Chamberlain's Line Violation in Basilar Invagination Patients Compared with Normal Subjects: A Systematic Literature Review and Meta-Analysis.

OBJECTIVE: To compare the measured odontoid tip violation above Chamberlain's line described in the literature to diagnose basilar invagination (BI) and to establish the normal placement of the dens tip defining individuals without BI (normal subjects). METHODS: A systematic literature review was performed to identify clinical or radiological studies that expressed the amount of odontoid violation above Chamberlain's line in patients with a BI diagnosis. In addition, a meta-analysis was performed to evaluate normal subjects' values of Chamberlain's line violation (CLV). RESULTS: There were 23 studies included (13 radiological and 10 clinical). Most studies used computed tomography and/or magnetic resonance imaging. Eight different cutoff values were used to measure dislocated odontoid apexes above Chamberlain's line regardless of the radiological modality. The mean measured amount of CLV was 3.95 mm (median 5 mm; range, 0-9 mm). The meta-analysis included 8 studies (1233 patients) with a normal sample population with a mean normal CLV of -0.63 mm (below the line) (95% confidence interval [-0.8, 1.18 mm], random effects model). CONCLUSIONS: Different values were found in the assessed studies used for CLV in BI diagnosis. This variability is especially important for type B BI, as type A BI has other craniocervical diagnostic parameters. Considering the results obtained in this meta-analysis, BI should be diagnosed in the case of any dens violation >1.18 mm.

The impact of traumatic herniated discs in cervical facets dislocations treatments: systematic review and meta-analysis.

BACKGROUND: Traumatic facet dislocations in the subaxial cervical spine, also known as locked facets, are commonly associated with neurological deficits. The fear of the presence of an associated traumatic disc herniation and consequent neurological worsening usually causes a delay in the spinal realignment. This study's aim is an analysis of safety and efficacy when treating acute cervical traumatic facet dislocations using cranial-cervical traction or posterior open reduction and fixation in the presence of disc herniations. METHODS: Inclusion criteria addressed the following patient groups: (1) MRI diagnosis of traumatic cervical facet dislocations with disc herniation, (2) intervention: either cranial-cervical traction or posterior open reduction and fixation, (4) neurological outcomes after treatment, (5) adult 18 plus years of age, (6) sample sizes greater than 20 patients, (7) English language publication. The following databases and search tools were analyzed: MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, and the clinical trial registries (ClinicalTrials.gov), October 2021. RESULTS: Six studies were found, 2 with posterior open reduction and fixation and 4 with cranial-cervical traction, totalizing 197 patients. Neurological worsening was reported only in 1 case (0.5%). CONCLUSIONS: Traumatic disc herniation in cervical facet dislocations is not an absolute contraindication of cranial-cervical traction or posterior open reduction. Early realignment of the spine could bring more neurological benefits than waiting for an MRI or surgical discectomy. However, caution is needed in this review's data interpretation until prospective and well-designed studies are performed.

Role of Atlas Assimilation in the Context of Craniocervical Junction Anomalies.

Atlas assimilation (AA) may be associated with atlantoaxial dislocation, Chiari malformation (CM), and basilar invagination. The importance of AA in the context of craniocervical junction (CVJ) anomalies is unclear. Considering this context, this study's objective is to discuss the role of AA in the management of CVJ anomalies, especially in CM. A comprehensive literature review was performed. In addition, some illustrative cases were discussed on the basis of our review. Finally, we propose a theoretic algorithm to evaluate patients with AA and CM. AA is a proatlas segmentation anomaly that may be complete or incomplete. It may be totally asymptomatic or symptomatic as the result of transferred shifted forces onto the C1-2 joints, leading to clear instability (atlantoaxial dislocation) or mild C1-2 instability. Cautious surgical planning may be required due to associated vertebral artery anomalies. AA with concomitant C2-C3 segmentation failure is highly associated with late C1-C2 instability. CVJ decompression failure was reported in patients with CM and a low clivus canal angle (<130-135 degrees). Patients with assimilated anterior C1 arches usually have evident AAD. CM patients with AA generally have type 1 BI or type 2 BI and are reported with higher rates of CVJ instabilities when compared with those "pure" CM. Dynamic examinations may provide additional evidence of atlantoaxial instability. Although AA per se is not considered an unstable configuration, further and detailed evaluations of patients with CM associated with AA are necessary. Some associated unstable configurations required concomitant CVJ fixation.

