Posterior Atlantoaxial Screw Placement in a Portuguese Population: A Morphometric Analysis Based on Computed Tomography Scan Measurements / Colocação de parafusos atlantoaxiais posteriores em uma população portuguesa: Uma análise morfométrica baseada em medidas de tomografia computadorizada

Abstract Objective The present study aims to evaluate the screw length and trajectory angles for posterior atlantoaxial fixation in a Portuguese population, through the study of cervical computed tomography (CT) scans. Methods Cervical CT scans of 50 adults were measured according to predefined screw trajectories of C1-C2 transarticular (C1C2TA), C1 lateral mass (C1LM), C2 pedicle (C2P), C2 pars and C2 laminar (C2L) screws. For each of these trajectories, screw length and angles were measured and compared between males and females. Results For the C1C2TA screw trajectory, the mean length, medial, and cranial angles were 34.12 ± 3.19 mm, 6.24° ± 3.06, and 59.25° ± 5.68, respectively, and for the C1LM screw trajectory, they were 27.12 ± 2.15 mm, 15.82° ± 5.07, and 13.53° ± 4.80, respectively. The mean length, medial, and cranial angles for the C2P screw trajectory were 23.44 ± 2.49 mm, 27.40° ± 4.88, and 30.41° ± 7.27, respectively; and for the C2 pars screw trajectory, they were 16.84 ± 2.08 mm, 20.09° ± 6.83, and 47.53° ± 6,97. The mean length, lateral, and cranial angles for the C2L screw trajectory were 29.10 ± 2.48 mm, 49.80° ± 4.71, and 21.56° ± 7.76, respectively. There were no gender differences except for the lengths of the C1C2TA (p= 0,020) and C2L (p= 0,001) screws, which were greater in males than in females. Conclusion The present study provides anatomical references for the posterior atlantoaxial fixation in a Portuguese population. These detailed data are essential to aid spine surgeons to achieve safe and effective screw placement.

Resumo Objetivo O presente estudo tem como objetivo avaliar o comprimento e os ângulos de trajetória do parafuso para fixação atlantoaxial posterior em uma população portuguesa por meio do estudo de tomografia computadorizada (TC) cervical. Métodos Tomografias computadorizadas cervicais de 50 adultos foram analisadas quanto às trajetórias pré-definidas dos parafusos transarticulares C1-C2 (C1C2TA), na massa lateral de C1 (C1LM), no pedículo de C2 (C2P) e na pars de C2 e C2 laminar (C2L). O comprimento e os ângulos dos parafusos em cada uma destas trajetórias foram medidos e comparados entre homens e mulheres. Resultados O comprimento médio e ângulos medial e cranial da trajetória do parafuso C1C2TA foram de 34,12 ± 3,19 mm, 6,24° ± 3,06 e 59,25° ± 5,68, respectivamente; as medidas da trajetória do parafuso C1LM foram 27,12 ± 2,15 mm, 15,82° ± 5,07 e 13,53° ± 4,80. O comprimento médio e os ângulos medial e cranial da trajetória do parafuso C2P foram de 23,44 ± 2,49 mm, 27,40° ± 4,88 e 30,41° ± 7,27, respectivamente; as medidas da trajetória do parafuso da pars de C2 foram 16,84 ± 2,08 mm, 20,09° ± 6,83 e 47,53° ± 6,97. O comprimento médio e ângulos lateral e cranial da trajetória do parafuso C2L foram de 29,10 ± 2,48 mm, 49,80° ± 4,71 e 21,56° ± 7,76, respectivamente. Não houve diferenças entre os gêneros, à exceção do comprimento dos parafusos C1C2TA (p= 0,020) e C2L (p= 0,001), que foi maior no sexo masculino do que no feminino. Conclusão O presente estudo fornece referências anatômicas para a fixação atlantoaxial posterior em uma população portuguesa. Estes dados detalhados são essenciais para ajudar os cirurgiões de coluna a colocar os parafusos de maneira segura e eficaz.

Angle class II/2nd division: is there an alignment? / Classe II/2ª divisão de Angle: existe alinhamento?

Introduction: Interdisciplinary investigative study of the stomatognathic-cervical complex, necessary to understand the structure and biomechanics of this system in Angle Class I and II / 2nd Division participants. Objective: To evaluate alignment and position of cranial cervical structures on radiographs and their functional relationship with the stomatognathic system. Material and method: Trans Oral and Profile radiographs were submitted to biomechanical analysis, considered the linear and angular measurement of Atlas and Axis through the application included in the radiogram software. Result: We observed a significant difference in the angular measurements of vertical alignment between the Skull, Axis, and the Mandible (p = <0.001), and in the left joint between the Atlas and the Axis (AE: p = 0.011; SEA: p = 0.042). Among the linear measures of the distances between the Atlas and the Axis, the AOD distance presented statistics quite close to the level of significance (p = 0.0502), but above. There was no statistically significant difference in the other measures. Conclusion: In this study, the alignment between the Atlas and Axis cervical vertebrae and the mandible and angles of the atlanto-occipital joints are altered in Class II / 2nd Division participants. There is no difference in the size and distance of the Atlas and the Axis between the Classes.

