Minimally Invasive Treatment of Facet Osteoarthritis Pain in Spine: A Clinical Approach Evaluating Cryotherapy.

BACKGROUND: Chronic pain management remains a challenging aspect of neurosurgical care, with facet arthrosis being a significant contributor to the global burden of low back pain. This study evaluates the effectiveness of cryotherapy as a minimally invasive treatment for patients with facet arthrosis. By focusing on reducing drug dependency and pain intensity, the research aims to contribute to the evolving field of pain management techniques, offering an alternative to traditional pain management strategies. METHODS: Through a retrospective longitudinal analysis of patients with facet osteoarthritis treated via cryotherapy between 2013 and 2023, we evaluated the impact on medication usage and pain levels, utilizing the Visual Analog Scale for pre- and posttreatment comparisons. RESULTS: The study encompassed 118 subjects, revealing significant pain alleviation, with Visual Analog Scale scores plummeting from 9.0 initially to 2.0 after treatment. Additionally, 67 patients (56.78%) reported decreased medication consumption. These outcomes underscore cryotherapy's potential as a pivotal tool in chronic pain management. CONCLUSIONS: The findings illuminate cryotherapy's efficacy in diminishing pain and curtailing medication dependency among patients with facet arthrosis. This study reaffirms cryotherapy's role in pain management and propels the discourse on nontraditional therapeutic avenues, highlighting the urgent need for personalized and innovative treatment frameworks.

Osteoarthritis and joint replacements of the lower limb and spine in ex-professional soccer players: A systematic review.

After a professional career as a soccer player, the risk of developing osteoarthritis (OA) in different joints of the spine and lower limb might be increased. The extent of this problem to date is not clear. Therefore, the aim of this systematic review is to summarize the prevalence of OA and joint replacement of the lower limb and spine in former professional soccer players. Relevant databases were searched with different combinations of key words: for example, OA, hip, knee, ankle, foot, joint replacement, soccer. Studies were included if they were original research, included a sample of former professional male soccer players, and had OA in the lower limb and/or spine; OA was diagnosed either through questionnaires or X-rays; and the article is in English, Dutch, or German. Sixteen studies with 1576 former players and 2153 control subjects were included in the review. Studies agreed that the prevalence of hip OA and hip replacements is significantly higher in former players compared to the control group. For the ankle and spine, there is only limited information, and for the prevalence of knee OA and knee replacement, the results are contradictory. The quality of the included studies was moderate. Future studies should have a prospective design to control for confounding factors, to identify possible risk factors and consequences for the individuals, and to be able to develop a prevention program.

Percutaneous Drainage of Chronic Destructive Lumbar Osteomyelitis Abscess Via the Use of Bilateral Transpedicular Trocar Access.

BACKGROUND: Pyogenic spondylodiskitis is an infection of intervertebral disks and spinal vertebral bodies. Various minimally invasive approaches to the infected disk spaces/abscesses have been described for management of early stages of the infection. Patients with chronic occurrence present with extensive infection, neurologic deficits, and bone destruction. Such patients commonly have substantial medical comorbidities. Despite the increased risks of complications, they often are treated with open surgical approaches without minimally invasive options. We describe a bilateral transpedicular approach to vertebral body abscess in a chronically infected patient with intraoperative contiguous irrigation. CASE DESCRIPTION: We present 2 cases, a 58-year-old man and a 61-year-old man, both with a diagnosis of vertebral osteomyelitis. Images of lumbar spine showed epidural abscess and adjacent vertebral body destruction. Because of their poor clinical condition and chronicity of disease, these patients underwent percutaneous bilateral transpedicular approach. CONCLUSION: Patients in poor health and with chronic vertebral osteomyelitis may benefit from minimally invasive percutaneous transpedicular drainage and irrigation of the abscess, representing a minimally invasive and effective treatment alternative for these patients.

Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO(®) CT scanner.

