Enhanced technique of dural closure using autologous fat graft and Gelfoam for effective management of dural tear following interlaminar endoscopic lumbar spine surgery.

BACKGROUND: Incidental dural tears are common complications in lumbar spine surgery, particularly in endoscopic procedures where primary closure via suturing is challenging. The absence of a standardized approach for dural closure in endoscopic spine surgery necessitates exploring alternative techniques. OBJECTIVE: This study introduces a surgical technique for dural closure utilizing fat graft and Gelfoam, offering an effective alternative to standard approaches in endoscopic spine surgery. METHODS: Surgical data from patients who underwent interlaminar endoscopic discectomy or stenosis decompression at Lerdsin Hospital from October 2014 to October 2021 were analyzed. RESULTS: Among 393 cases, dural tears occurred in 2% (8 patients). Our technique achieved successful closure in all these cases, with no incidents of cerebrospinal fluid leakage or wound complications. The majority of patients showed favorable clinical outcomes, except for one case involving concomitant nerve root injury. CONCLUSION: This study demonstrates that using fat graft and Gelfoam for dural closure is a simple, reliable, and safe technique, particularly effective for challenging-to-repair areas in interlaminar endoscopic lumbar spine surgery.

Full-Endoscopic Anterior Odontoid Screw Fixation: A Novel Surgical Technique.

OBJECTIVE: First, to propose a novel minimally invasive technique of full-endoscopic anterior odontoid fixation (FEAOF) that aims to reduce the risk of retropharyngeal approach (both open and percutaneous techniques) to anterior odontoid screw fixation. Second, to describe steps of the procedure and, lastly, to report the initial outcomes in patients treated with this novel technique. METHODS: Four non-consecutive patients who were diagnosed with a displaced odontoid fracture (Anderson-D'Alonzo classification type II and Grauer subclassification type A or B) from 2019 to 2020 underwent surgical fixation by our novel technique for anterior odontoid screw fixation. A detailed technical approach of FEAOF for the surgical treatment of type II odontoid fractures was described, and the patients' outcomes based on postoperative radiographic results including computed tomography (CT), clinical outcome parameters including visual analogue scale (VAS) for neck pain both preoperatively and at postoperative follow-up, and range of neck motion at the final follow-up were reported. RESULTS: The mean age was 33.5 years (24-41), three patients were male. The mean operative time was 93.75 min, and the mean blood loss was 7.5 ml. An immediate post-operative thin-sliced CT showed that all patients achieved satisfactory reduction and proper screw position. No screw malposition or penetration was found. At a 6-month follow-up, a thin-sliced CT demonstrated solid bony union in every case. The mean VAS for neck pain was reduced from 6.5 to 0.6 at the 6-months follow-up. At the final follow-up, all patients showed improvement in ranges of motion without any complications; however, one patient was lost to follow-up. CONCLUSIONS: FEAOF is a feasible and effective option for treating type II odontoid fractures. The procedure is less invasive than other techniques and provides clear direct visualization of the involved structures.

Surgeons' Perspective, Learning Curve, Motivation, and Obstacles of Full-Endoscopic Spine Surgery in Thailand: Results From A Nationwide Survey.

Objective: To report a nationwide survey of the endoscopic spine surgeons across Thailand. Furthermore, the survey will be focused on the perspective of experience, learning curve, motivations, and obstacles at the beginning of their practices. Materials and Methods: The online survey consisting of 16 items was distributed to spine surgeons who are performing endoscopic spine surgery in Thailand via the Google forms web-based questionnaire to investigate participants' demographics, backgrounds, experience in endoscopic spine surgery, motivations, obstacles, and future perspectives. The data was recorded from January 7, 2020 to January 21, 2022. Descriptive statistics were used for analysis. Results: A total of 42 surveys were submitted by 6 neurosurgeons (14.3%) and 36 orthopedic surgeons (85.7%). From the surgeons' perspective, the average number of cases that should be performed until one feels confident, consistently good outcomes, and has minimal complications was 27.44 ± 32.46 cases. For surgeons who starting the endoscopic spine practice, at least 3 workshop participation is needed. Personal interest (39 selected responses) and trending marketing or business purpose (25 selected responses) were the primary motivators for endoscopic spine surgery implementation. Lack of support (18 selected responses) and afraid of complications (16 selected responses) were pertinent obstacles to endoscopic spine surgery implementation. Conclusions: The trend of endoscopic spine surgery has continued to grow in Thailand, shown by the rate of implementation of endoscopic spine surgery reported by Thai spine surgeons. The number of appropriate cases until one feels confident was around 28 cases. The primary motivator and obstacles were personal interest and lack of support.

