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Complications and outcomes of posterior fusion in children with atlantoaxial instability.

Eur Spine J. 2011 Nov 24;

Authors: Tauchi R, Imagama S, Ito Z, Ando K, Hirano K, Muramoto A, Matsui H, Kato F, Yukawa Y, Sato K, Kanemura T, Yoshihara H, Kamiya M, Matsuyama Y, Ishiguro N

INTRODUCTION: Atlantoaxial instability (AAI) is an uncommon disease in children. Surgical treatment of pediatric patients with AAI poses a challenge to spine surgeons because of the patients’ immature bone quality, extensive anatomical variability, and smaller osseous structures. In this study, the authors report complications and outcomes after posterior fusion in children with AAI. METHODS: The authors reviewed medical records of patients 13 years old and younger with AAI who underwent posterior fusion in the Nagoya Spine Group hospitals, a multicenter cooperative study group, from January 1995 to December 2007. We identified 11 patients who underwent posterior fusion, and analyzed their clinical outcomes and complications. To determine if vertical growth within the construct continued after posterior fusion, in three patients at 5 or more years following occipito-cervical (O-C) fusion, intervertebral disc heights and vertebral heights between the fused and non-fused levels were compared on the final follow-up. RESULTS: The initial surgeries were C1-C2 fusions in six patients and O-C fusion in five patients. Successful fusion ultimately occurred in all patients, however, the complication rate related to the operations was high (64%). Complications included neurologic deterioration, pedicle fracture with pedicle screw insertion, C1 posterior arch fracture with lateral mass screw insertion, perforation of the skull with a head pin placement, and fusion extension to adjacent vertebrae. Two patients required reoperation. The mean fixed and non-fixed intervertebral disc heights on the final follow-up were 2.6 and 5.3 mm, respectively, showing that the disc height of the fixed level was less than the non-fused level. Each vertebra lengthened similarly between fused and non-fused levels except for C2 which had a lower growth rate than the other vertebrae. CONCLUSIONS: A high complication rate should be anticipated after posterior fusion in children with AAI. Careful consideration should be paid to pediatric patients with AAI treated by screw and/or rod systems. After posterior fusion in pediatric patients, each vertebra continued to grow, in contrast the disc height decreased between fused levels.

PMID: 22113532 [PubMed – as supplied by publisher]

The role of imaging in the pre- and postoperative evaluation of posterior occipito-cervical fusion.

Radiol Med. 2011 Nov 17;

Authors: Leone A, Costantini A, Visocchi M, Vestito A, Colelli P, Magarelli N, Colosimo C, Bonomo L

PURPOSE: Occipitocervical fusion is required when the occipitoatlantal joint is unstable. The purpose of this paper is to discuss the role of imaging in the pre- and postoperative evaluation of posterior occipitocervical fusion (POCF), focusing on contoured loop fixation by Hartshill and Songer instrumentation. MATERIALS AND METHODS: We studied 21 patients (eight males, 12 females; age range 6-70 years; mean age 32.6 years) with craniocervical instability who underwent POCF with Hartshill U-shaped rod and Songer sublaminar wires. Pre- and postoperative radiographic, computed tomography (CT) and magnetic resonance (MR) imaging examinations were performed in all patients. A 3-to 6-month period of external orthosis with halo vest, sterno-occipitalmandibular immobiliser (SOMI) brace or Philadelphia collar followed surgery. Follow-up was 12-96 (mean 53.1) months. RESULTS: Clinical assessment using the Frankel scale revealed improvement or deterioration arrest in all but two patients: one with C3 failure and halo destabilisation; the other, who had exhibited myelopathy signs on preoperative MR imaging and persistent basilar impression, showed increasing and progressive neurological deficits despite successful POCF. CONCLUSIONS: Pre- and postoperative imaging is extremely useful in patients scheduled to undergo POCF. Preoperative MR screening of basilar impression associated with possible spinal cord lesions appears mandatory to predict possible deterioration and prevent undesired failure of the operation and it may suggest the need for an alternative surgical approach, such as the transoral approach.

PMID: 22095415 [PubMed – as supplied by publisher]

Aplasia of anterior arch of atlas associated with multiple congenital disorders: Case report.

Neurosurgery. 2011 Jun 24;

Authors: Martirosyan NL, Cavalcanti DD, Kalani MY, Maughan PH, Theodore N

BACKGROUND AND IMPORTANCE:: Congenital clefts and aplasias of the atlas vertebra are rare. A nonfused posterior arch occurs in 4% of the population; in contrast, a nonfused anterior arch occurs in only 0.1%. To our knowledge, this is the first description of the combination of anterior arch aplasia and a cleft of the posterior arch of the atlas associated with Klippel-Feil and Treacher-Collins syndromes and Sprengel’s deformity. CLINICAL PRESENTATION:: An 11-year-old girl presented with neck pain and symptoms of myelopathy, including upper and lower extremity paresthesia. Computed tomography revealed significant congenital bony anomalies of the cervical spine, with congenital fusion of C2 through C5. There was aplasia of the anterior ring of C1 (2.3-cm gap was present within the anterior aspect of the lateral masses). The posterior elements of C3 and C4 were fused, and signs of Sprengel’s deformity were present. Magnetic resonance imaging revealed effacement of the ventral cerebrospinal fluid space at the craniocervical junction and mild mass effect at the cervicomedullary junction. Flexion and extension views showed abnormal motion at the craniocervical junction. There was no evidence of atlantoaxial instability, basilar invagination, or Chiari malformation. Occipito-C4-scapular fusion was performed to prevent spinal cord injury and further neurologic symptoms. Postoperatively, the patient did extremely well and her preoperative symptoms resolved. CONCLUSION:: We describe a rare case of aplasia of the anterior arch of the atlas and posterior arch midline cleft in association with Treacher-Collins syndrome, Klippel-Feil syndrome, and Sprengel’s deformity. The patient’s atlantoaxial instability was managed surgically with a unique construct that provided occipito-C4-scapular fusion.

PMID: 21712741 [PubMed – as supplied by publisher]

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