Indications for surgery in upper cervical spine injury

20% of all spine injuries are cervical spine injuries. Surgical treatment of these injuries must take into account the great mobility of this part of the spinal column. Therefore, biomechanical aspects must be considered, especially in the upper cervical spine — C1 and C2. Describing our own therapeutical regimen in 35 patients with unstable upper cervical spine injuries we explain the biomechanical background and review the literature. It becomes evident that ventral approaches are superior to dorsal techniques for decompression, reposition, and stabilization with minimal loss of mobility.     

单纯前路手术治疗下颈椎脱位

目的探讨早期单纯前路手术治疗下颈椎脱位的临床疗效;方法对2005—06—2011—08收治的41例下颈椎脱位患者,采用颅骨牵引下复位或术中复位,单纯行前路减压,钛网或自体髂骨块植骨融合,前路钢板固定治疗。结果所有病例均得到良好复位,根据x线片定期检查结果,颈椎生理弧度及椎间隙高度良好,植骨融合确切,未出现内固定失用。术后随访10～28个月,Frankel分级显示,绝大部分患者术后神经功能得到不同程度的改善;结论早期行单纯前路手术治疗下颈椎脱位,可获得良好的解剖学复位,能有效地解除脊髓压迫,使脊柱获得即刻稳定。     

颈椎前路手术的早期并发症及其预防和处理

[目的]分析颈椎前路手术早期的各种并发症,探讨相关的影响因素及应对策略.[方法]回顾分析本院1997年1月～2011年3月559例经颈椎前路手术的各种早期并发症发生情况,对患者的病种、性别、年龄、全身并发症情况、手术、麻醉、护理及瘫痪情况多因素进行分析,分析相关并发症的可能发生原因,介绍处理方法.[结果]118例患者141例次出现术后早期并发症,发生率25.22％,其中,术后吞咽困难53例,喉上神经或喉返神经损伤11例,颈部切口血肿4例,脊髓损害加重3例,食道瘘1例,脑脊液漏4例,取骨区血肿或脂肪液化感染5例,低钠血症39例,肺部感染12例,下肢深静脉血栓形成5例,死亡4例.[结论]充分的术前准备与评估,熟悉的颈椎前路手术解剖知识及认真仔细的操作,术后仔细的观察及护理是预防颈椎前路手术早期并发症的关键.     

Esophagus perforation complicating anterior cervical spine surgery

Purpose  

To study the diagnosis and treatment strategy of esophagus perforation complicating anterior cervical spine surgery.     

颈椎前路术后吞咽困难的相关因素分析

目的:探讨颈椎前路手术后发生吞咽困难的相关因素。方法:随访2008年8月～2010年7月收治的颈椎前路手术患者135例,其中男82例,女53例;年龄32～80岁,平均58.2岁;诊断为脊髓型颈椎病58例,神经根型颈椎病32例,混合型颈椎病18例,后纵韧带骨化症27例。入院后均由同一组医师治疗,手术方式分为颈椎前路减压融合术(ACDF)、颈椎前路次全切减压融合术(ACCF)和人工颈椎间盘置换术(TDR)。观察患者手术后是否存在吞咽困难:对于存在吞咽困难的患者均静脉应用甲泼尼松龙及对症治疗。结果:术后共有36例(26.7%)患者出现吞咽困难,男11例,女25例,年龄42～80岁,平均59.6岁;其余99例,年龄32~76岁,平均52.3岁,发生吞咽困难者平均年龄显著高于未发生者(P<0.05)。发生吞咽困难患者中使用钛板内固定35例,其中单节段2例(9.1%),双节段13例(21.0%),多节段(包括三节段及三节段以上者)20例(52.6%);颈椎人工椎间盘置换者1例;术后吞咽困难发生率使用内固定者较人工椎间盘置换者高(P<0.05),多节段内固定者较单、双节段者明显升高(P<0.05)。手术最高节段累及C2或C3者23例,术后吞咽困难发生率26.1%;累及C4或C5者88例,发生率28.4%;累及C6或C7者24例,发生率20.1%,三组两两比较无统计学差异(P>0.05)。吞咽困难者的手术时间、失血量及住院天数与未发生吞咽困难者比较均无统计学差异(P>0.05)。35例(97.2%)患者的吞咽困难症状在术后6个月内减轻或消失,1例至随访1年时症状才消失。结论:女性、高龄、使用钛板内置物、手术节段多可能是颈椎前路手术后发生吞咽困难的相关因素,临床医生应给予相应重视和采取相应措施以减少其发生。     

