Background: Vertebral artery injuries are often not diagnosed because they are asymptomatic. But there is information that up to 19% of all patients who incur trauma to the lower cervical spine have vertebral artery injuries. This incidence increase in flexion-distraction injuries. It is unclear as to the individual contribution of various force loads and resultant deformity on the etiology of these injuries. Purpose: To evaluate the degree of vertebral artery deformation and potential injury in staged flexion-distraction deformities of the cervical spine. Study design: Thirtyfive fresh frozen cervical spine specimens underwent vertebral artery cannulization and angiography to determine the static influence of the four stages of subaxial flexion-distraction injuries as described by Allen et al. on the vertebral artery patency. Methods: Each specimen was examined radiographically so as to exclude any preexisting cervical deformities. A cannula was inserted into the isolated cranial and caudal stumps of the vertebral arteries and perfused with contrast agent. A fluoro image intensifier recorded deformation in dye fluid passage in the four stages of flexion-distraction injuries. Results: No significant deformation in vertebral artery flow was noted in the flexion-distraction stage I injuries within the physiological range of cervical flexion. Flexion-distraction type II and III injuries demonstrated considerable impairment to vertebral artery dye flow in proportion to the degree of vertebral deformity. Manipulating the dislocated vertebral segments into a localized lordosis further impaired vertebral vessel patency. Coexisting rupture of the vertebral radicular vessel was a constant finding in stage II and III injuries. Longitudinal stretch deformities of the vertebral artery were limited primarily to the injured vertebral segments. Stage IV injuries resulted in irreversible disruption of vertebral dye flow. Conclusion: The static deformity of flexion-distraction stage II to IV subaxial cervical injuries results in significant objective compression of the vertebral vasculature, what seems to have consequences in treatment and establishing the diagnosis

Injuries of the cervical spine can be classified into six categories according to a mechanistic system describing the biomechanical deficiencies incurred in a cervical spine injury. However high velocity flexion compression loads cause multiple contiguous and noncontiguous fractures due to multiple force vectors. A universal classification system cannot be applied. Instability exists if there is greater than 3.5 mm of translation or greater than 11 degrees of angulation as compared to other segments. The degree of ligamentous injury on MRI correlates with instability in patients with lateral mass facet fractures, with rupture of multiple ligaments including the anterior longitudinal, posterior longitudinal, interspinous, or facet capsule. Patients with less than 13 mm of narrowing of the sagittal canal are predisposed to neurologic injury. Vertical compression injuries cause canal occlusion and vertebral column shortening. The timing of surgery in cases of spinal cord injury is controversial. There is no difference in outcome between early (< 72 hours) and late (> 5 days) surgery. However, there remains at least a theoretical benefit to early surgery. Compression-flexion injuries result in loss of the anterior column by compression followed by the posterior column in distraction. The injury is considered unstable if there is a vertical cleavage fracture of the vertebral body or displacement. Treatment includes a cervical orthosis or halo for minor injuries, depending on the degree of kyphosis. Major injuries with displacement should be treated surgically by anterior corpectomy and plate or an anterior/posterior fusion, depending on the degree of posterior instability. The most common level of vertical-compression injuries is at the C6 or C7 level. Minimally displaced injuries can be treated with a collar or halo. Fragmentation and peripheral displacement of the bony fragments needs a halo followed by surgery and this may include an anterior corpectomy and plating. Distraction-flexion injuries may result in facet sub-luxation with less than 25% displacement, or dislocation of one (UFD) or both (BFD) facet joints. When there is 3 mm of translation (25%), the canal is occluded 20–25%. With 6mm of translation (50%), there is 40–50% canal occlusion. MRI can help analyse the soft tissue and ligamentous injuries. In UFD, all posterior ligamentous structures including joint capsule, and half the disc annulus are disrupted. Disruption of ALL and PLL is not necessary to create a UFD. In addition to the posterior structures, the ALL, the PLL and disc are disrupted in BFD. Rupture of the intervertebral disc may include posterior herniation or circumferential disruption. All distraction flexion injuries should be reduced closed. The necessity of a preoperative MRI is undetermined. Preoperative MRI is recommended if there is an unreliable exam due to the patient being uncooperative, if there is neurological worsening with, or failure of closed reduction. If the patient is neurologically intact and closed reduction successful, a posterior cervical fusion is advocated if there is no evidence of an extruded disc on the post reduction MRI. If the closed reduction failed, or MRI indicated, and there is no evidence of a herniated disc, an open posterior reduction followed by fusion is performed. Anterior discectomy with reduction, a graft and a plate is performed for a herniated disc. Compression-extension injuries fail by compression of the posterior elements followed by distraction of the anterior elements. There are unilateral or bilateral fractures of the laminae/neural arch with degrees of displacement. Undisplaced neural arch fractures can be treated with a cervical orthosis or halo. Displaced neural arch fractures are treated with a posterior cervical fusion. There are two stages in the distraction-extension injury group. The anterior longitudinal ligament is disrupted with possibly a transverse fracture of the body. With more major injuries, there is a significant displacement injuring the posterior column. Stage 1 injuries can be treated with a halo and Stage 2 with an anterior decompression and fusion with a plating device. There are two stages to lateral flexion injuries. Minor injuries include asymmetric centrum fracture and a unilateral arch fracture. In addition, there is displacement of the body with contralateral ligamentous failure in major injuries. The treatment for Stage 1 is usually a collar while treatment for Stage 2 is usually a posterior cervical fusion. Posterior stabilization procedures may be performed with wires and cables with or without rods. Posterior clamps usually are not recommended; while plates and screws are preferred. The plates and screws are biomechanically superior to wiring and avoid canal penetration. They are ideal when there is loss of the posterior elements. Pedicle fixation should be considered when operating on the C2 or C7 level. One in five patients may have complete disruption of vertebral artery blood flow. This occurs most commonly with flexion-distraction or flexion-compression injuries. Vertebral artery evaluation is recommended in patients with flexion injuries and symptoms consistent with vertebral artery insufficiency. It is important to understand the mechanism of injury; to understand which elements are compromised. We have to get the appropriate imaging studies, we have to be cognizant of the fact that the vertebral artery may be injured, or there may be an associated herniated disc. We have to understand the degree of instability, which dictates the appropriate treatment and we have to understand the risk benefit of the specific internal fixation systems that we use