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

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.

The effect of filum terminale sectioning for Chiari 1 malformation treatment: systematic review.

PURPOSE: Symptomatic Chiari type I malformation (CM) is treated with posterior fossa decompression with/ without duroplasty. Few authors suggested cerebellar tonsil caudal migration due to a supposed "caudal traction" of cranial nerve structures in a so-called occult tethered cord syndrome. For these authors, filum terminale (FT) sectioning may improve CM symptoms. The objective of this review is to evaluate the effect of FT sectioning on the treatment of CM. METHODS: Using the PRISMA guidelines for systematic reviews, we reviewed studies to evaluate patient's outcomes with CM who underwent FT sectioning. The MINORS instrument was used for methodological quality assessment. The included studies' levels of evidence (LOE) were classified according to the Oxford Centre of Evidence-Based Medicine. RESULTS: Two studies from the same group of authors were included. We cannot assure if the cited cases in the first study were also included in their latter published study. The described results suggest that outcomes were not collected in a standardized fashion. Outcomes are described vaguely as a percentage of improvement. Case series samples were small and included not only patients with CM but also patients with scoliosis and syringomyelia. The MINORS score reported that both studies had low methodological quality. Both included studies were classified as level 4 of evidence. CONCLUSION: There is no scientific support for filum terminale sectioning in patients with CM without evidence of tethered cord. This procedure may be considered experimental and should be validated in a strict criterion of inclusion clinical trial comparing outcomes in posterior fossa decompression.

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.

Intraoperative vancomycin powder and post-operative infection after spinal surgery: a systematic review and meta-analysis

SUMMARY

Intraoperative Neurophysiological Monitoring in Spine Surgery: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic literature review and meta-analysis. OBJECTIVE: The objective of this systematic literature review was to evaluate if intraoperative neurophysiological monitoring (IONM) can prevent neurological injury during spinal operative surgical procedures. SUMMARY OF BACKGROUND DATA: IONM seems to have presumable positive effects in identifying neurological deficits. However, the role of IONM in the decrease of new neurological deficits remains unclear. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews and Meta-analysis, we reviewed clinical comparative studies who evaluate the rate of new neurological events in patients who had a spinal surgery with and without IONM. Studies were then classified according to their level of evidence. Methodological quality was assessed according to methodological index for non-randomized studies instrument. RESULTS: Six studies were evaluated comparing neurological events with and without IONM use by the random effects model. There was a great statistical heterogeneity. The pooled odds ratio (OR) was 0.72 {0.71; 1.79}, P = 0.4584. A specific analysis was done for two studies reporting the results of IONM for spinal surgery of intramedullary lesions. The OR was 0.1993 (0.0384; 1.0350), P = 0.0550. CONCLUSION: IONM did not result into fewer neurological events with the obtained evidence of the included studies. For intramedullary lesions, there was a trend to fewer neurological events in patients who underwent surgery with IONM. Further prospective randomized studies are necessary to clarify the indications of IONM in spinal surgeries. LEVEL OF EVIDENCE: 2.

The pathophysiology, classification, treatment, and prognosis of a spontaneous thoracic spinal cord herniation: A case study with literature review.

BACKGROUND: Spinal cord herniation was first described in 1974. It generally occurs in middle-aged adults in the thoracic spine. Symptoms typically include back pain and progressive paraparesis characterized by Brown-Séquard syndrome. Surgical reduction of the hernia improves the attendant symptoms and signs, even in patients with longstanding deficits. CASE DESCRIPTION: A 66-year-old female with back pain for 7 years, accompanied by paresthesias and a progressive paraparesis, underwent a thoracic MRI which documented a ventral spinal cord herniation at the T4 level. Following a laminectomy, with reduction of the hernia and ventral dural repair, the patient improved. CONCLUSION: Herniation of the thoracic cord, documented on MR, may produce symptomatic paraparesis which may resolve following laminectomy with ventral dural repair.

