INTRODUCTION: Pathological destruction of the axis vertebra leads to a highly unstable condition in an upper cervical spine. As surgical resection and anatomical reconstruction of the second cervical vertebrae represents a life threatening procedure, less radical approaches are preferred and only few cases of C2 prosthesis are described in literature. CASE DESCRIPTION: The focus of this case report is a 21-year-old man with a pathological fracture of C2 managed primarily surgically with the C1-C3 dorsal fusion. Due to the progression of giant cell tumor and destruction of the axis vertebra, C2 prosthesis through anterior approach and dorsal occipito-cervical fusion C0-C4 were performed. Postoperative infection was managed surgically with a 2-staged dorsal debridement, ostheosynthesis material change and autologous bone graft. After a 4 week-intravenous therapy with the ceftriaxone in combination with the amoxicillin/clavulanate, followed by 12 week per oral therapy with amoxicillin/clavulanate in combination with ciprofloxacin, the complete recovery of the infection was achieved. Radiotherapy was initiated 2 months after the last revision surgery and the patient showed a good clinical outcome with stable construct at a 1 year follow-up. A review of literature of all reported C2 prosthesis cases was performed CONCLUSION: C2 prosthesis allows a more radical resection in pathological processes involving the axis vertebra. Combined with the posterior fusion, immediate stability is achieved. Anterior surgical approach is through a highly unsterile oral environment which presents a high-risk of postoperative infection.
- MeSH
- axis chirurgie zranění MeSH
- fraktury páteře * chirurgie MeSH
- fraktury spontánní chirurgie etiologie MeSH
- fúze páteře * metody MeSH
- implantace protézy metody MeSH
- krční obratle chirurgie zranění MeSH
- lidé MeSH
- mladý dospělý MeSH
- nádory páteře chirurgie MeSH
- Check Tag
- lidé MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
- přehledy MeSH
Objective: Retrospective evaluation of the results of conservative and surgical treatment in senior population patients with type 2 and 3 odontoid fracture according to Anderson DʼAlonzo (A-A) classification treated at the Trauma Clinic of the University Hospital in Brno from 2013 to 2017. Material and methods: The monitored set consisted of 52 patients (28 women, 24 men) aged over 65, the average age being 82 years (66 – 93 years) and the median being 76 years. Fractures of the dens were evaluated according to Anderson and DʼAlonzo classification. Conservative therapy using the Philadelphia-type hard collar for 12 weeks was indicated in patients with non-dislocated or minimally dislocated type II and type III odontoid fracture. Surgical treatment using 2 compression screws C1-2 posterior fusion was primarily indicated in dislocated fractures. The patient monitoring length was minimally 6 months from the injury. X-ray check-ups including clinical check-up of the monitored patients were performed on day 4 - 7 from the diagnosed odontoid fracture or after the surgery performed and also in week 4, 8, 12 and 24 after the injury, when functional x-rays of cervical spine were also made. Results: According to x-ray images, healing of the fracture was observed after 6 months of treatment in 47 % of the patients with type II odontoid fracture. Fracture line persisted in 53 % of patients, but the treatment was conservative without clinical correlate and with regard to comorbidities, meaning recommended use of a soft collar for verticalization. In type III odontoid fractures, healing of the fractures was observed in 71 % of the patients. Besides non-healing of the fracture, we evaluated the other therapeutic complications as well. The least complications occurred in conservatively treated patients with a hard collar, where we particularly observed collar galls. Most complications were represented in patients treated by Halo fixation, where we observed numerous complications such as pin track infection, swallowing disorders, pneumonia, and in 53 % of patients recurring loss of odontoid fracture reposition with subsequent non-healing of the fracture. Conclusion: Odontoid fractures belong to the most frequent cervical spine injuries in the elderly population; the incidence has been increasing and there is no uniform treatment concept which, however, should be individual, also with regard to the associated comorbidities. And with regard to the aforementioned it is important to realize that even a stable ligament false joint is tolerated very well by the elderly people and where neurological symptomatology is absent, it is not always necessary to aim for bone healing of the fracture.
