Craniovertebral Junction and Spine

Is central atlantoaxial instability the nodal point of pathogenesis of "idiopathic" dorsal spinal kyphoscoliosis? Atul Goel Journal of Craniovertebral Junction and Spine 2019 10(1):1-2

Treatment algorithm for spontaneous spinal infections: A review of the literature Fabrizio Gregori, Giovanni Grasso, Giancarlo Iaiani, Nicola Marotta, Fabio Torregrossa, Alessandro Landi Journal of Craniovertebral Junction and Spine 2019 10(1):3-9 Background: Primary spinal infections are rare pathologies with an estimated incidence of 5% of all osteomyelitis. The diagnosis can be challenging and this might result in a late identification. The etiological diagnosis is the primary concern to determine the most appropriate treatment. The aim of this review article was to identify the importance of a methodological attitude toward accurate and prompt diagnosis using an algorithm to aid on spinal infection management. Methods: A search was done on spinal infection in some databases including PubMed, ISI Web of Knowledge, Google Scholar, Ebsco, Embasco, and Scopus. Results: Literature reveals that on the basis of a clinical suspicion, the diagnosis can be formulated with a rational use of physical, radiological, and microbiological examinations. Microbiological culture samples can be obtained by a percutaneous computed tomography-guided procedure or by an open surgical biopsy. When possible, the samples should be harvested before antibiotic treatment is started. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and failure of conservative treatment. Conclusion: A multidisciplinary approach involving both a spinal surgeon and an infectious disease specialist is necessary to better define the treatment strategy. Based on literature findings, a treatment algorithm for the diagnosis and management of primary spinal infections is proposed.

Diffusion tensor imaging as an additional postoperative prognostic predictor factor in cervical myelopathy patients: An observational study Sunil Bhosale, Pramod Ingale, Sudhir Srivastava, Nandan Marathe, Prajakta Bhide Journal of Craniovertebral Junction and Spine 2019 10(1):10-13 Introduction: Multiple investigation modalities have been invented for diagnosis and for planning management of degenerative cervical myelopathy, which include magnetic resonance imaging (MRI), computed tomography scan, and plain X-rays. Diffusion tensor imaging (DTI) of the spinal cord is a special variety of MRI where diffusion of water molecules across and along the tracts is mapped. The changes in anisotropy at the stenotic level can be a postoperative prognostic factor. The aim of this study was to establish postoperative prognostic predictive value of DTI in cases of degenerative cervical myelopathy. Materials and Methods: The study included 30 indoor patients in a tertiary care hospital diagnosed with degenerative compressive cervical myelopathy based on both clinical and radiological parameters with complete clinical data including follow-up. All patients with medical neurological diseases, cases who underwent repeat surgery, cases who developed surgical site infection, and those patients who were lost to follow-up were excluded from the study. The patients underwent operative decompression through either anterior or posterior approach with or without fixation with titanium implants as per indication. All patients underwent pre- and postoperative DTI. The fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were noted in both pre- and postoperative imaging. Epidemiological data such as age and sex were noted. Pre- and postoperative modified Japanese Orthopedic Association (mJOA) scores were calculated. Results: There was a significant improvement in FA values postoperatively. Preoperatively, both FA and ADC values showed a significant correlation with preoperative Neurological status of the patient while postoperatively only FA values were found to be significantly correlated. The regression equations for determining postoperative mJOA score based on preoperative FA and ADC values revealed mJOA = 9.77 + 12.1 (FA), mJOA = 14.2 + 2408.4 (ADC), and mJOA = 9.54 + 11.2 (FA) +1575.5 (ADC). This means that postoperative mJOA score, i.e., postoperative clinical status improvement can be determined using DTI variables which are an objective preoperative data. However, relative strength of prediction for FA value is 66.7% and for ADC value is 28.7%. Conclusion: DTI tractography of the spinal cord will be a helpful objective prognostic factor for patients in whom surgery is planned. However, a study with larger subject size is required to increase the accuracy of determination of regression coefficient.

Effectiveness of titanium plate usage in laminoplasty Arya Nick Shamie, Hamed Yazdanshenas Journal of Craniovertebral Junction and Spine 2019 10(1):14-18 Background: Laminoplasty is an established technique for the treatment of cervical stenosis. However, the usage of plates to maintain patency of the laminoplasty door has not been well reported. This study plans to compare the clinical outcomes of laminoplasty with the usage of Sofamor-Danek laminoplasty plates versus techniques without plate usage. Materials and Methods: This study conducted a 2-year medical record review of all patients with multilevel cervical myelopathy who were treated with laminoplasty at UCLA or Cedars-Sinai medical center. Of 46 patients 18 had sufficient documentation to assess clinical outcome, 11 of which had placement of laminoplasty plates. Clinical outcomes were assessed using Odom's scoring criteria. Results: Blood loss and hospital stay are decreased with plate usage during laminoplasty. Average Estimated Blood Loss (EBL) was 160 cc with plate and 380 cc without. Hospital stay was 4.8 days with plate and 5.6 days without. There were no complications during any of the laminoplasty procedures regardless of instrumentation. All patients demonstrated improvement in symptoms after laminoplasty, with 73% of patients in the plate cohort having Odom Scores of “Excellent” versus 44% in the nonplate group. All patients, regardless of technique, showed improvement in symptoms. Conclusions: Laminoplasty with plate utilization is an effective treatment for cervical myelopathy. The similarity in outcomes and complications between these two similar cohorts suggests plate usage in laminoplasty is an attractive alternative to other methods. We hope that future efforts will continue to demonstrate the effectiveness and perhaps superiority of plate utilization in laminoplasty.