Introdução: Estudo interdisciplinar investigativo do complexo cérvico-estomatognático, necessário para compreender a estrutura e a biomecânica desse sistema em participantes Classe I e II/2ª Divisão de Angle. Objetivo: Avaliar o alinhamento e a posição das estruturas crânio cervicais nas radiografias de participantes Classe I e II/2ª Divisão de Angle e sua relação funcional com o sistema estomatognático. Material e método: As imagens digitais Trans Oral e Perfil de participantes com maloclusão Classe I e II/2ª Divisão de Angle foram submetidas à medição linear e angular do crânio, mandíbula, Atlas e do Áxis através do software Advantage Workstation 4.6 (AW4.6 ext. 04). Resultado: Houve diferença significativa nas medidas angulares de alinhamento vertical entre o Crânio, Áxis e a Mandíbula (p = <0,001), e da articulação esquerda entre o Atlas e o Áxis (AE: p = 0,011; AAE: p = 0,042). Das medidas lineares das distâncias entre o Atlas e o Áxis, a distância AOD apresentou estatística bastante próxima do nível de significância (p=0,0502), porém acima. Não houve diferença significativamente estatística nas demais medidas avaliadas. Conclusão: Neste estudo, o alinhamento entre as vértebras cervicais Atlas e Áxis e a mandíbula e os ângulos das articulações atlanto occipitais se mostraram alterados nos participantes Classe II/2ª Divisão de Angle. Não há diferença significativa no tamanho e distância do Atlas e do Áxis entre as Classes.

Subluxación rotatoria atloaxoidea o síndrome de Grisel. A propósito de un caso / Rotatory subluxation of the atlantoaxial joint or Grisel's syndrome. Case report

La tortícolis es una contractura involuntaria unilateral del esternocleidomastoideo y de la musculatura posterior del cuello que causa la inclinación de la cabeza hacia un lado. Se han descrito múltiples causas de torticolis siendo una de ellas la subluxación atloaxoidea atraumática asociada a un proceso de carácter inflamatorio en la región de cabeza y cuello, llamada síndrome de Grisel. Aunque la mayoría de los pacientes suelen recuperarse sin secuelas tras tratamiento médico existe la posibilidad de complicaciones graves con déficits funcionales, de ahí la importancia de la realización de un diagnóstico y tratamiento precoz.

Torticollis is an unilateral involuntary contracture of the sternocleidomastoid and posterior neck musculature that causes the head tilts to the one side. Multiple causes of torticolis have been described, one of them being the non-traumatic rotatory subluxation of the atlantoaxial joint associated with an inflammatory process in the head and neck region, called Grisel's syndrome. Although most patients usually recover without sequels after medical treatment, there is the possibility of serious complications with functional deficits, that is why the importance of an early diagnosis and treatment of this potology.

Traumatic atlantoaxial rotatory dislocation in the pediatric population / Luxação rotacional traumática de c1-c2 na população pediátrica / Luxación rotatoria traumática de c1-c2 en población pediátrica

ABSTRACT Objective: The treatment of C1-C2 rotatory dislocation remains controversial and surgery is rare. Surgical treatment is indicated when the injury satisfies the instability criteria or when it cannot be reduced. The objective of this study is to analyze the principles and the adaptations necessary for treating these injuries in the pediatric population. Methods: A retrospective case series study. Three cases of patients diagnosed with traumatic C1-C2 rotatory dislocation and treated surgically in our hospital were studied. Through critical analysis of the available literature, a practical guide was proposed to establish the principles and competencies for the treatment of these injuries. Results: The operated cases were female patients between 8 and 16 years of age, with a diagnosis of traumatic atlantoaxial dislocation. Two patients required preoperative skeletal traction with halo. All patients underwent posterior instrumented arthrodesis, two with a transarticular screw technique and one with mass and C2 isthmic (Göel-Harms) screws. Conclusion:. It is essential to determine if the injury is stable and reducible. We recommend treating this type of injury keeping the criteria and competencies related to the stability, alignment, biology and function of the spine in mind. Level of evidence IV; Case series.

RESUMO Objetivo: O tratamento da luxação rotacional de C1-C2 permanece controverso, e a cirurgia é rara. O tratamento cirúrgico é indicado quando a lesão satisfaz os critérios de instabilidade ou quando não pode ser reduzida. O objetivo deste estudo é analisar os princípios e a adequação necessários para tratar essas lesões na população pediátrica. Métodos: Estudo retrospectivo de série de casos. Foram estudados três casos em pacientes tratados cirurgicamente em nosso hospital com diagnóstico de luxação rotacional traumática de C1-C2. Por meio de análise crítica da literatura disponível, foi proposto um guia prático para estabelecer os princípios e a adequação do tratamento dessas lesões. Resultados: Os casos submetidos à cirurgia foram pacientes do sexo feminino, entre 8 e 16 anos de idade, com diagnóstico de luxação atlantoaxial traumática. Duas pacientes precisaram de tração esquelética pré-operatória com halo. Todas as pacientes foram submetidas à artrodese instrumentada por via posterior, duas com técnica de parafuso transarticular e uma com parafusos de massa e pedículo e lâmina em C2 (técnica de Göel-Harms). Conclusões: É essencial determinar se a lesão é estável e se pode ser reduzida. Recomenda-se tratar esse tipo de lesão tendo em mente os critérios e a adequação relacionados com estabilidade, alinhamento, biologia e função da coluna vertebral. Nível de evidência IV; Série de casos.

RESUMEN Objetivo: El tratamiento de la luxación rotatoria de C1-C2 permanece controversial y la cirugía es rara. Se indica tratamiento quirúrgico cuándo la lesión cumple criterios de inestabilidad o cuándo es considerada irreductible. El objetivo de este estudio es revisar los principios y competencias necesarios para tratar esas lesiones en la población pediátrica. Métodos: Estudio retrospectivo de serie de casos. Se estudian tres casos en pacientes tratados quirúrgicamente en nuestro hospital con diagnóstico de luxación rotatoria de C1-C2 traumática. A través del análisis crítico de la literatura disponible se elabora un esquema práctico para establecer los principios y competencias para el abordaje de estas lesiones. Resultados: Los casos intervenidos fueron pacientes de sexo femenino entre 8 y 16 años, con diagnóstico de luxación atlantoaxoidea traumática. Dos pacientes requirieron tracción esquelética preoperatoria con halo. A todas las pacientes se les practicó artrodesis instrumentada por vía posterior, dos con técnica de tornillos transarticulares y una con tornillos de masa e ístmicos de C2 (Göel-Harms). Conclusiones: Resulta imprescindible determinar si la lesión es estable y reductible. Siempre abordar este tipo de lesiones teniendo presentes los criterios y competencias relacionados con la estabilidad, alineación, biología y función de la columna vertebral. Nivel de Evidencia IV; Serie de casos.

