Percutaneous anterolateral balloon kyphoplasty for metastatic lytic lesions of the cervical spine

The purpose of our report is to describe a new application of kyphoplasty, the percutaneous anterolateral balloon kyphoplasty that we performed in two cases of metastatic osteolytic lesions in cervical spine. The first patient, aged 48 years, with primary malignancy in lungs had two metastatic lesions in C2 and C6 vertebrae. Patient’s complaints were about pain and restriction of movements (due to the pain) in the cervical spine. The second patient, aged 70 years, with primary malignancy in stomach, had multiple metastatic lesions in thoracolumbar spine and C3, C4 and C5 vertebrae without neurological symptoms. The main symptoms were from cervical spine with severe pain even in bed rest and systematic use of opiate-base analgesis. The preoperative status was evaluated with X-rays, CT scan, MRI scan and with Karnofsky score and visual analogue pain (VAS) scale. Both patients underwent percutaneous anterolateral balloon kyphoplasty via the anterolateral approach in cervical spine under general anaesthesia. No clinical complications occurred during or after the procedure. Both patients experienced pain relief immediately after balloon kyphoplasty and during the following days. The stiffness also resolved rapidly and cervical collars were removed. VAS score significantly improved from 85 and 95 preoperatively to 30 in both patients. Karnofsky score showed also improvement from 40 and 30 preoperatively to 80 and 70, respectively, at the final follow-up (7 months after the procedure). Fluoroscopy-guided percutaneous anterolateral ballon kyphoplasty proved to be safe and effective minimally invasive procedure for metastatic osteolytic lesions of the cervical spine, reducing pain and avoiding vertebral collapse. Experience and attention are necessary in order to avoid complications.     

Occurrence and Significance of Odontoid Lateral Mass Interspace Asymmetry in Trauma Patients

Background

The odontoid lateral mass interspace (OLMI) is the space between the lateral aspect of the dens axis and the medial circumference of the massa lateralis atlantis. The position of OLMI asymmetry as a normal variant or pathologic finding is an area of debate and clinical interest in trauma patients. We designed this prospective study to lay a framework for proposing strategies for the appropriate use of OLMI.

Methods

A total of 301 adult patients admitted for trauma were included. Computed tomography (CT) and magnetic resonance imaging (MRI) of the cervical spine were performed and examined for the presence OLMI asymmetry and bony/ligamentous lesions of the occipitoatlantoaxial complex.

Results

Head rotation is linked to the occurrence of OLMI asymmetry. Reliable OLMI asymmetry evaluation is limited by observer agreement under a threshold value of 1.0 mm. In all, 86 patients (28.6 %) were found to have OLMI asymmetry on CT after trauma. Among these patients, 17.4 % had a bony/ligamentous lesion of the occipitoatlantoaxial complex. Among the patients without OLMI asymmetry, 8.8 % were found to have such lesions.

Conclusions

OLMI asymmetry should only be investigated by CT scans of the head in optimal position and with the threshold value of 1.0 mm. OLMI asymmetry should not be used alone as a sign of a cervical spine lesion. MRI should be performed if: (1) the physician has a high degree of suspicion of a cervical spine lesion; (2) OLMI asymmetry was demonstrated on a technically adequate CT scan; (3) clinical symptoms persist in patients with OLMI asymmetry when no acute MRI was performed.     

Simultaneous noncontiguous cervical spine injuries in a pediatric patient: case report

OBJECTIVE AND IMPORTANCE: Noncontiguous traumatic injuries of the cervical spine in children are rare. We present the case of a child who simultaneously sustained a separation of the odontoid synchondrosis and a C6-C7 dislocation with a complete spinal cord injury. The management of simultaneous cervical spine injuries is discussed. CLINICAL PRESENTATION: A boy aged 4 years and 2 months was a restrained back-seat passenger involved in a head-on motor vehicle accident. The patient lacked neurological function below C7. Imaging studies revealed a separation of the odontoid synchondrosis as well as a traumatic dislocation of the spine at C6-C7. INTERVENTION: The patient was placed in a halo vest shortly after admission. Four days after his injury, he underwent a posterior wiring and fusion of C6 to C7. As the C6-C7 dislocation was reduced by posterior element wiring, intraoperative x-rays showed a gradual increase in the subluxation of C1 on C2. This increase in C1-C2 subluxation required intraoperative repositioning of the halo crown on the ventral halo vest posts to maintain acceptable C1-C2 alignment. Postoperatively, ideal alignment of the odontoid peg on the body of C2 could not be achieved by halo adjustments alone. The patient required a custom-made posterior neck cushion attached to the halo vest to maintain cervical lordosis and good alignment of the odontoid peg on the body of C2. CONCLUSION: Simultaneous traumatic cervical spine injuries in pediatric patients are rare. The intraoperative reduction of one spine injury can affect the alignment at the location of the second injury. In this case, a custom adjustment of the halo vest improved the alignment of the odontoid peg on the body of C2.     

