alignment preoperatively (31%) and patients with preexisting subluxation before decompression (73%). Despite these high rates of reported subluxation, only four fusion operations were performed and radiological progression did not correlate with outcome. These data and outcomes are surprising and seemingly in conflict with other studies. We do not know how extensive the pars interarticularis and facet joint bone resections were in these patients. I suspect the rates of subluxation and outcome in this or similar studies are related to the amount of facet or pars
Richard C. E. Anderson, Peter Kan, Wayne M. Gluf and Douglas L. Brockmeyer
Despite decades of surgical experience, the long-term consequences of occipitocervical (OC) and atlantoax-ial (C1–2) fusions in children are unknown. The purpose of this study was to determine the long-term effects of these fusions on growth and alignment of the maturing cervical spine.
A retrospective chart review was conducted for patients 6 years of age or younger (mean 4.7 years, range 1.7–6.8 years) who underwent OC or C1–2 fusion at the Primary Children’s Medical Center at the University of Utah within the last 10 years. Immediate postoperative plain radiographs and computed tomography (CT) scans were compared with the most recent plain and dynamic radiographs to assess changes in spinal growth and alignment.
Seventeen children met entry criteria for the study. All patients had fusion documented on follow-up radiography or CT scans. At a mean follow up of 28 months, there were no cases of sagittal malalignment (kyphotic or swanneck deformity), subaxial instability (osteophyte formation or subluxation), or unintended fusion of adjacent levels. The lordotic curvature of the cervical spine increased from a mean of 15° postoperatively to 27° at follow up (p = 0.06). A mean of 34% of the vertical growth of the cervical spine occurred within the fusion segment. When data were analyzed pertaining to a subgroup of five patients who underwent follow-up periods for longer than 48 months (mean 50.2 months, range 48–54 months), similar results were seen.
Preliminary follow-up results indicate that, compared with older children, children 6 years of age or younger undergoing OC or C1–2 fusion are not at an increased risk of spinal deformity or subaxial instability. Longer follow-up periods, during which measurements of the spinal canal are taken, will be necessary to determine precisely how children’s spines grow and remodel after an upper cervical spine fusion.
Langston T. Holly, J. Patrick Johnson, Jeffrey E. Masciopinto and Ulrich Batzdorf
The authors review the management of five patients with posttraumatic syringomyelia (PTS) associated with an uncorrected spinal deformity. Patients with evidence of progressive neurological deterioration underwent ventral spinal decompressive surgery.
The mean patient age at the time of injury was 39 years, and the time between injury and the diagnosis of PTS ranged from 2 to 22 years. Mechanisms of injury consisted of fracture/subluxations in three patients and burst fractures in two. All patients experienced delayed neurological deterioration consistent with PTS. Magnetic resonance imaging revealed ventral deformities, and the spinal canal stenosis ranged from 20 to 50% (mean 39%). All patients underwent ventral epidural spinal decompressive surgery to correct the bone deformity and restore the spinal canal.
The mean follow-up period was 38 months. The decompressive intervention was initially successful in treating the neurological deterioration in all patients. Symptoms resolved completely in four patients, and the other experienced neurological improvement. Postoperative magnetic resonance imaging revealed a reduction in the size of syrinx cavity in the patients whose symptoms resolved and no change in the remaining patient. Two patients required a subsequent second-stage posterior intradural exploration and duraplasty for recurrence of symptoms and/or syrinx.
Posttraumatic spinal deformity may cause spinal canal stenosis and alter subarachnoid cerebrospinal fluid (CSF) flow in certain patients. Ventral epidural spinal decompressive surgery may result in neurological improvement and a reduction of the syrinx cavity, avoiding the need for placement of a shunt or other intradural procedures. However, some patients will also require reconstruction of the posterior subarachnoid space with duraplasty if the ventral decompressive procedure achieves only partial restoration of the subarachnoid CSF flow.
