Only Cervical Segments C0-C2, Not C3 Are Relevant for Subgrouping Migraine Patients According to Manual Palpation and Pain Provocation

Background and Aims: Subgrouping of migraine patients according to the pain response to manual palpation of the upper cervical spine has been recently described. Based on the neuroanatomy and the convergence of spinal and trigeminal nerves in the trigeminocervical complex, the cervical segments C1 to C3 are potentially relevant. To date it has not been investigated whether palpation results of all upper cervical segments are based on one underlying construct which allows combining the results of several tests.Methods: Seventy-one migraine patients with chronic or frequent episodic migraine diagnosed according to the IHS classification version 3 were examined by one physiotherapist. Manual palpation was performed on the upper three cervical segments unilaterally left and right. The results of the palpation according to the patients’ responses were combined using factor analysis to determine whether results from all three segments form one underlying construct. In addition, item response theory (IRT) was used to investigate the structure of the response pattern as well as item difficulty and discriminationFindings: Factor analysis (principal component) showed that the palpation of C3 loads less onto the underlying construct than the palpation of C1 and C2. Considering a cut-off value >1.0, the eigenvalues of all three segments do not represent one underlying construct. When excluding the results from C3, remaining items form one construct. The internal consistency of the pain response to palpation of C1 and C2 is acceptable with a Cronbach’s alpha of 0.69. IRT analysis showed that the rating scale model fits best to the pain response pattern. The discrimination value (1.24) was equal for all 4 items. Item difficulty showed a clear hierarchical structure between the palpation of C1 and C2, indicating that people with a higher impairment are more likely to respond with referred pain during palpation of the segment C2. Conclusion: Statistical analysis confirms that results from the palpation of the cervical segments C1 and C2 in migraine patients can be combined. IRT analysis confirmed the ordinal pattern of the pain response and showed the higher probability of a pain response during palpation of C2. Registration of main Study: German registry of clinical trials (DRKS00015995), Registered 20. December 2018, https://www.drks.de/drks_web/setLocale_EN.do

Tumoral Calcinosis of the Cervical Spine Associated with a Pathologic Odontoid Fracture

Tumoral calcinosis involves focal calcium deposits in the soft tissues surrounding a joint and most commonly occurs in the hips and elbows, rarely in the cervical spine. Furthermore, it has not been known to be associated with pathologic fractures. To the best of our knowledge, our case report highlights the first case of a pathologic type II odontoid fracture associated with adjacent tumoral calcinosis, resulting in pain, dysphagia, and severe spinal stenosis. The patient underwent a posterior occipitocervical fusion and C1 laminectomy, along with planned tracheostomy and gastrostomy to avoid expected difficulty with postoperative extubation and dysphagia. Additionally, we present a review of existing literature on tumoral calcinosis in the upper cervical spine.

Upper Cervical Compression Myelopathy Caused by the Retro-Odontoid Pseudotumor With Degenerative Osteoarthritis and Calcium Pyrophosphate Dihydrate Disease: A Case Report and Literature Review

The retro-odontoid pseudotumor is often concurrent with atlantoaxial subluxation (AAS). Therefore, the pseudotumor is relatively common in rheumatoid arthritis (RA) but rare in primary osteoarthritis (OA). This is a case report of an elderly male patient suffering from neck pain and compression myelopathy caused by the craniocervical pseudotumor with OA but without atlantoaxial instability. He had long-lasting peripheral and spinal pain treated by nonsteroidal anti-inflammatory drugs. Imaging found upper cervical spondylosis without AAS or dynamic instability but with periodontoid calcifications and ossifications, suggesting calcium pyrophosphate dihydrate (CPPD) crystal deposition. Based on a comprehensive literature search and review, CPPD disease around the atlantodental joint is a possible contributor to secondary OA development and retro-odontoid pannus formation through chronic inflammation, which can be enough severe to induce compression myelopathy in non-RA patients without AAS. The global increase in the aged population advises caution regarding more prevalent upper cervical spine disorders associated with OA and CPPD.