Does computed tomography-guided percutaneous catheter drainage is effective for spinal tuberculous abscess: a midterm results.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To evaluate an effectiveness and report a midterm clinical outcome in pain and neurological status in spinal tuberculous abscess after treated by CT-guided percutaneous catheter drainage. OVERVIEW OF LITERATURE: Spinal tuberculosis is one of the destructive forms of tuberculosis infection, which can cause undesirable consequences. The gold standard of surgical treatment of spinal tuberculosis with tuberculous abscess is radical debridement, abscess drainage, and bone grafting of the defect via anterior approach. However, this treatment may lead to several serious complications. CT-guided percutaneous catheter drainage is an alternative procedure for this condition and may reduce the serious complications from standard surgical treatment. MATERIALS AND METHODS: The medical record of the patients with spinal tuberculosis with tuberculous abscess who underwent CT-guided percutaneous catheter drainage (CT-guided PCD) from 2015 to 2021. The visual analog pain scale (VAS), Frankel grading scale, duration of drainage, amount of spinal tuberculous abscess, and complications were evaluated. RESULTS: Twenty-nine patients (mean age 44 years old) were included in the study. All patients were followed up for 24 to 72 months with an average of 36 months. Level involvements were mostly found in L1-L2 followed by L2-L3 and T12-L1 levels. A 14-Fr catheter was the mostly use followed by 16-Fr catheter. Amount of abscess drainage ranged from 110 to 2,490 ml (mean 599 ml). The drainage duration ranged from 6 to 42 days (mean 17 days). Additional surgery was performed in three patients due to subsequent mechanical instability developed despite successful drainage of abscess. At the last follow-up, VAS, Frankel grading scale were improved significantly in all patients without complications. CONCLUSIONS: CT-guided percutaneous catheter drainage is a safe and effective alternative procedure in the treatment of spinal tuberculous abscess patients with high success rate, less complications, and satisfied midterm outcomes.

Comparison of post-operative wound pain between interlaminar and transforaminal endoscopic spine surgery: which is superior?

STUDY DESIGN: Prospective cohort study PURPOSE: The objective is to compare post-operative wound pain in patients treated by endoscopic surgery between interlaminar and transforaminal approach at lumbar region. OVERVIEW OF LITERATURE: There are two common approaches for endoscopic lumbar spine surgery, interlaminar and transforaminal approach. The wound size of these two approaches is about the same. However, post-operative wound pain may differ according to the entrance area. METHODS: We conducted a prospectively cohort study including all patients underwent full endoscopic lumbar spine surgery by single surgeon between January 2016 to October 2019. Wound pain using visual analog scale (VAS) at post-operative day 1 and day 14 were collected. VAS back pain, VAS leg pain, Oswestry Disability Index (ODI), modified McNab criteria and complications were also collected. RESULTS: There were 313 patients included in the study. There was no significant difference in VAS wound pain between interlaminar and transforaminal group. Interestingly, subgroup analysis in interlaminar group found statistically significant higher VAS for wound pain at post-operative day 1 when significant bone resection was done by power burr. VAS back-leg pain and ODI have improved significantly between pre-operative and last follow up in both approaches. CONCLUSIONS: Wound pain from endoscopic spine surgery is minimal. This study found no difference in wound pain between endoscopic interlaminar and transforaminal approach. Both approaches show favorable clinical outcomes with few serious complications rate. Further study with long term follow up is needed.

Full-endoscopic decompression for thoracic myelopathy caused by ossification of the ligamentum flavum: patient series.

BACKGROUND: This study aimed to describe the least invasive surgical technique of endoscopic decompression for thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) and to review the literature available on the diagnosis and treatment of OLF. OBSERVATIONS: The mean age of the patients was 51.2 (range, 40-62) years, and the mean preoperative, 2-week postoperative, and last follow-up modified Japanese Orthopaedic Association scores were 6.6 (range, 4-10), 9.6 (range, 7-11), and 13 (range, 10-14), respectively. All patients were discharged within 48 hours after the surgery. The mean follow-up period was 13.2 (range, 7-18) months. No complication was found perioperatively, and none of the patients had postoperative instability during the follow-up period. LESSONS: Based on this clinical case series and literature review, the authors conclude that endoscopic decompression surgery is feasible and effective for managing thoracic myelopathy caused by OLF while minimizing surrounding tissue damage. Additionally, it enables shorter periods of hospital stay.