Introduction: Oblique corpectomy is a surgical technique of spinal cord decompression through a limited bone resection of the postero lateral corner of the vertebral bodies. In this study the results of this technique applied in cases of spondylotic myelopathy and tumors are presented. Methods: The oblique corpectomy is achieved through a lateral approach with control and sometimes transposition of the VA. It can be used at any level from C2 to T1 and on as many levels as required from 1 to 5. It was mostly applied on cervical spondylotic myelopathy (N=157) or radiculopathy (N=89) but also on hourglass tumors (neurinomas N=67, meningiomas N=7, hemangioblastoma N=1, paraganglioma N=1) and different tumors N=49 involving the lateral part of the vertebral body such as osteoïd osteomas N=8, chordomas N=11, aneurysmal cyst N=3, sarcomas N=4. The total series includes 126 tumors. In most cases preservation of the main part of the vertebral bodies permitted to avoid bone grafting and plating. However stabilization procedure is still necessary when more than one disc are resected and when the discs are soft and not collapsed. Results: Excellent decompression was obtained in every case of spondylotic myelopathy and radiculopathy. Clinical results are similar to those obtained by any other techniques of decompression through anterior approach but without the complications related to grafting and plating. Improvement of the preoperative score was noted in 79% of patients with myelopathy stabilization in 13% and worsening in 8%. In patients with radiculopathy, good and excellent results were obtained in 85%. A better decompression of the intervertebral foramen is achieved through the oblique corpectomy since the whole length of the cervical nerve root from the dural sac to the vertebral artery can be decompressed. Instability requiring further stabilization procedure was observed only in 3 cases which in fact were preoperatively unstable. Complete tumor resection was achieved in every case especially for the lateral part located into the intervertebral foramen and around the vertebral artery. Even tumors extending from the outside of the spine to the intradural space could be entirely removed through the same approach. Grafting and plating were realized in 13 out of the 126 cases of tumor. Conclusion: Oblique corpectomy techniques is a safe technique which permits to decompress the spinal cord and cervical nerve roots from spondylotic elements and tumors. As compared to other techniques, it achieves a better decompression on the lateral part of the spinal canal and on the intervertebral foramen up to the vertebral artery. In many cases it does not require any complementary stabilization technique and avoids the use of instrumentation

