360° fixation with modern instrumentations of segment separation cervical spine injury in a 23-month-old.

In this case report clinical and technical lessons including seven years follow up learned from a flexion-distraction, highly unstable cervical spine injury causing a complete separation of C6-7 cervical segment with tetraparesis in a 23-month-old boy, are presented. To our knowledge this is the only documented case in medical literature where adult size implants (cage, plate and lateral mass screw-rod system) were utilized for cervical combined anterior and posterior internal fixation in a child under the age of two years without implant-size related problems. Seven years after the injury the child attends elementary school, can operate a wheelchair manually, and can eat and write. Computed tomography control showed no failure of the hardware and fusion was later observed in the intervertebral space of the stabilized cervical segment, however adjacent segment syndrome occurred without deterioration of the patient's status. The decision on the mode of realignment and fixation to be made in such a case was difficult because there is no standard procedure for infants.

Modified minimally invasive surgical approach to cervical neuromas with intraforaminal components: hemi-semi-laminectomy and supraforaminal burr hole (modified foraminotomy) technique.

OBJECTIVE: The aim of this study was to develop a minimal invasive approach suitable for exploring neuromas with an intraforaminal component in the cervical spine with the aim of preservation of as much of the mechanically relevant bone structures and facet joints as possible. METHODS: The authors used the hemi-semi-laminectomy combined with supraforaminal burr hole technique in 7 adult patients with neuroma extending inside the foramen in the region of the cervical spine. RESULTS: Under the operating microscope the operating field was sufficient for tumour removal according to the keyhole concept. The approach did not affect the extent of tumour resection, or neurological outcome. The affected nerve roots included C3 in 3 cases, C5 in 2, C4 and C6 in 1 case. The average follow-up was 9 months, with a range from 6 to 13 months. Histological results were as follows: 4 schwannomas and 3 neurofibromas. CONCLUSION: This modified surgical approach fulfills the requirements of other minimal invasive techniques and helps to prevent damage to the crucial posterior stabilizers of the spine, and disintegration of the vertebral arches and facet joints is reduced. The approach is suitable for exploring and removing neuromas located in the spinal canal and the neuroforamen.

Early experiences with image-guided transoral surgery for the pathologies of the upper cervical spine.

STUDY DESIGN: Technical note. OBJECTIVES: Three years of convincing experience with cranial neuronavigation suggested the application of the cranial software and registration method for the transoral access to the C1-C2 vertebrae. BACKGROUND DATA: The C1-C2 vertebrae are located in close vicinity to the cranial base. If the intersegmental movements of the C0-C1/C1-C2 segments are prevented with HALO fixation, the upper cervical spine can be considered as a caudal part of the skull base and included in the extended navigation space of the skull. METHODS: Three patients were selected for navigation-assisted transoral odontoidectomy. Before surgery the patients were fixed and scanned in a HALO device. The fiducials were attached supraorbitally and to both mastoids, determining a wide registration area and allowing the caudal extension of the navigation space. The BrainLAB VectorVision navigation system was used in cranial mode during the operations. RESULTS: Neuronavigation and fluoroscopy-controlled transoral surgery were performed with success in all three cases. The registration accuracy was 1.5, 2.7, and 3.1 mm. CONCLUSION: Image guidance during transoral exposure of the upper cervical spine offered excellent three-dimensional guidance on the ventral surface of the craniocervical junction, allowing a safer, more controlled surgery. As the targets of the transoral spinal surgery are fixed bony and ligamentous structures, no shifting occurs and continuous high navigation accuracy can be achieved. The use of the navigation can reduce the significance of the intraoperative fluoroscopy, diminishing the radiograph load of the patient and the operating room team.

Direct anterior screw fixation for recent and remote odontoid fractures.

OBJECT: The management of odontoid fractures remains controversial. Only direct anterior screw fixation provides immediate stabilization of the spine and may preserve normal C1-2 motion. To determine the indications, optimum timing, and results for direct anterior screw fixation of odontoid fractures, the authors reviewed the surgery-related outcome of patients who underwent this procedure at two institutions. METHODS: One hundred forty-seven consecutive patients (98 males and 49 females) who underwent direct anterior screw fixation for recent (< or = 6 months postinjury [129 patients]) or remote (> or = 18 months postinjury [18 patients]) Type II (138 cases) or III (nine cases) odontoid fractures at the University of Utah (94 patients) and National Institute of Traumatology in Budapest, Hungary (53 patients) between 1986 and 1998 are included in this study (mean follow up 18.2 months). Data obtained from clinical examination, review of hospital charts, operative findings, and imaging studies were used to analyze the surgery-related results in these patients. In patients with recent fractures there was an overall bone fusion rate of 88%. The rate of anatomical bone fusion of recent fractures was significantly (p < or = 0.05) higher in fractures oriented in the horizontal and posterior oblique direction (compared with anterior oblique), but this finding was independent (p > or = 0.05) of age, sex, number of screws placed (one or two), and the degree or the direction of odontoid displacement. In patients with remote fractures there was a significantly lower rate of bone fusion (25%). Overall, complications related to hardware failure occurred in 14 patients (10%) and those unrelated to hardware in three patients (2%). There was one death (1%) related to surgery. CONCLUSIONS: Direct anterior screw fixation is an effective and safe method for treating recent odontoid fractures (<6 months postinjury). It confers immediate stability, preserves C1-2 rotatory motion, and achieves a fusion rate that compares favorably with alternative treatment methods. In contradistinction, in patients with remote fractures (> or = 18 months postinjury) a significantly lower rate of fusion is found when using this technique, and these patients are believed to be poor candidates for this procedure.

Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique.

Sixty-one patients treated with C1-2 transarticular screw fixation for spinal instability participated in a detailed clinical and radiological study to determine outcome and clarify potential hazards. The most common condition was rheumatoid arthritis (37 patients) followed by traumatic instability (15 patients). Twenty-one of these patients (one-third) underwent either surgical revision for a previously failed posterior fusion technique or a combined anteroposterior procedure. Eleven patients underwent transoral odontoidectomy and excision of the arch of C-1 prior to posterior surgery. No patient died, but there were five vertebral artery (VA) injuries and one temporary cranial nerve palsy. Screw malposition (14% of placements) was comparable to another large series reported by Grob, et al. There were five broken screws, and all were associated with incorrect placement. Anatomical measurements were made on 25 axis bones. In 20% the VA groove on one side was large enough to reduce the width of the C-2 pedicle, thus preventing the safe passage of a 3.5-mm diameter screw. In addition to the obvious dangers in patients with damaged or deficient atlantoaxial lateral mass, the following risk factors were identified in this series: 1) incomplete reduction prior to screw placement, accounting for two-thirds of screw complications and all five VA injuries; 2) previous transoral surgery with removal of the anterior tubercle or the arch of the atlas, thus obliterating an important fluoroscopic landmark; and 3) failure to appreciate the size of the VA in the axis pedicle and lateral mass. A low trajectory with screw placement below the atlas tubercle was found in patients with VA laceration. The technique that was associated with an 87% fusion rate requires detailed computerized tomography scanning prior to surgery, very careful attention to local anatomy, and nearly complete atlantoaxial reduction during surgery.

Is the technique of posterior transarticular screw fixation suitable for rheumatoid atlanto-axial subluxation?

The rheumatoid patient with atlanto-axial subluxation presents a major challenge to the spinal surgeon, owing to the poor wound healing and bone quality. Traditional wiring techniques are associated with a high complication and failure rate. Posterior transarticular screw fixation of the atlanto-axial joint offers a credible alternative and when combined with a Gallie construct offers immediate true 3-point stability. It is, however, a difficult and demanding technique which carries a risk of vertebral artery, cranial nerve and spinal cord damage. The question that arises therefore is "Do the improved stability rates afforded by this technique really justify the risks of arterial and neurological damage?" To date there have been no studies of this technique dealing solely with the rheumatoid patient, with most reports dealing with a heterogeneous patient population, mainly trauma-related cases. The purpose of this report is to analyse critically our results with particular reference to the complications that we have encountered and the technical reasons for their occurrence. We analysed the clinical and radiological data of 38 rheumatoid patients (six males: 32 females, mean age of 54 years) with atlanto-axial subluxation who underwent transarticular screw fixation. Our analysis centred on screw malposition and complications. Parametric and non parametric statistical analysis was performed. Significance was accepted at the 5% level (p < 0.05). Our analysis revealed that three vertebral arteries were damaged. Two of these were recognized at the time of surgery, with the remaining case only suspected following postoperative CT to assess screw positioning. Vertebral artery occlusion was subsequently confirmed by angiography. All three patients were asymptomatic from their arterial injury. There was only one neurological complication in this series, and this was caused by a high screw, which damaged the hypoglossal nerve with a temporary nerve palsy ensuing. Four screws broke, all were made of titanium, but more importantly, all were also associated with contralateral screw malposition. Stability was achieved in 95% of cases overall. The high stability rates afforded by this technique do appear to justify the inherent risks of this procedure. If unilateral screw fixation only is achieved, we would recommend a period of halo immobilization until osseous union occurs.

Use of an adjustable, transportable, radiolucent spinal immobilization device in the comprehensive management of cervical spine instability. Technical note.

In this report the authors describe a device that consists of a transportable, radiolucent board that couples to a standard halo head ring. The board provides continuous cervical spine immobilization during all phases of acute medical treatment of cervical spine instability, including closed reduction, transport, radiographic imaging, and operative procedures. By combining the advantages of several existing systems, this immobilization device facilitates and improves the safety of comprehensive acute management of cervical spinal instability by eliminating the need for patient transfer from stretcher to radiography machine to operating table. Its radiolucent construction and its compatibility with standard operating tables allow unencumbered surgical access and ample room for biplanar fluoroscopy, thereby also facilitating operative procedures, particularly the placement of internal spinal fixation.