Comparison between 1 g and 2 g of Intrawound Vancomycin Powder Application for Prophylaxis in Posterior Instrumented Thoracic or Lumbosacral Spine Surgery: A Preliminary Report.

BACKGROUND: Surgical site infection (SSI) after instrumented spinal surgery is one of the most serious complications in spite of the routine use of prophylactic intravenous (IV) antibiotics. Many studies have suggested that intrawound vancomycin powder, applied during the intraoperative period, may decrease the incidence of SSI after surgery. However, the appropriate dose of vancomycin has not yet been reported. PURPOSE: The purpose of the study is to compare between the use of 1 g and 2 g intrawound vancomycin powder and to find out which of these two groups can reduce the rate of deep wound infection in posterior instrumented thoracic or lumbosacral spine surgery. MATERIALS AND METHODS: The preliminary study was conducted from July 2013 to July 2015 at Lerdsin Hospital. A total of 400 patients were enrolled in the study, and their individual demographics were recorded. All patients underwent posterior instrumented thoracic or lumbosacral spine surgery. Of these, 131 patients received IV cefazolin and 2 g of vancomycin powder intrawound application, 134 patients received 1 g of intrawound vancomycin powder in addition to IV cefazolin, and 135 patients were given only IV cefazolin and were assigned as the control group. RESULTS: One hundred and thirty-one patients were treated with posterior instrumented thoracic or lumbosacral fusions using IV cefazolin and adjuvant 2 g of intrawound vancomycin powder. Five patients in this group developed deep infections (3.8%). One hundred and thirty-four patients were treated with posterior instrumented thoracic or lumbosacral fusions using IV cefazolin and adjuvant 1 g of intrawound vancomycin powder. Of these, four patients developed deep infections (2.98%). One hundred and thirty-five patients in the control group were treated with posterior instrumented thoracic or lumbosacral using only IV cefazolin as prophylaxis. Of these, four patients developed deep infections (2.96%). Coagulase-negative staphylococcus was the most common isolated organism. There were no adverse clinical outcomes or wound complications due to local application of vancomycin powder. CONCLUSION: The preliminary result could not state the relation of intrawound vancomycin powder to the deep infection; further study with adequate sample size is required.

Comparison of Segmental Mobility in Lumbar Extension Radiographs between a New Technique ("Fulcrum Bending Position") and Conventional Standing Position in Spondylolisthesis Patients.

STUDY DESIGN: Cross-sectional study. PURPOSE: This was carried out to evaluate the benefit of a 'fulcrum bending position' compared with the standing position for evaluation of sagittal translation and sagittal rotation in symptomatic patients with spondylolisthesis. OVERVIEW OF LITERATURE: In lumbar X-ray, the standing position is the most common position used in determining abnormalities in lumbar movement. Lack of standardized method is one of the pitfalls in this technique. We hypothesized that the new technique, that is, fulcrum bending position, may reveal a higher translation and rotation in spondylolisthesis patients. METHODS: The extension lumbar radiographs of 36 patients with low-grade spondylolisthesis were included in the analysis and measurement. Sagittal translation and sagittal rotation were measured in both the routine standing position and in our new technique, the fulcrum bending position, which involves taking lateral cross-table images in the supine position wherein the patient lies on a cylindrical pipe to achieve maximum passive back extension by the fulcrum principle. RESULTS: Results of the measurement of sagittal translation in both positions revealed that compared with the extension standing position, the fulcrum bending position achieved a statistically significant increase of 1.57 mm in translation of the vertebra position (95% confidence interval [CI], 0.52-2.61; p=0.004). The measurement of sagittal rotation in both positions revealed that when compared with the extension standing position, the fulcrum bending position achieved a statistically significant increase of 3.47° in the rotation of the vertebra (95% CI, 1.64-5.30; p<0.001). CONCLUSIONS: For evaluation of both sagittal translation and sagittal rotation in symptomatic patients with spondylolisthesis, compared with the extension standing position, the fulcrum bending position can achieve an increased change in magnitude. Our technique, that is, the fulcrum bending position, may offer an alternative method in the detection or exclusion of pathological mobility in patients with spondylolisthesis.

Extended Posterior Decompression and Instrumented Fusion for Spinal Tuberculosis.