INTRODUCTION: Oblique corpectomy is a surgical technique of spinal cord decompression through a limited bone resection of the posterolateral corner of the vertebral bodies. In this study the results of this technique applied in cases of spondylotic myelopathy and tumours are presented. METHODS: The oblique corpectomy is achieved through a lateral approach with control and sometimes transposition of the VA. It can be used at any level from C2 to T1 and on as many levels as required from 1 to 5. It was mostly applied on cervical spondylotic myelopathy (N=157) or radiculopathy (N=89) but also on hourglass tumours (neurinomas N=67, meningiomas N=7, hemangioblastoma N=1, paraganglioma N=1) and different tumours N=49 involving the lateral part of the vertebral body such as osteoid osteomas N=8, chordomas N=11, aneurysmal cyst N=3, sarcomas N=4. The total series includes 126 tumours. In most cases preservation of the main part of the vertebral bodies permitted to avoid bone grafting and plating. However stabilisation procedure is still necessary when more than one disc is resected and when the discs are soft and not collapsed. RESULTS: Excellent decompression was obtained in every case of spondylotic myelopathy and radiculopathy. Clinical results are similar to those obtained by any other techniques of decompression through anterior approach but without the complications related to grafting and plating. Improvement of the pre-operative score was noted in 79% of patients with myelopathy stabilisation in 13% and worsening in 8%. In patients with radiculopathy, good and excellent results were obtained in 85%. A better decompression of the intervertebral foramen is achieved through the oblique corpectomy since the whole length of the cervical nerve root from the dural sac to the vertebral artery can be decompressed. Instability requiring further stabilisation procedure was observed only in three cases which in fact were pre-operatively unstable. Complete tumour resection was achieved in every case especially for the lateral part located into the intervertebral foramen and around the vertebral artery. Even tumours extending from the outside of the spine to the intradural space could be entirely removed through the same approach. Grafting and plating were realised in 13 out of the 126 cases of tumour. CONCLUSION: Oblique corpectomy technique is a safe technique which permits to decompress the spinal cord and cervical nerve roots from spondylotic elements and tumours. As compared to other techniques, it achieves a better decompression on the lateral part of the spinal canal and on the intervertebral foramen up to the vertebral artery. In many cases it does not require any complementary stabilisation technique and avoids the use of instrumentation

To assess the outcome and safety of transarticular C1–C2 screw fixation. The clinical and radiological outcomes of 15 patients treated with posterior atlanto-axial transarticular screw fixation and posterior wiring was assessed at a minimum follow up of 6 months. Indications for fusion were rheumatoid arthritis in 8 (instability in 6 and secondary degenerative changes in 2), non-union odontoid fracture 4, symptomatic os-odontoideum one, C1–C2 arthrosis one and irreducible odontoid fracture one. Fusion was assessed with plain x-rays including flexion extension films. Twenty nine screws were placed under fluoroscopic guidance. Bilateral screws were placed in 14 patients and a single screw in one patient. This patient had a single screw placed due to the erosion of the contralateral C2 pars by an anomalous vertebral artery. All patients had radiological union. Two screws (7%) were malpositioned; neither was associated with clinical sequelae. No neurological or vascular injuries were noted. Transarticular C1–C2 fusion yielded a 100% fusion rate. The risk of neurological or vascular injury can be minimised by thorough assessment of pre operative CT scans to assess position of the vertebral artery and use of intra operative lateral and AP fluoroscopy

To assess the outcome and safety of transarticular C1-C2 screw fixation. The clinical and radiological outcomes of 15 patients treated with posterior atlantoaxial transarticular screw fixation and posterior wiring was assessed at a minimum follow up of six months. Indications for fusion were rheumatoid arthritis in eight (instability in six and secondary degenerative changes in two), non union odontoid fracture four, symptomatic osodontoideum one, C1-C2 arthrosis one and irreducible odontoid fracture one. Fusion was assessed with plain x-rays including flexion – extension films. Twenty nine screws were placed under fluroscopic guidance. Bilateral screws were placed in 14 patients and a single screw in one patient. This patient had a single screw placed due to the erosion of the controlateral C2 pars by an anomolous vertebral artery. All patients had radiological union. Two screws (7%) were malpositioned, neither was associated with clinical sequelae. No neurological or vascular injuries were noted. Transarticular C1-C2 fusion yielded a 100% fusion rate. The risk of neurological or vascular injury can be minimised by thorough assessment of pre operative CT scans to assess position of the vertebral artery and use of intra operative lateral and AP fluroscopy

