Transoral microsurgical odontoid resection and spinal cord monitoring

Four patients underwent transoral resection of the odontoid with utilization of microsurgical technique and spinal cord monitoring of somatosensory cortical evoked responses. All patients improved following surgery, and no operative morbidity or mortality was encountered. Spinal cord monitoring enhances the safety of the procedure and, reapplied at a later date, detects information of prognostic value.     

CT based evaluation of odontoid morphology in the Indian population

Background:

Anterior fixation using two 3.5 mm screws is typically recommended for type II odontoid fractures. However, it is unsuitable in patients with an odontoid diameter of <9.0 mm. There is no data regarding the morphology of odontoid process in the Indian population. The aim of our study was to: a) Measure the external diameters of odontoid process in the Indian population using CT scan and thus determine the feasibility of two 3.5 mm screw fixation in them. b) Determine if any correlation exists between body height (Ht) and weight (Wt) and external odontoid diameters.

Materials and Methods:

CT images of odontoid process of 100 consecutive patients were analyzed. Antero- posterior (AP) and transverse (TD), outer diameters of the odontoid process were measured from the base and at 1 mm interval upwards on axial CT images.

Results:

The mean AP and mean TD were 11.52 mm and 9.85 mm, respectively. Fifty-five (55%) of the patients had at least one TD <9.0 mm. Five (5%) patients had at least one TD <7.4 mm. None of the patients had any diameter <5.5 mm. Body Ht correlated significantly with mean AP and mean TD of the odontoid process (AP: r = 0.276, P = 0.013; TD: r = 0.359, P = 0.001), whereas body Wt correlated significantly only with mean TD (AP: r = 0.162, P = 0.15; TD: r = 0.297, P = 0.007).

Conclusion:

More than half of the study population (55%) was unsuitable for two 3.5 mm screw fixation for type II odontoid fracture. Two 2.7 mm screws can be safely used in 95% of the population. A 4.5 mm Herbert screw can be safely used in the entire population. We recommend two 2.7 mm screws or a 4.5 mm Herbert screw for fixation of these fractures in the Indian population. Body height showed a significant correlation with external odontoid diameters, whereas weight showed significant correlation only with TD of the odontoid process.     

Transoral resection of thyroid cancer metastasis to lateral retropharyngeal nodes

BACKGROUND: Lymph node metastasis from differentiated thyroid carcinoma may occur outside of the basins at greatest risk of spread, such as the lateral retropharyngeal lymph nodes. The extensive surgery of traditional approaches to the retropharyngeal space are rarely justified in the treatment of metastatic differentiated thyroid cancer. Therefore, a less invasive surgical approach is advantageous in resection of metastatic lateral retropharyngeal nodes. METHODS: To assess feasibility and safety, we report transoral excision guided by preoperative ultrasonography in a series of 3 consecutive patients with differentiated thyroid cancer metastatic to the retropharyngeal space. RESULTS: In all cases, the metastatic lateral retropharyngeal lymph node was successfully removed by transoral retropharyngotomy without complications. CONCLUSIONS: We advocate a transoral approach guided by preoperative ultrasonography for resection of differentiated thyroid cancer metastatic to the retropharyngeal lymph nodes. The approach is feasible, minimally invasive, and safe in achieving the goals in management of regionally metastatic disease.     

Transoral resection of odontoid process fragment in a rheumatoid patient using Coblation electrosurgery

A new technique is described for the removal of ligaments and soft tissue during a transoral resection of the odontoid process in a patient with rheumatoid arthritis. The technique employed is Coblation, a form of electrosurgery that operates at lower temperatures than conventional electrosurgical technique and, therefore, produces less collateral damage.     

Typical and atypical fractures of the odontoid process in young children

Summary The most common injury to the odontoid process in children under the age of seven years is a fracture through the synchondrosis with or without anterior displacement of the odontoid process, but this is not the only type of fracture of the odontoid process in this age-group. Fractures above and below the synchondrosis and fractures with posterior displacement were described. Typical clinical features of these fractures are: (1) major and blunt trauma, (2) neck pain and resistance to active and passive head movements; and (3) no or only slight neurological deficits. Conservative treatment had excellent results in the majority of cases. Nevertheless, there are a few specific indications for surgery.     