PURPOSE: Current solutions for navigated spine surgery remain hampered by restrictions in surgical workflow as well as a limited versatility and applicability. Against this background, we report the first experience of navigated spinal instrumentation with the mobile AIRO(®) intraoperative computed tomography (iCT) scanner. METHODS: AIRO(®) iCT was used for navigated posterior spinal instrumentation of 170 screws in 23 consecutive patients operated on in our Department between the first use of the system in May 2014 and August 2014. The indications for AIRO(®) were based on the surgical region, anatomical complexity and the need for >3 segment instrumentation. Following navigated screw insertion, screw positions were confirmed intraoperatively by a second iCT scan. CT data on screw placement accuracy were retrospectively reviewed and analyzed by an independent observer. RESULTS: AIRO(®)-based spinal navigation was easy to implement and successfully accomplished in all patients, adding around 18-34 min to the net surgery time. A systematic description of the authors' approach, setup in the OR and workflow integration of the AIRO(®) is presented. Analysis of screw placement accuracy revealed 9 (5.3%) screws with minor pedicle breaches (<2 mm). A total of 7 screws (4.1%) were misplaced >2 mm, resulting in an accuracy rate of 95.9%. CONCLUSIONS: The AIRO(®) system is an easy-to-use and versatile iCT for navigated spinal instrumentation and provides high pedicle screw accuracy rates. Although the authors' experience suggests that the learning curve associated with AIRO(®)-based spinal navigation is steep, a systematic user-based approach to the technology is required.

Operative treatment of degenerative lumbar spine spondylolisthesis.

INTRODUCTION: Management of degenerative lumbosacral spondylolisthesis with spinal stenosis is still controversial. Surgery is widely used, as well as non-surgical treatment. AIM: To evaluate the clinical results and functional outcome after operative treatment in Grade II and III lumbar spine spondylolisthesis. MATERIAL AND METHODS: Twelve patients with symptoms and image-confirmed degenerative spondylolisthesis entered the study. Mean patient age was 57 years. Spondylolisthesis Grade II or III, segment L4-L5 or L5-S1 were evaluated. All patients underwent similar protocols. Operative treatment was decompressive laminectomy, posterior one segment fixation, and fusion with autologous bone grafting. Functional outcome measures were Visual Analog Scale (VAS, 10-point scale) and Oswestry Disability Index (ODI, 100-percent scale) after 6 and 12 months. RESULTS: Patient follow-up was 12 months. Preoperatively, 7 patients had severe disability according to ODI, 4 had moderate disability. VAS measured 6 and 7 points in 6 patients, lowest score of 4 points and the highest score of 9. After 6 months, ODI showed 5 patients had minimal and 7 had moderate disability; 2 patients had 0 points on the VAS, 2 had a score of 1, 4 had a score of 2, highest score of 4 points. Treatment outcome effects after 1 year were 9 patients with minimal disability, 3 with moderate; VAS - 2 patients with O points, 3 with 1 point, 4 with 2 points. CONCLUSION: Patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and functional outcome during a period of 1 year.

¿Pueden influir las variables epidemiológicas el resultado a los 2 años de una cirugía por enfermedad lumbar degenerativa en términos de calidad de vida, discapacidad y dolor postoperatorio? / Can epidemiological factors affect the 2-year outcomes after surgery for degenerative lumbar disease in terms of quality of life, disability and post-surgical pain?

Objetivo: Evaluar si los factores epidemiológicos afectan a los resultados de la cirugía por enfermedad lumbar degenerativa en términos de calidad de vida, discapacidad y dolor crónico. Material y método: Doscientos sesenta y tres pacientes intervenidos por afección lumbar degenerativa fueron incluidos en el estudio (2005-2008). Variables epidemiológicas: edad, género, situación laboral y comorbilidad. Se completaron en el preoperatorio y 2 años tras la cirugía el Medical Outcomes Study Short Form-36 version 2, Oswestry Disability Index (ODI), Core Outcomes Measures Index (COMI) y EVA para dolor lumbar y ciático. En el análisis de los datos, se evaluó la correlación entre variables epidemiológicas y el cambio en los resultados de los cuestionarios, así como, la existencia de factores pronósticos independientes. Resultados: Edad media 54,00 años (22-86); 131 mujeres (49,8%); 42 pérdidas de seguimiento (16%). Se observaron correlaciones significativas (p < 0,05) entre la edad, el género, la comorbilidad, la incapacidad laboral permanente y el dolor preoperatorio con el cambio del ODI, el COMI, los componentes de salud física y mental y las EVA de lumbar y ciático. El análisis de regresión lineal muestra a las ILP y la edad como variables predictoras del cambio de la discapacidad (β = 14,146; IC del 95%, 9,09-29,58; p < 0,01, y β = 0,334; IC del 95%, 0,40-0,98, p < 0,05, respectivamente) y de la calidad de vida (β = −8,568; IC del 95%, −14,88, −2,26; p < 0,01 y β = −0,228, IC del 95%, −0,40, −0,06, p < 0,05, respectivamente). Conclusión: Según nuestros resultados, hemos de considerar al aumento de la edad y la incapacidad laboral permanente como factores epidemiológicos predictores negativos de los resultados tras cirugía por patología lumbar degenerativa (AU)