Pharyngocutaneous fistula after anterior cervical spine surgery

Pharyngocutaneous fistulae are rare complications of anterior spine surgery occurring in less than 0.1% of all anterior surgery cases. We report a case of a 19 year old female who sustained a C6 burst fracture with complete quadriplegia. She was treated urgently with a C6 corpectomy with anterior cage and plating followed by posterior cervical stabilization at another institution. Post operatively she developed a pharyngocutaneous fistula that failed to heal despite several attempts of closure and esophageal exclusion with a Jpeg tube. The patient was eventually successfully treated with a three-stage procedure consisting of firstly a posterior approach to reinforce the posterior stabilization of the cervical spine that was felt to be inadequate, secondly an anterior approach with removal of all the anterior instrumentation followed by iliac crest bone graft and thirdly a superior based sternocleidomastoid flap that was interposed between the esophagus and the anterior cervical spine. The patient's fistula healed successfully. However, yet asymptomatic, the anterior iliac crest bone graft resorbed almost completely at 16 months follow up. In light of this complication, we discuss the surgical options for the treatment of pharyngocutaneous fistulae and the closure of this fistula using a superiorly based sternocleidomastoid muscle flap.     

颈椎前路手术对脊髓型颈椎病患者椎间盘组织中炎性细胞因子的影响

目的 探讨颈椎前路手术对脊髓型颈椎病(CSM)患者椎间盘组织中炎性细胞因子的影响.方法 35例脊髓型颈椎病患者(CSM组)和30例颈椎外伤患者(对照组)均行颈椎前路手术治疗,观察治疗效果.采用固相分离放射免疫分析法(SPRIA)测定两组颈椎间盘组织中白细胞介素(IL)-6、IL-8、肿瘤坏死因子(TNF)－α水平.结果病程≤6个月组优良率为81.8％,病程＞6个月组优良率为38.5％,两组优良率比较差异有统计学意义(P＜0.05);CSM患者术前JOA评分为(9.73±2.12)分,术后JOA评分为(14.21±2.52)分,术后JOA评分显著高于术前(P＜0.05);CSM组颈椎间盘中IL-6、IL-8、TNF-α水平均显著高于对照组(P＜0.05).结论 颈椎前路手术是治疗CSM的一种较有效手术方法;IL-6、IL-8、TNF-α在颈椎间盘退变和CSM发病中起重要作用.     

颈椎前路术后吞咽困难危险因素的Meta分析

【摘要】 目的：系统评价颈椎前路术后发生吞咽困难的危险因素,明确独立危险因素,为颈椎前路手术围术期并发症的防治提供指导。方法：检索万方数据库（WanFang）、中国生物医学文献数据库（CBM）、中国知网（CNKI）、维普（VIP）、PubMed、Embase、 Cochrane Library、Web of Science共8个数据库,检索时限从建库至2023年7月15日,搜索关于颈椎前路术后吞咽困难的危险因素的病例对照研究和队列研究,采用纽卡斯尔-渥太华质量评定量表（Newcastle-Ottawa Scale,NOS）对纳入研究进行质量评价和数据提取（包括第一作者、发表年份、研究类型、样本量、评估方式、评估时间及危险因素）,通过Stata12软件进行Meta分析。结果：共纳入29篇文献,其中队列研究4篇,病例对照研究25篇,所有文献均为高质量研究,包括颈椎前路术后吞咽困难患者89571 例,对照组3092967例。年龄[优势比（odds ratio,OR）=1.093,95%置信区间（confidential interval,CI）：1.067~1.120]、女性（OR=2.419,95%CI：1.654~3.539）、糖尿病（OR=2.733,95%CI：2.240~3.333）、病程（OR=4.259,95%CI：2.458~7.381）、手术节段数量（OR=1.791,95%CI：1.718~1.868）、手术节段位置（OR=2.332,95%CI：1.812~3.003）、手术时间（OR=1.434,95%CI：1.110~1.852）、钢板内置物（OR=2.188,95%CI：1.413~3.175）及翻修手术（OR=2.687,95%CI：2.316-3.119）与颈椎前路术后发生吞咽困难相关,而吸烟（OR=1.323,95%CI：0.852~2.056）、高血压（OR=1.006,95%CI：0.591~1.713）、体重指数（body mass index,BMI）（OR=1.037,95%CI：0.929~1.159）、颈椎间盘置换（OR=0.577,95%CI：0.085~3.943）、C2-7角度变化（difference between postoperative and preoperative C2-C7 angle,dC2-7）＞5°（OR=1.716,95%CI：0.925~3.183）等因素与其不相关。结论：女性、高龄、术前病程长、合并糖尿病、双节段或多节段手术、高位颈椎手术、手术时间长、使用钢板及翻修手术的患者颈椎前路术后更易发生吞咽困难。     