Edward L. Seljeskog and Shelley N. Chou
I n 1913, Wood-Jones 12 published a report describing the pathological anatomy of the cervical spine in judicial hanging. He emphasized the importance of the submental position of the hangman's knot to produce a lesion that includes a bilateral avulsion fracture of the arch of C-2 and an anterior fracture dislocation of the axis through the C2-3 interspace ( Fig. 1 ). In 1965, Schneider, et al. , 11 reported several cases of a similar fracture in individuals who had undergone acute upper cervical hyperextension injuries. A subluxation resembling the hangman
Richard D. Bucholz and K. Charles Cheung
immobilized for a minimum of 3 months. At the end of the treatment period, the halo ring was disconnected from the vest and flexion/extension lateral radiography was performed. If there was no movement or subluxation at the fracture site, the patient was placed in a Philadelphia collar for an additional 4 weeks. Lateral radiographs were obtained every 3 to 6 months for 1 to 2 years. Patients who experienced subluxation while in the halo device or after removal of the fixation device, or those who developed a progressive neurological deficit while in the fixation device
John T. Lucas, Gordon D. Hungerford and Phanor L. Perot Jr.
been accomplished, so traction was discontinued. A Minerva jacket was applied for 3 months and was then replaced by a firm cervical collar. X-ray films at that time revealed a persistent C1–2 subluxation of 6 or 7 mm ( Fig. 3 ). Somatosensory evoked potentials from the arms and legs were essentially normal. Fig. 2. Three types of traction are being applied to the patient. From left to right: conventional cervical traction with Cone-Barton tongs; soft low posterior cervical traction with vector directed anteriorly to reduce anterior subluxation of the atlas on
Michael H. Sukoff, Milton M. Kadin and Terrance Moran
right and hypalgesia below T-4. The cranial nerves were normal. The neck was held rigidly. X-ray films of the cervical spine revealed subluxation of the odontoid process ( Fig. 1 ). The patient was treated with skeletal traction. Within ½ hour, neurological recovery began. Fig. 1. Midline sagittal tomogram (November 4, 1969) showing atlantoaxial subluxation by widening of the distance between the anterior ring of C-1 and odontoid (normal, 2 mm) up to 10 mm ( small closed arrow ); the film also shows the anterior offset of the spinous process of C-1 ( large
Andrievs J. Dzenitis
and implicated in tuberculosis, syphilis, 27 and steroid therapy. 12 According to the recent observations of Tishler and Martel, 24 and Spitzer et al. , 22 nontraumatic or spontaneous atlanto-axial dislocation is a significantly common occurrence in mongolism, and may be a reflection of the congenital laxity of ligaments and joints present in these patients. However, no neurological sequelae have been observed in these individuals to date. 15, 16, 22 This is a report of a mongoloid child with spontaneous atlanto-axial subluxation causing spinal cord
Paul R. Cooper and Wendy Cohen
T he goal of early management of patients with cervical spine and/or spinal cord injuries is the preservation of injured but still viable neural tissue, and the prevention of injury to normal spinal cord or nerve roots. This objective is initially achieved by external immobilization and reduction of fractures or subluxations with the use of cervical traction. The diagnostic assessment of such patients has two objectives: 1) the evaluation of injuries to bones or ligaments and the determination of the effect of such injuries on spinal stability; and 2) the
Paolo Missori, Massimo Miscusi, Sergio Paolini, Claudio DiBiasi, Vannina Finocchi, Simone Peschillo and Roberto Delfini
A tlantoaxial rotatory dislocations can vary from complete to partial. Atlantoaxial rotatory fixation is a complete dislocation of the inferior atlantal and superior axial articular facets in a fixed position. Atlantoaxial rotatory subluxation is an incomplete dislocation of the inferior atlantal and superior axial articular facets. In contrast to AARS, which is almost always reducible, AARF can be reducible or irreducible, and AARS can become AARF, particularly when interposition of soft tissue prevents relocation. A rare complication after trauma in children