Special Considerations for Surgical Fusion of the Occiput and Cervical Spine

OBJECTIVEThe long-term effects of surgical fusion on the growing subaxial cervical spine are largely unknown. Recent cross-sectional studies have demonstrated that there is continued growth of the cervical spine through the teenage years. The purpose of this multicenter study was to determine the effects of rigid instrumentation and fusion on the growing subaxial cervical spine by investigating vertical growth, cervical alignment, cervical curvature, and adjacent-segment instability over time.METHODSA total of 15 centers participated in this multi-institutional retrospective study. Cases involving children less than 16 years of age who underwent rigid instrumentation and fusion of the subaxial cervical spine (C-2 and T-1 inclusive) with at least 1 year of clinical and radiographic follow-up were investigated. Charts were reviewed for clinical data. Postoperative and most recent radiographs, CT, and MR images were used to measure vertical growth and assess alignment and stability.RESULTSEighty-one patients were included in the study, with a mean follow-up of 33 months. Ninety-five percent of patients had complete clinical resolution or significant improvement in symptoms. Postoperative cervical kyphosis was seen in only 4 patients (5%), and none developed a swan-neck deformity, unintended adjacent-level fusion, or instability. Of patients with at least 2 years of follow-up, 62% demonstrated growth across the fusion construct. On average, vertical growth was 79% (4-level constructs), 83% (3-level constructs), or 100% (2-level constructs) of expected growth. When comparing the group with continued vertical growth to the one without growth, there were no statistically significant differences in terms of age, sex, underlying etiology, surgical approach, or number of levels fused.CONCLUSIONSContinued vertical growth of the subaxial spine occurs in nearly two-thirds of children after rigid instrumentation and fusion of the subaxial spine. Failure of continued vertical growth is not associated with the patient’s age, sex, underlying etiology, number of levels fused, or surgical approach. Further studies are needed to understand this dichotomy and determine the long-term biomechanical effects of surgery on the growing pediatric cervical spine.

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A novel anterior technique for simultaneous single-stage anterior and posterior cervical release for fixed kyphosis

Journal of Neurosurgery Spine ◽

10.3171/spi/2008/8/6/594 ◽

2008 ◽

Vol 8 (6) ◽

pp. 594-599 ◽

Cited By ~ 6

Author(s):

Vincent Y. Wang ◽

Henry Aryan ◽

Christopher P. Ames

Keyword(s):

Cervical Spine ◽

Vertebral Body ◽

Muscle Spasm ◽

Lateral Mass ◽

Disc Disease ◽

Nerve Roots ◽

Surgical Fusion ◽

Mass Release ◽

Prior Surgery ◽

Growing Spine

✓The incidence rate of kyphosis of the cervical spine after a laminectomy can be as high as 20% after a multilevel laminectomy. The loss of the posterior tension band leads to increased load on the vertebral body and discs, leading to further degenerative changes and kyphotic deformities. The initial decompression of the spinal cord disappears as the cord is stretched over the anterior lesions. Muscle damage and facet degeneration from prior surgery contribute to additional pain, muscle spasm, and motion. Occasionally prior surgical fusion that fails to address the kyphosis or spontaneous fusion in a kyphotic position (observed more in laminectomies performed in the growing spine) can result in a challenging rigid deformity with anterior vertebral body and lateral mass facet fusion. For this fixed deformity, anterior and posterior release are often necessary for restoration of lordosis, which can result in the need for a 540° procedure. In this report the authors describe an anterior technique for simultaneous anterior and posterior lateral mass release. The vertebral artery is mobilized using this technique, allowing for its lateral retraction. The nerve roots are visualized and retracted superiorly and inferiorly. The lateral mass and facets can then be accessed anteriorly using an osteotome or drill for the release. The authors illustrate this technique in a patient who developed fixed scoliosis and kyphosis of the cervical spine after surgery for degenerative disc disease. To the authors' knowledge, this is the first report of this technique.

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Special Considerations for Surgical Fusion of the Occiput and Cervical Spine

Textbook of Pediatric Neurosurgery ◽

10.1007/978-3-319-31512-6_128-1 ◽

2017 ◽

pp. 1-19

Author(s):

Kyle G. Halvorson ◽

Douglas L. Brockmeyer

Keyword(s):

Cervical Spine ◽

Surgical Fusion

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Halo vest versus spinal fusion for cervical injury: evidence from an outcome study

Journal of Neurosurgery ◽

10.3171/jns.1989.70.6.0884 ◽

1989 ◽

Vol 70 (6) ◽

pp. 884-892 ◽

Cited By ~ 87

Author(s):

Richard D. Bucholz ◽

K. Charles Cheung

Keyword(s):