Combined double fracture of the odontoid process and fracture of the atlas

We report a rare case of double fractures of the odontoid process combined with a fracture of the anterior arch of the atlas. Combined fractures of the odontoid process and the upper cervical spine are not unusual. The presence of two different patterns of odontoid process fractures combined with a fracture of the anterior arch of the atlas is not reported in the literature available to us. The authors report on a patient who sustained two fractures in the odontoid process of C2 and a fracture of the anterior arch of C1. As the initial plain films were not clear enough to detect suspected lesions in the upper cervical spine, the patient underwent full investigation with CT scan and MRI. Reconstructive images showed the fractures of the odontoid process and the one of the atlas. The patient was treated conservatively with the application of cranial traction. The patient died 10 days later of unrelated cardiopulmonary insufficiency. During this period, there was no particular problem from the cervical spine. We recommend a high level of alert and suspicion to every case of upper cervical spine injury since, due to the complexity of the anatomy of this transitional area, a different biomechanical behavior exists leading to a variety of combination of fractures.     

Cervical spine fractures in the elderly: morbidity and mortality after operative treatment

Purpose

Although there are currently many different strategies and recommendations in the therapy of cervical spine fractures in elderly patients, there are still no generally accepted treatment algorithms. The aim of the present study was to analyze the morbidity, mortality, and outcome of operated cervical spine injuries in the elderly.

Methods

This study presents a retrospective review of 69 patients aged 65 years or older admitted to our level I trauma center with cervical spine injury, who had undergone surgical treatment. The data were acquired by analysis of the hospital inpatient enquiry system and radiological review.

Results

The ratio between male and female patients was 37:32. The average age of the patients was 76 years (ranging from 65 to 96 years) for males and 80 years (ranging from 66 to 93 years) for females. Injury to the cervical spine was caused by low-energy trauma in 71 % and high-energy trauma in 29 %, respectively. 55.1 % sustained isolated cervical spine injuries, 39.1 % injuries to two adjacent vertebrae, 2.9 % injuries to three adjacent vertebrae, and 2.9 % an odontoid fracture combined with associated fracture(s) in non-contiguous vertebra(e). Isolated spine injury level was dominated by C2 (47.8 %). The most common site for injuries to two adjacent vertebrae was observed at C6/C7 (14.5 %). The morbidity included cerebral complications, respiratory complications, Clostridium difficile-associated disease, heart failure, and acute renal failure. Operative complications included dislocation/malposition, neurovascular lesions, wound infection, and transient swallowing difficulty. The mortality rate at 3 months was 26.1 %, with an in-hospital mortality of 21.7 %. Age was associated with mortality at 3 months. A cervical fracture-induced neurological deficit was documented in 26.1 %, resulting in a mortality of 44.4 % (8/18). Twenty-seven of 33 patients living at home/nursing home at the time of injury returned to their home/nursing home after their hospitalization. The overall outcome was predominantly related to age and the severity of neurological deficit.

Conclusions

In elderly patients with cervical spine fractures, the hospital course is complicated by medical issues and early mortality rates are significant. Therefore, treatment strategies should be carefully individualized to the patients and their comorbidities.     