Purpose: To evaluate the influence of epidemiological factors on the outcomes of surgery for degenerative lumbar disease in terms of quality of life, disability and chronic pain. Material and method: A total of 263 patients who received surgery for degenerative lumbar disease (2005-2008) were included in the study. The epidemiological data collected were age, gender, employment status, and co-morbidity. The SF-36, Oswestry Disability Index (ODI), Core Outcomes Measures Index (COMI), and VAS score for lumbar and sciatic pain were measure before and 2 years after surgery. The correlation between epidemiological data and questionnaire results, as well as any independent prognostic factors, were assessed in the data analysis. Results: The mean age of the patients was 54.0 years (22-86), and 131 were female (49.8%). There were 42 (16%) lost to follow-up. Statistically significant correlations (P < 0.05) were observed between age, gender, co-morbidity, permanent sick leave, and pre-operative pain with changes in the ODI, COMI, physical and SF-36 mental scales, and lumbar and sciatic VAS. Linear regression analysis showed permanent sick leave and age as predictive factors of disability (β = 14.146; 95% CI : 9.09-29.58; P < 0.01 and β = 0.334; 95% CI: 0.40-0.98, P < 0.05, respectively), and change in quality of life (β = −8.568; 95% CI: −14.88 to −2.26; P < 0.01 and β = −0.228, 95% CI: −0.40 to −0.06, P < 0.05, respectively). Conclusion: Based on our findings, age and permanent sick leave have to be considered as negative epidemiologic predictive factors of the outcome of degenerative lumbar disease surgery (AU)

The use of fusion mass screws in revision spinal deformity surgery.

STUDY DESIGN: To report the use of a posterior based 'fusion mass screw' (FMS) as a primary or salvage fixation point in a revision spinal deformity following a previous posterior spinal fusion (PSF). Our experience of this technique in a case report and the clinical and radiological results are reported. OBJECTIVES: To describe the technique and uses of the FMS as a primary/salvage fixation point in osteotomies in previously arthrodesed spinal deformity surgery. Obtaining fixation points to correct and stabilize a spinal deformity with coronal and sagittal imbalance in a previously arthrodesed spine during revision surgery can be challenging. Several alternate pedicle fixation techniques and laminar screw techniques have been described in the literature. However, there is no description of these techniques in the presence of a spinal fusion with distorted anatomy. A pedicle screw placed coronally across a thick posterior fusion mass can provide an alternate method of fixation in these cases with complex anatomy. METHODS: Two cases of complex spinal deformity and corrective spinal osteotomies using fusion mass screws (FMSs) placed coronally across the posterior fusion mass are described. The first case is an 8-year-old patient with Marfan's syndrome who developed a crank shaft phenomenon and severe thoracolumbar kyphoscoliosis following a previous PSF. The second case is a 53-year-old patient with coronal imbalance following PSF as a child using Harrington instrumentation who developed distal degeneration with stenosis in her remaining mobile segments. Both patients underwent vertebral column resection and osteotomy closure plus stabilisation using FMS. The clinical and radiological results and technique for insertion of the FMS are described. CONCLUSION: In this report, we present a novel method of using posterior FMSs to achieve fixation and correction in cases of revision deformity surgery with difficult anatomy. While we feel pedicle screws are the gold standard in deformity correction, knowledge of alternatives such as the FMS can allow surgeons to achieve stable constructs when faced with challenging situations.

[Case-control study on needle-knife to cut off the medial branch of the lumbar posterior ramus under C-arm guiding for the treatment of low back pain caused by lumbar facet osteoarthritis].