- MeSH
- axis chirurgie diagnostické zobrazování zranění MeSH
- dens axis * chirurgie diagnostické zobrazování zranění MeSH
- fraktury páteře * chirurgie diagnostické zobrazování terapie MeSH
- imobilizace metody MeSH
- konzervativní terapie MeSH
- kostní šrouby škodlivé účinky statistika a číselné údaje MeSH
- lidé MeSH
- pooperační komplikace MeSH
- retrospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- vnitřní fixace fraktury metody statistika a číselné údaje MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- Publikační typ
- srovnávací studie MeSH
Cíl: Retrospektivní zhodnocení výsledků konzervativní a operační léčby u pacientů seniorské populace s frakturou dens axis 2. a 3. typu dle Anderson D‘Alonzovy (A-A) klasifikace léčených na Klinice úrazové chirurgie FN Brno v letech 2013–2017. Materiál a metody: Sledovaný soubor tvořilo 52 pacientů (28 žen, 24 mužů), kterých věk byl nad 65 let a průměrný věk byl 82 let (66–93 let) a medián pak 76 let. Zlomeniny dentu byly hodnoceny podle Anderson a DʼAlonzovy klasifikace. Konzervativní léčba pevným krčním límcem typu Philadelphia na 12 týdnů byla indikována u pacientů s nedislokovanou nebo minimálně dislokovanou zlomeninou dens axis 2. a 3. typu. Operační léčba dvěmi kompresními šrouby nebo zadní C1-2 fúzí byla primárně indikována u dislokovaných zlomenin. Délka sledování pacientů byla minimálně šest měsíců od úrazu. RTG kontroly včetně klinické kontroly u sledovaných pacientů byly v průběhu léčby prováděny čtvrtý až sedmý den po diagnostice zlomeniny dentu nebo po provedení operačního zákroku a dále po 4, 8, 12 a 24 týdenním odstupu od úrazu, kdy byly provedeny i funkční RTG snímky krční páteře. Výsledky: U zlomenin dentu 2. typu bylo po šesti měsících léčby dle RTG snímků pozorováno zhojení zlomeniny u 47 % pacientů. U 53 % pacientů přetrvávala lomná linie ale bez klinického korelátu a vzhledem ke komorbiditám byla léčba konzervativní, v podobě doporučení užívání měkkého krčního límce na vertikalizaci. U zlomenin dentu 3. typu bylo pozorováno zhojení zlomenin u 71 % pacientů. Kromě nezhojení zlomeniny jsme hodnotili i další komplikace léčby. Nejméně komplikací bylo zastoupeno u konzervativně léčených pacientů pevným krčním límcem, kdy jsme zaznamenali zejména otlaky od límce. Nejvíce komplikací bylo zastoupeno u pacientů léčených Halo fixací, kde jsme zaznamenali řadu komplikací jako pin track infekt, poruchy polykání, pneumonie a u 53 % pacientů opakovanou ztrátu repozice zlomeniny dentu s následným nezhojením zlomeniny. Závěr: Zlomeniny dens axis patří v seniorské populaci k nejčastějšímu zranění krční páteře, jejich výskyt narůstá a neexistuje jednotný koncept léčby, která by ale měla být individuální i vzhledem k přidruženým komorbiditám. A vzhledem k výše uvedenému je důležité si uvědomit, že i stabilní vazivový pakloub je seniory velmi dobře tolerován a v případě absence neurologické symptomatologie není nutné se vždy se snažit o kostěné zhojení zlomeniny.
