Search Results (36)

Background: Traumatic fractures of the cervical spine pose significant challenges in management, particularly in young patients, where preserving mobility is crucial. Patient Characteristics: A 30-year-old woman presented with a C3 lateral mass and pedicle fracture following a motor vehicle collision. Initial conservative management with a rigid cervical collar for three months failed to reduce the diastasis, and the debilitating neck pain worsened. Preoperative imaging confirmed fracture instability without spinal cord compression. Intervention and Outcome: Preoperative screw trajectory planning was conducted with the My Spine MC system (Medacta), and fine-tuning was achieved on a 3D-printed model of the vertebra. A posterior midline approach was employed to expose the C3 vertebra, and a Herbert screw was inserted under fluoroscopic guidance. Imaging at three months demonstrated significant fracture reduction and early bone fusion. The patient achieved substantial improvement in functional mobility without complications. Conclusion: Herbert screw fixation holds potential as a less-invasive alternative to conventional posterior stabilization for selected cervical fractures. This technical note provides the reader with the required information to support surgical planning and execution. Full article

Background/Objectives: Although lateral mass screws lower the risk of vertebral artery injury, they are shorter and have a weaker purchase than a pedicle screw, thereby posing the risk of mechanical failure following a ≥3-level posterior cervical fusion (PCF). Therefore, the purpose of this study is to demonstrate that the posterior en bloc fusion of C2-7 is mechanically stronger than shorter, regionally confined posterior fusions of the cervical spine. Methods: We included 178 patients who underwent PCF with ≥3 levels. Patients who underwent PCF that included both C2 and C7 were classified as the en bloc fusion group (EBF group, n = 116), while PCF cases not including these levels were assigned to a regional fusion group (RF group, n = 62). The fusion rate, incidences of mechanical failure, and clinical outcomes were evaluated using univariate analysis between the two groups. Results: The fusion rate was significantly higher in the EBF group than in the RF group (p = 0.038). In contrast, the mechanical failure rate was significantly lower in the EBF group (8/116 [6.9%] vs. 16/62 [25.8%], p = 0.047). Although the ROM was significantly higher in the RF group (p < 0.001), the functional scores did not significantly differ between the two groups. Conclusions: EBF seems to lower the rate of mechanical failure, as well as similar clinical outcomes, compared to RF. When the possibility of mechanical failure is high after PCF, extending the fusion level to C2 and C7 could be considered to minimize mechanical failure, rather than stopping at C3 or C6. Full article

Background and Objectives: Atlantoaxial tuberculosis (TB) is rare, and its diagnosis is difficult. Herein, we present a rare case with a challenging diagnostic journey of atlantoaxial TB spanning over two years. Materials and Methods: A 70-year-old immunocompetent female patient presented with a four-week history of nuchal pain, stiffness, and headache. She did not have any TB-associated constitutional symptoms. The result of the initial biopsy indicated only a nonfermenting Gram-negative bacillus and the histopathological report revealed concurrent acute and chronic inflammation. Posterior fusion with bilateral C1 lateral mass and C2 transpedicular screw fixation was performed after a five-week course of antibiotics. Results: However, the atlantoaxial abscess progressed and led to myelopathy two years later. Tuberculous spondylitis was not confirmed until the second biopsy. We chose the transoral approach for prompt abscess evacuation and to prevent unnecessary damage to the nearby vital neurovascular structures. The sputum culture and chest radiograph did not reveal concurrent pulmonary TB. Conclusions: Spinal TB has a greater likelihood of presenting with a cold abscess without the typical constitutional symptoms of pulmonary TB. Distinctive magnetic resonance imaging (MRI) features, such as a thin and smooth abscess wall, subligamentous spread, severe vertebral body destruction, and heterogenous vertebral wall enhancement, might help to differentiate between tuberculous and pyogenic spondylitis. We hope to offer meaningful insights to clinicians facing similar intricate scenarios, including subtle clues that may lead to a quicker diagnosis and the considerations we made while designing a treatment plan. Full article