Hyperextension of the head versus cervical vertebrae morphology in mouth and nasal breathers: a preliminary study

Objective: This study aimed to compare through cone-beam computed tomography (CBCT) the morphology of the cervical vertebrae atlas (C1) and axis (C2) in mouth breathers (MB) and nose breathers (NB), correlating them with the head and neck postures of the two groups. Materials and Methods: CBCT images of 36 subjects aged 11 to 22 years were evaluated using the InVivo Dental 5.1 (Anatomage, San Jose, California) software. The following measurements were used to assess C1 and C2 morphology: posterior height, anterior height, length, and volume. The craniocervical angle (NSL/OPT) was used to evaluate head posture concerning the neck. Results: The posterior height, length, and volume of C1 and C2 were lower in the MB group, but only the posterior size was significantly shorter than the NB group (C1, p=0.01 / C2, =0.05). Mouth breathers also showed a considerably higher craniocervical angle (p=0.04). Spearman test showed a significant positive correlation between C1 and C2 length and craniocervical angle (C1, =0.629, p=0.005 / C2, =0.665, p=0.003). Conclusion: The mouth breathers showed an increased craniocervical angle and decreased posterior height of the C1 vertebra concerning nasal breathers. The hyperextension of the head present is positively correlated with the length of the vertebra.

Objetivo: Este estudo teve como objetivo comparar por meio da tomografia computadorizada de feixe cônico (TCFC) a morfologia do atlas das vértebras cervicais (C1) e do eixo (C2) em respiradores orais (MB) e nasais (RN), correlacionando-os com a cabeça e posturas do pescoço dos dois grupos. Materiais e Métodos: Imagens de CBCT de 36 indivíduos com idades entre 11 e 22 anos foram avaliadas usando o software InVivo Dental 5.1 (Anatomage, San Jose, Califórnia). As seguintes medidas foram usadas para avaliar a morfologia de C1 e C2: altura posterior, altura anterior, comprimento e volume. O ângulo craniocervical (NSL/OPT) foi utilizado para avaliar a postura da cabeça em relação ao pescoço. Resultados: A altura posterior, comprimento e volume de C1 e C2 foram menores no grupo MB, mas apenas o tamanho posterior foi significativamente menor que o grupo RN (C1, p=0,01 / C2, =0,05). Os respiradores orais também apresentaram um ângulo craniocervical consideravelmente maior (p=0,04). O teste de Spearman mostrou correlação positiva significativa entre comprimento de C1 e C2 e ângulo craniocervical (C1, =0,629, p=0,005 / C2, =0,665, p=0,003). Conclusão: Os respiradores orais apresentaram aumento do ângulo craniocervical e diminuição da altura posterior da vértebra C1 em relação aos respiradores nasais. A hiperextensão da cabeça presente está positivamente correlacionada com o comprimento da vértebra.

Treatment strategy and curative effect analysis of os odontoideum complicated with atlantoaxial joint dislocation / 中国骨伤

OBJECTIVE@#To explore the treatment strategy and clinical efficacy for os odontoideum complicated with atlantoaxial dislocation.@*METHODS@#The clinical data of 17 patients with os odontoideum complicated with atlantoaxial dislocation surgically treated from January 2006 to January 2015 were retrospectively analyzed, including 7 males and 10 females, aged 17 to 53 (43.1±11.3) years old;course of disease was 3 to 27(10.2±6.9) months. All patients received cranial traction before operation, 12 of 14 patients with reducible dislocation were treated by posterior atlantoaxial fixation and fusion, and 2 patients with atlantooccipital deformity were treated by posterior occipitocervical fixation and fusion;3 patients with irreducible alantoaxial dislocation were treated by transoral approach decompression combined with posterior atlantoaxial fixation and fusion. The operation time, intraoperative blood loss and perioperative complications were recorded. Visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) score were used to evaluate the change of neck pain and neurological function. Atlantoaxial joint fusion rate was evaluated by CT scan.@*RESULTS@#The operation time of posterior fixation and fusion ranged from 86 to 170 (92.2±27.5) min, and the intraoperative blood loss was 200-350 (250.7±65.2) ml. No vertebral artery injury and spinal cord injury were recorded. Among the patients underwent atlantoaxial fixation and fusion, 1 patient with reducible dislocation fixed by C@*CONCLUSION@#Surgical treatment of os odontoideum complicated with atlantoaxial dislocation can achieve satisfactory results, improve the patient's neurological function and improve the quality of life, however the surgical options needs to be individualized.

Tendinitis calcificante del musculo largo del cuello: presentación de un caso clínico / Calcific tendinitis of the longus colli muscle: a case report / Tendinite calcificante do músculo longo do pescoço: apresentação de um caso clínico

La tendinitis calcificante del músculo largo del cuello es una patología subdiagnsoticada, de baja frecuencia, autolimitada. Se presenta clínicamente como una de las causas de odinofagia en la consulta médica. Se produce debido al depósito de cristales de hidroxiapatita en espacio retrofaríngeo, desencadenándose una respuesta inflamatoria local. En la TMLC el principal diagnóstico diferencial es el absceso retrofaríngeo, ya que puede presentarse clínicamente con odinofagia, disfagia , disminución de la movilidad del cuello y cervicalgia. En nuestro trabajo se analiza un caso clínico sobre dicha patología, en un hombre de 45 años; realizando un análisis de la sintomatología, diagnóstico y tratamiento de esta entidad.