OBJECTIVE: To study the clinical efficacy of needle-knife to cut off the medial branch of the lumbar posterior ramus under C-arm guiding to treat low back pain caused by lumbar facet osteoarthritis. METHODS: From July 2009 to June 2011, 60 patients with low back pain caused by lumbar facet osteoarthritis were reviewed,including 34 males and 26 females, ranging in age from 39 to 73 years old,averaged 61.9 years old; the duration of the disease ranged from 6 to 120 months, with a mean of 18.9 months. All the patients were divided into two groups, 30 patients (18 males and 12 females, ranging in age from 39 to 71 years old, needle-knife group) were treated with needle-knife to cut off medial branch of the lumbar posterior ramus under C -arm guiding and the other 30 patients(16 males and 14 females, ranging in age from 41 to 73 years old, hormone injection group) were treated with hormone injection in lumbar facet joint under C-arm guiding. The preoperative JOA scores and the scores at the 1st, 12th and 26th weeks after treatment were analyzed. RESULTS: Before treatment,the JOA scores between the two groups had no significant difference (P= 0.479); after 1 week of treatment, the JOA scores between the two groups had significant difference (P= 0.040), the improvement rate of hormone injection group was superior than that of the needle-knife group,which were (58.73+/-18.20)% in needle-knife group and (71.10+/-22.19)% in hormone injection group; after 12 weeks of treatment, the JOA scores between the two groups had no significant difference(P=0.569), and the improvement rate between the two groups had no significant difference,which were (50.09+/-19.33)% in the needle-knife group and (48.70+/-18.36)%) in the hormone injection group; after 26 weeks of treatment,the JOA scores between the two groups had significant difference (P=0.000), the improvement rate of hormone injection group was superior than that of the needle-knife group,which were (48.56+/-28.24)% in needle-knife group and (15.62+/-11.23 )% in hormone injection group. CONCLUSION: Using needle-knife to cut off the medial branch of the lumbar posterior ramus could get longer efficacy than hormone injection in the treatment of lumbar facet osteoarthritis.

Comparison of minimally invasive fusion and instrumentation versus open surgery for severe stenotic spondylolisthesis with high-grade facet joint osteoarthritis.

PURPOSE: The object of this study was to compare minimally invasive surgery (MIS) with open surgery in a severely affected subgroup of degenerative spondylolisthetic patients with severe stenosis (SDS) and high-grade facet osteoarthritis (FJO). METHODS: From January 2009 to February 2010, 49 patients with severe SDS and high-grade FJO were treated using either MIS or open TLIF. Intraoperative and diagnostic data, including perioperative complications and length of hospital stay (LOS), were collected, using retrospective chart review. Surgical short- and long-term outcomes were assessed according to the Oswestry disability index (ODI) and visual analog scale (VAS) for back and leg pain. RESULTS: Comparing MIS and open surgery, the MIS group had lesser blood loss, significantly lesser need for transfusion (p = 0.02), more rapid improvement of postoperative back pain in the first 6 weeks of follow-up and a shorter LOS. On the other hand, we experienced in the MIS group a longer operative time. The distribution on the postoperative ODI (p = 0.841), VAS leg (p = 0.943) and back pain (p = 0.735) scores after a mean follow-up of 2 years were similar. The overall proportion of complications showed no significant difference between the groups (29% in the MIS group vs. 28% in the open group, p = 0.999). CONCLUSION: Minimally invasive surgery for severe SDS leads to adequate and safe decompression of lumbar stenosis and results in a faster recovery of symptoms and disability in the early postoperative period.

Outcomes of fusion for lateral atlantoaxial osteoarthritis: meta-analysis and review of literature.