- MeSH
- axis chirurgie diagnostické zobrazování zranění MeSH
- dens axis * chirurgie diagnostické zobrazování zranění MeSH
- fraktury páteře * chirurgie diagnostické zobrazování terapie MeSH
- imobilizace metody MeSH
- konzervativní terapie MeSH
- kostní šrouby škodlivé účinky statistika a číselné údaje MeSH
- lidé MeSH
- pooperační komplikace MeSH
- retrospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- vnitřní fixace fraktury metody statistika a číselné údaje MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- Publikační typ
- srovnávací studie MeSH
PURPOSE OF THE STUDY: Radical resection of a vertebra is reserved only for specific tumors that invade the surrounding tissues and recur when not removed completely. The vertebra may be removed using a piecemeal technique or en bloc, using only two (in thoracolumbar spine) or more osteotomies (in cervical spine). We present our technique of en bloc resection of subaxial cervical vertebra for Ewing's sarcoma of C3, with preservation of all nerve roots and both vertebral arteries. To our knowledge, this surgical technique has not been reported in the English literature. The aim of this study is to describe the new technique of radical resection of subaxial cervical vertebra. MATERIAL AND METHODS: A transoral biopsy of tumor tissue anterior to C2-C3 was performed in 8-year old boy, revealing a diagnosis of Ewing's sarcoma. The patient was started on neoadjuvant chemotherapy. After 6 chemotherapy cycles with the VIDE regimen, the soft-tissue component completely regressed, with the only a residual deposit in C3 vertebral body. Based on further multidisciplinary meeting, an en bloc spondylectomy of C3 was recommended, preferably with preservation of nerve roots and vertebral arteries. In August 2014, prior to the planned surgery, we performed another thorough examination of the patient using plain films, CT and MRI. Neither angiography nor embolization was performed. DESCRIPTION OF SURGICAL TECHNIQUE: The first stage of the operation consisted of resection of the posterior structures. We exposed the posterior elements of C2 to C4 by the mid-line incision. The C3 arch was without pathological changes. After partial resection of the C2 inferior and C4 superior articular processes we performed bilateral osteotomy in the region of the pedicle adjacent to the arch with a chisel and removed the whole of the C3 posterior arch. Subsequently we perforated the transverse foramina close to the pedicle, using fine Kerrison rongeurs. The lateral parts around vertebral arteries were left in situ. In the next step we used instrumentation with polyaxial screws to stabilize the C2-C4 section. After 19 days we performed the second stage surgery from an anterior approach with the removal of the anterior and lateral parts of the vertebra. We made a transverse incision anterior to the sternocleidomastoid between the internal carotid artery and the trachea on the right side at the level of C3 to expose the spine. We resected C2-C3 and C3-C4 intervertebral discs and then performed osteotomy with fine Kerrison rongeurs on both sides, again, close to the vertebral body. Subsequently, the vertebral body was released and extracted en bloc. In the next step, both vertebral arteries were mobilized and shifted medially and the lateral portions of the transverse processes were released and removed en bloc. The empty space was filled with solid allograft and the C2-C4 levels were bridged by the cervical plate in 2+1+2 configuration. RESULTS: There were no complications during both surgeries. The follow-up CT examination 4 months after the operation revealed a clear bone fusion of C2-C4, both anteriorly between vertebral bodies and posteriorly between the arches. Clinically the patient has reached 8 month follow up and had no complaints, both he and his parents were satisfied. Physiotherapy is proceeding according to plan. The patient remains under supervision at our centre. DISCUSSION: Total en bloc resection of a subaxial cervical vertebra with preservation of neural and vascular structures has been described in the English literature only once. In 2007 was published a total en bloc resection of C5 for chordoma, preserving the above mentioned structures. Authors removed the lamina en bloc after bilateral osteotomy. Transverse foramina were perforated by the Gigli saw and removed in piecemeal fashion, including the posterior tubercle. In the next step, they removed the vertebral body and the anterior tubercle from the anterior approach. However, their treatment differs from the technique described here and does not correspond fully to the principle of en bloc resection. Our surgical technique is based on a similar principle of performing several osteotomies without the use of high speed burr, while preserving all neural and vascular structures. The difference can be particularly seen in the approach to remove lateral parts of the transverse foramen, which are surrounding the vertebral arteries. We consider it as ideal to split the cervical vertebra by smooth cuts into four parts and remove them en bloc. CONCLUSION: Total en bloc spondylectomy of a subaxial cervical vertebra with preservation of vertebral arteries and nerve roots is a radical surgery that should be used to treat only the most serious conditions. The risk of neurological deficit is outweighed by the benefits of oncological radicality. This new surgical technique has not yet been described and it is clear, that a larger cohort of patients is necessary to assess and potentially modify this technique so that it can be used more frequently in the future.