Pediatric transoral surgery: indications, complications, and long-term outcome.

Knowledge of the role and hazards of transoral surgery has expanded rapidly, but the application of this technique in children has been limited. To assess its usefulness, 27 pediatric patients who underwent transoral surgery between 1985 and 1994 were studied. Transoral surgery was performed for irreducible anterior neuraxial compression at the craniovertebral junction caused by basilar impression, atlantoaxial subluxation with pseudotumor, or chordoma. The patients ranged in age from 3 to 17 years. Symptomatic presentation varied widely, but 89% had significant neurological deficits before surgery. No patient with normal strength deteriorated after surgery. Of the 16 patients with a preoperative motor deficit, nine improved rapidly, three were unchanged, and four significantly worsened in the perioperative period. Those with mobile atlantoaxial subluxation were most vulnerable to surgically related neurological morbidity. Twenty-four patients were alive for long-term follow-up study (average 5.7 years, range 1-9.2 years). Of those with preoperative weakness, nine improved one Frankel grade, four remained the same, and one deteriorated from Frankel Grade D to C. Swallowing and speech worsened in five patients; this occurred only after resection of lesions above the foramen magnum (p<0.05) when rostral pharyngeal disruption resulted in velopharyngeal dysfunction. This study, unlike previous reviews of pediatric transoral operations, leads the authors to suggest that although transoral surgery can be effective, it also carries a significant risk of neurological injury in patients with symptomatic spinal cord compression and it is also associated with long-term swallowing and speech difficulties.

[Early experience with the use of the Halo device in the treatment of damage to the cervical spine]. / Halo-készülékkel szerzett korai tapasztalataink nyaki gerinckórképek kezelése során.

Authors report on their experiences gained in 5 cases with the Halo device. The method of treatment is described. On the basis of a literary overview the field of indication, the advantages and the disadvantages of the method are described. In the assessment of the method it is stressed that according to their opinion this is the best conservative method of treatment, and the results compete with that of the operative treatment.

Ventral spondylodesis: basic method in the treatment of cervical spine injuries.

Ventral spondylodesis or ventrofixation is the most important surgical method for the treatment of severe cervical spine injuries accompanied by instability. Its wide indications include fracture-dislocations, compression fractures of the vertebral body, injuries to the disc, luxations, 'tear drop fractures' as well as "hangman's fractures". The essential parts of its technique: previous reduction by traction, anterior cervical approach, removal of the injured parts of vertebral body and disc(s), replacement by corticocancellous bone graft with subsequent plate-screw fixation. The authors performed in their Institute nearly 100 operations of this type, in a 10-year period of which; detailed account is given. Good results of surgery can be expected only by ensuring adequate technical conditions and professional knowledge, performing the operations in centres having sufficient experience.

[Results of rectoscopical investigations in unselected patients: contribution to the problems of prophylactical investigations (author's transl)]. / Ergebnisse rektoskopischer Untersuchungen an unausgewähltem Patiengut. Beitrag zum Thema Vorsorgeuntersuchungen.

A report and analysis is given about the results of totally 1665 rectoscopical investigations, which were done in unselected patients suffering from common internal diseases. In 7 cases (that means 0.4% of the whole collective) a carcinoma could be detected. An evidently great number of 304 patients were carriers of polyps (that means 17.6% of the whole collective), of whom 77% were male and 23% were female carriers of polyps. The differentiation of the polyps moreover was done according to the histological criteria: There were 126 prospectively precancerous polyps (that means 7.4% of the whole collective of 1665 patients). These results are compared with data in the literature. The number of prospectively important findings is found higher than commonly is expected. The security of the diagnostic significance of the rectoscopical investigations cannot be obtained by other methods of prophylactical investigations. Therefore this method should be practiced in internal, but among all in clinical conditions in first stage. Only more consequent medical procedures in future are able to help to gain more successful results in treating colorectal cancer.

[The oral application of berotec in the therapy of obstructive airway diseases]. / Zur oralen Anwendung von Berotec in der Therapie obstruktiver Erkrankungen der Atemwege.

The intensity and duration of action of Berotec (fenoterol) syrup in doses of 2.5 mg and 5.0 mg were investigated in an acute cross-over study in comparison with placebo, using the double blind technique. By measurement of the forced expiratory volume (FEV1) and the forced expiratory flow rate (FEF200-1200) significant improvement in pulmonary function could be detected from 1 to 4 hours after administration of 2.5 mg and from 1 to 8 hours after administration fo 5.0 mg Berotec syrup. The intensity of action exhibited a statistically significant dose dependence and was greater after the 5.0 mg dose (p=0.05) than after 2 puffs from Berotec metered aerosol taken by the patients in a pre-test. Minor side effects were observed in 2 cases: in one patient on the 5.0 mg dose they were clearly sympathomimetic and accompanied by a stronger bronchodilating effect.