Atlanto-axial rotatory fixation (AARF) is uncommon and is usually associated with a history of trauma to the neck or an upper respiratory tract infection. In patients who present early, correction of the deformity with traction and orthoses has been reported. Owing to failure of reduction, patients presenting late (more than a month after the condition developed) have been treated with an in situ C1/C2 fusion. Follow-up of in situ fusions has shown both progression of the deformity and correction through compensatory mechanisms. Over a five-year period seven AARF patients (16%), ranging in age from 5 to 11 years, presented more than three months after injury. All patients had a ‘cock robin’ posture and were neurologically intact. In three patients the injury was sustained in a fall from a tree and in four it was due to a motor vehicle accident. Two patients sustained additional fractures. All patients had CT scans. In four patients MR scans and MR angiography were used to evaluate the pathology in the atlanto-axial complex, including the vertebral artery, and revealed soft-tissue interposition in the atlanto-axial joint and atlantodental interval. There was thrombosis of the vertebral artery in two patients. Clinical and radiological correction of the deformity was achieved with transoral release and skull traction, followed by fusion. While in previous studies there has been speculation on the causes of failure of closed reduction, MRI and the transoral procedure identified the pathology in this uncommon condition

Introduction and Aims: C1 lateral mass screw fixation offers a powerful alternative biomechanical fixaion for upper cervical disorders. The anatomical constraints to this fixation have not been described yet and are essential to ensure avoidance of neurovascular damage. Method: Fifty patients (including five patients with rheumatoid arthritis) underwent upper cervical CT scans. Analysis of these CT scans involved use of calibrated scan measurements to identify the midpoint of the posterior lateral mass, the dimensions of the lateral mass, the direction of optimum screw passage, the position of the vertebral foramen at C1 and the ideal entry point for lateral mass screw fixation. Results: The average length of screw within the lateral mass was 20mm with 13.5mm of screw not in bone, behind the lateral mass, but necessary to allow rod placement posteriorly adjacent to other fixation points. The safest entry point was directly beneath the medial edge of the lamina origin. The ideal direction of screw angulation is parallel with the posterior arch, in the saggital plane. This entry point was on average 8.8mm from the vertebral artery foramen laterally and 5.8mm from the medial aspect of the lateral mass. Vertical space available for sublaminar screw placement was 3mm or less in 9% of lateral masses. Conclusion: C1 lateral mass screws are best placed beneath the lamina origin, parallel with the arch in the saggital plane using an entrypoint in line with the medial edge of the lamina origin. An entry point under the midpoint of the lamina origin, or passing through the lamina at its attachment to the lateral mass, is likely to damage the vertebral artery in a significant proportion of cases

Purpose: Upper cervical spine stabilization in children can be challenging due to anatomic abnormalities such as incomplete posterior elements, vertebral artery variability and small patient size. Several techniques have been described for stabilization of the upper cervical spine, each with its own advantages and disadvantages. Since the introduction of the technique by Harms, many authors have shown C1 lateral mass screws to be safe and effective in the stabilization of the upper cervical spine in adults. No large series of paediatric C1 lateral mass screw fixation has been reported in the literature. The purpose of this study was to describe the indications, technique, and outcomes of C1 lateral mass screw fixation in a consecutive series of 11 paediatric patients. Method: A database generated retrospective review of all patients who underwent C1 lateral mass screw fixation as part of an upper cervical spine stabilization construct was performed. In all patients the C2 dorsal root ganglion was sacrificed. Patient demographics and clinical outcomes were obtained through chart review. Radiographs immediately post-operatively, at six-weeks, three-months, and final follow-up were reviewed. Results: Eleven consecutive paediatric patients underwent bilateral C1 lateral mass screw fixation for a variety of conditions including C1-C2 instability, deformity, congenital malformation, trauma, as well as revision surgery. The average age was 10 years (range 4 to 16 years) with a mean follow-up of 11 months (range 6 – 18 months). There were no iatrogenic vertebral artery, hypoglossal nerve or spinal cord injuries. All 11 patients had solid fusion clinically and radiographically, with no loss of fixation. The C2 dorsal root ganglion was sacrificed in all patients with resulting minor occipital parasthaesia that progressively diminished in severity. Conclusion: This is the largest series of consecutive patients reported in the literature to date showing that the technique is safe and effective, with acceptable morbidity when applied to the paediatric population. We believe that C1 lateral mass screws offer significant advantages over traditional fixation techniques when the C1 vertebra is to be included in an upper cervical instrumented construct