Calcific tendinitis of the long neck muscle is an underdiagnosed, low frequency, self-limited pathology. It is clinically presented as one of the causes of odynophagia in the medical consultation. It occurs due to the deposit of hydroxyapatite crystals in the retropharyngeal space, triggering a local inflammatory response. On This patholgy, the main differential diagnosis is retropharyngeal abscess, since it can present clinically with odynophagia, dysphagia, decreased mobility of the neck, and neck pain. In our work, a clinical case of this pathology is analyzed, in a 45-year-old man; performing an analysis of the symptoms, diagnosis and treatment of this entity.

A tendinite calcificante do músculo longo do pescoço é uma patologia subdiagnsoticada, de baixa frequência, autolimitada. Apresenta-se clinicamente como uma das causas de odinofagia na consulta médica. Ocorre devido ao depósito de cristais de hidroxiapatita em espaço retrofaríngeo, desencadeando-se uma resposta inflamatória local. Na TMLC o principal diagnóstico diferencial é o abscesso retrofaríngeo, já que pode apresentar-se clinicamente com odinofagia, disfagia , diminuição da mobilidade do pescoço e cervicalgia. Em nosso trabalho analisa-se um caso clínico sobre essa patologia, em um homem de 45 anos; realizando uma análise da sintomatologia, diagnóstico e tratamento desta entidade.

Fusión cervical anterior C2-C3 para espondilolistesis traumática del axis grado III / Anterior C2-C3 Cervical Fusion for Traumatic Spondylolisthesis of the Axis Grade III

RESUMEN Se trata de un paciente masculino de 85 años de edad, que sufrió una caída y fue inmovilizado y trasladado al servicio de urgencia; refería dolor cervical y rigidez del cuello. Al examen neurológico no se constata déficit neurológico, salvo la contractura de la musculatura cervical. Se le diagnosticó espondilolistesis traumática del axis grado III confirmada mediante estudios radiográficos. Se le realizó abordaje anterior retrofaríngeo extendido con fijación con láminas y tornillos C2-3. El paciente utilizó ortesis rígida externa durante 4 semanas. Su evolución fue favorable(AU)

ABSTRACT This is an 85-year-old male patient who fell and was immobilized and transferred to the emergency department. He complained of neck pain and neck stiffness. Neurological examination revealed no neurological deficit, except for the contracture of the cervical musculature. Traumatic spondylolisthesis of the axis grade III confirmed by radiographic studies was diagnosed. An extended anterior retropharyngeal approach was performed with fixation with blades and C2-3 screws. The patient wore a rigid external orthosis for 4 weeks. His evolution was favorable(AU)

Anatomical evaluation of the pedicle of the axis through computerized tomography in adults / Avaliação anatômica do pedículo do áxis através de tomografia computadorizada em adultos / Evaluación anatómica del pedículo del axis a través de la tomografía computarizada en adultos

ABSTRACT Objectives: The topography of the high cervical spine involves several traumatic, degenerative, and rheumatologic pathologies. With the evolution of surgical techniques and synthesis materials available for use in such region, an optimization of the anatomical understanding of this area is required. Methods: Therefore, this study evaluated 62 computed tomographies of the high cervical spine in an adult population, aiming at the study of the anatomical parameters of the axis pedicle. The measures analyzed in this observational study were pedicle length at axial section, pedicle length at sagittal section, pedicle thickness at axial section and interpedicular angulation. Results: Computed tomography is a necessary exam for the programming of C2 pedicle screws and is useful for determining the anatomical changes and evaluating the length of the screws that will be used. Furthermore, no statistically significant difference was observed in the length, angulation, and diameter of the pedicles of the axis in relation to sex or age. Conclusion: Regarding sex and age, no statistically significant difference on length, angulation, and pedicle diameter occur. There is an urgent need for computed tomography for surgical planning. Level of Evidence II; Transversal Diagnostic Studies - Investigation of a Diagnosis Test.

RESUMO Objetivos: A topografia da coluna cervical alta envolve diversas patologias de cunho traumático, degenerativo e reumatológico. Com a evolução de técnicas cirúrgicas e de materiais de síntese disponíveis para uso em tal região, é necessária uma otimização do entendimento anatômico desta área. Métodos: Assim, este estudo avaliou 62 tomografias computadorizadas da coluna cervical alta na população adulta, visando o estudo dos parâmetros anatômicos do pedículo do Áxis. Comprimento do pedículo no corte axial, comprimento do pedículo no corte sagital, espessura do pedículo no corte axial e angulação interpedicular foram as medidas analisadas neste estudo observacional. Resultados: A tomografia computadorizada mostra-se como um exame necessário para a programação da passagem de parafusos pediculares de C2, sendo útil para determinar as alterações anatômicas e avaliar o comprimento dos parafusos que irão ser utilizados. Também, não foram observadas diferenças estatisticamente significantes no comprimento, angulação e diâmetro dos pedículos do áxis em relação ao sexo. Conclusão: Não foram observadas diferenças estatisticamente significantes no comprimento, na angulação e no diâmetro dos pedículos. Urge a necessidade da Tomografia Computadorizada para o planejamento cirúrgico. Nível de Evidência II; Estudos Transversais de diagnósticos - Investigação de um exame para diagnóstico.

