnoses of both normal and ankylosis and fair agreement for lesser degrees of facet arthrosis. MRI inter-rater reliability showed fair/moderate agreement in normal and ankylosed segments and only slight agreement with lesser degrees of facet arthrosis. CT intrarater reliability showed substantial agreement in normal or ankylosed joints, but only fair agreement for all other categories; MRI showed only fair agreement. CONCLUSION: The ability of MRI to adequately determine the presence or amount of facet arthrosis is not reliable. Additionally, for abnormal facets, MRI was not reliable in adequately determining the degree of arthrosis. Our data suggest that computed tomography remains necessary in diagnosing facet arthrosis before CDA.

Endonasal endoscopic resection of the odontoid process in a nonachondroplastic dwarf with juvenile rheumatoid arthritis: feasibility of the approach and utility of the intraoperative Iso-C three-dimensional navigation. Case report.

The authors report a case of a nonachondroplastic dwarf with severe basilar invagination and compression of the cervicomedullary junction (CMJ) due to juvenile rheumatoid arthritis. Initially excellent reduction of the invagination and decompression of the CMJ was achieved using posterior fixation. However, 1 month postoperatively symptoms recurred and the authors found imaging evidence of recurrence as well. The patient subsequently underwent an endoscopic transnasal resection of the dens with assistance of Iso-C navigation. He recovered well and tolerated regular diet on postoperative Day 2.

Application of full-scale three-dimensional models in patients with rheumatoid cervical spine.

Full-scale three-dimensional (3D) models offer a useful tool in preoperative planning, allowing full-scale stereoscopic recognition from any direction and distance with tactile feedback. Although skills and implants have progressed with various innovations, rheumatoid cervical spine surgery remains challenging. No previous studies have documented the usefulness of full-scale 3D models in this complicated situation. The present study assessed the utility of full-scale 3D models in rheumatoid cervical spine surgery. Polyurethane or plaster 3D models of 15 full-sized occipitocervical or upper cervical spines were fabricated using rapid prototyping (stereolithography) techniques from 1-mm slices of individual CT data. A comfortable alignment for patients was reproduced from CT data obtained with the patient in a comfortable occipitocervical position. Usefulness of these models was analyzed. Using models as a template, appropriate shape of the plate-rod construct could be created in advance. No troublesome Halo-vests were needed for preoperative adjustment of occipitocervical angle. No patients complained of dysphasia following surgery. Screw entry points and trajectories were simultaneously determined with full-scale dimensions and perspective, proving particularly valuable in cases involving high-riding vertebral artery. Full-scale stereoscopic recognition has never been achieved with any existing imaging modalities. Full-scale 3D models thus appear useful and applicable to all complicated spinal surgeries. The combination of computer-assisted navigation systems and full-scale 3D models appears likely to provide much better surgical results.

Mediastinal migration of distal occipito-thoracic instrumentation.

We present the occurrence and management of mediastinal migration of the distal aspect of a posterior occipito-thoracic screw-rod construct. No similar occurrence was found in the literature. This event occurred following an emergency tracheotomy (requiring neck hyperextension) in a patient with severe rheumatoid arthritis, who had previously undergone decompression and an Occiput-T2 instrumented fusion for cranio-cervical and sub-axial cervical spine instability. Imaging showed fracture-subluxation of T1/2 and T2/3 with the bilateral C7, T1 and T2 screws in the mediastinum causing tracheal and esophageal compression. Removal of the instrumentation, decompression (T2 corpectomy) and construct revision down to T10 was safely performed from a posterior approach. Severe osteoporosis, some pre-existing screw loosening and hyperextension of the neck were the predisposing factors of this near catastrophic event. By staying directly posterior to the rod and following the fibrous tract already created, the instrumentation was safely removed from the mediastinum.