Is cervical instability the cause of lumbar canal stenosis? Atul Goel, Ravikiran Vutha, Abhidha Shah, Survendra Rai, Abhinandan Patil Journal of Craniovertebral Junction and Spine 2019 10(1):19-23 Aim: On the basis of an experience with 12 cases, the validity and rationale of cervical spinal stabilization for cases having both cervical and lumbar spinal canal stenosis is analyzed. Materials and Methods: From March 2017 to May 2018, 12 patients presented with a major symptom of neurogenic claudication pain generally related to lumbar canal stenosis in addition to other symptoms related to cervical myelopathy. The average age was 57 years. All patients were clinically and radiologically diagnosed to have both cervical and lumbar spinal canal stenosis. Based on the concept that degenerative spinal spondylotic myelopathy is an outcome of spinal instability, all patients underwent cervical spinal stabilization. No decompression by bone resection was done. The lumbar spine was not surgically treated. Visual analog scale, the Japanese Orthopaedic Association, and Oswestry Disability Index were used to monitor patients before and after surgery. Results: There was dramatic relief from symptoms related both to cervical and to lumbar canal stenosis in the postoperative period. During the average period of follow-up of 12 months, none of the patients have experienced recurrence of lumbar pain or needed any surgery. Conclusion: The report highlights the possibility of recovery in lumbar canal stenosis related symptoms following cervical spinal stabilization surgery for associated cervical spinal stenosis. We conclude that in select cases, cervical spinal instability may be the cause of clinical and radiological observations in cases having lumbar canal stenosis.

Effect of posterior fusion surgery on idiopathic scoliosis in Iran Masih Falahatian, Mohammad Farid Masaeli Journal of Craniovertebral Junction and Spine 2019 10(1):24-27 Background: Scoliosis is a sideways curve in the spine. Considering that postoperative complications are common among these patients, the aim of this study is to examine the postoperative complications of posterior fusion surgery with instrumentation among adult patients with idiopathic scoliosis. Methods: In this cross-sectional descriptive study, the postoperative complications were examined among 93 patients with idiopathic scoliosis who underwent posterior fusion surgery with instrumentation. The convenience sampling was used by referring to the files of these patients. The patients were classified into four groups according to the type of scoliosis deformity (long C-shaped, thoracic, thoracolumbar/lumbar, and double-curve) and the complications were compared together. Results: Postoperative respiratory problems were significantly different between the four groups of scoliosis deformity (P = 0.009); 35 cases of postoperative complications occurred and 20 of them were related to postoperative pulmonary complications. Conclusion: Postoperative complications are common among patients with idiopathic scoliosis who underwent posterior fusion surgery with instrumentation; in addition, pulmonary complications are the most common postoperative complication among these patients.

Clinical presentation and outcome after anterior cervical discectomy and fusion for degenerative cervical disc disease Ninad N Srikhande, V A. Kiran Kumar, NA Sai Kiran, Amrita Ghosh, Ranabir Pal, Luis Rafael Moscote-Salazar, V Anil Kumar, Vishnu Vardhan Reddy, Amit Agrawal Journal of Craniovertebral Junction and Spine 2019 10(1):28-32 Background: Anterior cervical discectomy and fusion (ACDF) is a well-described surgical approach for symptomatic degenerative cervical disc disease which does not respond to conservative management. In the present study, we assessed clinical presentation and outcomes of ACDF. Materials and Methods: The present study was conducted from October 1, 2015, to October 31, 2017, in the Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, among 100 consecutive adult patients who underwent single- or two-level ACDF for degenerative cervical disc disease. Results: The mean age was 47.2 ± 12.8 years (range: 20–74 years). Majority of the patients were male (86/100). Presenting symptoms were neck pain (77%), limb weakness (73%), paresthesias (53%), radicular pain (49%), stiffness in limbs (16%), and bladder involvement (13%). Fusion was done with stand-alone titanium cage/bone graft or titanium cage/bone graft with anterior cervical plate. At the time of discharge, significant improvement in preoperative symptoms (neck pain [47/77-61%], radicular pain [31/49-63%], limb weakness [53/73-72.6%], paresthesias [44/53-83%], stiffness in limbs [13/16-81%], and bladder symptoms [8/13-61%]) was reported by majority of these patients. Majority of these patients also reported improvement in preoperative sensory deficits at the time of discharge. Postoperative complications were hoarseness of voice (22%), dysphagia (16%), deterioration of motor power (8%), and postoperative hematoma (7%). Conclusions: A significant proportion of patients with degenerative cervical disc disease show remarkable recovery after ACDF.