Surgical treatment of metastatic lesion of the spine. A review of 51 consecutive cases operated

Abstract Metastatic lesions of the spine have recently become a debated topic in orthopaedics, because more and more patients survive long enough to require surgical treatment. The aim of this study is to review a series of 51 patients affected by metastatic lesions of the spine. Fifty-one patients affected by metastatic lesions of the spine were treated between 1987 and 2000. In 5 cases the cervical spine was involved, in 27 the thoracic and in 19 the lumbar spine. Surgery was planned according to the following labelling factors: type of malignancy, life expectancy, neurological involvement, pain, site of lesion, lesion extension and spine stability. Surgical treatment consisted of: minimally invasive cord decompression in 3 cases, posterior stabilization in 21, posterior stabilization and cord decompression in 13 cases, anterior resection and reconstruction of anterior column associated or not at posterior stabilization in 14 cases. Two patients died due to complications related to surgery. At the last available follow-up of 4 (±2.5) years, 29 patients had excellent results, 16 had good results, 2 fair and 2 poor results. One fair and 1 poor result had recurrence of the metastatic lesions of the spine and needed another operation. We believe that surgical treatment of metastatic lesion of the spine has a positive cost/benefit ratio for the patient's condition; in fact most of our patients had improvement of quality of life. The labelling factors of each lesion have to be carefully studied together with the oncologist to decide the correct surgical option because unsatisfactory results could be sometimes related to incorrect evaluation of the evolution of the neoplasm.     

Dysphagia and airway compromise as a result of retropharyngeal haematoma following undiagnosed odontoid peg fracture: a case report

Airway compromise following a cervical spine injury is an unusual cause of respiratory distress. We describe a patient who developed a retropharyngeal haematoma that caused dysphagia, dysarthria and acute airway compromise seven days following a fall, with no other signs of cervical spine injury. The patient was found to have a type 2 fracture through the junction of the odontoid peg and body of C2 with an associated prevertebral haematoma and soft tissue oedema. Later, the patient developed stridor and required an emergency orotracheal intubation and admission to the intensive care unit. As presented in this case report, cervical fracture can result in mechanical airway compromise with an associated retropharyngeal haematoma and prevertebral soft tissue oedema. In elderly patients with a minor history of falls one should always think of possible fractures and appropriate investigations should be carried out. Retropharyngeal haematomas secondary to cervical spine fractures require a prompt multidisciplinary approach and appropriate management of both the airway and cervical spine. Joint care from the orthopaedic, anaesthetic, and ear, nose and throat teams is necessary.     

Anesthetic management of a patient in prone position with a drill bit penetrating the spinal canal at C1-C2, using a laryngeal mask

Airway management in patients with penetrating neck trauma must guarantee cervical spine stability. Moreover, the prone position increases the risk of difficult ventilation and cervical spine injury. A 19-yr-old patient was brought to the emergency room in prone position with a drill bit protruding from the posterolateral aspect of his neck. The bit had entered the spinal canal below the first cervical vertebra, and placed near the odontoid peg. He was referred for surgical removal of the drill. The use of an inhaled induction of anesthesia, avoiding muscle relaxants, and ventilation through a laryngeal mask airway inserted in the prone position seemed to offer a satisfactory approach. IMPLICATIONS: Management of patients with penetrating neck trauma must guarantee cervical spine stability. Moreover, the prone position increases the risk of difficult ventilation and cervical spine injury. Anesthesia may be induced and the airway can be managed with the patient already in the prone position for surgery.     

Positive and negative prognostic variables for patients undergoing spine surgery for metastatic breast disease

The histology of the primary tumor in metastatic spine disease plays an important role in its treatment and prognosis. However, there is paucity in the literature of histology-specific analysis of spinal metastases. In this study, prognostic variables were reviewed for patients who underwent surgery for breast metastases to the spinal column. Respective chart review was done to first identify all patients with breast cancer over an 8-year period at a major cancer center and then to select all those with symptomatic metastatic disease to the spine who underwent spinal surgery. Univariate and multivariate analyses were used to assess several prognostic variables. Presence of visceral metastases, multiplicity of bony lesions, presence of estrogen receptors (ER), and segment of spine (cervical, thoracic, lumbar, sacral) in which metastases arose were compared with patient survival. Eighty-seven patients underwent 125 spinal surgeries. Those with estrogen receptor (ER) positivity had a longer median survival after surgery compared to those with estrogen receptor negativity. Patients with cervical location of metastasis had a shorter median survival compared with those having metastases in other areas of the spine. The presence of visceral metastases or a multiplicity of bony lesions did not have prognostic value. In patients with spinal metastases from breast cancer, aggressive surgical management may be an option for providing significant pain relief and preservation/improvement of neurological function. Interestingly, in patients undergoing such surgery, cervical location of metastasis is a negative prognostic variable, and ER-positivity is associated with better survival, while presence of visceral or multiple bony lesions does not significantly alter survival.     