Introduction: C1 lateral mass screw fixation offers a powerful alternative biomechanical fixation for upper cervical disorders. The anatomical constraints to this fixation have not been described yet and are essential to ensure avoidance of neurovascular damage. Methods: 50 patients (including 5 patients with rheumatoid arthritis) underwent upper cervical CT scans. Analysis of these CT scans involved use of calibrated scan measurements to identify the midpoint of the posterior lateral mass, the dimensions of the lateral mass, the direction of optimum screw passage, the position of the vertebral foramen at C1 and the ideal entry point for lateral mass screw fixation. Results: The average length of screw within the lateral mass was 20 mm with 13.5mm of screw not in bone, behind the lateral mass, but necessary to allow rod placement posteriorly adjacent to other fixation points. The safest entry point was directly beneath the medial edge of the lamina origin. The ideal direction of screw angulation is parallel with the posterior arch, in the saggital plane. This entrypoint was on average 8.8 mm from the vertebral artery foramen laterally and 5.8 mm from the medial aspect of the lateral mass. Vertical space available for sublaminar screw placement was 3mm or less in 9% of lateral masses. Discussion: C1 lateral mass screws are best placed beneath the lamina origin, parallel with the arch in the saggital plane using an entrypoint in line with the medial edge of the lamina origin. An entry point under the midpoint of the lamina origin, or passing through the lamina at its attachment to the lateral mass, is likely to damage the vertebral artery in a significant proportion of cases

Background: A 9- year-old child with osteogenesis imperfecta and severe cervical kyphosis associated with wedged vertebrae and progressive neurological deterioration is presented. There is no report of upper cervical kyphosis associated with wedged vertebrae in osteogenesis imperfecta in the literature. We discuss the methods and difficulties in the surgical management of this condition and to highlight the appropriate surgical approach. Methods: Methods:A 9-year-old girl presented with progressive cervical kyphosis and quadriparesis. At the age of 3 years she underwent posterior cervical fusion (C1–C6) for instability and deformity. Radiological and laboratory investigations confirmed the diagnosis of osteogenesis imperfecta. Radiographs of the cervical spine revealed a kyphotic deformity of 120° Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT) scans showed anterior cord compression due to wedged vertebrae at C3 and C4. MRI-Angiography was performed pre-operatively to identify the anatomical position of the vertebral arteries. A modified anterolateral approach to the upper cervical spine was performed. Anterior C3 and C4 corpectomies with interbody fusion with cage and plate fixation was carried out. Results: Postoperatively the patient made a full neurological recovery and significant correction of the deformity was achieved and correction was maintained at final follow-up. Conclusion: Cervical kyphotic deformity in Osteogenesis Imperfecta is uncommon. Association of this condition with wedged vertebrae is rare. Surgical decompression of the upper cervical spine with severe kyphosis is a challenging problem. Which surgical approach should be used is controversial? There are difficulties exposing wedged vertebrae by a standard anterior or chin split approach to perform vertebrectomy. Costo-transversectomy has been used successfully in patients with Gibbous deformity in the thoracic spine but due the presence of vertebral artery in the cervical spine posterolateral approach is impossible. We have used a modified anterolateral approach to overcome this problem. Spinal stabilisation in children with Osteogenesis Imperfecta and poor bone quality is another challenge. We have used a small diameter MOSS cage with maxillofacial plate and screws to achieve stabilisation and fusion. The purpose of this report is to highlight the importance of diagnosis of progressive cervical kyphotic deformity in children with osteogenesis imperfecta and also to describe the difficulties encountered with surgical management of this condition

Objective:. To observe the incidence of intra-operative vascular injuries during anterior cervical decompression and fusion (ACDF). Secondly, management and monitoring of the outcome post vascular injury during ACDF. Methods:. This a prospective study. A review of all spinal patients' records was performed from June 2006 to April 2011. A comprehensive literature review was also utilized. Inclusion criteria – all patients had ACDF post trauma. All non-traumatic cases were excluded. Results:. The study consisted of 55 patients; 15 were females and 40 were males. The age distribution was 23–65 years. Two patients were excluded due to non-traumatic causes. Of the remaining 53 patients, four sustained intra-operative vascular injuries during ACDF surgery. All 4 patients had corpectomies, and one case was an iatrogenic injury. The commonly injured vessel during the ACDF surgery was the left vertebral artery. Haemostatic control was achieved via tamponade and haemostatic agents. The left common carotid was iatrogenically injured in one case and was treated by microvascular repair. Three patients were treated with antiplatelet therapy for three months duration. The patient with an iatrogenic injury was treated with anticoagulation therapy for three months duration. All computerized tomographic angiograms at three months follow up illustrated patent vessels. Conclusion:. There is an increased incidence of intra operative vascular injuries during ACDF associated with corpectomies. It is essential to be aware of the low incidence of intra operative arterial injury during ACDF and to have a management approach, such as tamponade or microvascular repair. Anticoagulation and antiplatelet therapy is effective in decreasing the complications of vascular injuries post ACDF