Vertical fracture of the odontoid process. A case report

Odontoid process fractures are commonly classified as types I through III according to the Anderson & D'Alonzo scheme. A fourth type of fracture not included in this classification has been described as "vertical odontoid fracture". These fractures are located in the vertical plan of the dens. We describe a new case of an oblique coronally oriented fracture through the odontoid process with extension to the body of C2. Our patient is a 22-year-old lady who sustained a road traffic accident with head, facial and cervical trauma. Computed tomography with 2D and 3D reconstruction characterized the fracture. We suppose that the mechanism of injury was an axial load associated with dorsal to ventral force. The patient was placed on a halo-vest for 12 weeks with good healing and no evidence of instability on flexion-extension studies 6 months later. This case demonstrates that the odontoid and C2 vertebral body fractures belong to the same spectrum and are determined by the patient's anatomy and the mechanism of the injury.     

前路螺钉内固定治疗齿状突骨折的疗效分析

目的　研究颈前路螺钉内固定治疗齿状突骨折的疗效。方法　对 7例齿状突骨折患者 ,在X线监测下施行颈前路螺钉内固定法治疗。结果　随访 6～ 16个月 ,全部获得愈合 ,无并发症。结论　齿状突骨折应用螺钉内固定 ,可获得良好的治疗结果     

齿状突骨折伴寰枢关节脱位的治疗

目的　报告 38例齿状突骨折致寰枢关节脱位患者的治疗结果。方法　手术 35例 ,保守治疗 3例 ;随访 6个月～ 5年 ,平均 2 1.4个月。介绍了齿状突骨折所致寰枢关节脱位的症状、体征、影像学表现特点及治疗方法 ,并对其临床特点、损伤机制及手术适应证的选择进行了讨论。结果　优 2 4例 ,良 11例 ,无变化 3例。结论　手术治疗应为首选 ,移位≥ 4m m作为判断严重骨折脱位和选择术式的标准     

Transoral transpalatal removal of a giant premesencephalic clivus chordoma

Summary Due to their surgical inaccessibility and resistance to radiotherapy, clivus chordomas represent a formidable therapeutic challenge. The transoral approach to chordomas of the clivus has been usually restricted to relatively small or midsized neoplasms, located at the lower end of the clivus or at the anterior clival-cervical junction. In this report the transoral transpalatal transclival removal of a giant recurrent chordoma occupying the whole length of the clivus with considerable premesencephalic extension and brain stem compression is described. Regression of preoperative symtoms without additional postoperative morbidity could be achieved by radical transoral tumour extirpation documented by magnetic resonance imaging.     

Diagnostic pitfalls in osteomyelitis of the odontoid process: case report

BACKGROUND

Pyogenic osteomyelitis of the odontoid process is a very rare disease associated with a variety of clinical symptoms, and previous reports have stressed the difficulties inherent in making the diagnosis. The authors present a case of osteomyelitis of the odontoid process with epidural abscess in which magnetic resonance imaging (MRI) was used in the diagnosis, assessment of the extent of concomitant epidural abscess, treatment effect, and long-term follow-up.

CASE DESCRIPTION

A 68-year-old male was admitted to our hospital with cervical pain, neck stiffness, and fever. Although the diagnosis was missed at the beginning, the patient was diagnosed with osteomyelitis of the odontoid process with a paravertebral epidural abscess by MRI. The patient became asymptomatic after 3 months of antibiotic therapy.

CONCLUSION

Pyogenic osteomyelitis of the odontoid process is a rare condition requiring a high index of suspicion for diagnosis. MRI examination should be considered in the diagnosis in patients with neck pain combined with fever. Serial MRI during and after antibiotic therapy provided an objective assessment of the healing rate of the lesions.     

The borders of the odontoid process of c2 in adults and in children including the estimation of odontoid/body ratio

The odontoid process of C2 projects upward from the superior roof of the body of C2. There is a confusion about the inferior border of the odontoid. The aims of this clinical study were to describe the inferior border of the odontoid process based on the remnant of dentocentral synchondrosis in adults, and the estimation of the odontoid/body ratio in pediatric and adult ages. Sixty-six cases were included for this study. Forty-four of them were in adult ages and the remaining 22 of them were in pediatric ages. The region of occiput, C1, C2, and C3, was examined with the magnetic resonance imaging (MRI) in all cases. The length of the odontoid process was estimated by using radiological images of MR from the tip of the odontoid to the remnant of dentocentral synchondrosis. The portion located under the level of synchondrosis was considered as the body of C2. The average length of the odontoid was 18. 6 mm in pediatric and 21. 3 mm in adult cases. In adult females, the length of the odontoid process (19. 1 mm in length) was smaller than those of adult males (23. 6 mm in length). The average ratio of odontoid/body was two in pediatric and 1.8 in adult cases. This study demonstrated that the neck of the odontoid segment at the level of superior articulating facets is not the synchondrosis between the odontoid process and the body of C2. The synchondrosis is located well below the level of superior articulating facets. It can be demonstrated with sagittal and coronal images of MR in both of pediatric and adult individuals.     