New classification system for ossification of the posterior longitudinal ligament using CT images

Background

Ossification of the posterior longitudinal ligament (OPLL) is most frequently seen in the cervical spine. The types of cervical OPLL are classified into continuous, mixed, segmental, and other based on plain lateral X-ray. Computed tomography (CT) imaging is often used in clinical practice for evaluating ossified lesions as it can detect their precise location, size, and shape. However, to date, no CT classification of OPLL lesions has been proposed.

Methods

One hundred and forty-four patients diagnosed with cervical OPLL by plain radiograph were included in this study. Sagittal and axial CT images of the cervical spine were obtained. We propose three classification systems: A, B, and axial. Classification A comprises two lesion types: bridge and nonbridge. Classification B requires examiners to describe all vertebral and intervertebral levels where OPLL exits in the cervical spine. Axial classification comprises central and lateral lesions identified on axial CT images. Seven observers evaluated CT images using this classification system, and intra- and interrater reliability were examined.

Results

Averaged Fleiss’ kappa coefficient of interrater agreement was 0.43 ± 0.26 among the seven observers, averaged intrarater reliability for the existence of OPLL was 72.4 ± 8.8 % [95 % confidence interval (CI) 67.5–76.8]. Fifty-four patients (37.5 %) had the bridge type and 90 the nonbridge type according to Classification A; 102 (70.8 %) had central and 42 (29.2 %) lateral OPLL in the axial classification. Four representative cases defined according to the three classification types are reported here.

Conclusion

Subcommittee members of the Investigation Committee on the Ossification of the Spinal Ligaments of the Japanese Ministry of Public Health and Welfare propose three new classification systems of cervical OPLL based on CT imaging: A, B, and axial.     

Isolated cervical metastasis of breast cancer: a case report and literature review

Metastasis of distant malignancies to the cervix is a rare event. Patients usually present with abnormal bleeding, pain, and dyspareunia. A smaller number of patients are asymptomatic, and their tumors can be diagnosed early by Pap smears. We present 56-year-old woman with a history of intraductal breast cancer that presented with vaginal bleeding. Colposcopic pathology and fractional curettage revealed a lesion similar to her primary breast cancer. She underwent an extensive workup and hysterectomy that revealed no other lesions. Currently, she is alive and well. Cervical metastasis should be considered in women with a history of breast cancer who present with vaginal bleeding. Aggressive treatment of isolated cervical metastasis from breast cancer is warranted in appropriate patients.     

Surgical kyphoplasty for management of axis metastasis: technical note kyphoplastie de C2

C2 vertebral metastases are seldom encountered. They usually cause disabling pain at the upper cervical level and can also result in life-threatening spinal instability. The technique described herein may provide a valuable minimally invasive option for treating this condition. We report a case of C2 metastasis resulting from gastric adenocarcinoma in a 58-year-old male; since there was no spinal instability, open kyphoplasty was performed at C2, resulting in the healing of the body and the base of the odontoid of the C2 vertebra. The X-ray follow-up more than six months after surgery confirmed the absence of any spinal instability at the craniocervical junction. Open kyphoplasty at C2 provides a means to manage a metastasis located in the body of the C2 vertebra. This method maintains the rotatory function of the upper cervical spine, which seems to be a crucial factor, given the poor prognosis usually associated with this condition.     