Manejo das neoplasias metastáticas da coluna vertebral - uma atualização / Management of metastatic spinal column neoplasms - an update

O aumento da sobrevivência do paciente oncológico decorrente da melhoria e do avanço das modalidades terapêuticas promove progressivo aumento da prevalência das neoplasias metastáticas da coluna vertebral, tornando o seu conhecimento condição sine qua non para os profissionais da área de saúde. As metástases na coluna vertebral são usualmente procedentes de neoplasia maligna da mama, pulmão e próstata, o gênero masculino é o mais acometido e a dor é o sintoma inicial em mais de 90% dos pacientes. Estima-se que 30-90% dos pacientes com câncer em estágio terminal apresentem metástase em algum segmento da coluna vertebral. A alta prevalência das neoplasias malignas e a significativa experiência dos autores no tratamento das metástases na coluna vertebral motivaram uma atualização do tema. Acreditamos que a padronização da conduta e o conhecimento pormenorizado dos principais aspectos da doença, podem promover a melhor opção terapêutica. O presente estudo visa à revisão e descrição didática dos principais aspectos relacionados à fisiopatologia, diagnóstico e tratamento desta entidade.

The increased survival of cancer patients due to the improvement and advancement of therapeutic modalities has promoted progressive increase in the prevalence of metastatic tumors of the spine, making it important for healthcare professionals to acquire knowledge in the field. Spinal column metastases are usually secondary to malignant neoplasm of the breast, lung and prostate, male gender being the most often affected and pain being the initial symptom in 90% of patients. It is estimated that 30-90% of terminally ill patients with cancer have metastases at some spinal column segment. Clinical history, physical and neurological assessments are critical to determine the degree and extent of the lesion, and therefore choose the appropriate imaging method to be requested. This study aims to perform a review and didactic description of the main aspects related to the physiopathology, diagnosis and treatment of this disease.

Management of metastatic spinal column neoplasms--an update.

The increased survival of cancer patients due to the improvement and advancement of therapeutic modalities has promoted progressive increase in the prevalence of metastatic tumors of the spine, making it important for healthcare professionals to acquire knowledge in the field. Spinal column metastases are usually secondary to malignant neoplasm of the breast, lung and prostate, male gender being the most often affected and pain being the initial symptom in 90% of patients. It is estimated that 30-90% of terminally ill patients with cancer have metastases at some spinal column segment. Clinical history, physical and neurological assessments are critical to determine the degree and extent of the lesion, and therefore choose the appropriate imaging method to be requested. This study aims to perform a review and didactic description of the main aspects related to the physiopathology, diagnosis and treatment of this disease.

Paralisia cruzada de Bell em um paciente vítima de ferimento por projétil de arma de fogo na região cervical: a evidência radiológica de uma teoria anatômica / Bell’s Cruciate paralysis in a patient victim of a gunshot wound in the cervical region: the radiologic evidence of an anatomic theory

A paralisia cruzada de Bell é caracterizada pela paralisia dos membros superiores associada a pouco ou nenhum déficitem membros inferiores. Seu diagnóstico é geralmente subestimado, tendo em vista que seus sintomas são semelhantes aosproduzidos pela síndrome centromedular, que tem uma incidência consideravelmente maior. O presente relato descreve o casode um paciente masculino de 16 anos de idade, vítima de ferimento por projetil de arma de fogo em região cervical anteriorque desenvolveu paralisia cruzada de Bell. A ressonância magnética (RM) de coluna cervical demonstrou alteração de sinal natransição bulbomedular, com localização anterior. Uma somatotopia do trato corticoespinal foi sugerida por Bell, em 1970, natransição bulbomedular, com a hipótese de que fibras responsáveis pelos movimentos dos membros superiores cruzariam maissuperiores e superficiais que fibras responsáveis pela movimentação dos membros inferiores. Esse caso associa os achados doexame neurológico com as imagens de RM para corroborar a teoria anatômica de Bell.

Traumatic atlantoaxial rotatory subluxation in adults: report of two cases and literature review / Subluxación atlantoaxial rotatoria traumática en adultos: reporte de dos casos y revisión de la literatura

Atlantoaxial subluxation is defined as an instability of the atlas (C1) over the axis (C2), due to failure or rupture of the ligament complex in the C1-C2 joint. It occurs most frequently in childhood, due to atlantoaxial ligament laxity, a common condition at this age group and may have traumatic or nontraumatic causes. The clinical features of this entity are the presence of upper cervical pain, limitation of neck mobility, torticollis and muscle spasm. The treatment of rotatory subluxation should be individualized because there is no evidence in the literature showing the superiority of a particular therapeutic proposal. In this study we describe two cases of atlantoaxial subluxation of traumatic origin in adults and review the literature regarding the main aspects of this entity.