RESUMEN Objetivos: La topografía de la columna cervical alta involucra diversas patologías de origen traumático, degenerativo y reumatológico. Con la evolución de técnicas quirúrgicas y de materiales de síntesis disponibles para uso en tal región, es necesaria una optimización del entendimiento anatómico de esta área. Métodos: Así, este estudio evaluó 62 tomografías computarizadas de columna cervical alta en una población adulta, visando el estudio de los parámetros anatómicos del pedículo de axis. Las medidas analizadas en este estudio observacional fueron la longitud del pedículo en corte axial, la longitud del pedículo en corte sagital, el espesor del pedículo en corte axial y la angulación interpedicular. Resultados: La tomografía computarizada se muestra como un examen necesario para la programación del paso de tornillos pediculares de C2, siendo útil para determinar los cambios anatómicos y evaluar la longitud de los tornillos que se van a utilizar. Además, no se observó diferencias estadísticamente significativas en la longitud, angulación y diámetro de los pedículos del áxis en relación al sexo. Conclusión: En relación al sexo y edad no ocurren diferencias estadísticamente significativas en la longitud, la angulación y el diámetro de los pedículos. Urge la necesidad de la tomografía computarizada para la planificación quirúrgica. Nivel de Evidencia II; Estudios transversales de diagnóstico - Investigación de un examen para diagnóstico.

Dimorfismo sexual da vértebra áxis em uma coleção osteológica brasileira / Sex dimorphism by the axis vertebra in a Brazilian osteological collection

O objetivo desse estudo foi verificar o dimorfismo sexual por meio de medidas lineares (Comprimento do corpo e processo odontóide, Comprimento do processo odontóide, Comprimento do forame vertebral, Largura do forame vertebral, Distância dos processos transversos, Distância do processo transverso esquerdo ao processo espinhoso, Distância do processo transverso direito ao processo espinhoso) da segunda vertebra cervical denominada de áxis. Para tanto foram analisadas 181 áxis, sendo 103 masculinas e 78 femininas, na faixa de idade de 22 a 85 anos, pertencentes ao "Biobanco Tomográfico e Osteológico Prof. Eduardo Daruge da FOP/UNICAMP". Tais medidas foram feitas pelo paquímetro digital marca Stainless ­ hardned ® 150 mm Mauá ­ São Paulo, Brasil, após a calibração inter e intraoperador realizada por meio do teste de correlação intraclasse, teve como resultado o valor de 0,98 considerado excelente. Verificou-se que todas as medidas estudadas são dimórficas e foi possível estabelecer um novo modelo de regressão logística, a partir dos dados obtidos junto às ossadas. Concluiu-se que o modelo de regressão logística gerado ­ Germano Sexo = [- 22.7 + (0.16 × Comprimento do corpo) + (0.31 × Comprimento do forame vertebral) + (0.28 × Distância dos processos transversos)] ­ possui 72,4 % de acerto.

The objective of this study was to verify the sexual dimorphism through linear measurements (length of the body and dentinoid process, length of the dentinoid process, length of the vertebral foramen, width of the vertebral foramen, distance of the transverse processes, distance from the left transverse process to the spinal process , Distance from the right transverse process to the spinous process) of the second cervical vertebra known as the Áxis. For this purpose, 181 Axioms were analyzed, of which 103 were male and 78 were female, in the age range of 22 to 85 years, belonging to the "Tomographic and Osteological Biobank Prof. Eduardo Daruge of FOP / UNICAMP ". These measurements were made by the stainless - hardned ® digital pachymetro 150 mm Mauá - São Paulo, Brazil, after the inter and intra - operator calibration performed through the intraclass correlation test, resulting in a value of 0.98 considered excellent. It was verified that all the measures studied are dimorphic and it was possible to establish a new model of logistic regression, based on the data obtained from the bones. It was concluded that the logistic regression model generated Germano Gender = [- 22.7 + (0.16 × Body length) + (0.31 × Vertebral foramen length) + (0.28 × Distance of transverse processes), with 72.4% of hit.

Axis screws: results and complications of a large case series

SUMMARY OBJECTIVE: To present the surgical results of patients who underwent axis screw instrumentation, discussing surgical nuances and complications of the techniques used. METHODS: Retrospective case-series evaluation of patients who underwent spinal surgery with axis instrumentation using screws. RESULTS: Sixty-five patients were included in this study. The most common cause of mechanical instability was spinal cord trauma involving the axis (36 patients - 55.4%), followed by congenital craniocervical malformation (12 patients - 18.5%). Thirty-seven (57%) patients required concomitant C1 fusion. Bilateral axis fixation was performed in almost all cases. Twenty-three patients (35.4%) underwent bilateral laminar screws fixation; pars screws were used in twenty-two patients (33.8%), and pedicular screws were used isolated in only three patients (4.6%). In fourteen patients (21.5%), we performed a hybrid construction. There was no neurological worsening nor vertebral artery injury in this series. CONCLUSION: Axis screw instrumentation proved to be a safe and efficient method for cervical stabilization. Laminar and pars screws were the most commonly used

RESUMO OBJETIVO: Apresentar os resultados cirúrgicos de pacientes submetidos à instrumentação com parafusos do áxis, discutindo nuances cirúrgicas e complicações das técnicas utilizadas. MÉTODOS: Série retrospectiva de pacientes submetidos à instrumentação do áxis utilizando parafusos. RESULTADOS: Sessenta e cinco pacientes foram incluídos neste estudo. A causa mais comum de instabilidade foi trauma raquimedular envolvendo o áxis (36 pacientes - 55,4%), seguida por malformação craniocervical congênita (12 pacientes - 18,5%). Trinta e sete (57%) pacientes necessitaram concomitante fusão de C1. Fixação bilateral foi realizada em quase todos os casos. Vinte e três pacientes (35,4%) foram submetidos à fixação com parafusos de lâmina; parafusos de pars foram utilizados em 22 pacientes (33,8%) e de pedículo, isoladamente, em três (4,6%). Em 14 casos (21,5%), realizamos técnicas combinadas. Não houve piora neurológica ou lesão de artéria vertebral nesta série de casos. CONCLUSÃO: A instrumentação com parafusos do áxis foi um método seguro e eficaz para estabilização cervical. A fixação da lâmina e a da pars foram as técnicas mais utilizadas.