Evaluation of 138 fractures of the cervical spine during a recent 5-year period (1979 to 1983). Therapeutic approaches

138 cervical spine fractures are reviewed during a recent period of 5 years (1979-1983). Their frequency stay high. The serial concern 67% of men and 33% of women. We observe a peak age between 20 and 30 (23%). 65% of lesions are caused by a traffic injury, 27% by a falling down, 10% by a diving. 45% of cases interest the upper cervical spine (C1-C2) with a high proportion of odontoid process fractures (60%) and Hangman's fractures (30%); 54% of cases concern the lower cervical spine (C3-C7) with an important part of fracture-luxation (72%), specially C5-C6 (35%). Clinically, we note almost a same part of fractures without neurological disturbances (54%) and with neurological abnormalities (46%). In this situation, the sensitive and motor loss are often severe (78%). In 40%, the injuries are polytraumatism and association spine lesion, cranio-cerebral lesion is the most frequent (61%). In upper cervical spine fractures, after Crutchfield or Gardner traction, posterior fixation was performed (62%). The treatment was conservative in 30%. In lower cervical spine lesions, a secondary surgical approach by an antero-lateral way was made (53%). The treatment was initially surgical in 13% and conservative in 28%. The mortality rate of this pathology is important (22%; i.e. 30 deaths on 138 cases).     

Persistent local pain after posterior spine surgery for thoracic lesions

Many surgeons have investigated local pain associated with posterior spine surgery for cervical or lumbar lesions. However, little information is available concerning local pain after posterior thoracic spine surgery. This prospective study was, thus, performed to investigate the frequency and clinical features of local pain after posterior spine surgery for thoracic lesions. In 29 consecutive patients undergoing posterior spine surgery for various thoracic spinal disorders, local pain was investigated before and after surgery. In all 19 patients with preoperative back pain presumably due to thoracic lesions, pain was well alleviated after surgery. In contrast, 6 patients (21%) newly developed persistent shoulder angle pain after surgery, which resembled axial pain after cervical laminoplasty. In 5 of these 6 patients surgical exposure was extended to the cervicothoracic junction, whereas persistent shoulder angle pain was independent of disease etiologies and surgical procedure, and all of the 5 patients had no other etiologies of local pain such as surgical site infections, hardware failures, pseudoarthrosis, other metastasis, and vertebral fractures. These results suggest that dissection of muscle attachments to the cervicothoracic junction would play some part in the development of persistent local pain after posterior spine surgery for thoracic lesions, although surgical exposure of the zygapophysial joints at the cervicothoracic junction might be a possible source of postoperative shoulder pain. Therefore, to minimize such surgical complications, muscle insertions into the cervicothoracic junction should be preserved as far as possible.     

The pediatric trauma C-spine: is the 'odontoid' view necessary?

BACKGROUND/PURPOSE: The "odontoid view" is a difficult and often hazardous film to obtain in young children. The aim of this study was to determine if the transoral roentgenogram is necessary in the evaluation of the pediatric cervical spine. METHODS: A retrospective, multiinstitutional review was performed of all patients 16 years of age and under with documented cervical spine injury in a large metropolitan area during the past decade. Fifty-one children with cervical spine injury were identified from the medical records at 4 hospitals. RESULTS: The 0- to 8-year-old age group had a significantly higher incidence of upper (occiput to C3) cervical injury than the 9- to 16-year-old age group (67% v 39%; P < .05). In the 0- to 8-year-old group the initial lateral/anteroposterior radiograph made the diagnosis of cervical spine injury in 13 of 15 patients (87%), and in no patients was the transoral odontoid view used to make the diagnosis of cervical spine injury. In only 1 patient in the 9- to 16-year-old age group with a type III odontoid fracture was this view deemed useful. The overall mortality rate in this series was 7.8% with all deaths secondary to associated head injury. CONCLUSIONS: In the 0- to 8-year-old age group in whom the incidence of cervical spine injury is rare but frequently involves the upper cervical spine, the transoral odontoid roentgenogram may be of little value in the evaluation of the spine and should not be considered necessary in "clearing" the pediatric cervical spine. An alternative evaluation of these patients would include an initial lateral and AP radiograph, followed by computed tomography scan.     