Odontoid fractures (OFs) represent up to 15% of all cervical fractures encountered and present most commonly amongst elderly patients, typically in the setting of low energy trauma such as falls. The Anderson and D’Alonzo classification and Roy-Camille subtype description are the most clinically noteworthy descriptions of OFs used. Even though most patients will not present with neurological injury, mechanical instability can occur with type II and type III (Anderson and D’Alonzo) fractures, particularly if the transverse ligament of the atlas is ruptured; however, this is very rare. Conservative treatment is usually employed for type I and type III injuries, and to a varying degree for non-displaced type II injuries. Surgical treatment is typically reserved for type II fractures, patients with neurological injury, and in the setting of other associated fractures or ligamentous injury. Anterior screw fixation is a viable option in the setting of a favorable fracture line orientation in type II fractures, whereas posterior C1–C2 screw fixation is an option for any type II or type III fracture presentation. There is evidence that surgery for type II fractures has higher rates of union and lower mortality than nonoperative treatments. While surgical options have increased over the decades and the management of OF has been optimized by considering fracture subtypes and patient factors, there remains a significant morbidity and mortality associated with OFs. The aging population and changing demographics suggest that there will be an ongoing rise in the incidence of OFs. Therefore, the appropriate management of these cases will be essential for ensuring optimization of health care resources and the quality of life of affected patients Full article

Considering that people with Parkinson’s disease (PD) experience challenges in the control of both balance and eye movements, this study investigated the effects of saccadic eye movements on body sway in people with PD in two bases of support positions (side-by-side and tandem stances). Ten people with PD and 11 healthy individuals performed (a) fixation; (b) horizontal saccadic eye movements to the right and left; and (c) vertical saccadic eye movements up and down. The protocol for each postural task consisted of one block of six trials, making a total of 12 trials. Body sway and gaze parameters were measured during the trials. In both people with PD and healthy individuals, anterior–posterior body sway was significantly reduced in horizontal saccadic eye movements in contrast to fixation, regardless of the body position (side-by-side and tandem stances). Furthermore, vertical saccadic eye movements increased the area of sway in contrast to horizontal ones (and not to fixation) in people with PD. In addition, people with PD showed a higher number of fixations in all experimental conditions, without changes in the mean duration of fixations in both body positions. In conclusion, individuals with PD can improve body sway by coupling eye movements and postural sway when performing horizontal saccadic eye movements but not when performing vertical saccadic eye movements. Full article

Two cases of complicated pain exist: posterior screw fixation and myofascial pain. Intramuscular pulsed radiofrequency (PRF) may be an alternative treatment for such patients. This is a two-stage animal study. In the first stage, two muscle groups and two nerve groups were subdivided into a high-temperature group with PRF at 58 °C and a regular temperature with PRF at 42 °C in rats. In the second stage, two nerve injury groups were subdivided into nerve injury with PRF 42 °C on the sciatic nerve and muscle. Blood and spinal cord samples were collected. In the first stage, the immunohistochemical analysis showed that PRF upregulated brain-derived neurotrophic factor (BDNF) in the spinal cord in both groups of rats. In the second stage, the immunohistochemical analysis showed significant BDNF and tropomyosin receptor kinase B (TrkB) expression within the spinal cord after PRF in muscles and nerves after nerve injury. The blood biomarkers showed a significant increase in BDNF levels. PRF in the muscle in rats could upregulate BDNF-TrkB in the spinal cord, similar to PRF on the sciatica nerve for pain relief in rats. PRF could be considered clinically for patients with complicated pain and this study also demonstrated the role of BDNF in pain modulation. The optimal temperature for PRF was 42 °C. Full article