To describe a modification of the existing technique for C2 translaminar screw fixation that can be used for salvage in difficult cases. Bilateral crossing C2 laminar screws have recently become popular as an alternative technique for C2 fixation. This technique is particularly useful in patients with anomalous anatomy, as a salvage technique where other modes of fixation have failed or as a primary procedure. However, reported disadvantages of this technique include breach of the dorsal lamina and spinal canal, early hardware failure and difficulty in bone graft placement due to the position of the polyaxial screw heads. To address some of these issues, a modified technique is described. In this technique, the upper part of the spinous process of C2 is removed and the entry point of the screw is in the base of this removed spinous process. From October 2008 to March 2009, 6 patients underwent insertion of unilateral translaminar screws using our technique. The indications were: basilar invagination(three cases), C1/C2 fracture (two cases), tumour (one case). Age varied from 22 to 81 years (mean 48 years). All patients had post-operative x-ray and CT scan to assess position of the screws. Mean follow-up was 6 months. The screw position was satisfactory in all patients. There were no intraoperative or early postoperative complications. Our modification enables placement of bone graft on the C2 lamina and is also less likely to cause inadvertent cortical breach. Because of these advantages, it is especially suitable for patients with advanced rheumatoid arthritis with destruction of the lateral masses of C2 or as part of a hybrid construct in patients with unilateral high riding vertebral artery. This technique is not suitable for bilateral translaminar screw placement

Purpose of study. Transarticular screw fixation offers acceptably high fusion rates but is not possible in 18% of patients due to a high riding vertebral artery. It also requires pre-operative anatomical reduction which is not always possible. The Harms' technique utilises a posterior C1 lateral mass and C2 pedicle screw. This allows easier access due to the angle of drilling and has become an increasingly popular surgical technique. The aim of this study is to review and compare the above techniques with regard to surgery, complications and outcome. Description of methods. This study is a retrospective chart and radiographic review of patients undergoing posterior C1-2 fusion in a single institution in the period 2003 to 2011. The most common aetiology was rheumatoid arthritis and post-traumatic instability. All atlanto-axial instability patients that came to surgery are included in this study, and only cases with less than six months follow-up were excluded. We report on surgical indications, surgical outcomes, complications and radiographic outcomes. Summary of results. No statistically significant differences were found in blood loss (p=0.47) or surgical time (p=0.44) using the Mann-Whitney U test. Complications in patients undergoing transarticular screw fixation included the need to abandon transarticular screws in two cases due to technical difficulty, metalware failure in two cases and intra-operative cerebrospinal fluid leaks in 2 cases. The Harms technique was associated with a single case of cerebrospinal fluid leak. Conclusion. There is no significant difference in surgical time and blood loss between the two techniques. Both are reliable in terms of fusion. The Harms technique offers the advantage of intra-operative reduction and a smaller wound due to the direction of access. The decision to use one or the other is based on the surgeons skill levels, ability to pre-operative reduce the joint and possibly the cost. NO DISCLOSURES

Purpose: The purpose of the study is to access the efficacy of CT angiogram evaluation of the vertebral artery in patients with blunt cervical trauma. Our hypothesis was that there was no protocal for evaluation or treatment of vertebral artery injuries, and that patients with proven vertebral artery injury were not being treated and patients at risk were not being evaluated. An appropriate protocal was established. Method: 721consequtive patients with blunt cervical spine injuries were reviewed for cervical injury at risk for vertebral artery injury (C1–C3 fractures, fractures through transverse foreman, and significant subluxationor dislocation of the cervical spine), subsequent CT angiograms done to evaluate possible vertebral artery injury, treatment and clinical course. Results: 271 patients met criteria for possible vertebral artery injury. 156 had CT angiograms, of which 19 were positive for vertebral artery injury. 12 of the 19 patients with positive CT angiograms for vertebral artery injury were not treated with antithrombotic therapy because of associated injuries. An additional 115 patients had cervical spine injuries at risk for vertebral artry injury and did not have a CT angiogram done. There were 3 patients who had CVA’s, one patient who had a positive CT angiogram for Vertebral artery injury and 2 patients at risk and not evaluated. Conclusion:. Patients with blunt cervical trauma are at risk for vertebral artery injury, which can result in significant neurological sequalae. Antthrombotic therapy can lessen the likilihood of neurological sequalae following a vertebral artery injury. Screening for vertebral artery injury following blunt cervical trauma should be done for C1–C3 fractures, fractures through transverse foramen and significant subluxation or dislocation of the cervical spine. CT angiogram is an accurate screening method, but should be done only if antithrombotic therapy can be initiated