STUDY DESIGN: Retrospective cohort. PURPOSE: To evaluate clinical outcomes, including pain and neurologic status, and to evaluate radiographic outcomes of patients treated with extended posterior decompression, posterior fixation, and fusion in different vertebral segments. OVERVIEW OF LITERATURE: The standard surgical treatment of spinal tuberculosis is radical debridement via anterior approach. However, this approach may lead to several serious complications. Meanwhile, extended posterior approach, the posterior surgical approach, involving the removal of posterior elements, ribs, and pedicles, is an alternative option that can achieve the aims of treatment in this disease and may reduce the serious complications from anterior approach. METHODS: The medical records and imaging of 50 patients admitted with spinal tuberculosis from January 2010 to June 2016 were reviewed. The Visual Analog Scale (VAS), Frankel grading scale, and kyphotic Cobb angle between the pre- and postoperative periods were used to evaluate the patients. RESULTS: The patients had significant improvement of VAS score in all the groups. The T/T-L, L, and L-S group scores improved from 7.2±1.5 to 1.7±1.2 (p<0.01), from 8.1±1.8 to 1.7±1.4 (p<0.01), and from 7.9±2.2 to 1.7±0.8 (p<0.01), respectively, and overall, the patient scores (n=50) improved from 7.8±1.4 to 1.7±1.3 (p<0.01). Ten patients (20%) had Frankel grade E preoperatively, which was improved to 38 patients (76%) postoperatively. A significant improvement of the kyphotic Cobb angle was observed when compared at the preoperative, early postoperative, and final follow-up period in the T/T-L, L, and L-S groups. The loss of correction angle in the LS group was 7.7°±4.3° at the final follow-up compared with the early postoperative correction angle at 9.1°±5.8°, with no statistically significant difference. CONCLUSIONS: Extended posterior decompression, posterior instrumentation, and fusion are effective methods of surgery for treatment of spinal tuberculosis involved in the thoracic, thoracolumbar, lumbar, and lumbosacral regions.

Congenital Spinal Canal Stenosis with Ossification of the Ligamentum Flavum in an Achondroplastic Patient: A Case Report and Literature Review.

Achondroplasia has an effect on intracartilaginous ossification during the development of the spine resulting in a narrow spinal canal. This abnormal anatomy could make an achondroplastic patient tend to have spinal canal stenosis. We reported a case of congenital spinal canal stenosis with achondroplasia combined with ossified ligamentum flavum (OLF) at the thoracolumbar and lumbar spine, which was treated by decompressive surgery. We reported a 52-year-old Thai male with achondroplasia presented with progressive myelopathy and neurogenic claudication due to spinal canal stenosis. Spinal canal stenosis was observed at T10/11 and L1-L5 and OLF at T10/11 through L5 varying in size. Laminectomy and removal of the OLF were performed at T11 and L1-L5. The patient's neurological symptom improved after the surgery. He could walk with a walker at the time of 6-month follow-up postoperatively. In this report, we describe a rare case of achondroplasia with OLF presenting with progressive myelopathy and claudication symptoms from multiple levels of spinal canal stenosis. Laminectomy, removal of the ossified ligament, and fusion with instrumentation resulted in the improvement of the patient's neurological symptoms and function.

Chronic posterior atlantoaxial subluxation associated with os odontoideum: a rare condition. A case report and literature review.

Introduction: Os odontoideum is a rare cervical lesion. This unusual condition is sometimes associated with atlantoaxial subluxation, which is mostly anterior subluxation. Posterior atlantoaxial subluxation due to os odontoideum is extremely rare. Case presentation: We report an unusual case of a 60-year-old Thai female, who was diagnosed as having chronic posterior atlantoaxial subluxation associated with os odontoideum with progressive myelopathy. The patient underwent posterior arch of C1 laminectomy and an occipito-C3 fusion using an occipital plate, C2 pedicle screws, C3 lateral mass screws and autologous iliac crest strut bone graft arthrodesis. During three years of follow-up, she was clinically significantly improved and postoperative radiographs showed a solid osseous fusion without loss of correction or implant failure. Discussion: Chronic posterior atlantoaxial subluxation associated with os odontoideum is rare. This condition can cause occipital-cervical pain, myelopathy, intracranial symptoms, or death. Surgical decompression and stabilization is the treatment of choice. Principles of treatment are to prevent sudden death from neurological compromise, improve neurological status, stabilize the cervical spine, and improve quality of life. Surgical options include atlantoaxial fusion, occipito-C2 fusion, and occipito-C3 fusion. Decision making depends on the location of spinal cord compression, area for arthrodesis, and bone quality.

Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials.