Background: This study aims to investigate the postoperative improvement of paralysis, fusion rate and risk factors for kyphosis progression in adults affected with spinal caries. Methods: Overall, 134 patients with spinal caries from the thoracic to lumbar spine from 1992 to 2021 were included in this study. Data concerning the affected level (thoracic, thoracolumbar, lumbar, and lumbosacral), bone fusion rate, and progression of the postoperative local kyphosis angle were collected. The risk factors for the progression of local kyphosis angle after anterior spinal fixation (ASF) were determined using linear regression analysis. Results: Preoperatively, the degree of spinal cord paralysis was D and E on Frankel classification. Improvement of paralysis was good with surgery, especially from C, D. The overall bone fusion rate was 83.2%. The only factor influencing the progression of local kyphosis angle after ASF was the level of the affected vertebra. Progression of kyphosis angle after ASF was very advanced in the thoracolumbar transition area. Conclusions: Surgical improvement in paraplegia and the fusion rate of ASF with only grafted bone was good. However, in patients affected in the thoracolumbar spine region, posterior instrumentation is desirable because of local kyphosis progression risk after surgery. Full article

Despite advancement in surgical innovation, C1-C2 fixation remains challenging due to risks of screw malposition and vertebral artery (VA) injuries. Traditional image-based navigation, while useful, often demands that surgeons frequently shift their attention to external monitors, potentially causing distractions. In this article, we introduce a microscope-based augmented reality (AR) navigation system that projects both anatomical information and real-time navigation images directly onto the surgical field. In the present case report, we discuss a 37-year-old female who suffered from os odontoideum with C1-C2 subluxation. Employing AR-assisted navigation, the patient underwent the successful posterior instrumentation of C1-C2. The integrated AR system offers direct visualization, potentially minimizing surgical distractions. In our opinion, as AR technology advances, its adoption in surgical practices and education is anticipated to expand. Full article

Klippel–Feil syndrome (KFS) is characterized by the congenital fusion of the cervical vertebrae and is sometimes accompanied by anomalies in the craniocervical junction. In basilar invagination (BI), which is a dislocation of the dens in an upper direction, compression of the brainstem and cervical cord results in neurological defects and surgery is required. A 16-year-old boy diagnosed with KFS and severe BI presented with spastic tetraplegia, opisthotonus and dyspnea. CT scans showed basilar impression, occipitalization of C1 and fusion of C2/C3. MRI showed ventral compression of the medullocervical junction. Posterior occipitocervical reduction and fusion along with decompression were performed. Paralysis gradually improved postoperatively over 3 weeks. However, severe spasticity and opisthotonus persisted and intrathecal baclofen (ITB) therapy was initiated. Following this, opisthotonus disappeared and spasticity of the extremities improved. Rehabilitation therapy continued by controlling the dose of ITB. Five years after the surgery, self-propelled wheelchair driving was achieved and activities of daily life improved. The treatment strategy for patients with BI and congenital anomalies remains controversial. Posterior reduction and internal fixation using instrumentation were effective techniques in this case. Spasticity control achieved through a combination of surgery and ITB treatment enabled the amelioration of therapeutic efficacy of rehabilitation and the improvement of ADL. Full article

Background: In patients with Chiari 1.5 malformation (CM1.5), a more aggressive disease course and an increased association with craniovertebral junction (CVJ) anomalies has been suggested. The best management of this subgroup of patients is not clearly defined, also due to the lack of specific series elucidating this anomaly’s peculiar characteristics. Methods: We evaluated a series of 33 patients (25 females, 8 males; mean age at surgery: 13 years) fulfilling the criteria for Chiari 1.5 diagnosis who underwent posterior fossa decompression and duraplasty (PFDD) between 2006 and 2021. Results: Headache was present in all children, five presented central apnea, five had dysphagia, and three had rhinolalia. Syringomyelia was present in 19 (58%) children. Twenty patients (61%) showed various CVJ anomalies, but only one child presented instability requiring arthrodesis. The mean tonsil displacement below the foramen magnum was 19.9 mm (range: 12–30), without significant correlation with the severity of symptoms. Syringomyelia recurred or was unchanged in three patients, and one needed C1–C2 fixation. The headache disappeared in 28 children (84%). Arachnoid opening and tonsil coagulation or resection was necessary for 19 children (58%). Conclusions: In our pediatric CM series, the need for tonsil resection or coagulation was higher in CM1.5 children due to a more severe crowding. Full article