The posterior midline approach used in spinal surgery has been associated with a significant rate of wound dehiscence. This study investigates anatomical study of the arterial supply of the cervical and thoracic spinal muscles and overlying skin at each vertebral level. It aimed to provide possible anatomical basis for such wound complications. A dissection and angiographic study was undertaken on 8 cadaveric neck and posterior torso from 6 embalmed and 2 fresh human cadavers. Harvested cadavers were warmed and hydrogen peroxide was injected into the major arteries. Lead oxide contrast mixture was injected in stepwise manner into the subclavian and posterior intercostal arteries of each specimen. Specimens were subsequently cross-sectioned at each vertebral level and bones elevated from the soft tissue. Radiographs were taken at each stage of this process and analysed. The cervical paraspinal muscles were supplied by the deep cervical arteries, transverse cervical arteries and vertebral arteries. The thoracic paraspinal muscles were supplied by the superior intercostal arteries, transverse cervical arteries and posterior intercostal arteries. In the thoracic region, two small vessels provide the longitudinal connection between the segmental arteries and in the cervical region, deep cervical arteries provide such connection from C3 to C6. The arterial vessels supplying the paraspinal muscles on the left and right side anastomose with each other, posterior to the spinous processes in all vertebral levels. At cervical vertebral levels, source arteries travel near the surgical field and are not routinely cauterised; Haematoma is postulated to be the cause of wound complications. At thoracic levels, source arteries travel in the surgical field and tissue ischemia is a contributing factor to wound complications, especially in operations over extensive levels. Post-operative wound complications is a multi-factorial clinical problem, the anatomical findings in this study provide possible explanations for wound dehiscence in the posterior midline approach. It is postulated that drain tubes may reduce the incidence of haematoma in the cervical level

Introduction. To introduce a new classification method and analyze related risk factor about lateral wall perforation associated with lower cervical pedicle screw and free-hand insertion technique. Methods. A Retrospective study was made to analyze 214 patients (1024 screws) with various cervical spine disorders, involved in pedicle screw instrumentation at C3-7 from July 2004 to July 2009. Researchers assessed the position of the screws in the pedicle by carefully probing intraoperatively and studying postoperative thin-slice computed tomography scan. Perforation of lateral wall was classified into two phases. Phase I refers to the burst of the pedicle by screw, which means that the length of screw threads penetrating the external cortex of pedicles on CT scan is 2 mm, whereas in Phase, the length is >2 mm. The Penetrated screws and related factors were analyzed though Backward Stepwise (Wald) Logistic regression. Results. During the follow-up, 2 screws were reported to be broken and 1 screw loosened. Of the screws inserted, total of 129 screws 12.60% have shown violated of lateral pedicle walls, included 101 screws (9.86%) causative of Phase I and 28 screws (2.73%) of Phase II. Two variance were deduced in the regression analysis, which concerned to ratio variance between inner and lateral walls, PRC 0.695, OR value = 2.003and angle difference variance between screws implanted and measurements preoperativePRC −1.542, OR value = 0.214). Conclusions. Free-hand lower cervical pedicle screw insertion in this series was comparatively safety. Phase I Penetration was believed to be safe of vertebral artery and Phase II faced to higher risk of artery damage. The main risk factor of lateral wall perforation was the ratio variance between inner and lateral wall, while the main protection factor was the angle difference variance between screws implanted and CT measurements

