Experiencia en patología cervical alta en el Hospital Guillermo Almenara Irigoyen 2016 - 2021

Introducción : El complejo C0-C1-C2 es responsable de la transición de la carga axial, con función biomecánica única, siendo afectada por múltiples patologías, que por lo general la literatura no las considera como un solo ítem, sino que lo desarrolla según su etiología, pero en nuestro estudio se ha considerado en 5 grupos: traumática, congénita, inflamatoria reumática, neoplásica y degenerativa. Objetivo : Determinar las características epidemiológicas, clínicas y del tratamiento en la patología cervical alta. Materiales y métodos : Se incluyeron a todos los pacientes con diagnóstico clínico radiológico de alguna patología cervical alta que hayan sido sometidos a tratamiento quirúrgico entre 2016 y 2021 en el Hospital Almenara. Se usó el test "t" de student y de chi cuadrado. Se dividió a los pacientes en alguno de los 5 grupos antes mencionados. Resultados : Se consideraron 31 pacientes, con una edad media de 51.16 años. La patología cervical alta más frecuente fue la traumática con el 35.48%. El déficit motor se presentó en el 51.61% y el déficit sensitivo se presentó en el 54.84%. La cirugía más frecuente fue la fijación cervical alta con el 43.89%. La tasa de complicaciones fue del 16.13% con una mortalidad del 0%. Conclusiones : La patología cervical alta es rara, siendo la del tipo traumática la más frecuente, pero un manejo oportuno y adecuado permite un mejor pronóstico funcional del paciente.

Introduction : The C0-C1-C2 complex is responsible of axial load transition, and its biomechanical function is unique, it is affected by multiple pathological conditions; and generally speaking, the literature does not consider these conditions as a single item, it describes them according to etiology. For our study we considered five groups: trauma-related, congenital, rheumatic-inflammatory, neoplastic, and degenerative. Objective : To determine epidemiological, clinical, and therapy-related characteristics in upper cervical pathological conditions. Materials and methods : All patients with a clinical-radiological diagnosis of any upper cervical pathological condition that had undergone surgery between 2016 and 2021 in Guillermo Almenara Hospital were included. Student's t test and chi square methods were used. patients were divided into one of the five aforementioned groups. Results : Thirty-one patients were included in the study; their mean age was 51.16 years. The most frequent upper cervical pathological condition was trauma-related, with 35.48%. Motor deficit occurred in 51.61% of all patients, and sensitive deficit occurred in 54.84%. The most frequently surgical procedure performed was upper cervical fixation, in 43.89% of all patients. Complication rate was 16.13%, and mortality was 0%. Conclusions : Upper cervical pathological conditions are rare, trauma-related conditions are most frequent, but timely and adequate management allow us to achieve better functional prognosis for these patients.

Biomechanical evaluation of four surgical techniques for ventral stabilization of the atlantoaxial joint in dogs

ABSTRACT Purpose: This study compared, through biomechanical evaluation under ventral flexion load, four surgical techniques for ventral stabilization of the atlantoaxial joint in dogs. Methods: In total, 28 identical atlantoaxial joint models were created by digital printing from computed tomography images of a dog, and the specimens were divided into four groups of seven. In each group, a different technique for ventral stabilization of the atlantoaxial joint was performed: transarticular lag screws, polyaxial screws, multiple screws and bone cement (polymethylmethacrylate-PMMA), and atlantoaxial plate. After the stabilization technique, biomechanical evaluation was performed under ventral flexion load, both with a predefined constant load and with a gradually increasing load until stabilization failure. Results: All specimens, regardless of stabilization technique, were able to support the predefined load without failing. However, the PMMA method provided significant more rigidity (p ≤ 0.05) and also best resisted the gradual increase in load, supporting a significantly higher maximum force (p ≤ 0.05). There was no statistical difference in flexural strength between the transarticular lag screws and plate groups. The polyaxial screws method was significantly less resistant to loading (p ≤ 0.05) than the other groups. Conclusions: The PMMA technique had biomechanical advantages in ventral atlantoaxial stabilization over the other evaluated methods.

Análise biomecânica das fixações atlantoaxiais: estudo experimental / Análise biomecânica das fixações atlantoaxiais: estudo experimental