The C2 Pedicle Width, Pars Length, and Laminar Thickness in Concurrent Ipsilateral Ponticulus Posticus and High-Riding Vertebral Artery: A Radiological Computed Tomography Scan-Based Study

STUDY DESIGN: Retrospective radiological study. PURPOSE: We aimed to determine the prevalence of ponticulus posticus (PP) and high-riding vertebral artery (HRVA) occurring simultaneously on the same side (PP+HRVA) and in cases of PP+HRVA, to assess C2 radio-anatomical measurements for C2 pars length, pedicle width, and laminar thickness. OVERVIEW OF LITERATURE: PP and HRVA predispose individuals to vertebral artery injuries during atlantoaxial fixation. In cases of PP+HRVA, the construct options thus become limited. METHODS: Consecutive computed tomography scans (n=210) were reviewed for PP and HRVA (defined as an internal height of <2 mm and an isthmus height of <5 mm). In scans with PP+HRVA, we measured the ipsilateral pedicle width, pars length, and laminar thickness and compared them with controls (those without PP or HRVA). RESULTS: PP was present in 14.76% and HRVA in 20% of scans. Of the 420 sides in 210 scans, PP+HRVA was present on 13 sides (seven right and six left). In scans with PP+HRVA, the C2 pars length was shorter compared with controls (13.69 mm in PP+HRVA vs. 20.65 mm in controls, p<0.001). The mean C2 pedicle width was 2.53 mm in scans with PP+HRVA vs. 5.83 mm in controls (p<0.001). The mean laminar thickness was 4.92 and 5.48 mm in scans with PP+HRVA and controls, respectively (p=0.209). CONCLUSIONS: The prevalence of PP+HRVA was approximately 3% in the present study. Our data suggest that, in such situations, C2 pedicle width and pars length create important safety limitations for a proposed screw, whereas the translaminar thickness appears safe for a proposed screw.

Análisis morfométrico del axis para la fijación atlantoaxial / Morphometric analysis of the axis for atlantoaxial fixation

El objetivo de este estudio fue evaluar de manera integral los parámetros morfométricos de la vértebra axis (C2) en la población mexicana involucrados en la realización de procedimientos quirúrgicos con el fin de proveer datos cuantitativos indispensables en su abordaje quirúrgico. Para este estudio se utilizaron un total de 576 vértebras axis (C2) de población mexicana contemporánea. Las mediciones de las vértebras se efectuaron bilateralmente utilizando un vernier digital milimétrico con una precisión de 0.01 mm (Mitutoyo Digimatic w/Absolute Encoders- Series 500). Un total de 576 vértebras axis (C2), fueron medidas de manera bilateral, todas nuestras mediciones se reportaron en mm. El promedio del ancho del pedículo fue de 8,96 mm con una DE ± 2,11 mm. El promedio de la altura del pedículo fue de 10,82 mm con una DE de ± 1,89 mm. El promedio de la altura del proceso odontoideo fue de 16,90 mm con una DE de ± 2,99 mm. El promedio del ancho del proceso odontoideo fue de 9,99 mm con una de DE de ± 0,80 mm. El promedio del diámetro de la faceta articular fue de 8,44 mm con una DE de ± 1,04 mm. El promedio del diámetro AP del cuerpo vertebral fue de 15,11 mm con una DE de ± 1,88 mm. El promedio del diámetro trasverso del cuerpo vertebral fue de 17,93 mm con una DE de ± 2,22 mm. El promedio de la altura del cuerpo vertebral fue de 18,54 mm con una DE de 2,38 mm. El promedio de la altura de las láminas fue de 11,53 mm con una DE de ± 1,39 mm. El promedio del ancho de las láminas fue de 6,10 mm con una DE de ± 1,44 mm. Los resultados obtenidos en nuestras mediciones demuestran una variación con los resultados de otros autores en diferentes estudios de piezas osteológicas y de estudios de imagen del axis (C2), lo que sugiere, con el fin de reducir los riesgo de daño a estructuras neurovasculares, utilizar técnicas y medidas especiales para la estabilización atlantoaxial de la población mexicana.

The aim of the study was to evaluate the morphometric parameters of the axis vértebra (C2) in the Mexican population involved in the performance of surgical procedures in order to provide essential quantitative data in their surgical approach. A total of 576 axis vertebrae (C2) of contemporary Mexican population were used for this study. The measurements of the vertebrae were made bilaterally using a millimeter digital vernier with an accuracy of 0.01 millimeters (Mitutoyo Digimatic w / Absolute Encoders - Series 500). A total of 576 axis vertebrae (C2) were measured bilaterally, all our measurements were reported in millimeters. The average width of the pedicle was 8.96 mm with a SD ± 2.11 mm. The average height of the pedicle was 10.82 mm with a SD of ± 1.89 mm. The average height of the odontoid process was 16.90 mm with a SD of ± 2.99 mm. The average width of the odontoid process was 9.99 mm with a SD of ± 0.80 mm. The average diameter of the articular facet was 8.44 mm with a SD of ± 1.04 mm. The average diameter of the AP of the vertebral body was 15.11 mm with a SD of ± 1.88 mm. The average transverse diameter of the vertebral body was 17.93 mm with a SD of ± 2.22 mm. The average height of the vertebral body was 18.54 mm with a SD of 2.38 mm. The average height of the lamina was 11.53 mm with a SD of ± 1.39 mm. The average width of the lamina was 6.10 mm with a SD of ± 1.44 mm. The results obtained in our measurements show a variation with the results of other authors in different studies of osteological pieces and studies of the axis image (C2), which suggests the use of techniques and special measures for the atlantoaxial stabilization of the Mexican population in order to reduce the risk of damage to neurovascular structures.