- MeSH
- artrodéza metody MeSH
- axis chirurgie MeSH
- bederní obratle chirurgie MeSH
- biopsie MeSH
- dítě MeSH
- Ewingův sarkom patologie chirurgie MeSH
- krční obratle chirurgie MeSH
- lidé MeSH
- magnetická rezonanční tomografie metody MeSH
- nádory páteře patologie chirurgie MeSH
- následné studie MeSH
- osteotomie metody MeSH
- pooperační péče MeSH
- zákroky plastické chirurgie MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
The authors describe their experience with treatment of two neurologically intact male patients, aged 70 and 74 years, presenting with combined lateral atlanto-axial dislocation and odontoid type II fracture. The mechanism of these two craniovertebral junction injuries had been lateroflexion of the neck. The initial attempt at closed reduction using axial traction failed. The authors succeeded with a closed reduction maneuver under general anaesthesia in the first patient in whom long-term stability was achieved by transarticular C2-C1 fixation, together with interlaminar fusion. In the second patient, closed reduction was unsuccessful due to intra-articular soft tissue interposition. Release and reduction were achieved by instrumentation of C1 lateral masses and transpedicular anchorage of screws into the C2.The subsequent Harms C1-C2 stabilisation proved to be effective both in achieving long-term stability and segmental fusion of lateral masses. Aspects of biomechanics as well as a review of pertinent literature are presented.
- MeSH
- atlas (obratel) chirurgie zranění MeSH
- axis chirurgie zranění MeSH
- dens axis * chirurgie zranění MeSH
- dislokace kloubu * diagnóza etiologie chirurgie MeSH
- fixace fraktury * metody MeSH
- fraktury páteře diagnóza etiologie chirurgie MeSH
- krční obratle chirurgie zranění MeSH
- lidé MeSH
- ortopedické výkony metody MeSH
- senioři MeSH
- trakce metody MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- Publikační typ
- kazuistiky MeSH
Revmatoidní artritida představuje chronické zánětlivé onemocnění, které se manifestuje multiorgánovým postižením. Typickým projevem je chronická symetrická polyartritida vedoucí ke vzniku kloubních destrukcí a deformit. Páteř je onemocněním nejčastěji postižena v oblasti kraniocervikálního přechodu. Zvýšená laxita vazů vede k rozvoji nestability, jejímiž nejběžnějšími projevy jsou atlantoaxiální dislokace a kraniální migrace zubu čepovce. Popsaná nestabilita může vést až ke vzniku a progresi neurologického postižení, včetně náhlého úmrtí. Včasné zavedení agresivní farmakoterapie může zpomalit progresi onemocnění, nicméně při radiologické progresi nestability nebo vzniku neurologického postižení je chirurgická léčba jedinou smysluplnou léčebnou modalitou. Indikací k chirurgické terapii může být i bolest nezvládnutelná konzervativní léčbou odpovídající popsané nestabilitě. Multidisciplinární spolupráce je nezbytným předpokladem optimálního dlouhodobého výsledku léčby.
Rheumatoid arthritis is a chronic, systemic inflammatory disorder affecting multiple organ systems. The disorder typically manifests with chronic symetric polyarthritis resulting in destruction of joints and development of joint deformities. The craniocervical junction is the section of the spine most frequently affected by the disease. Increased ligamentous laxity is responsible for a development of craniocervical instability. Anterior atlanto-axial subluxation and cranial settling of dens axis are the most common manifestations of the instability. The instability might be responsible for the development or progression of neurological deficit, including sudden death. Early initiation of aggressive pharmacotherapy may slowdown the disease progression, although surgical treatment is the only meaningful therapeutic modality in patients with radiological progression of the instability or who develop neurological deficit. Surgery may also be indicated for pain associated with the craniocervical instability and unresponsive to conservative treatment. A multidisciplinary approach is the prerequisite for optimal long-term outcome.