Study Design: Consecutive case series. Objective: To propose a screw placement method in patients with extremely small lumbar pedicles (ESLPs) (<2 mm) to maintain screw density and correction power, without relying on the O-arm navigation system. Summary of Background Data: In scoliosis surgery, ESLPs can hinder probe passage, resulting in exclusion or substitution of the pedicle screws with a hook. Screw density affects correction power, making it necessary to maximize the number of screw placements, especially in the lumbar curve. Limited studies provide technical guidelines for screw placement in patients with ESLPs, independent of the O-arm navigation system. Methods: We enrolled 19 patients who underwent scoliosis correction surgery using our novel screw placement method for ESLPs. Clinical, radiological, and surgical parameters were assessed. After posterior exposure of the spine, the C-arm fluoroscope was rotated to obtain a true posterior–anterior view and both pedicles were symmetrically visualized. An imaginary pedicle outline was presumed based on the elliptical or linear shadow from the pedicle. The screw entry point was established at a 2 (or 10) o’clock position in the presumed pedicle outline. After adjusting the gear-shift convergence, both cortices of the transverse process were penetrated and the tip was advanced towards the lateral vertebral body wall, where an extrapedicular screw was placed with tricortical fixation. Results: Out of 90 lumbar screws in 19 patients, 33 screws were inserted using our novel method, without correction loss or complications during an average follow-up period of 28.44 months, except radiological loosening of one screw. Conclusions: Our new extrapedicular screw placement method into the vertebral body provides an easy, accurate, and safe alternative for scoliosis patients with ESLPs without relying on the O-arm navigation system. Surgeons must consider utilizing this method to enhance correction power in scoliosis surgery, regardless of the small size of the lumbar pedicle. Full article

Background and Objectives: C-arm-free MIS techniques can offer significantly reduced rates of postoperative complications such as inadequate decompression, blood loss, and instrumentation misplacement. Another advantageous long-term aspect is the notably diminished exposure to radiation, which is known to cause malignant changes. This study emphasizes that, in some cases of spinal conditions that require a procedural intervention, C-arm-free MIS techniques hold stronger indications than open surgeries guided by image intensifiers. Materials and Methods: This study includes a retrospective analysis and review of various cervical and thoracic spinal procedures, performed in our hospital, applying C-arm-free techniques. The course of this study explains the basic steps of the procedures and demonstrates postoperative and intraoperative results. For anterior cervical surgery, we performed OPLL resection, while for posterior cervical surgery, we performed posterior fossa decompression for Chiari malformation, minimally invasive cervical pedicle screw fixation (MICEPS), and modified Goel technique with C1 lateral mass screw for atlantoaxial subluxation. Regarding the thoracic spine, we performed anterior correction for Lenke type 5 scoliosis and transdiscal screw fixation for diffuse idiopathic skeletal hyperostosis fractures. Results: C-arm-free techniques are safe procedures that provide precise and high-quality postoperative results by offering sufficient spine alignment and adequate decompression depending on the case. Navigation can offer significant assistance in the absence of normal anatomical landmarks, yet the surgeon should always appraise the quality of the information received from the software. Conclusions: Navigated C-arm-free techniques are safe and precise procedures implemented in the treatment of surgically demanding conditions. They can significantly increase accuracy while decreasing operative time. They represent the advancement in the field of spine surgery and are hailed as the future of the same. Full article

This paper presents a comparative analysis of the biomechanical characteristics of an external fixator with a frame made of two different materials (stainless steel and composite material) during anterior–posterior bending. Before the test itself, two representative configurations of the Sarafix fixator were selected for application on the lower leg and upper extremities under the designations B50 and C50, which are most widely used in orthopedic practice. The examination of the biomechanical characteristics of the external fixator was carried out using the structural analysis of the construction performance of the Sarafix fixator using the finite element method, the results of which were verified through experimental tests. The developed experimental and FEM models study the movement of the fracture crack and enable the determination of the stiffness of structural designs as well as the control of the generated stresses at the characteristic locations of the fixator. The results show that the fixator with a carbon frame has lower stresses at critical points in the construction compared to the fixator with a steel frame, in the amount of up to 49% (at the measuring point MT+) or up to 46% (at the measuring point MT−) for both fixture test configurations. The fixator with a carbon frame has greater displacements at the fracture site compared to the fixator with a steel frame, in the amount of up to 45% (for configuration B50) or up to 31% (for configuration C50). The stiffness of the structure for both test configurations of the fixator is lower in the fixator with a carbon frame compared to the fixator with a steel frame by up to 27%. Based on the findings of this study, we can conclude that a fixator with a steel frame has better biomechanical characteristics compared to a carbon frame. Full article