OBJECTIVE: Atlantoaxial osteoarthritis (AAOA) is an underrecognized source of neck pain, limitation of range of motion, and cervicogenic headaches. When conservative treatments such as facet injections fail, fusion may be indicated. We reviewed published series describing posterior fusions for atlantoaxial osteoarthritis of the facet joints. METHODS: Online databases were searched for English-language articles describing the diagnosis and treatment of AAOA. Twenty-three studies reporting on 246 patients treated with posterior fusion for lateral AAOA fulfilled inclusion criteria. Standard statistical and formal meta-analytic techniques were used to assess outcomes. RESULTS: All studies provided class III evidence. The 30-day perioperative mortality was 1.2% and neurologic injury did not occur. Patients were followed for a mean of nearly 5 years. Fusion was successful in 98% of patients with a single operation and with 99.5% of patients after revision surgery. Intractable preoperative neck pain either resolved completely or improved in 97.7% of patients. Using meta-analytic techniques, the point estimate for improvement or resolution of pain was 92.6% (confidence interval = 86.8%-96.0%) and the rate of arthrodesis for AAOA was 92.2% (confidence interval = 85.6%-95.9%) and there were no differences among the various techniques used for fusion. Operative complications were few. CONCLUSIONS: Posterior C1-2 fusion is a safe and effective treatment option for patients with intractable neck pain secondary to lateral AAOA. Modern fusion options offer a high rate of arthrodesis and low risk of morbidity if conservative therapies fail to provide adequate pain relief.

Morphometric analysis using multiplanar reconstructed CT of the lumbar pedicle in patients with degenerative lumbar scoliosis characterized by a Cobb angle of 30° or greater.

OBJECT: Although the anatomy of the thoracic pedicle in adolescent idiopathic scoliosis is well known, that of the lumbar pedicle in degenerative lumbar scoliosis is not. The morphometric differences between the pedicles on the concave and convex sides can result in an increased risk of malpositioned pedicle screws. The purpose of this study was to analyze the lumbar pedicle morphology in degenerative lumbar scoliosis using multiplanar reconstructed CT. METHODS: The study group comprised 16 consecutive patients (1 man and 15 women, mean age 70.9 ± 4.5 years) with degenerative lumbar scoliosis characterized by a Cobb angle of at least 30° who underwent preoperative helical CT scans. The CT data in DICOM format were reconstructed, and the following parameters were measured for each pedicle inside the curves: the inner cortical transverse pedicle width (TPWi) and outer cortical transverse pedicle width (TPWo) and axial angle, all on an axial plane, and the inner cortical minimum pedicle diameter (MPDi) and outer cortical minimum pedicle diameter (MPDo) and cephalocaudal inclination of the pedicle, all on the plane perpendicular to the pedicle axis. The cortical thickness and cortical ratio of the pedicles on the axial plane and the plane perpendicular to the pedicle axis were calculated. Data were obtained for a total of 124 pedicles; L-1, 26 pedicles in 13 patients; L-2, 32 pedicles in 16 patients; L-3, 32 pedicles in 16 patients; L-4, 28 pedicles in 14 patients; and L-5, 6 pedicles in 3 patients. RESULTS: Among the target vertebrae, the TPWi, MPDi, and MPDo were significantly smaller and the axial angle was significantly larger on the concave side than on the convex side (TPWi, 6.37 vs 6.70 mm, p < 0.01; MPDi, 5.15 vs 5.67 mm, p < 0.01; MPDo, 7.91 vs 8.37 mm, p < 0.05; axial angle, 11.79° vs 10.56°, p < 0.01). The cortical ratio of the pedicles was larger on the concave side than on the convex side (on the axial plane, 0.29 vs 0.26, p < 0.05; on the plane perpendicular to the pedicle axis, 0.36 vs 0.32, p < 0.01). These differences were most evident at L-4. CONCLUSIONS: This study demonstrated lumbar pedicle asymmetry in degenerative lumbar scoliosis. The authors speculate that these asymmetrical changes were attributed to the remodeling caused by axial load imbalance and the limited space available for pedicles on the concave side. On the concave side, because of the narrower pedicle diameter and larger axial angle, surgeons should carefully determine screw size and direction when inserting pedicle screws to prevent possible pedicle wall breakage and neural damage.

Comparison of lifetime incremental cost:utility ratios of surgery relative to failed medical management for the treatment of hip, knee and spine osteoarthritis modelled using 2-year postsurgical values.