Objective: To review the clinical outcome of 37 consecutive patients undergoing C1– C2 transarticular fixation for patients with Rheumatoid Arthritis. Design: Prospective Observational Study. Methods: There were 37 patients at 2 centres. Age range was 37– 82 years. The time since diagnosis to treatment was 2– 23 years. Clinical presentation included suboccipital pain in 26/ 37 patients and neck pain in 29/37 patients. 22 patients had presented with myelopathy ( Ranawat grade II or III A). The preoperative imaging included Plain X Rays, CT scans and MRI scans. All patients underwent C1/ C2 transarticular screws ( Stealth guided) except 4 patients in which an aberrant course of the vertebral artery was identified. Outcome measures: Functional outcome, Complications, Postoperative Neurological Status, Neck Disability index, Myelopathy disability index. Results: 1 patient had died at 12 month followup. Neck pain improved in 22( 75%) of patients by > 5 points on the VAS. Suboccipital pain had improved in all patients. 17 patients (80%) improved following operation on the Ranawat Grading, 2 patient were worse and 3 patients remained the same. > 70% patients reported improvement in neck disability index and > 50% patients reported improvement in myelopathy disability index. Conclusions: C1/ C2 Transarticular fixation with spinal navigation is a safe technique for treating atlantoaxial instability in patients with Rheumatoid Arthritis. This study demonstrates improvement in all domains including neck disability, myelopathy scores and functional outcome

Introduction: The efficacy and complications of the transarticular screw procedure have been reported by many authors. However, few have reported this procedure for child younger than 10 years old. We have treated two children for atlantoaxial subluxation with transarticular screws, using a soft collar without a halo-vest, and have achieved bone union in good reduced position. Methods/results. Case 1: a 5-year-old boy with mental retardation and cerebellar infarction due to an insufficiency of the vertebral artery resulting in severe atlantoaxial instability. He presented with a high degree of congenital atlantoaxial subluxation complicated by Os odontoideum. He has been treated with transarticular screw and iliac bone graft by Brooks procedure. Case 2: an 8-year-old boy with congenital spondyloepiphyseal dysplasia and a right valgus knee. He, too, presented with a high degree of congenital atlantoaxial subluxation complicated by Os odontoideum, and has been treated with transarticular screw and iliac bone graft by Brooks procedure. In both cases, we used two half-thread cortical screws with a diameter of 2.7mm and a length of 30mm for the transarticular screw procedure. Discussion/conclusion: Rigid external fixation was obtained by Halo-vest. This method, however, would be expected to cause mental stress for the child patient and the family. More rigid internal fixation would be required to resolve this problem. More rigid internal fixation can be obtained with the transarticular screw, and postoperative orthosis can be performed easily, without the need for a Halo-vest

Neck pain can be caused by pressure on the spinal cord or nerve roots from bone or disc impingement. This can be treated by surgically decompressing the cervical spine, which involves excising the bone or disc that is impinging on the nerves or widening the spinal canal or neural foramen. Conventional practise is to fuse the adjacent intervertebral joint after surgery to prevent intervertebral motion and subsequent recompression of the spinal cord or nerve root. However fusion procedures cause physiological stress transfer to adjacent segments which may cause Adjacent Segment Degeneration (ASD), a rapid degeneration of the adjacent discs due to increased stress. ASD is more likely to occur in fusions of two or more levels than single level fusions and is more common where there is existing degeneration of the adjacent discs, which is not unusual in people over 30 years of age. Partial dynamic stabilisation, which generally involves a semi-rigid spinal fixation, allows a controlled amount of intervertebral motion (less than physiological, but more than fusion) to prevent increased stress on the adjacent segments (potentially preventing ASD) whilst still preventing neural recompression. Partial dynamic stabilisation is suitable for treating spinal instability after decompression as well as certain degenerative instabilities and chronic pain syndromes. Dynamic stabilisation and semi-rigid fixation systems for the spine are typically fixated posteriorly. However, choice of posterior surgical stabilisation techniques in the cervical spine is limited due to the size of the osseous material available for fixation and the close proximity of the neural structures and the vertebral artery. Posterior dynamic stabilisation systems for stabilisation of the lumbar spine often use the pedicle as an anchor point. Using the pedicle of the cervical spine as an anchor point is technically difficult because of its small size, angulation and proximity to neurovascular structures. Therefore, one of the main challenges to provide stabilisation in the cervical spine is the limitations of the anatomy. This presentation will introduce a novel spinal implant (patent pending) which is proposed for the cervical spine to provide partial dynamic stabilisation in the C3 to T1 region from a posterior approach. The implant is a single unit with a safe and technically simple insertion technique into the lateral masses. The implant uses a simple mechanism to allow limited intervertebral motion at each instrumented level. It is hoped that the simplicity of the device and removing the need to provide a bone graft anteriorly may reduce the cost of the procedure compared to traditional fusion and competing surgeries