Posterior stabilization of the lower cervical spine with lateral mass plates and screws

Posterior cervical fixation using lateral mass plates and screws is becoming increasingly used and accepted.Advantages include increased rigidity, ability to be used in cases where the lamina or spinous processes are deficient or missing, use across the occipito-cervical or cervico-thoracic junction, and need for less postoperative bracing. Safe placement of lateral mass screws requires complete exposure and identification of the boundaries of the lateral masses. The starting point for screw placement is 1 to 2 mm medial to the center of lateral mass. The screws are angulated outward 10 to 20 degrees and cranially 20 to 30 degrees to be parallel to the facet joints. An adjustable drill guide facilitates safe drilling and tapping techniques. All 102 patients with unstable cervical spines treated with AO reconstruction plates and autogenous bone graft had healed fusions based on flexion-extension radiographs. The reductions achieved postoperatively were maintained at follow-up. Two patients had transient radiculopathies secondary to screw placement. The indications for lateral mass fixation include cases where the lamina or spinal processes are deficient or missing, multilevel or rotational instabilities, when extension to the thoracic spine or occiput is required or when decreased bracing is beneficial.     

Videolaryngoscopy vs. flexible fibrescopy for tracheal intubation in patients with cervical spine immobilisation: a randomised controlled trial

In patients with cervical spine immobilisation, tracheal intubation devices other than a direct laryngoscope are frequently used to facilitate tracheal intubation and avoid related complications. In this randomised controlled trial, we compared videolaryngoscopic and fibrescopic tracheal intubation in patients with a cervical collar. Tracheal intubation was performed using either a videolaryngoscope with a non-channelled Macintosh blade (n = 166) or a flexible fibrescope (n = 164) in patients having elective cervical spine surgery whose neck was immobilised with a cervical collar to simulate a difficult airway. The primary outcome was the first attempt success rate of tracheal intubation. Secondary outcomes were the overall success rate of tracheal intubation; time to tracheal intubation; use of additional airway manoeuvres; and incidence and severity of tracheal intubation-related airway complications. First attempt success rate was higher in the videolaryngoscope group than in the fibrescope group (164/166 (98.8%) vs. 149/164 (90.9%), p = 0.003). Tracheal intubation was successful within three attempts in all patients. Median (IQR [range]) time to tracheal intubation was shorter (50.0 (41.0–72.0 [25.0–170.0]) s vs. 81.0 (65.0–107.0 [24.0–178.0]) s, p < 0.001) and additional airway manoeuvres were less frequent (30/166 (18.1%) vs. 91/164 (55.5%), p < 0.001) in the videolaryngoscope group compared with the fibrescope group. The incidence and severity of intubation-related airway complications were not different between the two groups. When performing tracheal intubation in patients with a cervical collar, videolaryngoscopy with a non-channelled Macintosh blade was superior to flexible fibrescopy.     

Indications for halo immobilization of the cervical spine

Summary In the United States, cervical spine injuries are routinely immobilized with the halo apparatus. In Europe, this device is seldom used except in the treatment of spinal deviations. Based on studies of five cases the authors discuss the indications for use of the halo device in cervical spine injuries.     

颈椎外伤前路手术中体感诱发电位监护应用

目的探讨体感诱发电位(somatosensory evoked potential,SSEP)在颈椎外伤前路手术中的作用。方法 2008-07-2015-02收治颈椎外伤前路手术患者53例,年龄16~69岁,男44例,女9例。对照组(33例)无SSEP监护,监护组20例。在麻醉诱导后摆放体位前确立SSEP基线,波幅降低50%或潜伏期延长10%为报警标准。记录SSEP报警因素、改善措施及有无医源性神经损伤。计算SSEP监护神经损伤的敏感性和特异性。结果 53例病人术后未出现新的神经损伤。SSEP监护颈椎外伤前路手术中神经损伤的敏感性和特异性为100%。结论在颈椎外伤前路手术中SSEP监护医源性神经损伤是有意义的。     