Introdução: o tratamento cirúrgico de pacientes com fraturas do processo odontoide tem sido controverso. As principais técnicas cirúrgicas para o segmento C1-C2 incluem além da artrodese cervical (aramagem tipo Gallie, parafusos transarticulares e aramagem tipo 88), a fixação direta com parafuso no processo odontoide. Objetivo: comparar a estabilidade mecânica destes quatro tipos de osteossínteses do segmento atlantoaxial (C1-C2). Metodologia: vinte segmentos atlantoaxiais de cadáveres humanos adultos foram preparados com fraturas do tipo 2 de Anderson e D'Alonso e divididos em quatro grupos: aramagem tipo Gallie (aG); parafusos transarticulares (pT); parafuso no processo odontoide (pD); aramagem tipo 88 (a88). Os corpos de prova foram submetidos a esforços de flexocompressão em máquina universal de ensaios mecânicos para análise de resistência, elasticidade e deformações. Resultados:na fase de acomodação, os parafusos no processo odontoide apresentaram pouquíssima mobilidade com cargas baixas. Na fase de elasticidade, não houve diferença significativa entre as construções testadas. Com relação à resistência máxima suportada pelas construções, houve uma diferença estatisticamente significativa a favor da aramagem tipo Gallie. Conclusão: nossos testes mostraram que em relação à acomodação houve diferença significativa entre a aramagem tipo Gallie e o parafuso no processo odontoide; e quanto à resistência máxima, entre a aramagem tipo Gallie e o parafuso transarticular.

Introduction: the surgical treatment of patients with fractures of the odontoid process has been controversial. The main surgical techniques for C1-C2 are: Gallie wiring, transarticular screw, direct odontoid process screw and 88 posterior laminar wiring. Objective: to compare the mechanical stability of these four types of atlantoaxial segment osteosynthesis (C1/C2). Methodology: twenty atlantoaxial segments of adult human cadavers were prepared with Anderson and D'Alonso type II fractures and divided into four groups: Gallie wiring; transarticular screw; odontoid process screw; 88 wiring. After being fixed with each osteosynthesis technique, they were submitted to flexocompression efforts in a universal mechanical testing machine for analysis of strength, elasticity and deformations. Results: in the accommodation phase, the odontoid process screws showed very little mobility with low loads. In the elasticity phase, there was no significant difference between the constructions tested. With regard to the maximum resistance supported by the constructions, there was a statistically significant difference in favor of Gallie wiring. Conclusion: Our tests showed a significant difference between Gallie wiring and odontoid process screw in accommodation; and between the Gallie wiring and the transarticular screw in maximum resistance test

Craniometric parameters for the evaluation of platybasia and basilar invagination on magnetic resonance imaging: a reproducibility study / Parâmetros craniométricos para platibasia e invaginação basilar na ressonância magnética: estudo de reprodutibilidade

Abstract Objective: The present study aims to perform a reproducibility study of the clivus-canal angle (CCA), Welcker's basal angle (WBA), and the distance from the odontoid process to Chamberlain's line (DOCL) on magnetic resonance imaging (MRI). Materials and Methods: Two medical students and two radiologists respectively evaluated 100 and 50 consecutive MRI scans of adult skulls, selected randomly. Each examiner, working independently and blinded to the previous results, performed readings for each patient on two different occasions. Measurements were performed in T1-weighted sequences acquired in the midsagittal plane. The levels of intraobserver reproducibility and interobserver agreement were evaluated by calculating the intraclass correlation coefficients (ICCs) and the corresponding 95% confidence intervals. Results: The mean values obtained by the examiners were 150° for the CCA, 130° for the WBA, and 2.5 mm for the DOCL. The ICC for interobserver agreement was 0.980, 0.935, and 0.967, for the CCA, WBA, and DOCL, respectively, for the students, compared with 0.977, 0.941, and 0.982, respectively, for the radiologists, and 0.980, 0.992, and 0.990, respectively, for all of the examiners together. In the analysis of intraobserver agreement, the ICC ranged from 0.929 to 0.959 for the CCA, from 0.918 to 0.964 for the WBA, and from 0.918 to 0.981 for the DOCL. Conclusion: The measurement of the CCA, WBA, and DOCL appears to show excellent intraobserver reproducibility and interobserver agreement on MRI.

Resumo Objetivo: Realizar um estudo de reprodutibilidade do ângulo clivocanal (ACC), ângulo basal de Welcker (ABW) e distância do odontoide à linha de Chamberlain (DOLC) em ressonância magnética (RM). Materiais e Métodos: Quatro examinadores, dois graduandos de medicina e dois radiologistas, avaliaram, respectivamente, 100 e 50 indivíduos adultos submetidos a RM de crânio, consecutiva e aleatoriamente. Cada um realizou duas leituras para cada paciente em diferentes ocasiões, de forma cega e independente. As análises de concordância intraobservador e interobservador foram realizadas pelo coeficiente de correlação intraclasse (CCI), com intervalo de confiança de 95%. Resultados: As medidas médias, considerando todos os examinadores, foram: ACC = 150°, ABW = 130°, DOLC = 2,5 mm. A análise interobservador entre os estudantes revelou CCI de 0,980, 0,935 e 0,967 para ACC, ABW e DOLC, respectivamente, e para os radiologistas, CCI de 0,977, 0,941 e 0,982, respectivamente. A análise interobservador entre estudantes e radiologistas revelou CCI de 0,980, 0,992 e 0,990, respectivamente. Em relação à análise intraobservador, as medidas do ACC tiveram CCI variando entre 0,929 e 0,959, ABW entre 0,918 e 0,964 e DOLC entre 0,918 e 0,981. Conclusão: ACC, ABW e DOLC obtiveram excelentes reprodutibilidades intraobservador e interobservador na RM.