BACKGROUND: Demand for surgery to treat osteoarthritis (OA) of the hip, knee and spine has risen dramatically. Whereas total hip (THA) and total knee arthroplasty (TKA) have been widely accepted as cost-effective, spine surgeries (decompression, decompression with fusion) to treat degenerative conditions remain underfunded compared with other surgeries. METHODS: An incremental cost-utility analysis comparing decompression and decompression with fusion to THA and TKA, from the perspective of the provincial health insurance system, was based on an observational matched-cohort study of prospectively collected outcomes and retrospectively collected costs. Patient outcomes were measured using short-form (SF)-36 surveys over a 2-year follow-up period. Utility was modelled over the lifetime, and quality-adjusted life years (QALYs) were determined. We calculated the incremental cost per QALY gained by estimating mean incremental lifetime costs and QALYs of surgery compared with medical management of each diagnosis group after discounting costs and QALYs at 3%. Sensitivity analyses were also conducted. RESULTS: The lifetime incremental cost:utility ratios (ICURs) discounted at 3% were $5321 per QALY for THA, $11,275 per QALY for TKA, $2307 per QALY for spinal decompression and $7153 per QALY for spinal decompression with fusion. The sensitivity analyses did not alter the ranking of the lifetime ICURs. CONCLUSION: In appropriately selected patients with leg-dominant symptoms secondary to focal lumbar spinal stenosis who have failed medical management, the lifetime ICUR for surgical treatment of.

[Surgical treatment for atlantoaxial osteoarthritis (AAOA): a prospective study of twenty-seven patients]. / Operacní lécba atlantoaxiální artrózy (AAOA): prospektivní studie 27 pacientu

PURPOSE OF THE STUDY: Atlantoaxial osteoarthritis (AAOA) is a clinical syndrome with signs distinctly different from those of degenerative sub - axial spine disease. Its diagnosis may long be delayed, partly because of insufficient knowledge and partly due to difficulties in interpreting both anteroposterior and lateral radiographs. The aim of this prospective study was to evaluate the first 27 AAOA patients treated at our department. MATERIAL: From 2001 we performed atlantoaxial fixation with fusion in a total of 29 patients with painful arthritis of the atlanto axial complex. The 27 patients treated before the end of 2010 were enrolled in the study and analysed in detail. This group included 13 women and 14 men aged between 35 and 72 years, with an average age of 53.5 years. In all patients atlanto - axial fixation was performed using the polyaxial screw-rod system according to Harms. METHODS: The patients were followed up at 6 and 12 weeks, 6 and 12 months and then once a year after surgery. X-ray examinations were done at the same intervals as clinical examinations; functional radiographs were made at 12 to 14 weeks after surgery. The definitive analysis of the group was made in the range of 4 to 59 months (average, 25.7 months) after the primary operation. Patients' subjective evaluation was based on NPDI and VAS scores and a question of whether the patient would undergo the surgery again. Objective evaluation included clinical outcomes - pain and neurological findings; radiographic results - stability and healing of C1-C2 fusion; and complications during surgery and in early and late postoperative periods. As intra-operative complications were regarded those associated with the surgical approach, nerve injury and vertebral artery injury. Early post-operative complications included poor wound healing and changes in the patient's neurological status, late complications included instrumentation failure and infection. Patients' clinical status (NPDI, VAS) was statistically evaluated using the one-way ANOVA. RESULTS: The mean VAS score was pre-operatively 7.0 and post-operatively 5.6 at 3 months, 5.0 at 6 months, 5.1 at 1 year; 3.9 at 2 years and 4.0 at 3 years. The mean NPDI value was pre-operatively 39.6 and post-operatively 38.7 at 3 months, 36.0 at 6 months, 34.5 at 1 year, 34.3 at 2 years and 33.1 at 3 years. The question of willingness to undergo the same operation again was answered in the affirmative by 21 patients (77.8%), in the negative by five (18.5%) and one patient did not know (3.7%). Complete bone fusion, as assessed by radiography or CT scanning, was achieved in 26 out of 27 patients (96.3%). In one patient the result was ambiguous but, at 3 months as well as the next follow-ups, C1-C2 complex stability was found. DISCUSSION: All patients in our group underwent a unified system of clinical, radiological, CT and MRI examination. In the decision-making process, emphasis was placed on a correlation of clinical findings with CT scanning results. All patients were operated on from the posterior approach using the Harms method, and radiological outcomes were similar to those of Grob et al. who used the Magerl's technique of C1-C2 fixation. The VAS and NPDI scores demonstrated significant improvement as early as 3 post-operative months, with still further improvement in the following period. The stable clinical status of the patients was achieved at 2 years after surgery. From the practical standpoint we were interested in an answer to the question of whether the patients would be willing to undergo the procedure again. Almost 80% of affirmative answers testified to the correct choice of treatment. The values found corresponded to those reported by Grob at al. CONCLUSIONS: Patients with painful osteoarthritis refractory to conservative treatment will benefit from atlantoaxial fixation and fusion. For the patient, restricted cervical rotation is acceptable in return for pain relief. From the surgical point of view, the risk of complications associated with the operative technique did not exceed a tolerable rate.