Pelvic ring injuries are uncommon but serious injuries. Percutaneous sacro-iliac screw fixation (SSF) is the standard treatment for posterior stabilization of pelvic fractures. Compression forces of the SSF might cause deformity of the sacrum and the pelvic ring. The aim of this radio-volumetric study is to evaluate the morphometry of the sacrum and pelvic ring in SSF for posterior pelvic fractures. (1) Methods: We conducted a radio-volumetric study measuring the bony sacral volume before and after SSF for a pelvic fracture based on a three-dimensional reconstruction of the pre- and postoperative computed tomography scan of 19 patients with a C-type pelvic fracture. In addition to the bony sacral volume, we assessed the pelvic deformity and the load bearing axis. We compared the results of patients without anterior stabilization (Group A) to patients who had additional ORIF of the anterior pelvic ring. (2) Results: Median age of the patients was 41.2 years (±17.8). All patients received percutaneous SSF with partially threaded 7.3 mm screws. The sacral volume decreased from 202.9 to 194.3 cm³ in group A (non-operative treatment anterior, n = 10) and an increase of sacral volume from 229.8 to 250.4 cm³ in group B (anterior ORIF; n = 9). Evaluation of the pelvic deformity also reflected this trend by a decrease of the ipsilateral load-bearing angle in group A (37.0° to 36.4°) and an increase of this angle in group B (36.3 to 39.9°). (3) Conclusions: Bony sacral volume and pelvic deformity after sacro-iliac screw fixation in pelvic fractures depend on treatment of the anterior pelvic ring. Reduction and fixation of the anterior fracture shows an increase of the bony sacral volume and the load bearing angle leading to a closer to normal reconstruction of the pelvic anatomy. Full article

Background and Objectives:: There were limited studies which investigated nail diameter as a predictor for cephalomedullary nail (CMN) failure in intertrochanteric fracture (ITF). We aimed to evaluate the surgical outcomes of CMN in fragility ITF following nail–canal (N–C) diameter discordance. Materials and Methods: From November 2010 to March 2022, we retrospectively reviewed 120 consecutive patients who underwent CMN surgeries due to fragility ITF. We included patients with acceptable reduction and a tip–apex distance ≤ 25 mm. The N–C diameter differences both in anterior–posterior (AP) and lateral-view X-rays were measured, and we compared the number of excessive sliding instances and the rate of implant failure between the N–C concordance (≤3 mm) and discordance (>3 mm) group. Simple linear regression was used to determine the strength of the relationship between the N–C difference and sliding distance. Results: The sliding distance showed no differences between the groups in the AP (3.6 vs. 3.3 mm, p = 0.75) and lateral view (3.5 vs. 3.4 mm, p = 0.91). For analyses in the AP view, the AP-concordance and AP-discordance groups had 14 (25%) and 14 patients (22%) with a sliding distance of >5 mm (p = 0.69), while treatment failure occurred in 3 (5%) and 3 (3%) patients, respectively (p = 0.66). For analyses in the lateral view, the lat-concordance and lat-discordance groups had 8 (27%) and 20 patients (22%) with a sliding distance of >5 mm (p = 0.62), while treatment failure occurred in 1 (3%) and 4 (4%) patients, respectively (p = 1.00). Linear regression analyses showed that the N–C difference in either views was not a significant predictor of sliding distance in both the AP (R² = 0.002, p = 0.60) and lateral views (R² = 0.007, p = 0.35). Conclusions: If appropriate fracture reduction and fixation are achieved, the N–C discordance of short CMN does not affect treatment outcomes in ITF. Full article