Síndrome de la apófisis odontoides coronada, una manifestación inusual de dolor cervical. Presentación de un caso / Crowned Dens Syndrome, an Unusual Manifestation of Cervical Pain. A Case Report

Resumen Las enfermedades por depósito de cristales de pirofostato dehidratado de calcio o hidroxiapatita se pueden manifestar en cualquier articulación, y cuando se acumulan en la columna cervical pueden ser causa de dolor. El síndrome de la apófisis odontoides coronada es una rara condición clínica que se presenta por calcificación, en forma de corona, de los ligamentos que rodean a la apófisis odontoides. Se presenta el caso de un hombre de 70 años, con una semana de cervicalgia, cefalea y fiebre, que ingresó por sospecha de patología neurológica. Se realizó tomografía computarizada (TC) de cráneo que documentó calificaciones lentiformes del ligamento transverso del atlas. Se instauró manejo con corticoides y antiinflamatorios no esteroideos con mejoría. Una adecuada anamnesis junto con estudio por imagen evita procedimientos innecesarios y permite incluir esta entidad en el diagnóstico diferencial del dolor cervical agudo.

Abstract The calcium pyrophosphate dehydrate (CPPD) or hydroxyapatite (HA) crystal deposition disease can appear in any joint and the accumulation fo crystals in the cervical spine may be painful. Crowned dens syndrome is a rare clinical condition that involves crown-like calcification of the ligaments around the odontoid process. A 70-year-old man presented cervical pain, fever and a headache for over a week, therefore, a neurological condition was suspected. A CT scan revealed lentiform calcifications of the transverse ligament of the atlas. Steroid treatment and a non-steroidal anti-inflammatory diminished the symptoms. A proper clinical history and imaging studies avoid unnecessary procedures and makes it possible to include this entity as a differential diagnosis in acute cervical pain.

Retro-odontoid pseudotumor: a poorly recognized alteration of the craniocervical junction

SUMMARY INTRODUCTION Retro-odontoid pseudotumor (ROP) is a rare disease that affects the atlantoaxial joint and, in general, is associated with local biomechanical alterations that may or may not cause instability. METHODS Descriptive study of the literature available in databases MEDLINE/PubMed, LILACS, and Scopus. The research was conducted in April 2019. DISCUSSION ROP is, possibly, a syndromic designation that encompasses a significant variety of diseases of the atlantoaxial joint. There are different pathophysiological mechanisms implicated in its genesis. The patients, almost in their entirety, present with severe myelopathy, and most of them are treated surgically, with the posterior decompression being the most commonly used method, with or without arthrodesis. Evolution is usually favorable. CONCLUSION The ROP is still poorly recognized as a differential diagnosis between the diseases of the cranial-cervical junction. The information available in the literature analyzed was based mainly on the study of reports or case series; therefore, it is insufficient to define conducts with a high level of scientific evidence.

RESUMO INTRODUÇÃO O pseudotumor retro-odontoide (PRO) é uma patologia rara que acomete a articulação atlantoaxial e, em geral, está associada a alterações biomecânicas locais que podem ou não causar instabilidade. METODOLOGIA Estudo descritivo da literatura disponível nas bases de dados Medline/PubMed, Lilacs e Scopus. A pesquisa foi realizada em abril de 2019. DISCUSSÃO O PRO é, possivelmente, uma designação sindrômica que abrange uma variedade significativa de doenças da articulação atlantoaxial. Existem diferentes mecanismos fisiopatológicos implicados em sua gênese. Os pacientes, quase em sua totalidade, apresentam quadro de mielopatia grave e a maioria deles é tratada cirurgicamente, sendo a descompressão posterior o método mais utilizado, com ou sem artrodese. A evolução costuma ser favorável. CONCLUSÃO O PRO ainda é pouco reconhecido como diagnóstico diferencial entre as doenças da junção crânio-cervical. As informações disponíveis na literatura analisada foram baseadas principalmente no estudo de relatos ou séries de casos, sendo, portanto, insuficientes para definir condutas com alto nível de evidência científica.

Advances in research of odontoid fractures in the elderly / 中华外科杂志

Odontoid fractures constitute the most common cervical spine fracture in the population aged. The optimal management strategy for odontoid fractures remains controversial, especially in the elderly, because of the high morbidity and mortality with both conservative and operative intervention. This review discusses the management of odontoid fractures among the elderly, with a focus on the various treatment options and their outcomes.