Aplicación de magnetoterapia y craneopuntura en un paciente con cuadriparesia / Use of magnetotherapy and craneopuncture in a patient with quadriparesis

Se presenta el caso clínico de un paciente con diagnóstico de cuadriparesia debido a una fractura vertebral cervical y compresión medular graves, producidas por una caída desde una altura de 2 metros. Según el examen físico, los estudios radiológicos y la aplicación de escalas neurológicas, presentaba pérdida total de la función motora, de la discriminación sensorial del dolor y de la temperatura por debajo del nivel de lesión. Debido a las secuelas de las lesiones traumáticas en el sistema nervioso central, se aplicó tratamiento bioenergético rehabilitador: magnetoterapia y craneopuntura, complementado con kinesioterapia y terapia ocupacional, y se obtuvo una mejoría de la fuerza, el tono muscular y la capacidad funcional, con coordinación de la marcha.

The case report of a patient with diagnosis of quadriparesis due to a cervical vertebral fracture and severe medullary compression, taking place due to a fall from a height of 2 meters is presented. According to the physical examination, the radiological studies and the use of neurological scales, he presented total loss of the motor function, of the sensorial discrimination of pain and of temperature under the lesion level. Due to the sequels of the traumatic lesions in the central nervous system, bioenergetic rehabilitative treatment was applied: magnetotherapy and craneopuncture, supplemented with kinesiotherapy and occupational therapy, and an improvement of the force, the muscle tone and the functional capacity, with coordination of walking was obtained.

Axis Screw Fixation ­ A Step-by-Step Review of the Surgical Techniques

In this article, we present the techniques of axis screw fixation (laminar, pars, pedicle and transarticular screws), discussing the indications and contraindications of each one, as well as surgical tips and anatomical landmarks.

No presente artigo, apresentamos as técnicas de fixação do áxis com parafusos (lamina, parafusos de pars, pedículo e transarticular), discutindos as indicações e contraindicações das mesmas, assim como dicas cirúrgicas e parâmetros anatômicos relevantes.

Results of the use of peek cages in the treatment of basilar invagination by Goel technique / Resultados do uso de cage em peek no tratamento da invaginação basilar pela técnica de Goel / Resultados de la utilización de caja de peek en el tratamiento de la invaginación basilar por la técnica de Goel

ABSTRACT Objective: Analysis of the use of polyetheretherketone (PEEK) cages for atlantoaxial facet realignment and distraction for treatment of basilar invagination by Goel technique. Method: Retrospective descriptive statistical analysis of the neurological status, pain, presence of subsidence and bone fusion with the use of PEEK cages in 8 atlantoaxial joints of 4 patients with basilar invagination. All patients were treated with atlantoaxial facet distraction and realignment and subsequent arthrodesis C1-C2 by the technique of Goel modified by the use of PEEK cage. Results: All patients showed improvement in Nurick neurological assessment scale and Visual Analogue Scale (VAS) of pain. There were no cases of subsidence, migration, or damage to the vertebral artery during the insertion of the cage. All joints evolved with bone fusion, assessed by dynamic radiographs, and computed tomography. Two patients developed neuropathic pain in dermatome of C2 and one patient had unilateral vertebral artery injury during C2 instrumentation treated with insertion of pedicle screw to control the bleeding. Conclusion: The results of the treatment of basilar invagination by the Goel technique with the use of PEEK cages shown to be effective and safe although further studies are needed to confirm this use.

RESUMO Objetivo: Análise do uso do implante tipo cage em poli-éter-éter-cetona (PEEK) no realinhamento e distração facetária atlantoaxial da invaginação basilar pela técnica de Goel. Método: Análise estatística descritiva retrospectiva de estado neurológico, dor, presença de fusão óssea e subsidência com o uso do cage em PEEK em 8 articulações atlantoaxiais de 4 pacientes portadores de invaginação basilar, todos tratados com distração, realinhamento atlantoaxial e artrodese posterior C1-C2 pela técnica de Goel, modificada pela utilização do cage em PEEK. Resultados: Todos os pacientes apresentaram melhora na escala de avaliação neurológica de Nurick e na Escala Visual Analógica (EVA) de dor. Não ocorreu caso de subsidência, migração ou dano à artéria vertebral decorrente da colocação do cage. Cem por cento das articulações evoluíram com fusão óssea, avaliada por radiografia dinâmica e tomografia computadorizada. Dois pacientes evoluíram com dor neuropática no dermátomo de C2 e em um paciente houve lesão unilateral da artéria vertebral durante a instrumentação de C2, tratada com inserção do parafuso pedicular para controle do sangramento. Conclusão: Os resultados da redução vertical da invaginação basilar pela técnica de Goel com a utilização de cage em PEEK mostrou ser eficaz e segura, porém ainda são necessários estudos para confirmar essa utilização.

RESUMEN Objetivo: Análisis del uso del implante tipo caja en poli-éter-éter-cetona (PEEK) en el realineamiento y distracción facetaria atlantoaxial de la invaginación basilar por la técnica de Goel. Métodos: Fue realizado un análisis estadístico descriptivo retrospectivo del status neurológico, dolor, presencia de fusión ósea y hundimiento con el uso de la caja en PEEK en 8 articulaciones atlantoaxiales de 4 pacientes que presentaban invaginación basilar, todos tratados con distracción y realineamiento atlantoaxial y artrodesis posterior C1-C2 mediante la técnica de Goel. Resultados: Todos los pacientes presentaron mejoría en la escala de evaluación neurológica de Nurick y en la Escala Visual Analógica (EVA) del dolor. No hubo casos de hundimiento, migración o daño a la arteria vertebral debido a la colocación del implante. El 100% de las articulaciones evolucionaron con fusión ósea evaluada por radiografía dinámica y tomografía computarizada. Dos pacientes evolucionaron con dolor neuropático en el dermatomo de C2, y en un paciente hubo lesión unilateral de la arteria vertebral durante la instrumentación de C2, tratada con inserción de un tornillo pedicular para control del sangrado. Conclusión: Los resultados de la reducción vertical de la invaginación basilar por la técnica de Goel con el uso de caja en PEEK han demostrado ser eficaz y segura pero se necesitan más estudios para confirmar este uso.