Cervical Spine ◽

Medical Center ◽

Spine Injury ◽

Cervical Injury ◽

Halo Vest ◽

Content Type ◽

Cervical Spine Injuries ◽

Surgical Fusion ◽

Spine Injuries ◽

Halo Device

✓ The indications for surgical fusion, as opposed to halo fixation, in the management of cervical spine injury are still unclear. At St. Louis University Medical Center a conservative protocol has been adopted to treat almost all cervical spine fractures with halo fixation. To determine what factors have contributed to failure of halo fixation, the records and radiographs of all patients with cervical spine injuries who were treated at that institution between 1984 and 1986 were reviewed. During this interval, 124 patients were treated, consisting of 93 men and 31 women between 6 and 94 years old. Of these, 15 (12%) had cervical fusion without preoperative halo device application. This group included eight patients with old injuries and delayed diagnosis, three with nonreducible locked facets, and four with miscellaneous indications. The remaining 109 patients were treated with halo vests. Four died before completing the 3-month standard treatment. Of those completing the treatment, 48 had C1–2 level injuries and 57 had C3–T1 level injuries. Sixteen patients (15%) failed their halo treatments and required surgical fusion: eight while still in halo fixation and eight after they had completed treatment with a halo device. Failure of halo treatment was indicated by recurrent dislocation in 13 patients and increased neurological deficit in three. Thirteen of the patients who failed treatment had C3–T1 injuries and three had C1–2 injuries. Of 27 patients with odontoid fractures, only two (7.4%) failed halo fixation. There were no failures in 11 patients with hangman's fractures. Of the 57 patients with C3–T1 injuries, 13 (23%) failed treatment, nine of whom had locked or “perched” facets. The factors causing failure of halo fixation were analyzed. The overall success rate was 85%, suggesting that the halo vest can be used to treat most patients with cervical spine injuries. Under certain circumstances (in the presence of old injuries, difficult reduction, or locked or “perched” facets), surgery may be indicated to avoid unnecessary delay in definitive management.

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Surgical treatment for patients with cervical flexion myelopathy

Journal of Neurosurgery Spine ◽

10.3171/spi.1999.91.1.0033 ◽

1999 ◽

Vol 91 (1) ◽

pp. 33-42 ◽

Cited By ~ 8

Author(s):

Michihiro Kohno ◽

Hiroshi Takahashi ◽

Katsuhisa Ide ◽

Kenta Yamakawa ◽

Tatsuya Saitoh ◽

...

Keyword(s):

Cervical Spine ◽

Muscular Atrophy ◽

Rare Condition ◽

Long Bone ◽

Content Type ◽

Neurological Improvement ◽

Surgical Fusion ◽

Number Of Patients ◽

Cervical Flexion Myelopathy ◽

Fine Print

Object. Cervical flexion myelopathy is a rare condition that mainly affects adolescent boys. In recent years, avoidance of neck flexion has been advocated as the treatment for cervical flexion myelopathy, and treatment with a cervical collar and surgery in which fusion of the cervical spine is performed have been found to be effective. However, previously reported series contained only a limited number of patients. The authors report their experience with treating 10 male patients in whom surgery was performed to correct cervical flexion myelopathy, and they evaluate the patients' surgical outcome. Methods. The authors performed anterior decompressive surgery and fusion in the cervical spine by using a long bone graft after resection of one or two vertebrae in seven patients. The other three patients underwent posterior fusion of four or five laminae. After surgery, symptom progression was stopped in all patients, muscle strength improved in seven, and sensory disturbance was alleviated in another two. However, the muscular atrophy in the upper extremities, which was evident in nine patients preoperatively, improved in only two. Conclusions. Because some neurological improvement was seen in nine of 10 patients, it is believed that surgical fusion of the cervical spine is an effective treatment for patients with cervical flexion myelopathy.

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Clinical Update: Evaluation of the Cervical Spine

Guides Newsletter ◽

10.1001/amaguidesnewsletters.1998.janfeb04 ◽

1998 ◽

Vol 3 (1) ◽

pp. 6-7

Author(s):

Robert H. Haralson

Keyword(s):

Cervical Spine

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Motion Analysis of the Cervical Spine

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2004.sepoct01 ◽

2004 ◽

Vol 9 (5) ◽

pp. 1-11

Author(s):

Patrick R. Luers

Keyword(s):

Cervical Spine ◽

Intervertebral Disk ◽

Radiographic Evaluation ◽

Ligamentous Injury ◽

Pattern Of Injury ◽

Motion Segment ◽

Single Pattern ◽

Compensatory Motion ◽

Loss Of Motion ◽

Flexion And Extension

Abstract The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, defines a motion segment as “two adjacent vertebrae, the intervertebral disk, the apophyseal or facet joints, and ligamentous structures between the vertebrae.” The range of motion from segment to segment varies, and loss of motion segment integrity is defined as “an anteroposterior motion of one vertebra over another that is greater than 3.5 mm in the cervical spine, greater than 2.5 mm in the thoracic spine, and greater than 4.5 mm in the lumbar spine.” Multiple etiologies are associated with increased motion in the cervical spine; some are physiologic or compensatory and others are pathologic. The standard radiographic evaluation of instability and ligamentous injury in the cervical spine consists of lateral flexion and extension x-ray views, but no single pattern of injury is identified in whiplash injuries. Fluoroscopy or cineradiographic techniques may be more sensitive than other methods for evaluating subtle abnormal motion in the cervical spine. The increased motion thus detected then must be evaluated to determine whether it represents normal physiologic motion, normal compensatory motion, motion related to underlying degenerative disk and/or facet disease, or increased motion related to ligamentous injury. Imaging studies should be performed and interpreted as instructed in the AMA Guides.

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