Related issues on selection of minimally invasive treatments for odontoid fractures / 中华创伤杂志

Odontoid fracture is the most common type of upper cervical vertebral fractures. Because the blood supply of odontoid is poor and the healing rate of part fractures is low, surgical treatment can increase the chance of fracture healing. Compared with traditional open surgery, minimally invasive treatment has obvious advantages, such as less trauma and faster recovery. Different types of odontoid fracture should be treated with different surgical methods. Only by accurately classifying odontoid fractures and choosing accurate minimally invasive treatment methods can we achieve safe and effective expected results. The author introduces the classification of odontoid fracture and the selection strategies of minimally invasive treatment methods, and puts forward the existing problems and development prospects, so as to provide help for the treatment and research of odontoid fracture.

Related issues on selection of minimally invasive treatments for odontoid fractures / 中华创伤杂志

Odontoid fracture is the most common type of upper cervical vertebral fractures.Because the blood supply of odontoid is poor and the healing rate of part fractures is low,surgical treatment can increase the chance of fracture healing.Compared with traditional open surgery,minimally invasive treatment has obvious advantages,such as less trauma and faster recovery.Different types of odontoid fracture should be treated with different surgical methods.Only by accurately classifying odontoid fractures and choosing accurate minimally invasive treatment methods can we achieve safe and effective expected results.The author introduces the classification of odontoid fracture and the selection strategies of minimally invasive treatment methods,and puts forward the existing problems and development prospects,so as to provide help for the treatment and research of odontoid fracture.

Comparison between non-fusion and fusion internal fixation with posterior pedicle screw for odontoid fracture / 中华创伤杂志

Objective To investigate the clinical efficacy of non-fusion and fusion internal fixation with posterior pedicle screw for odontoid fractures. Methods A retrospective case control study was conducted to analyze the clinical data of 46 patients with odontoid fractures admitted to Henan Provincial People's Hospital from January 2013 to June 2015. There were 35 males and 11 females, aged 19-62 years [(36. 9 ± 1. 6)years]. The preoperative odontoid fractures were classified as type IIA in five patients, type IIB in eight, type IIC in 22, shallow type III in six according to Anderson and D'Alonzo typing. The fractures of five patients were not classified. According to the ASIA grading, the preoperative spinal cord function was graded as D or E in the 46 patients. Among the patients, 15 underwent posterior pedicle screw non-fusion internal fixation ( Group A) , with 60 pedicle screws removed 12-29 months after operation. A total of 31 patients were treated with fusion internal fixation with posterior pedicle screw ( Group B) , with 124 pedicle screws free from removal after operation. The follow-up time, operation time, intraoperative fluoroscopy time, intraoperative blood loss as well as visual analog scale (VAS), cervical rotation degree, and neck disability index ( NDI) before operation, 1 year after surgery ( when no internal fixation was removed ) and at the last follow-up were compared between the two groups. Results There were no significant differences between the two groups in the follow-up time, operation time, intraoperative fluoroscopy time, intraoperative blood loss, VAS score, neck rotation degree, NDI score before operation and at 1 year after operation (P >0. 05). There were significant differences between two groups in VAS scores, neck rotation degree, NDI scores indicating driving and walking and recreational activities at the last follow-up ( P <0. 05 ) . There were no significant differences between two groups in other NDI scores items, including neck discomfort, personal care, lifting heavy objects, reading & watching TV, headache situation, attention, working status, and sleep disorder at the last follow-up ( P> 0. 05 ) . Conclusions Posterior pedicle screw internal fixation for odontoid process fracture has good curative effect. Non-fusion internal fixation with posterior pedicle screw is more conducive to the recovery of cervical spine rotation function, the relief of neck and back pain, and the improvement of patients' driving, walking and entertainment activities.

Síndrome de la apófisis odontoides coronada, una manifestación inusual de dolor cervical: presentación de un caso / Crowned Dens Syndrome, An Unusual Manifestation of Cervical Pain: A Case Report

Las enfermedades por depósito de cristales de pirofosfato dihidratado de calcio o hidroxiapatita se pueden manifestar en cualquier articulación y cuando se acumulan en la columna cervical pueden causar dolor. El síndrome de la apófisis odontoides coronada es una rara condición clínica que consiste en la calcificación en forma de corona de los ligamentos que rodean a la apófisis odontoides. Se describe el caso de un hombre de 70 años de edad con una semana de cervicalgia, cefalea y fiebre, que ingresa por sospecha de patología neurológica. Se realiza TC de cráneo que documenta calcificaciones lentiformes del ligamento transverso del atlas. Se instaura manejo con corticosteroides y antiinflamatorios no esteroideos, con mejoría. Una adecuada anamnesis, junto con estudio por imagen, evita procedimientos innecesarios y permite incluir esta entidad en el diagnóstico diferencial del dolor cervical agudo.