Lumbar rocking test: A new clinical test for predicting lumbar instability Ashok Keshav Rathod, Bipul Kumar Garg, Varun Mukesh Sahetia Journal of Craniovertebral Junction and Spine 2019 10(1):33-38 Purpose: Significant number of low back pain is caused by spinal instability. Clinical and radiological tests are used to diagnose lumbar instability, but the practical utility of clinical tests has not been studied extensively. Hence, it was decided to study lumbar rocking test and passive lumbar extension (PLE) clinical tests to identify their accuracy for lumbar instability, in comparison to the radiological assessment. Materials and Methods: This cross-sectional prospective study was conducted in 2017 at an Indian tertiary care center, after Ethics Committee approval. No financial transection involved anywhere at any stage of the study. Patients of 30–65 years having low back pain were included following informed consent. Clinical tests conducted were rocking test and PLE tests. All patients were subjected to a neutral anteroposterior, lateral and flexion-extension X-rays of lumbosacral spine. The association between clinical tests and lumbar instability was represented by Chi-square analysis. The rest of the findings were represented as descriptive statistics. Results: Fifty patients enrolled in the study, of which 28 (56%) were females. On X-rays, the maximum angular rotation and sagittal translation were seen at L5–S1 level. 35 (70%) and 46 (92%) patients showed positive PLE and rocking test, respectively. Significant association (P < 0.05) was seen between rocking test and lumbar instability. The sensitivity of rocking test was 95.56% and positive predictive value as 93.47%. Conclusion: Clinical tests can be used effectively for the diagnosis of lumbar spine instability. Rocking test was found to be accurate and sensitive for detecting subtle lumbar instability.

Proposal of a new anatomical landmark to identify the disc space in endoscopic lumbar discectomy Keyvan Mostofi, Morad Peyravi, Babak Gharaei Moghaddam, Reza Karimi Khouzani Journal of Craniovertebral Junction and Spine 2019 10(1):39-41 Introduction: In endoscopic lumbar discectomy for posterolateral disc herniation, we determined some anatomical landmarks for improved disc space access. These landmarks are based on the beginning of the insertion of the ligamentum flavum (LF) to vertebral lamina. Materials and Methods: In 978 patients operated by posterolateral disc herniation, we measured prospectively the distance between the beginning of the insertion of the LF and space disc rostrally. Results: The distance between the beginning of the insertion of the LF and space disc was broader at the level of L3–L4, with an average of 14 mm. At L4–L5, the average distance was 13.5. At L5–S1, the average distance was 12 mm. Conclusion: Knowing the accurate distance between the insertion of LF and disc space contributes to reducing the average duration of the surgical procedure to avoid empirical search of disc space by a surgeon and avoiding unnecessary and excessive LF and bone removal.

Superficial anterior atlanto-occipital ligament: Anatomy of a forgotten structure with relevance to craniocervical stability Shogo Kikuta, Joe Iwanaga, Koichi Watanabe, R Shane Tubbs Journal of Craniovertebral Junction and Spine 2019 10(1):42-45 Introduction: The superficial anterior atlanto-occipital ligament (SAAOL) is a narrowband located anterior to the anterior atlanto-occipital membrane. Nearly forgotten, it has not been well described in older anatomical textbooks and is missing in the current anatomical literature. As all of the binding structures of the craniocervical junction (CCJ) are important in maintaining stability, this study aims to clarify the anatomy and potential function of the SAAOL. Materials and Methods: The CCJ from ten fresh-frozen cadavers was studied. These specimens were derived from three males and seven females, and the age at death ranged from 57 to 91 years (mean, 79.8 years). The length, width, and thickness of the SAAOL were measured. In five specimens, the force to failure was recorded. Results: The SAAOL was found between the anterior tubercle of the atlas and the occiput and located as central thick fibers in front of the anterior atlanto-occipital membrane in 9 (90%) specimens. In one specimen, the vertical band to the occipital bone did not attach to the anterior tubercle of the atlas, but extended to the anterior aspect of the axis. The mean length, width, and thickness of the SAAOL were 19.8, 6.2, and 0.6 mm, respectively. The force to failure for the ligament was 38.8 N. Conclusion: The SAAOL was a constant structure of the anterior atlanto-occipital joint. This ligament seems to be a secondary stabilizer of the CCJ by limiting the extension of CCJ. Knowledge of this ligament may help in further understanding of craniocervical stability.