[Sagittal deformity. Basic principles of surgical strategies]. / Sagittale Deformität : Grundlagen der operativen Strategien.

There is a large body of literature supporting the importance of restoring sagittal balance to the spine. The main message is this: regardless of the specific surgical strategy and treatment or pathology, rebalancing results in a positive patient outcome. Complex deformity patients need to be evaluated with attention to the global balance and the operative planning and strategy must be adapted accordingly. Spinal fusions are not always considered within the framework of sagittal balance. Unsuccessful outcome including continued pain, adjacent level disease, accelerated degenerative changes of the spine, pseudarthrosis and hip and knee changes, may then ensue. Certainly, those patients need to be re-evaluated with attention to the global balance of the spine. The reason for the outcome may be sagittal imbalance and osteotomy techniques as well as fusion extension may be needed. The postoperative outcome can only be improved when the sagittal balance is already considered in the planning and treatment strategy during initial correction surgery. Concerning sagittal balance a paradigm shift seems to occur.

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.

An observational study of patient-rated outcome after atlantoaxial fusion in patients with rheumatoid arthritis and osteoarthritis.

BACKGROUND: Fusion is used to address several types of abnormality of the atlantoaxial segment. Traditionally, outcome has been assessed by achieving solid bony union. Recently, however, patient-rated outcome instruments have been increasingly used, although these may be influenced by concomitant comorbidity. QUESTIONS/PURPOSES: We therefore asked whether patients with rheumatoid arthritis (RA), with its associated comorbidity, had worse self-rated outcomes after C1-2 fusion than patients with osteoarthritis (OA). PATIENTS AND METHODS: We retrospectively reviewed all 30 (23 OA and seven RA) prospectively followed patients in our local Spine Registry (part of the Spine Society of Europe Spine Tango Registry) who had undergone C1-2 fusion. Before surgery and 3 and 12 months later, patients completed the multidimensional Core Outcome Measures Index (COMI) questionnaire. Global outcome and satisfaction with treatment were also assessed. RESULTS: We found no group differences for duration of operation, blood loss, or perioperative surgical or general complications. Compared with the OA group, the RA group showed a better baseline COMI score and less improvement in the COMI from preoperatively to 12 months followup. However, the proportion of "good" global scores at 12 months followup was similarly high in both groups (87% OA and 86% RA) as was satisfaction (96% for OA versus 86% for RA). CONCLUSIONS: Symptoms and impairment were less severe in the RA group at baseline and showed less improvement after surgery, but the proportion of "good global outcomes" was similar in both groups, and the great majority of patients in both groups were satisfied with their treatment. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgical treatment for atlantooccipital osteoarthritis: a case report of two patients.

BACKGROUND/PURPOSE: Although rarely discussed in the literature and difficult to evaluate on plain radiographs, atlantooccipital osteoarthritis can be a source of persistent suboccipital pain. Our objective in this report is to describe two cases with atlantooccipital (O-C1) osteoarthritis treated with posterior occipitocervical fusion. METHODS AND RESULTS: Two patients presented with unilateral suboccipital pain, which was refractory to conservative treatment. One patient suffered from long-standing rheumatoid arthritis while the other patient did not have pertinent medical issues. After non-diagnostic plain film imaging, CT scan demonstrated unilateral osteoarthritis of the atlantooccipital and atlantoaxial joint in both patients who subsequently underwent posterior O-C2 fusion with resolution of their preoperative symptoms. CONCLUSIONS: This is, to our knowledge, the first case report which specifically focused on surgical treatment of atlantooccipital osteoarthritis. Occipitocervical fusion is a treatment option for patients with atlantooccipital osteoarthritis when suboccipital pain is not responsive to conservative treatment.

A safe approach to explore/identify the V(2) segment of the vertebral artery during anterior approaches to cervical spine and/or arterial repairs: anatomical study.