The calcium pyrophosphate dehydrate (CPPD) or hydroxyapatite (HA) crystal deposition disease can manifest in any joint and when it comprises the cervical spine can lead to pain. Crowned dens syndrome is a rare clinical condition that is featured by crown-like calcification of ligaments around the odontoid process. We describe the case of a 70-year-old man with cervical pain, headache and fever for over a week in whom a neurological condition was suspected. A CT scan revealed lentiform calcifications of the transverse ligament of the atlas. Treatment with steroids and non-steroidal anti-inflammatory improve the symptoms. A proper clinical history and imaging studies avoid unnecessary procedures and can let this entity to be included as a differential diagnosis in acute cervical pain.

Una causa infrecuente de dolor de cuello. Síndrome de la apófisis odontoides coronada / An infrequent cause of neck pain. Crowned dens síndrome

Resumen En la práctica clínica habitual existe un crecimiento en la demanda asistencial de servicios de urgencias. El dolor cervical es una patología muy frecuente que compete a diversos profesionales sanitarios. El síndrome de apófisis odontoides coronada, es una patología muy poco frecuente, que hace parte del espectro de las enfermedades por microcristales de pirofosfato cálcico, ocasionando una calcificación de ligamentos del proceso de odontoides cervical, llevando a una clínica de cervicalgia, fiebre y rigidez de nuca. Esta patología entra en el diagnóstico diferencial con patologías potencialmente graves. En muchas ocasiones lleva a procedimientos y gastos farmacológicos innecesarios, principalmente por el desconocimiento que la transforma en una patología infradiag-nosticada. (Acta Med Colomb 2018; 43: 230-232).

Abstract In the usual clinical practice there is a growth in the demand for emergency services. Cervical pain is a very common pathology that concerns various health professionals. The crowned den syndrome is a very rare pathology, which is part of the spectrum of microcrystalline diseases of calcium pyrophosphate, causing a calcification of ligaments of the cervical odontoid process, leading to clinical signs of neck pain, fever and neck stiffness. This pathology enters into the differential diagnosis with potentially serious pathologies. In many cases it leads to unnecessary pharmacological procedures and expenses, mainly due to the ignorance that turns it into an infra diagnosed pathology. (Acta Med Colomb 2018; 43: 230-232).

Reduction and internal fixation of complex fractures of the odontoid by the transoral approach / Redução e osteossíntese de fratura complexa do odontoide por via transoral / Reducción y fijación interna de fracturas complejas de la odontoides por la vía transoral

ABSTRACT Type II odontoid fractures with irreducible posterior displacement are uncommon, and can cause spinal cord compression, respiratory failure and even death. Treatment is usually surgical, with transoral decompression and posterior fusion or with reduction and fusion of C1-C2 by the transoral approach. We describe a case of type II odontoid fracture with irreducible posterior atlantoaxial dislocation that was treated exclusively by the transoral approach with osteosynthesis of the odontoid, thus preserving functional segmental mobility. Level of Evidence III; therapeutic study.

RESUMO As fraturas do odontoide tipo II com deslocamento posterior irredutível não são comuns e podem causar compressão medular, insuficiência respiratória e até óbito. O tratamento habitualmente é cirúrgico, com descompressão transoral e fusão posterior, ou com a redução e fusão C1-C2 pela via transoral. Descrevemos um caso de fratura do odontoide tipo II, com deslocamento atlantoaxial posterior irredutível, que foi tratado exclusivamente por via transoral, com a osteossíntese do odontoide, preservando, assim, a mobilidade funcional segmentar. Nível de Evidência III; Estudo terapêutico

RESUMEN Las fracturas tipo II de la odontoides con desplazamiento posterior irreductible son poco comunes y pueden causar compresión de la médula espinal, insuficiencia respiratoria e incluso la muerte. El tratamiento suele ser quirúrgico con descompresión transoral y fusión posterior o con reducción y fusión de C1-C2 por vía transoral. Se describe un caso de fractura tipo II de la odontoides con luxación atlantoaxial posterior irreductible que fue tratada exclusivamente por vía transoral con osteosíntesis de la odontoides, preservando así la movilidad segmentaria funcional. Nivel de Evidencia III; Estudio terapéutico.

Anterior fixation of odontoid fractures: results / Fixação anterior de fraturas do processo odontoide: resultados

ABSTRACT Objective: To evaluate the clinical and radiological outcomes of the surgical treatment in patients diagnosed with odontoid fracture who underwent open reduction and internal fixation (ORIF) with screws. Methods: This was a retrospective study with nine patients. Pain (visual analog scale [VAS]) and neurological status (Frankel scale) were assessed. The neck disability index (NDI) and the post-operative cervical range of motion were calculated. The cervical spine was radiologically evaluated (X-ray and CT) pre- and postoperatively. Results: The mean age of patients was 70 years. All patients presented type IIb (Grauer classification) fractures, with a mean deviation of 2.95 mm. Two patients had subaxial lesions. The mean follow-up was 30 months. The mean time from trauma to surgery was seven days. The pre-operative Frankel score was E in all except one patient (B), in whom a post-operative improvement from B to D was observed. Post-operative pain was 2/10 (VAS). A total of 77% of patients presented a mild or moderate disability (NDI). Six patients regained full range of cervical movement, and bone union required approximately 14 weeks. Pseudarthrosis complications were observed in two patients (77% union rate), one patient presented screw repositioning and one case, dysphonia. Conclusion: Delayed diagnosis is still an issue in the treatment of odontoid fractures, especially in elderly patients. Concomitant lesions, especially in younger patients, are not uncommon. The literature presents high fusion rates with ORIF (≥80%), which was also observed in the present study. However, surgical success depends on proper patient selection and strict knowledge of the technique. This pathology presents a reserved functional prognosis in the medium-term, especially in the elderly.