Novel Pharmacological Treatment for Depression

Development of various antidepressants such as monoamine oxidase inhibitors, tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and noradrenergic and specific serotonergic antidepressant has led to a tremendous progression of pharmaceutical treatment for depression, but still there are some limitations of current antidepressants, such as treatment-resistant depression and delayed onset of antidepressants. The pathogenesis of depression is unclear because depression is a heterogeneous disease state, and the mechanisms of antidepressants remain uncertain as well. Nevertheless, in an attempt to develop novel antidepressants, some trials have been conducted based on the potential biological mechanism discovered in the numerous research results. This review will provide information about the potential novel antidepressants and the current states of clinical studies using them. In particular, some potential novel antidepressants anti-inflammatory agents, antioxidants, anticholinergics, modulators of Hypothalamic Pituitary Adrenal Axis, glutamate, and opioid systems, as well as some neuropeptides such as susbstance P, neuropeptide Y, and galanin will be discussed.

Osteosintesis directa para tratar la espondilolistesis traumatica del axis. Reporte de un caso y revision bibliografica / Direct osteosynthesis to treat traumatic spondylolisthesis of the axis. Case report and literature review

La espondilolistesis traumática del axis representa un 5% de las fracturas cervicales y es definida por una fractura de la pars interarticularis de la segunda vértebra cervical. El mecanismo de esta fractura, en general, implica fuerzas de hiperextensión. Los aspectos más importantes relacionados con el pronóstico y tratamiento son el compromiso discal C2-C3, el compromiso neurológico y la presencia de luxación facetaria. En relación con los tratamientos conservador o quirúrgico en patrones no desplazados, la cirugía podría determinar una recuperación precoz. Por otro lado, se han descrito buenos resultados con el uso del halo chaleco. Se presenta un caso de espondilolistesis traumática del axis tratado con osteosíntesis directa a través de un abordaje posterior en un paciente que rechazó el tratamiento conservador.

Traumatic spondylolisthesis of the axis accounts for 5% of all cervical spine fractures and is defined as a pars interarticularis fracture in the second cervical vertebra. Its mechanism usually involves hyperextension forces. The most important aspects related to prognosis and treatment are C2-C3 disk injury, neurological involvement, facetary dislocation and displacement. As regards the conservative or surgical management in non-displaced patterns, surgical management could result in an early recovery; however, there are good results with halo vest immobilization. We present a case with C2 direct crew osteosynthesis through a posterior approach in a patient who refused conservative treatment.

Current Trends in Management for Central Nervous System Germ Cell Tumor / 임상소아혈액종양

Central nervous system germ cell tumor is a rare but important tumor in childhood brain tumors. It requires a multidisciplinary approach to increase survival and promote quality of life, and all three treatment modalities including surgery, radiotherapy and chemotherapy has its own distinct role for germ cell tumor. For germinoma, radiotherapy alone can cure the disease but, the effort to limit the long term toxicity and the proper combination of chemotherapy and radiotherapy are under investigation. Craniospinal irradiation is reserved only for the disseminated germinoma or nongerminomatous germ cell tumor (NGGCT). For germinoma, craniospinal irradiation of 20 to 24 Gy is sufficient to control microscopic disease in the spinal axis. Chemotherapy and radiotherapy composed of 30 to 40 Gy of local field radiotherapy and 20 to 24 Gy of whole ventricular irradiation are required for localized germinoma, but the proper combination of two modalities has yet to be defined. For NGGCT, both the chemotherapy and radiotherapy should be performed, and survival rate is substantially increasing with modern treatment protocols. The omission of craniospinal irradiation is being tried for the localized NGGCT in international cooperative group trials. Surgery has its role for the resection of residual disease after the treatment, and the extent of resection in NGGCT has the prognostic implication. Bifocal germ cell tumors and basal ganglia germ cell tumor have distinctive clinical course and mandate special attention. To advance clinical and biological perspectives in central nervous germ cell tumor, the cooperation and communication of the multidisciplinary specialists are essential.

A pillow of 8 cm height did not improve laryngeal view and alignment of airway axes but increased anesthesiologist discomfort compared to a pillow of 4 cm height during tracheal intubation in adult patients / 대한마취과학회지

BACKGROUND: Neck flexion by head elevation using an 8 to 10 cm thick pillow and head extension has been suggested to align the laryngeal, pharyngeal and oral axis and facilitate tracheal intubation. Presently, the laryngeal view and discomfort for tracheal intubation were evaluated according to two different degrees of head elevation in adult patients. METHODS: This prospective randomized, controlled study included 50 adult patients aged 18 to 90 years. After induction of anesthesia, the Cormack Lehane grade was evaluated in 25 patients using a direct laryngoscope while the patient's head was elevated with a 4 cm pillow (4 cm group) and then an 8 cm pillow (8 cm group). In the other 25 patients, the grades were evaluated in the opposite sequence and tracheal intubation was performed. The success rate and anesthesiologist's discomfort score for tracheal intubation, and laryngeal, pharyngeal and oral axes were assessed. RESULTS: There were no differences in the laryngeal view and success rate for tracheal intubation between the two groups. The discomfort score during tracheal intubation was higher in the 8 cm group when the patient's head was elevated 4 cm first and then 8 cm. The alignment of laryngeal, pharyngeal and oral axes were not different between the two degrees of head elevation. CONCLUSIONS: A pillow of 8 cm height did not improve laryngeal view and alignment of airway axes but increased the anesthesiologist discomfort, compared to a pillow of 4 cm height, during tracheal intubation in adult patients.