Complications of Posterior Fusion for Atlantoaxial Instability in Children With Down Syndrome

Objective: To clarify the complications of posterior fusion for atlantoaxial instability (AAI) in children with Down syndrome and to discuss the significance of surgical intervention.Methods: Twenty pediatric patients with Down syndrome underwent posterior fusion for AAI between February 2000 and September 2018 (age, 6.1 ± 1.9 years). C1–2 or C1–3 fusion and occipitocervical fusion were performed in 14 and 6 patients, respectively. The past medical history, operation time, estimated blood loss (EBL), duration of Halo vest immobilization, postoperative follow-up period, and intra- and perioperative complications were examined.Results: The operation time was 257.9 ± 55.6 minutes, and the EBL was 101.6 ± 77.9 mL. Complications related to the operation occurred in 6 patients (30.0%). They included 1 major complication (5.0%): hydrocephalus at 3 months postoperatively, possibly related to an intraoperative dural tear. Other surgery-related complications included 3 cases of superficial infections, 1 case of bone graft donor site deep infection, 1 case of C2 pedicle fracture, 1 case of Halo ring dislocation, 1 case of pseudoarthrosis that required revision surgery, and 1 case of temporary neurological deficit after Halo removal at 2 months postoperatively. Complications unrelated to the operation included 2 cases of respiratory infections and 1 case of implant loosening due to a fall at 9 months postoperatively.Conclusion: The complication rate of upper cervical fusion in patients with Down syndrome remained high; however, major complications decreased substantially. Improved intra- and perioperative management facilitates successful surgical intervention for upper cervical instability in pediatric patients with Down syndrome.

Giant cell tumor of the tenosynovial type in the prevertebral space with a cervical approach

<p class="abstract">The complex anatomy of the neck makes surgical interventions of cervical neoplasms a very complex process. The aforementioned challenges the surgeon to find a surgical approach with the least morbidity and cosmetic sequelae. This is particularly true in tumoral occupation of the prevertebral space (PVS), most frequently due to the extension of neoplasms from naso and oropharynx; whereas primary tumors of the PVS are extremely rare. There are a number of surgical approaches to access the skull base and the anterior region of the upper cervical spine, such as the transcervical-transtemporal approach, retraction and dissection of the soft palate, mandibular osteotomy, medial glossotomy, among others. The following article presents a case report in which a less invasive combined transcervical-transoral approach was performed on a tenosynovial giant cell tumor of the PVS. As an alternative in the treatment of these type of lesions, it is in our opinion equally effective and less morbid.</p>

"Hand as Foot Teaching Method" Application in Upper Cervical Anatomy and Common Diseases

Background“Hand as Foot teaching method” has been applied to the clinical teaching of various orthopaedic subspecialties and achieved good results, but it has not been carried out in the specialized teaching of spine surgery, especially the upper cervical spine. The orthopedics teaching team of the Second Affiliated Hospital of Harbin Medical University applied this teaching method to the clinical teaching of atlantoaxial anatomical relationships and common atlantoaxial diseases.MethodsThe "Hand as Foot Teaching Method" was used to teach key and difficult points for master students of osteology in the Second Affiliated Hospital of Harbin Medical University, supplemented by PPT + anatomical specimens to assist the teaching process.Results"Hand as Foot Teaching Method" can concretize the complex anatomical structure of upper cervical vertebra, thus deepening students' understanding and memory of difficult points, enhancing teacher-student interaction and activating the teaching atmosphere.Conclusion"Hand as Foot Teaching Method" can be applied to the clinical teaching of atlantoaxial knowledge. Compared with the simple application of PPT + model teaching, this teaching method is more helpful for students to grasp difficulties quickly and in three dimensions, significantly improve the teaching quality, and can even be applied to preoperative doctor-patient communication. It has application and promotion value in clinical teaching of spinal surgery.