Subluxación atlantoaxial se define a una inestabilidad del atlas (C1) sobre el axis (C2), debido a un fallo o rotura del complejo del ligamento de la articulación C1-C2. Es más frecuente en la infancia, debido a la laxitud del ligamento atlantoaxial, una condición común en este grupo de edad y puede tener causas traumáticas o no traumáticas. Las características clínicas de esta entidad son la presencia de dolor cervical superior, limitación de la movilidad del cuello, tortícolis y los espasmos musculares. El tratamiento de la subluxación rotatoria debe ser individualizado en porque no hay una evidencia en la literatura que muestra la superioridad de una propuesta terapéutica en particular. En este estudio se describen dos casos de subluxación atlantoaxial de origen traumático en adultos y se hace una revisión de la literatura respecto a los principales aspectos de esta entidad.

[Effectiveness of methylprednisolone in the acute phase of spinal cord injuries--a systematic review of randomized controlled trials]. / Efetividade da metilprednisolona na fase aguda do trauma raquimedular--revisão sistemática dos ensaios clínicos randomizados.

UNLABELLED: Steroid therapy has been tested as a protector in spinal cord injury. Multicenter studies evaluating the methylprednisolone (MP) in post traumatic neurological recovery have shown promising results according to NASCIS. A large number of critical studies related to the NASCIS results have been published. OBJECTIVE: To review literature related to use of methylprednisolone compared with placebo. METHODS: This analysis added the average improvement achieved in groups of patients who used MP and placebo (PL) to the average scores of groups at baseline, before treatment, resulting in the final neurological outcome for both groups. RESULTS: The motor score of the MP group was only 2.5 points higher than the PL in a one year follow-up. In neurologically intact patients, the total score is 70 points. Improvement in sensitive scores was also discrete (1.1 and 1.7 points for the pinprick and light touch respectively). A high rate of complications was observed in a group of patients about 60 years old who used MP. CONCLUSION: Differences in the clinical magnitude of benefit obtained (not confirmed by other studies) with the use of MP or PL are not significant, in comparison with the potential for complications when using methylprednisolone.

Efetividade da metilprednisolona na fase aguda do trauma raquimedular: revisão sistemática dos ensaios clínicos randomizados / Effectiveness of methylprednisolone in the acute phase of spinal cord injuries: a systematic review of randomized controlled trials

A corticoterapia tem sido testada como protetor neuronal no trauma. Os estudos multicêntricos avaliando a metilprednisolona (MP) na recuperação neurológica após trauma revelaram-se promissores (NASCIS). Porém, várias, críticas às suas metodologias foram publicadas. OBJETIVO: Revisar a literatura relacionada ao uso da metilprednisolona comparada com placebo. MÉTODOS: A análise feita somou a média da melhora obtida nos grupos de pacientes que usaram MP e placebo (PL) à média dos escores dos grupos na linha de base, antes de tratamento, obtendo-se o resultado neurológico final de ambos os grupos. RESULTADOS: O escore motor do grupo MP foi apenas 2,5 pontos maior que o PL em um ano de seguimento. O escore motor em indivíduos intactos é de 70 pontos. A melhora nos escores sensitivos foi igualmente discreta (1,1 e 1,7 pontos para sensibilidade a picadas e tato respectivamente). A taxa de complicações observada em grupo de pacientes em torno de 60 anos foi alta com o uso de MP. CONCLUSÃO: As diferenças na magnitude do benefício clínico obtido (não confirmado por outros estudos) com o uso da MP e com o PL não são significativas em confronto com o potencial de complicações do uso da medicação.

Steroid therapy has been tested as a protector in spinal cord injury. Multicenter studies evaluating the methylprednisolone (MP) in post traumatic neurological recovery have shown promising results according to NASCIS. A large number of critical studies related to the NASCIS results have been published. OBJECTIVE: To review literature related to use of methylprednisolone compared with placebo. METHODS: This analysis added the average improvement achieved in groups of patients who used MP and placebo (PL) to the average scores of groups at baseline, before treatment, resulting in the final neurological outcome for both groups. RESULTS: The motor score of the MP group was only 2.5 points higher than the PL in a one year follow-up. In neurologically intact patients, the total score is 70 points. Improvement in sensitive scores was also discrete (1.1 and 1.7 points for the pinprick and light touch respectively). A high rate of complications was observed in a group of patients about 60 years old who used MP. CONCLUSION: Differences in the clinical magnitude of benefit obtained (not confirmed by other studies) with the use of MP or PL are not significant, in comparison with the potential for complications when using methylprednisolone.