Anterior cervical approach for the treatment of axial or high thoracic levels.

PURPOSE: Application of the anterior sub-axial cervical approach to the axial spine or the high thoracic spine has been previously described. Evaluation methods to determine the feasibility of these approaches were also described but alternative method was utilized in the current study. We describe our experience expanding the boundaries of anterior cervical approach utilizing a novel algorithm for approach selection. MATERIALS AND METHODS: A retrospective analysis of patients' files and imaging data of all anterior cervical approach to treat pathologies above C2-3 disc space or below C7-D1 disc space. The decision to proceed with standard approach was based on CT or MRI scans and the pre-operative cervical range of motion. Post-operative course and surgical complications will be discussed. RESULTS: During a two year period 13 patients had undergone anterior cervical approach to the axial spine (3 patients) or the thoracic spine (10 patients). Ten patients were treated for tumour resection, one for trauma, one for myelopathy and the last for infective osteomyelitis with epidural abscess. Three patients were previously operated in another hospital via the posterior approach with remaining compressive mass necessitating anterior decompression. Complications were recorded in 30% of the patients. CONCLUSIONS: Approach to the axial or the high thoracic spine is more challenging and harbors approach-related complication. Pre-operative evaluation of patients imaging allows harnessing the standard approach for treatment of extreme levels with relative safety and efficiency. Spine surgeons' awareness to this technique may increase surgical efficacy while reducing the complication rates.

Successfully treated transoral crossbow injury to the axial spine causing mild neurologic deficit: case presentation.

PURPOSE: To detail the management, complications and results of a crossbow arrow injury, where the broadhead went through the mouth, tongue, soft palate, C2 vertebra, spinal canal, dural sack, exiting the neck posteriorly and the arrow shaft lodged in the spine causing mild spinal cord injury. METHODS: Case presentation. RESULTS: A penetrating axial cervical spine crossbow injury was treated successfully in spite of the following interdisciplinary complications: meningitis, cerebrospinal fluid leakage, re-bleeding, and cardiac arrest. The shaft was removed from the neck, and C1-3 dorsal stabilization was performed. Controlled Computed Tomography (CT) showed adequate implant position. After 4 months the patient's fine motor skills improved, and he became able to button his shirt on his own, and to eat and drink without any help. Additionally, he was able to walk without any support. At the time of control at the outpatient clinic his behavior was adequate: he cooperated with the examining doctor and answered with short sentences although his psychomotor skills were slightly slower. CONCLUSIONS: Although bow and crossbow spine injuries are rare nowadays they still occur. The removal of a penetrating missile resulting in such a spinal injury required a unique solution. General considerations, such as securing the airway, leaving the penetrating arrow in the neck and immobilizing both the arrow and neck for transport, thorough diagnostic imaging, preventing cerebrospinal fluid leakage, administering prophylactic antibiotics with broad coverage and stabilizing the spine if required, are advised.

Translaminar screw of C1 for the reinforcement of subaxial cervical spine reconstruction.

Translaminar screws in the cervical spine have been mostly employed at C2 level when conventional trajectories are challenging. However, reports in the literature of translaminar screw of C1 are remarkably anecdotal. We aimed to report a case using C1 translaminar in addition to C1 lateral mass screws for the reinforcement of subaxial cervical spine reconstruction. We present a 22-year-old female patient, who developed persistent cervical pain, and computed tomography scan demonstrated lytic lesions of the vertebral bodies and lateral masses from C3 to C6. Magnetic resonance imaging showed spinal cord compression without myelopathy. Surgical biopsy was inconclusive, and an oncological vertebral instability led to surgical stabilization. Laminectomy and bilateral facetectomy of levels involved was achieved, instrumentation from C1 to T3 and reconstruction with posterolateral fibula bilaterally, and without occipital fixation. A third satellite rod was placed using C1-2-7 translaminar screws. Translaminar screw of C1 is a feasible alternative for increasing the strength of the construct.

Peripheral Nerve Stimulation for Treatment of Cluneal Neuropathy Case Study.

Chronic low back pain is a prevalent and sometimes debilitating condition. This case report describes a 69-year-old female presenting with axial spine pain. The pain was inadequately controlled by opioids as she was treated unsuccessfully with hydrocodone and remained to have the pain between 7/10 and 10/10. Peripheral neural stimulation (PNS) was trialed and then used to control her pain. PNS is a device-based treatment option that appears effective in a subset of patients. It has been effectively used to treat many different chronic pain syndromes. The patient responded well to the treatment, with her pain intensity going down to between 2/10 and 5/10 on the same scale. She was able to discontinue her use of opioids. PNS can be a safe and effective treatment in patients who have not responded well to pharmacologic analgesia.

Intraoperative imaging and navigation for C1-C2 posterior fusion.