RESUMO Objetivo: Avaliar os resultados clínicos e radiológicos do tratamento cirúrgico em pacientes com diagnóstico de fratura do processo odontoide submetidos a redução aberta e fixação interna (RAFI) com parafusos. Métodos: Estudo retrospectivo com nove pacientes. Avaliada a dor (escala visual analógica [EVA]) e o estado neurológico (escala de Frankel). O Neck Disability Index (NDI) e a amplitude de movimento cervical pós-operatória foram calculados. A coluna cervical foi avaliada radiologicamente (raios X e TC) nos períodos pré- e pós-operatório. Resultados: A idade média dos pacientes foi de 70 anos. Todos apresentaram fraturas do tipo IIb (classificação de Grauer), com desvio médio de 2,95 mm. Dois apresentaram lesões subaxiais. O seguimento médio foi de 30 meses. O tempo médio entre trauma e cirurgia foi de sete dias. O escore pré-operatório de Frankel foi E em todos, exceto em um paciente (B), no qual se observou uma melhoria pós-operatória de B para D. A dor pós-operatória foi 2/10 (EVA). Apresentaram incapacidade leve ou moderada (NDI) 77% pacientes. Seis pacientes recuperaram toda a amplitude de movimento cervical; a consolidação óssea levou aproximadamente 14 semanas. Foram observadas complicações de pseudartrose em dois pacientes (taxa de consolidação: 77%), um paciente necessitou reposicionamento do parafuso e um paciente, disfonia. Conclusão: O diagnóstico tardio ainda é um problema no tratamento de fraturas do odontoide, especialmente em pacientes idosos. As lesões concomitantes, especialmente em pacientes mais jovens, não são incomuns. A literatura apresenta altas taxas de consolidação com RAFI (≥ 80%), o que também foi observado no presente estudo. No entanto, o sucesso cirúrgico depende da seleção adequada do paciente e do conhecimento rigoroso da técnica. Essa patologia apresenta um prognóstico funcional reservado em médio prazo, especialmente em idosos.

Acute neck pain due to crowned dens syndrome: A case report

Crowned dens syndrome (CDS) is a cause of neck pain characterized by calcium deposition in the periodontoid tissues. Clinical features of the syndrome are acute onset of neck pain and headache with fever. Computed tomographic imaging is necessary for diagnosis. The prognosis of CDS is excellent. Symptoms disappear within several weeks and calcifications may be absorbed. We report a case of CDS with acute onset of severe neck pain, facial pain, and pharyngeal pain provoked by swallowing.

Classification of the axial mastoid process and its clinical application / 中华创伤骨科杂志

Objective To explore a simple classification of the axial mastoid process and its clinical significance in improving the traditional screw insertion in the treatment of odontoid fracture with percutaneous anterior odontoid screwing. Methods The median sagittal CT images of 120 patients with cervical dis-ease were measured. They were 63 males and 57 females, aged from 31 to 59 years (average, 41.6 years). On their median sagittal CT images, line A was the connection of the lowest point of the anterior inferior boarder of the axis body to the vertex of the odontoid process and line B a parallel line to line A through the mastoid process. The distance between lines A and B was measured (the height of the axial mastoid process) and a complete statistical record was made to analyze the distribution and regularity of distances AB. The improved insertion points were indentified based on the above measurements (X25%and X75%) and clinical ex-perience. We reviewed 32 patients with odontoid fracture of Anderson&D' Alonzo typeⅡA, ⅡB or superficialⅢ. Of them 15 underwent percutaneous anterior screwing by the improved insertion points and 17 underwent percutaneous anterior screwing by the conventional insertion points. The 2 groups were compared in terms of incision length, operation time, bleeding, fluoroscopy frequency and hospital stay. Results Distance AB was 3.42 ± 0.68 mm. The distance AB <3 mm was classified as low-level mastoid process, the distance AB between 3 to 4 mm as slightly convex mastoid process, and the distance AB > 4 mm as convex mastoid process. Of the 120 patients, 32 (26.7% ) were classified as having a low-level mastoid process, 57 (47.5%) as having a slightly convex mastoid process, and 31 (25.8%) as having a convex mastoid process. Compared with the conventional insertion group, the improved insertion group had significantly shorter oper-ation time (31.32 ± 2.12 min versus 46.18 ± 3.63 min), significantly lower fluoroscopy frequency (18.20 ±1.57 times versus 21.27 ± 2.50 times) but significantly greater bleeding (43.22 ± 3.17 mL versus 31.22 ± 3.52 mL) (P <0.05). There were no significant differences between the 2 groups in incision length or hospital stay (P > 0.05). Conclusions In the treatment of odontoid fracture with percutaneous anterior odontoid screwing, the screw insertion can be improved according to our classification of the axial mastoid process. Our simple classification of the axial mastoid process may lead to more efficient operation and less radiation hazard.