Treatment for lumbar disc herniation after failed conservative treatment is discectomy. Discectomy can significantly relieve back pain as well as radicular symptoms. However, many patients with lumbar discectomy experience moderate-to-severe back pain and radicular leg pain. The results of application of epidural steroids (ES) for pain management after lumbar discectomy have previously been inconclusive. We have conducted a systematic review and meta-analysis aims to compare outcomes (efficacy and complications) of epidural steroid application and placebo after discectomy in lumbar disc herniation. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies that reported visual analog scale of back and leg pain, morphine consumption, hospital stay and post-operative complications of either group were identified from Medline and Scopus from the date of inception to 28 October 2017. A total of 12 studies were pooled and analysed, with nine studies having undergone conventional discectomy and three studies having undergone minimally invasive surgery (MIS) discectomy. Overall, there were 1006 patients (502 in the ES group and 504 in the placebo group) included. The unstandardized mean difference of VAS of back pain at 1 week and 1 month, leg pain at 1 week and 1 month, morphine consumption and hospital stay was - 0.53 (95% CI - 1.42, 0.36) score, - 0.89 (95% CI - 1.36, - 0.42) score, - 0.63 (95% CI - 0.75, - 0.50) score, - 0.47 (95% CI - 0.78, - 0.15) score, - 8.47 (95% CI - 16.16, - 0.78) mg and - 0.89 (95% CI - 1.49, - 0.30) days lower when compared to placebo after lumbar discectomy in patients with lumbar disc herniation. A total of ten studies compared the ratio of complication between the ES and placebo groups. No significant differences were noted for complications within the two groups (0.92; 95% CI 0.47, 1.83). This meta-analysis analysed lower back and leg pain, morphine consumption and hospital stay, with no significant difference in complications for ES application after lumbar discectomy in lumbar disc herniation. In terms of surgical approaches with MIS compared to conventional approach, this review demonstrates that ES can reduce post-operative morphine consumption when the surgical approach is conventional, but not for MIS.Level of evidence I.

Variation of C1 spinolaminar line and prevalence of C1 stenosis in normal population.

BACKGROUND: The variation of C1 spinolaminar line in normal population is not fully understood. The relative position of C1 lamina to C3-C2 spinolaminar line is reported as good screening tool for determination of C1 canal stenosis. OBJECTIVE: To determine the variation of C1 spinolaminar line and find the prevalence of C1 canal stenosis in normal population using C3-C2 spinolaminar test. MATERIALS AND METHODS: Three hundred and fifteen lateral cervical radiographs from 315 volunteers without neurological symptoms were analyzed. The relative position of C1 spinolaminar line was determined by C3-C2 spinolaminar and considered positive if C1 lamina lay ventral to C3-C2 line. C1 space available for cord (SAC) was measured from posterior border of dens to the C1 lamina to determine the sagittal diameter. RESULTS: The mean sagittal spinal canal diameter of C1 was 22.2 mm (13-26 mm). Of 315, 14 (4.4%) had positive, 184 (58.4%) had neutral, and 117 (37.1%) had negative C1 spinolaminar line in relation to C3-C2 line. The mean SAC among positive group was 14.9 mm compared to neutral and negative groups which were 22.2 and 23.3 mm, respectively. 21.4% of positive group had SAC of less than 12 mm. The 92.8% of positive C1 spinolaminar line was found in age ≥ 60 years. CONCLUSION: In a normal population, 4.4% has positive C1 spinolaminar line. The C1 stenosis is more prevalent in positive C1 spinolaminar line group.

Metastatic Basal Cell Adenocarcinoma of Submandibular Gland to the Spine: An Extremely Rare Condition.

BACKGROUND: Basal cell adenocarcinomas are rare malignant neoplasms of salivary glands, accounting for <1% of salivary gland tumors. Few cases of distant metastases have been reported. CASE DESCRIPTION: A 50-year-old Thai man was diagnosed with basal cell adenocarcinoma of the submandibular gland with pulmonary and cervical spine metastases with progressive myelopathy. He was treated with wide surgical resection of the soft tissue tumor and modified radical neck dissection, anterior cervical total corpectomy with fusion combined with posterior decompression and fusion of the cervical spine, and surgical wound coverage by anterolateral thigh free tissue transfer, followed by adjuvant radiotherapy. At 18-month follow-up, the patient remained in good condition, and no signs of local recurrence or contiguous spreading were detected. Postoperative radiographs showed solid osseous fusion without loss of correction or implant failure. CONCLUSIONS: This case highlighted an extremely rare condition of metastatic basal cell adenocarcinoma of the submandibular gland to the lung and spine, which, to our knowledge, has not been previously reported in the literature.