BACKGROUND: Cervical axial spine fusion is challenging as the anatomy is extremely variable, and screw misplacement can lead to severe complications. C1 lateral mass screws and C2 pedicle screws are routinely placed under either fluoroscopic guidance or imaging-assisted navigation. Here, we compared the two for axial screw placement. METHODS: We retrospectively evaluated patients' treated from 2011-2016 utilizing the Harm's procedure for C1-C2 screw fixation performed under either fluoroscopic guidance (nine patients) or image-assisted O-arm navigation (five patients). The groups had similar demographic and risk factors. Variables studied included operative time, estimated blood loss (EBL), accuracy of screw placement, screw reposition rates, and reoperation rates. RESULTS: The mean EBL was 555CC and 260CC, respectively (not a significant difference) utilizing fluoroscopic versus O-arm navigation. Of interest, the mean surgical duration was 27 min longer in the O-arm versus fluoroscopy group (P = 0.03). Ten C2 pedicle screws were performed using O-arm navigation. Alternatively, as 9 of 18 C2 pedicles were considered "risky" for the placement of fluoroscopic-guided pedicle screws, laminar screws were utilized. Although the accuracy rate of C1 and C2 screw placement was higher for the navigated group, this finding was not significant. Similarly, despite complications involving two unacceptably placed screws from the fluoroscopic guidance group, there were no neurological sequelae. CONCLUSION: Axial cervical spine instrumentation is challenging. Utilization of Imaging-assisted navigation increases the accuracy and safety of screw placement.

Biomechanics and Clinical Application of Translaminar Screws Fixation in Spine: A Review of the Literature.

STUDY DESIGN: Broad narrative review. OBJECTIVES: Translaminar screw (TLS) fixation was first described as a salvage technique for fixation of the axial spine. Better understanding of the spine anatomy allows for advancement in surgical techniques and expansion of TLS indications. The goal of this review is to discuss the anatomic feasibility of the TLS fixation in different region of the spine. METHODS: A review of the current literatures on the principles, biomechanics, and clinical application of the translaminar screw technique in the axial, subaxial, and thoracolumbar spine. RESULTS: Anatomic feasibility and biomechanical studies have demonstrated that TLS is a safe and strong fixation methods for fusion beyond just the axial spine. However, not all spine segments have wide enough lamina to accept TLS. Preoperative computed tomography scan can help ensure the feasibility and safety of TLS insertion. Recent clinical reports have validated the application of TLS in subaxial spine, thoracic spine, hangman's fracture, and pediatric population. CONCLUSIONS: TLS can be used beyond axial spine; however, TLS insertion is only warranted when the lamina is thick enough to avoid further complications such as breakage. Preoperative computed tomography scans can be used to determine feasibility of such fixation construct.

Sub-axial cervical spine injuries: Modified Stellerman's algorithm.

BACKGROUND: Global fusion is recommended in sub-axial cervical spine injuries with retrolisthesis, translation rotation injuries associated with end plate or tear drop fractures. We propose a modification of Stellerman's algorithm which we have used where in patients are primarily treated via anterior decompression and fixation. Global fusion was done only in cases where post-decompression traction does not achieve reduction in cases with locked facets. MATERIALS AND METHODS: Two hundred and thirty consecutive patients with sub-axial cervical spine injuries were studied in a prospective trial over a 7 year period. Seven cases with posterior compression alone were not subjected to our protocol. Of the other 223 cases, 191 cases who on radiological evaluation needed surgery were initially approached anteriorly. Decompression was effected through a corpectomy in 14 cases and a single or multiple level disc excisions were performed in the others. Cases with cervical listhesis (n=36) where on table reduction could not be achieved following decompression were subjected to progressive skeletal traction for 48 h. Posterior facetectomy and global fixation was done for patients in whom reduction could not be achieved despite post-decompression traction (n=11). RESULTS: Of the 223 cases, 20 cases were managed conservatively, 12 cases expired pre-operatively, and the remaining 191 cases needed surgical intervention. Out of the 154 cases of distraction/rotation/translation injuries on table reduction could be achieved in 118 cases (76.6%). Thirty-six patients had locked facets (23 cases were bifacetal, 13 cases unifacetal) and of these 36 cases reduction could be achieved with post-anterior decompression traction in 25 patients (16.2%); however, only 11 cases (7.1%)-8 bifacetal and 3 unifacetal dislocations-needed posterior facetectomy and global fusion. One hundred and forty-three patients were followed up for a minimum period of 6 months. One hundred and twenty-six patients showed evidence of complete fusion (88.1%) while the remaining 17 (11.8) showed evidence of partial fusion. There were no signs of instability on clinical and radiological evaluation in any of the cases. Reduction of graft height was noted in 18 patients (12.5%). There were eight cases of immediate postoperative mortality and two cases of delayed mortality in our series of cases. CONCLUSION: We feel that on table decompression and reduction followed by anterior stabilization can be used as the initial surgical approach to manage most types of cervical injuries. In rotation/translational cases where reduction cannot be achieved, monitored cervical traction on the decompressed spine can safely achieve reduction and hence avoid the need for a posterior facetectomy in a large percentage of cases.