Three-phase surgical treatment assisted with Halo-vest for special Anderson-D'Alonzo type Ⅱ and superficial type Ⅲ odontoid fractures / 中华创伤杂志

Objective To assess the efficacy of internal fixation assisted with Halo-vest in the treatment of Anderson-D'Alonzo type Ⅱ and superficial type Ⅲ odontoid fractures.Methods A retrospective case series study was made on 15 patients clinically diagnosed as Anderson-D'Alonzo type Ⅱ and type Ⅲ odontoid fractures with a fracture gap over 2 mm,displacement over 5 mm and broken end angel over 11° from January 2007 to January 2015.There were nine males and six females,aged 27-61 years [(44.5 ± 10.9)years].The patients were treated in "three phases" with the assistance of Halo-vest external fixation system and a novel guide pin aiming device.The three phases were as follows:phase Ⅰ:cervical traction reduction and halo-vest external fixation;phase Ⅱ:Halo-vest assisted internal fixation using the novel aiming device;phase Ⅲ:the Halo-vest fixation removal and cervical collar fixation.Operation duration,intraoperative bleeding,and postoperative visual analogue scale (VAS) pain score one month after the operation were recorded.The cervical lateral and open mouth X-ray or atlantoaxial CT scan with sagittal and coronal two-dimensional reconstruction were regularly reviewed,and the location of screws,reduction and fracture healing were evaluated.Results Operation duration ranged from 54 to 96 minutes [(71.3-± 11.9) min].The intraoperative blood loss was 5-60 ml [(32.6 ± 16.8) ml].There was no spinal cord or nerve root injury,cerebrospinal fluid leakage,wound infection or other complications.All patients were followed up for 12-36 months (mean,28 months).Fourteen patients were seen bony union 6 months after the surgery and one patient was seen a false joint.At the last follow-up,the patient with false joint was seen bone sclerosis,and other patients with sound bone healing.The preoperative VAS and that of one month after the operation was (7.3 ± 0.6) points and (1.6 ± 0.7) points,respectively (P ＜ 0.05).Conclusion For Anderson-D'Alonzo type Ⅱ and type Ⅲ odontoid fractures,which have a fracture gap greater than 2 mm,displacement more than 5 mm,broken end angle above 11 degrees,the three-phase Halo-vest assisted internal fixation can provide good stability before operation and promote bone healing and pain relief after operation.

Safe Margin beyond Dens Tips to Ventral Dura in Anterior Odontoid Screw Fixation: Analysis of Three-Dimensional Computed Tomography Scan of Odontoid Process

OBJECTIVE: Anterior odontoid screw fixation is a safe and effective method for the treatment of odontoid fractures. The surgical technique is recommended for perforation of the apical cortex of the dens by the lag screw. However, overpenetration of the apical cortex may lead to potentially serious complications such as damages of adjacent vascular and neural structures. The purpose of this study was to assess the role of three-dimensional computed tomography (CT) scan to evaluate the safe margin beyond dens tip to ventral dura for anterior odontoid screw fixation.METHODS: We retrospectively analyzed the three-dimensional CT scans of the cervical spines in 55 consecutive patients at our trauma center. The patients included 38 males and 17 females aged between 22 and 73 years (mean age±standard deviation, 45.8±14.2 years). Using sagittal images of 3-dimensional CT scan, the safe margins beyond dens tip to ventral dura as well as the appropriate screw length were measured.RESULTS: The mean width of the apical dens tip was 9.6±1.1 mm. The mean lengths from the screw entry point to the apical dens tip and posterior end of dens tip were 39.2±2.6 mm and 36.6±2.4 mm. The safe margin beyond apical dens tip to ventral dura was 7.7±1.7 mm. However, the safe margin beyond the posterior end of dens tip to ventral dura was decreased to 2.1±3.2 mm, which was statistically significant (p < 0.01). There were no significant differences of safe margins beyond dens tip to ventral dura with patient gender and age.CONCLUSION: Extension by several millimeters beyond the dens tip is safe, if the trajectory of anterior odontoid screw is targeted at the apical dens tip. However, if the trajectory of the screw is targeted to the posterior end of dens tip, extension beyond dens tip may lead to damage immediately adjacent to the vental dura mater.