Pediatric airway management: comparing the Berci–Kaplan Video Laryngoscope with direct laryngoscopy

Objectives:  To assess the utility of the Berci–Kaplan Video Laryngoscope (VL) in pediatric anesthesia.
Background:  The VL is designed to improve visualization of the glottis during tracheal intubation of normal and difficult airways in adults. This study was designed to assess the visual quality and the ease of tracheal intubation in children using the VL when compared with direct laryngoscopy (DL).
Methods:  Sixty children, aged 2–16 years requiring tracheal intubation, were enrolled in this prospective, randomized clinical trial. Following induction of anesthesia and muscle paralysis, the first laryngoscopy method, using either a DL or the VL, was performed by one anesthetist, and the laryngoscopic view was graded according to the Cormack–Lehane scale. Laryngoscopy and grading of the view in the second method were then performed by a second anesthetist. Tracheal intubation was completed following the second laryngoscopy, and time to intubation was recorded.
Results:  The average age and weight were 8.9 ± 3.6 years and 34.9 ± 16.0 kg respectively. Videolaryngoscopy improved 8/11 grade 2 views to grade 1 ( P  =   0.02), and one grade 3 to a grade 2. Three grade 2 views remained unchanged from DL to VL. 4/30 VL intubations required two attempts, and 1/30 failed after two attempts, but was easily intubated with DL. Median time (range) was 16.0 s (14.0–20.0 s) and 22.5 s (17.8–35.0 s) for DL and VL respectively ( P  <   0.001).
Conclusion:  Videolaryngoscopy provides better views than DL at the expense of time to intubate. Although the time taken to intubate is increased with the VL, it is clinically acceptable.     

Lamina-guided lateral mass screw placement in the sub-axial cervical spine

Lateral mass (LM) screws are commonly used in posterior instrumentation of the cervical spine because of their perceived safety over pedicle screws. A possible complication of cervical LM screw placement is vertebral artery injury or impingement. Several screw trajectories have been described to overcome the risks of neurovascular injury; however, each of these techniques relies on the surgeon’s visual estimation of the trajectory angle. As the reliability hereof is poorly investigated, alignment with a constant anatomical reference plane, such as the cervical lamina, may be advantageous. The aim of this investigation was to determine whether alignment of the LM screw trajectory parallel to the ipsilateral cervical lamina reliably avoids vertebral artery violation in the sub-axial cervical spine. 80 digital cervical spine CT were analysed (40 female, 40 male). Exclusion criteria were severe degeneration, malformations, tumour, vertebral body fractures and an age of less than 18 or greater than 80 years. Mean age of all subjects was 39.5 years (range 18–78); 399 subaxial cervical vertebrae (C3–C7) were included in the study. Measurements were performed on the axial CT view of C3–C7. A virtual screw trajectory with parallel alignment to the ipsilateral lamina was placed through the LM. Potential violation of the transverse foramen was assessed and the LM width available for screw purchase measured. There was no virtual violation of the vertebral artery of C3–C7 with lamina-guided LM screw placement. LM width available for screw purchase using this technique ranged from 5.2 to 7.4 mm. The sub-axial cervical lamina is a safe reference plane for LM screw placement. LM screws placed parallel to the ipsilateral lamina find sufficient LM width and are highly unlikely to injure the vertebral artery, even in bi-cortical placement. Placing LM screws parallel to the lamina appears favourable over conventional techniques.     

Comparison of two video-assisted techniques for the difficult intubation

BACKGROUND: Two recently developed video-optical intubation devices, the video-optical intubation stylet (VOIS) and the angled video intubation laryngoscope (AVIL) were compared for intubation times and success rate in a simulated difficult tracheal intubation setting. METHODS: Thirty anaesthetists were asked to perform 5 intubation attempts with both techniques. Intubation times were recorded and the subjective degree of difficulty and preference for each technique were requested. RESULTS: Intubation time with the VOIS was shorter (17.4+/-6.8 s) than with the AVIL (22.8+/-13.4 s; P=0.0001). Four of the 150 intubation attempts with the AVIL were scored as unsuccessful, due to prolonged intubation time (>60 s). The estimated degree of difficulty was not significantly different. CONCLUSION: In conclusion, both video-assisted intubation devices, the video-optical intubation stylet and the angled video intubation laryngoscope, can be considered to be simple and effective tools which facilitate tracheal intubation and which require only brief instruction and training.