Sublaminar wire migration into the medulla oblongata: a case report

Abstract

Atlantoaxial procedures have been developed in an effort to ensure solid C1-C2 fusion. However, techniques that involve sublaminar wiring have the potential for neural structure injury. We present the management of a patient who previously underwent Gallie fusion 10 years ago and is presenting with a dislodged titanium wire that has migrated into the medulla oblongata. A 52-year-old female patient known with rheumatoid arthritis presented with truncal ataxia and food regurgitation 10 years after undergoing a C1-C2 Gallie fusion. A computerized tomography (CT) scan revealed that a wire from her Gallie fusion procedure migrated into the medulla oblongata. The patient underwent foramen magnum decompression with C1 bilateral laminectomy, instrumentation, and removal of a migrated wire. Six months later, a CT scan showed that all occipital screws were pulled out. In the revision surgery, new occipital screws were placed with a resultant significant improvement in patient's gait postoperatively. Wire migration as a differential diagnosis should be considered in patients presenting with neurological dysfunction who underwent surgical treatment with sublaminar wire fusion techniques.

Atlantoaxial wiring hardware failure resulting in intracranial hemorrhage and hydrocephalus: illustrative case

“…21 Delayed cable fracture can also occur as a complication of sublaminar wiring; reports have described cable fracture and migration of the cable into the spinal cord occurring months to years after surgery and the potential to cause transient or permanent neurological deficit, meningitis due to cerebrospinal fluid leakage, or, as seen in our case, a subarachnoid hemorrhage. 8,13,[15][16][17]19…”

“…Only one similar case of subarachnoid hemorrhage related to atlantoaxial sublaminar wiring was described, by Kakarla et al in 2010, 17 but a case of wire migration through the dura into the brainstem causing neurological deficits has also been described, by Koziarz et al in 2017. 8 These cases highlight the risk of sublaminar wiring with the potential for direct brain and spinal cord injury, durotomy, or hemorrhage; other off-midline lateral mass screw fixation constructs limit the risk of injury directly to the spinal cord. 2 , 3 , 10 , 11 These constructs are also more stable than wires under tension.…”

“…The technique of sublaminar wiring (Brooks wiring) has been well established for atlantoaxial instrumented fusion in the context of instability caused by various pathologies. [1][2][3][4][5][6][7][8] Although different hardware constructs have been developed with different advantages, 2,3,5,[9][10][11][12] sublaminar wiring continues to be employed in various settings. 1 Atlantoaxial sublaminar wiring-related complications have been described, including hardware failure, nonunion, durotomy, spinal cord injury, and brain injury.…”

“…1 Atlantoaxial sublaminar wiring-related complications have been described, including hardware failure, nonunion, durotomy, spinal cord injury, and brain injury. 8,[13][14][15][16][17][18][19][20][21][22] We describe a rare but serious and potentially fatal complication of atlantoaxial sublaminar wiring failure with an atypical presentation of a progressively comatose patient with posterior fossa and upper spinal subdural and subarachnoid hemorrhage resulting in acute hydrocephalus. We also review the literature of spinal hardware failure in relation to subarachnoid hemorrhage.…”

“… 1 Atlantoaxial sublaminar wiring–related complications have been described, including hardware failure, nonunion, durotomy, spinal cord injury, and brain injury. 8 , 13–22 …”