Clinical decision making associated with an undetected odontoid fracture in an older individual referred to physical therapy for the treatment of neck pain

STUDY DESIGN: Resident's case problem. BACKGROUND: The purpose of this paper is to provide the examination of and decision-making process for a patient referred to physical therapy for the treatment of neck pain following trauma. She was found to have an underlying odontoid fracture that precluded physical therapy intervention. DIAGNOSIS: This case involved a 73-year-old woman who had a sudden onset of neck and left upper extremity pain after a fall 15 days prior to her initial physical therapy visit. Conventional cervical spine radiographs completed 1 day prior to her initial physical therapy visit were negative for a fracture. However, several components of this patient's history and physical examination were consistent with a condition for which physical therapy intervention would not be indicated until more definitive cervical spine diagnostic imaging had been completed; more specifically, the physical therapist was primarily concerned about the possibility of an undetected fracture. The referring physician was contacted and immediate magnetic resonance imaging was requested, which revealed a type II fracture of the odontoid. Thirty-four days after her fall, the patient underwent a C1-C2 fusion. DISCUSSION: When evaluating patients with neck pain who have a history of cervical spine trauma, it is important that physical therapists understand the clinical findings associated with cervical spine fractures, as these findings provide guidance for the use of cervical spine diagnostic imaging and medical referral prior to implementing physical therapy interventions. LEVEL OF EVIDENCE: Diagnosis, level 4.     

Fractures of the Odontoid in Children

Odontoid fractures are rare in children; they may, however, occur at any age with a prevalence in younger children. Below the age of 9, there is almost exclusively a separation of the subdental synchondrosis, whereas in children older than 9 years, the basal odontoid fracture resembles the adult type. Motor vehicle accidents (MVA) are the dominant trauma. Clinically, a substantial lesion of the upper cervical spine cannot be excluded the symptoms of odontoid fracture, such as neck pain or neck stiffness, being subtle and unspecific. Therefore, the diagnosis of odontoid fractures is based on radiographic screening of traumatized cervical spines with a standard three-view program (anteroposterior, lateral from the occiput on Th1, transoral dens view). Computed tomography (CT) and magnetic resonance imaging (MRI) are reserved to special indications. Acute odontoid fracture is mainly treated conservatively, preferably with a Minerva cast. In exceptional cases, operation with preservation of C1/C2 mobility may be indicated. The genesis of os odontoideum may be traumatic and is due to untreated odontoid fractures in children below the age of 2.5 years. Chronic atlanto-axial instability is treated by segmental fusion.     

Atraumatic odontoid fractures in patients with rheumatoid arthritis.

BACKGROUND CONTEXT: Instability of the cervical spine is a common problem in patients with rheumatoid arthritis. The natural course of rheumatoid arthritis in the cervical spine is well documented. However, the true prevalence of occult fractures of the odontoid process in patients with rheumatoid arthritis is not known. PURPOSE: To draw attention to the possibility of occult, atraumatic fractures of the odontoid process in patients with rheumatoid arthritis. STUDY DESIGN: We report on two cases with previously unrecognized fractures of the odontoid process. METHODS: In this case series, we review the individual radiographic findings and clinical observations in two rheumatoid patients in whom a fracture of the odontoid process was diagnosed. RESULTS: Each one of these two rheumatoid patients had an unrecognized fracture of the odontoid process without any prior history of trauma. Their fracture was identified serendipitously during workup for neck pain. CONCLUSIONS: Occult, atraumatic fractures of the odontoid process may be found in patients with long-standing rheumatoid arthritis. This injury should be suspected if previously asymptomatic patients complain about new onset of neck pain without significant trauma.     

Atypische dislozierte Densfraktur Typ II mit rotatorischer atlantoaxialer Luxation nach Reitunfall

We present a rare case of a combined dislocated odontoid dens fracture type II (Anderson/D’Alonzo) and rotational atlantoaxial luxation in a 15-year-old girl who was involved in a riding accident. She fell off her horse after it had stopped suddenly, losing consciousness for a few minutes. At presentation in the hospital, she had no complaints other than limited, painful neck movement. Radiologically, a posterior dislocation of an odontoid type II fracture (Anderson/D’Alonzo) was found. Computed tomography reconstruction demonstrated a rotational, hooklike fixed luxation of the left atlantoaxial facet joint. Manual repositioning after application of a cervical collar failed. Therefore, operative treatment was indicated for this highly unstable fracture. Posterior transarticular atlantoaxial screw fixation according to Magerl was performed; an iliac corticocancellous bone graft was harvested and shaped to conform to the posterior processes of C1 and C2. Additionally a hook-claw atlas fixation of C1 was done. To our knowledge, this is the first case of adolescent atlantoaxial cervical spine trauma in combination with an odontoid fracture and fixed rotational luxation reported in literature.