Postoperative Kinetics of C-Reactive Protein and Erythrocyte Sediment Rate in One-, Two-, and Multilevel Posterior Spinal Decompressions and Instrumentations.

STUDY DESIGN: Prospective study. OBJECTIVE: To characterize the normal pattern of kinetics of postoperative C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) after decompression, spinal instrumentation, and posterolateral fusion in 1, 2, and more than 2 levels. METHODS: Blood specimens were obtained from patients who underwent posterior decompression, instrumentation with pedicular screws, and posterolateral fusion from June 2009 to January 2011. CRP and ESR levels were measured on the day before surgery and on postoperative days 1, 3, 7, 11, 14, 28, and 42. RESULTS: Mean CRP levels peaked on the third day postoperatively in all groups. By day 7 postoperatively, it had dropped rapidly. At the 14th and 28th postoperative days, decreases to normal CRP levels were found in 16% and 80% of all patients, respectively. The pattern of decline in CRP was similar among groups. Values of ESR increased and peaked between the third and seventh postoperative days. ESR values gradually decreased. At the 42 day postoperatively, ESR level still remain above normal values in all groups. CONCLUSIONS: We compared conventional operation groups of 1-, 2-, and more than 2-level posterior instrumentation and found no statistically significant differences in the peak of CRP level, the ESR value, and the pattern of decline. CRP levels of 80% of the patients returned to normal within 4 weeks.

Primary leiomyosarcoma of the spine treated with total en bloc spondylectomy: the first case in Thailand-a case report and literature review.

Leiomyosarcoma is a rare type of malignant soft tissue tumor and also one of the most aggressive soft tissue sarcomas. It commonly occurs in uterus, abdominal viscera, retroperitoneal space and soft tissue of the extremities. Primary osseous leiomyosarcoma is a rare condition. Furthermore, primary leiomyosarcoma of the spine is extremely rare. Only few cases have been reported. However, the treatment and outcomes remains controversial. Therefore, the objective of this case report is to illustrate the management of this extremely rare disease by using total en bloc spondylectomy (TES) procedure, which is one of a suitable option for surgical resection of the spinal tumors. In this study, we presented an unusual case of a 61-year-old female, who was diagnosed as primary leiomyosarcoma of the twelfth thoracic spine with liver metastasis, treated with total en bloc spondylectomy of the twelfth thoracic vertebra followed by chemotherapy. On last follow-up, 6 months after the surgery, the clinical outcome remained in good condition and no signs of local recurrence. In conclusion, primary leiomyosarcoma of the spine is an extremely rare and difficult to diagnosis. Immunohistochemistry studies are very important for confirmation of the diagnosis. Standard treatment remains controversial. However, surgical resection is still treatment of choice. One of the most effective surgical options is TES, which give the better outcome and minimize local recurrence, if indicate.

A new method for measurement of occipitocervical angle by occiput-C3 angle.

BACKGROUND: The description of the measurement technique of the posterior occiput-third cervical spine (OC3) angle-before performing occipitocervical fusion is still controversial. Setting an appropriate alignment in occipitocervical instrumentation is important for successful fixation surgery. Several methods were used for quantifying occipitocervical alignment on the lateral radiograph. This study was performed to describe a measurement technique of OC3 angle and comparing reliability and reproducibility in the measurement of occipitocervical angle with previous method. The purpose of this study was to determine the best technique for assessing this angle. MATERIALS AND METHODS: Three hundred and twenty-six lateral cervical spine radiographs from volunteers without spinal disorder were taken in neutral position and collected from June 2011 to December 2012. Analysis consisted of measurement of the OC3 angle and posterior occipitocervical angle. Inter- and intra-observer reliabilities were assessed using limit agreement test. RESULTS: The mean OC3 angle measurements were approximately 107 (94-120) degrees. Intra- and inter-observer error assessed by 95% limit agreement was approximately ±5.5 and ±7.5, while the POCA measurements were approximately 108 (94-120) degrees. Intra- and inter-observer error assessed by 95% limit agreement was approximately ±13.3 and ±18.2. CONCLUSION: The OC3 angle measurement is a simple method, good inter- and intra-observer reliabilities to measure of the occipitocervical angle. That can be useful to setting the patient's position and facilitate confirmation of the occipitocervical neutral position during occipitocervical fusion.