The aim of this study is to evaluate the first results of the atlantoaxial fixation using polyaxial screw-rod system. Twenty-eight patients followed-up 12-29 months (average 17.1 months) were included in this study. The average age was 59.5 years (range 23-89 years). The atlantoaxial fusion was employed in 20 patients for an acute injury to the upper cervical spine, in 1 patient with rheumatoid arthritis for atlantoaxial vertical instability, in 1 patient for C1-C2 osteoarthritis, in 2 patients for malunion of the fractured dens. Temporary fixation was applied in two patients for type III displaced fractures of the dens and in two patients for the atlantoaxial rotatory dislocation. Retrospectively, we evaluated operative time, intraoperative bleeding and the interval of X-ray exposure. The resulting condition was subjectively evaluated by patients. We evaluated also the placement, direction and length of the screws. Fusion or stability in the temporary fixation was evaluated on radiographs taken at 3, 6, 12 weeks and 6 and 12 months after the surgery. As concerns complications, intraoperatively we monitored injury of the nerve structures and the vertebral artery. Monitoring of postoperative complications was focused on delayed healing of the wound, breaking or loosening of screws and development of malunion. Operative time ranged from 35 to 155 min, (average 83 min). Intraoperative blood loss ranged from 50 to 1,500 ml (average 540 ml). The image intensifier was used for a period of 24 s to 2 min 36 s (average 1 min 6 s). Within the postoperative evaluation, four patients complained of paresthesia in the region innervated by the greater occipital nerve. A total of 56 screws were inserted into C1, their length ranged from 26 to 34 mm (average, 30.8 mm). All screws were positioned correctly in the C1 lateral mass. Another 56 screws were inserted into C2. Their length ranged from 28 to 36 mm (average 31.4 mm). Three screws were malpositioned: one screw perforated the spinal canal and two screws protruded into the vertebral artery canal. C1-C2 stability was achieved in all patients 12 weeks after the surgery. No clinically manifested injury of the vertebral artery or nerve structures was observed in any of these cases. As for postoperative complications, we recorded wound dehiscence in one patient. The Harms C1-C2 fixation is a very effective method of stabilizing the atlantoaxial complex. The possibility of a temporary fixation without damage to the atlantoaxial joints and of reduction after the screws and rods had been inserted is quite unique.
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.
According to the available sources, no case of total spondylectomy of C2 with preservation of roots, preservation of vertebral arteries and a short fixation without occipitocervical fusion has been so far described in the literature.We decided to perform a radical surgery in a man, now 27 y. o., with solitary metastasis of thyroid adenocarcinoma. In the first step, we applied the posterior surgical approach. The patient was placed prone on a standard operating table with a support of head fixed by adhesive plaster, with the upper cervical spine slightly bent forward. We made a mid-line incision, extending from the external occipital protuberance to the C7 spinous process, controlled bleeding and exposed the C0-C4 section. Subsequently, the entire posterior epistropheus was resected, including most of the pedicles and the entire articular processes for C2-C3 articulation. Both the C2 roots were preserved, however, we had to control quite a profuse bleeding from the venous plexus around the left root. During dissection, the dural sac was damaged in the region of the attachment of the left root, which was treated by suture and covered with Tissucol fibrin sealant. Screws 4.0 mm thick, were inserted into the lateral masses of the atlas after Harms and 4.0mm screws into the C3 and C4 articular processes. On both sides, the screws were connected with 3.2 mm rods, and a transverse stabilizer was then applied to fix the two sides together. Cancellous bone grafts were harvested from the iliac crest and a massive posterolateral and posterior fusion of C1-C4 was performed. The second operation was performed after 21 days. Transoral transmandible approach without tongue splitting was applied. The patient was placed supine on a standard operating table with a support of neck, the head was fixed by adhesive plaster and slightly bent back, and tracheostomy was inserted. An arched incision through the middle of the red lip was made, extending 2 cm straight caudally and arching across the chin and neck, in the midline. On the caudal end we made a transverse inverted T incision. Subsequently, we exposed and osteotomised the mandible using the midline Z-type incision. In order to identify the space between the anterior arch of C1 and the C4 vertebral body, the Synframe retractor was inserted with one blade opening the mouth by pressure on the upper teeth and two blades pressing the tongue caudally. Then an inverted U incision through the mucosa of pharynx was made to identify paravertebral muscles. Caspar retractor was used to separate the muscles and expose C1-C3 laterally, including transversal processes with vertebral arteries. No pathological changes were manifested on the skeleton. First we removed the middle portion of the C2 vertebral body where we did not find any tumour, only sclerotic remodelling. Subsequently, we reamed the lower middle portion of the anterior arch of C1, extracted the dens and cut off the alar ligaments and the apical ligament of dens. The entire dens was then removed. Then we continued on the right sid...
Percutaneous vertebroplasty is a minimally invasive surgical technique involving transpedicular injection of polymethylmetacrylate into the vertebral body. The aim of this procedure is to enhance the mechanical strength of a pathologically changed vertebra. Currently, the method is most often used for painful osteoporotic vertebral fractures, aggressive haemangiomas, necrotic lesions and spinal tumours, particularly the metastatic ones. Although this method is less invasive, relatively straight-forward and effective, there may be complications. The authors present the case of a 70-year-old woman who, on the second day after surgery, developed a rare symptomatic pulmonary polymethylmetacrylate embolism after percutaneous vertebroplasty performed for osteoporotic fractures of the lumbar spine.
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