Safe Margin beyond Dens Tips to Ventral Dura in Anterior Odontoid Screw Fixation: Analysis of Three-Dimensional Computed Tomography Scan of Odontoid Process

OBJECTIVE: Anterior odontoid screw fixation is a safe and effective method for the treatment of odontoid fractures. The surgical technique is recommended for perforation of the apical cortex of the dens by the lag screw. However, overpenetration of the apical cortex may lead to potentially serious complications such as damages of adjacent vascular and neural structures. The purpose of this study was to assess the role of three-dimensional computed tomography (CT) scan to evaluate the safe margin beyond dens tip to ventral dura for anterior odontoid screw fixation. METHODS: We retrospectively analyzed the three-dimensional CT scans of the cervical spines in 55 consecutive patients at our trauma center. The patients included 38 males and 17 females aged between 22 and 73 years (mean age±standard deviation, 45.8±14.2 years). Using sagittal images of 3-dimensional CT scan, the safe margins beyond dens tip to ventral dura as well as the appropriate screw length were measured. RESULTS: The mean width of the apical dens tip was 9.6±1.1 mm. The mean lengths from the screw entry point to the apical dens tip and posterior end of dens tip were 39.2±2.6 mm and 36.6±2.4 mm. The safe margin beyond apical dens tip to ventral dura was 7.7±1.7 mm. However, the safe margin beyond the posterior end of dens tip to ventral dura was decreased to 2.1±3.2 mm, which was statistically significant (p < 0.01). There were no significant differences of safe margins beyond dens tip to ventral dura with patient gender and age. CONCLUSION: Extension by several millimeters beyond the dens tip is safe, if the trajectory of anterior odontoid screw is targeted at the apical dens tip. However, if the trajectory of the screw is targeted to the posterior end of dens tip, extension beyond dens tip may lead to damage immediately adjacent to the vental dura mater.

Odontoid process hypoplasia and bipartite atlas associated with atlanto-axial instability / Hipoplasia do processo odontóide e atlas bipartido associado a instabilidade atlanto-axial / Hipoplasia de la apófisis odontoide y atlas bipartito asociado con inestabilidad atlantoaxial

ABSTRACT Surgical treatment of craniocervical junction pathology has evolved considerably in recent years with the implementation of short fixation techniques rather than long occipito-cervical fixation (sub-axial). It is often difficult and sometimes misleading to determine the particular bone and vascular features (high riding vertebral artery, for instance) using only the conventional images in three orthogonal planes (axial, sagittal and coronal). The authors describe a rare clinical case of congenital malformation of the craniovertebral junction consisting of hypoplasia/agenesis of the odontoid process and bipartite atlas associated with atlantoaxial instability which was diagnosed late in life in a patient with a previous history of rheumatologic disease. The authors refer to the diagnostic process, including new imaging techniques, and three-dimensional multiplanar reconstruction. The authors also discuss the surgical technique and possible alternatives.

RESUMO O tratamento cirúrgico da patologia da charneira crânio-cervical tem evoluído consideravelmente nos últimos anos com a implementação de técnicas de fixação curta em detrimento de longas fixações occipito-cervicais (sub-axiais). Frequentemente é difícil e por vezes enganador determinar as variações ósseas e vasculares (artéria vertebral high-riding p.e.) apenas pelas imagens convencionais em três planos ortogonais (axial, sagital e coronal). Os autores descrevem um caso clínico raro de malformação congénita da charneira crânio-cervical constituída por hipoplasia/agenésia da odontoide e atlas bipartido, associado a instabilidade atlanto-axial e diagnosticado tardiamente em doente com antecedentes reumáticos prévios. Descreve-se o processo diagnóstico, incluindo novas técnicas de imagiologia e de reconstrução multiplanar tridimensional. Discute-se a técnica cirúrgica utilizada e possíveis alternativas.

RESUMEN El tratamiento quirúrgico de la patología de la región craneocervical ha evolucionado considerablemente en los últimos años con la aplicación de técnicas de fijación cortas en lugar de fijación occipito-cervical larga (sub-axial). A menudo es difícil y hasta engañoso determinar las características óseos y vasculares (arteria vertebral high-riding, por ejemplo) usando sólo imágenes convencionales en tres planos ortogonales (axial, sagital y coronal). Los autores describen un caso clínico poco frecuente de malformación congénita de la unión craneocervical que consiste en la hipoplasia/agenesia de la apófisis odontoides y atlas bipartito, asociado con la inestabilidad atlantoaxial, diagnosticado tardiamente en pacientes con enfermedades reumatológicas previas. Los autores relatan el proceso de diagnóstico, incluyendo nuevas técnicas de imagen y la reconstrucción multiplanar tridimensional. Los autores también discuten la técnica quirúrgica y las posibles alternativas.