- Klíčová slova
- revmatoidní artritida, nestabilita, chirurgická léčba,
- MeSH
- atlas (obratel) anatomie a histologie chirurgie patologie MeSH
- axis anatomie a histologie chirurgie patologie MeSH
- elektrofyziologie MeSH
- klinický obraz nemoci MeSH
- kostní šrouby škodlivé účinky využití MeSH
- krční obratle anatomie a histologie chirurgie patologie MeSH
- lidé MeSH
- nestabilita kloubu diagnóza chirurgie MeSH
- ortopedické výkony metody MeSH
- radiografie MeSH
- revmatoidní artritida epidemiologie chirurgie patofyziologie MeSH
- rozsah kloubních pohybů MeSH
- výsledky a postupy - zhodnocení (zdravotní péče) MeSH
- Check Tag
- lidé MeSH
STUDY DESIGN: A report on 3 patients undergoing total spondylectomy of the C2 vertebra for tumor and the technique for C1-3 reconstruction. OBJECTIVE: To illustrate the feasibility of complete resection of the C2 vertebra with preservation of the vertebral arteries and cervical nerve roots. BACKGROUND: Total spondylectomy provides improved progression free survival in many patients with locally aggressive spinal tumors. However, the perceived technical demands of effectively preserving both vertebral arteries, maintaining cervical nerve roots, and biomechanical reconstruction of the cranial-cervical junction often dissuades surgeons from carrying out total spondylectomy of the C2 vertebra. METHODS: A review of 3 patients undergoing total C2 spondylectomy for tumor (thyroid adenocarcinoma, chordoma, and solitary plasmocytoma) was done. The surgical procedure that was undertaken and the technique used are described. RESULTS: Postoperatively, all 3 patients had uneventful postoperative recovery with gradual improvement in their neurologic functions. CONCLUSION: Preservation of bilateral vertebral arteries and all cervical nerve roots is feasible when carrying out intralesional total spondylectomy in patients with C2 vertebral body tumors and should be considered in patients thought to benefit from total C2 vertebra excision. In an attempt to augment construct stability and provide anterior column load sharing, we have used mesh cage and iliac crest graft between C1 and C3 held in place with a short cervical plate without complications.
- MeSH
- adenokarcinom patologie chirurgie MeSH
- axis patologie chirurgie MeSH
- chordom patologie chirurgie MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- nádory páteře patologie chirurgie MeSH
- ortopedické výkony metody MeSH
- plazmocytom patologie chirurgie MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
- přehledy MeSH
Spinal navigation has substantially advanced during the past ten years. Surgeons have gained sufficient skills and confidence, and have introduced this technology to the anatomically challenging region of the upper cervical spine and craniocervical junction. The detailed evaluation of individual anatomy, rational pre-operative planning and final intraoperative control improve the safety and precision of classical surgical procedures. As methods technologically evolve, indication criteria change accordingly, but the basic principles of a relevatn choice remain; these are to reduce morbidity due to its three main causes, i.e., mechanical, neurological and vascular. We present an overview of current techniques and discuss their applicability in the region of the upper cervical spine and craniocervical junction. The systems allowing us to obtain live images intra-operatively, such as fluoroscopy or intra.operative CT, seem to be most versatile and accurate, especially when combined with traditional virtual navigation systems. Based on case histories, the authors suggest trends in the development of this field, with a focus on minimally invasive techniques. Key words: navigation, upper cervical spine, craniocervical junction.
- MeSH
- atlas (obratel) chirurgie MeSH
- axis chirurgie MeSH
- chirurgie s pomocí počítače MeSH
- fluoroskopie MeSH
- intervenční radiografie MeSH
- krční obratle chirurgie radiografie MeSH
- lidé MeSH
- magnetická rezonance intervenční MeSH
- počítačová rentgenová tomografie MeSH
- uživatelské rozhraní počítače MeSH
- zobrazování trojrozměrné MeSH
- Check Tag
- lidé MeSH
- MeSH
- axis chirurgie MeSH
- dospělí MeSH
- krční obratle chirurgie MeSH
- lidé MeSH
- magnetická rezonanční tomografie využití MeSH
- nádory páteře diagnóza chirurgie sekundární MeSH
- nádory štítné žlázy komplikace terapie MeSH
- ortopedické výkony metody využití MeSH
- pooperační péče MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