Efficacy of anterior odontoid screw fixation in the elderly patient: a CT-based biometrical analysis of odontoid fractures

In the elderly population, reported union rates with anterior odontoid screw fixation (AOSF) for odontoid fracture (OF) treatment vary between 23 and 93% when using plain radiographs. However, recent research revealed poor interobserver reliability for fusion assessment using plain radiographs compared to CT scans. Therefore, union rates in patients aged ≥60 years treated with AOSF have to be revisited using CT scans and factors for non-union to be analysed. Prospectively gathered consecutively treated patients using AOSF for odontoid fracture with age ≥60 years were reviewed. Medical charts were assessed for demographics, clinical outcomes and complications. Patients’ preoperative radiographs and CT scans were analysed to characterize fracture morphology and type, fracture displacement, presence of atlanto-dental osteoarthritis as well as a detailed morphometric assessment of fracture surfaces (in mm²). CT scans performed after a minimum of 3 months postoperatively were analysed for fracture union. Those patients not showing CT-based evidence of completely fused odontoid fracture were invited for radiographic follow-up at a minimum of 6 months follow-up. Follow-up CT-scan were studied for odontoid union as well as the number of screws used and the square surface of screws used for AOSF and the related corticocancellous osseous healing surface of the odontoid fragment (in %) were calculated. Patients were stratified whether they achieved osseous union or fibrous non-union. Patients with a non-union were subjected to flexion–extension lateral radiographs and the non-union defined as stable if no motion was detected. The sample included 13 male (72%) and 5 female (18%) patients. The interval from injury to AOSF was 4.1 ± 5.3 days (0–16 days). Age at injury was 78.1 ± 7.6 years (60–87 years) and follow-up was 75.7 ± 50.8 months (4.2–150.2 months). 10 patients had dislocated fractures, 14 had Type II and 4 “shallow” Type III fractures according to the Anderson classification, 2 had stable C1-ring fractures, 8 had displayed atlanto-dental osteoarthritis. Fracture square surface was 127.1 ± 50.9 mm² (56.3–215.9 mm²) and osseous healing surface was 84.0 ± 6.8% (67.6–91.1%). CT-based analysis revealed osseous union in 9 (50%) and non-union in 9 patients (50%). Union rates correlated with increased fracture surface (P = 0.02). Statistical analysis revealed a trend that the usage of two screws with AOSF correlates with increased fusion rates (P = 0.06). Stability at C1–2 was achieved in 89% of patients. CT scans are accepted as the standard of reference to assess osseous union. The current study offers an objective insight into the union rates of odontoid fractures treated with AOSF using CT scans in consecutive series of 18 patients ≥60 years. Literature serves evidence that elderly patients with unstable OF benefit from early surgical stabilization. However, although using AOSF for unstable OF yields segmental stability at C1–2 in a high number of patients as echoed in the current study, our analysis stressed that using follow-up CT scans in comparison to biplanar radiographs dramatically reduces osseous union rates compared to those previously reported for AOSF.     

Transoral approach to accessory parotid tumours: case series and literature review

Accessory parotid tumours are rare, accounting for less than 10% of parotid neoplasms. Although similar tumours affect both the accessory parotid and parotid, accessory parotid tumours are associated with higher rates of malignancy. Surgery is first line management. Standard surgical management involves a similar approach to superficial parotidectomy, despite the anterior location of these lesions. This approach requires extensive subcutaneous access and facial nerve dissection and therefore, poses significant risk. It can also result in poor cosmetic result due to scarring and Frey's Syndrome. On the contrary, a transoral approach to reduces the risk of cosmetic deformity, reduces recovery time and does not increase risk to the facial nerve. We present a case series of patients with accessory parotid masses, which have been successfully excised transoral and without endoscopic assistance.