OBJECT: The purpose of this study was to find a landmark according to which the surgeon can dissect the cervical spine safely, with the lowest possibility of damaging the vertebral artery (VA) during anterior approaches to the cervical spine or the VA. METHODS: The "safe zone" for each level of the cervical spine was described as an area where the surgeon can start from the midline in that zone and dissect the soft tissue laterally to end up on the transverse process and cross the VA while still on the transverse process. In other words, safe zone signifies the narrowest width of the transverse process at each level. In such an approach, the VA is protected from the inadvertent deep penetration of the instruments by the transverse process. The surgical safe zone for each level was the common area among at least 95% of the safe zones for that level. For the purpose of defining the upper and lower borders of the safe zone for each level, the line passing from the upper vertebral border perpendicular to the midline (upper vertebral border line) was used as a reference. Cervical spines of 64 formalin-fixed cadavers were dissected. The soft tissue in front of the transverse process and intertransverse space was removed. Digital pictures of the specimens were taken before and after removal of the transverse processes, and the distance to the upper and lower border of the safe zone from the upper vertebral border line was measured on the digital pictures with Image J software. The VA diameter and distance from the midline at each level were also measured. To compare the means, the authors used t-test and ANOVA. RESULTS: The surgical safe zone lies between 1 mm above and 1 mm below the upper vertebral border at the fourth vertebra, 2 mm above and 1 mm below the upper vertebral border at the fifth vertebra, and 1 mm above and 2 mm below the upper vertebral border of the sixth vertebra. The VA was observed to be tortuous in 13% of the intertransverse spaces. There is a positive association between disc degeneration and tortuosity of the VA at each level (p < 0.001). The artery becomes closer to the midline (p < 0.001) and moves posteriorly during its ascent. CONCLUSIONS: Dissection of the soft tissue off the bone along the surgical safe zone and removal of the transverse process afterward can be a practical and safe approach to avoid artery lacerations. The findings in the present study can be used in anterior approaches to the cervical spine, especially when the tortuosity of the artery mandates exposure of the VA prior to uncinate process resection, tumor excision, or VA repair.

Lumbar spine: reliability of MR imaging findings.

PURPOSE: To characterize the inter- and intraobserver variability of qualitative, non-disk contour degenerative findings of the lumbar spine at magnetic resonance (MR) imaging. MATERIALS AND METHODS: The case accrual method used to perform this institutional review board-approved, HIPAA-compliant retrospective study was the random selection of 111 interpretable MR examination cases of subjects from the Spine Patient Outcomes Research Trial. The subjects were aged 18-87 years (mean, 53 years +/- 16 [standard deviation]). Four independent readers rated the cases according to defined criteria. A subsample of 40 MR examination cases was selected for reevaluation at least 1 month later. The following findings were assessed: spondylolisthesis, disk degeneration, marrow endplate abnormality (Modic changes), posterior anular hyperintense zone (HIZ), and facet arthropathy. Inter- and intraobserver agreement in rating the data was summarized by using weighted kappa statistics. RESULTS: Interobserver agreement was good (kappa = 0.66) in rating disk degeneration and moderate in rating spondylolisthesis (kappa = 0.55), Modic changes (kappa = 0.59), facet arthropathy (kappa = 0.54), and posterior HIZ (kappa = 0.44). Interobserver agreement in rating the extent of Modic changes was moderate: kappa Values were 0.43 for determining superior anteroposterior extent, 0.47 for determining superior craniocaudal extent, 0.57 for determining inferior anteroposterior extent, and 0.48 for determining inferior craniocaudal extent. Intraobserver agreement was good in rating spondylolisthesis (kappa = 0.66), disk degeneration (kappa = 0.74), Modic changes (kappa = 0.64), facet arthropathy (kappa = 0.69), and posterior HIZ (kappa = 0.67). Intraobserver agreement in rating the extent of Modic changes was moderate, with kappa values of 0.54 for superior anteroposterior, 0.60 for inferior anteroposterior, 0.50 for superior craniocaudal, and 0.60 for inferior craniocaudal extent determinations. CONCLUSION: The interpretation of general lumbar spine MR characteristics has sufficient reliability to warrant the further evaluation of these features as potential prognostic indicators.