Browsing by Subject "Atlanto-Axial Joint"
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Item Open Access C-2 neurectomy during atlantoaxial instrumented fusion in the elderly: patient satisfaction and surgical outcome.(Journal of neurosurgery. Spine, 2011-07) Hamilton, D Kojo; Smith, Justin S; Sansur, Charles A; Dumont, Aaron S; Shaffrey, Christopher IObjective
The originally described technique of atlantoaxial stabilization using C-1 lateral mass and C-2 pars screws includes a C-2 neurectomy to provide adequate hemostasis and visualization for screw placement, enable adequate joint decortication and arthrodesis, and prevent new-onset postoperative C-2 neuralgia. However, inclusion of a C-2 neurectomy for this procedure remains controversial, likely due in part to a lack of studies that have specifically addressed whether it affects patient outcome. The authors' objective was to assess the surgical and clinical impact of routine C-2 neurectomy performed with C1-2 segmental instrumented arthrodesis in a consecutive series of elderly patients with C1-2 instability.Methods
Forty-four consecutive patients (mean age 71 years) underwent C1-2 instrumented fusion, including C-1 lateral mass screw insertion. Bilateral C-2 neurectomies were performed. Standardized clinical assessments were performed both pre- and postoperatively. Numbness or discomfort in a C-2 distribution was documented at follow-up. Fusion was assessed using the Lenke fusion grade.Results
Among all 44 patients, mean blood loss was 200 ml (range 100-350 ml) and mean operative time was 129 minutes (range 87-240 minutes). There were no intraoperative complications, and no patients reported new postoperative onset or worsening of C-2 neuralgia postoperatively. Outcomes for the 30 patients with a minimum 13-month follow-up (range 13-72 months) were assessed. At a mean follow-up of 36 months, Nurick grade and pain numeric rating scale scores improved from 3.7 to 1.0 (p < 0.001) and 9.4 to 0.6 (p < 0.001), respectively. The mean postoperative Neck Disability Index score was 7.3%. The fusion rate was 97%, and the patient satisfaction rate was 93%. All 24 patients with preoperative occipital neuralgia reported relief. Seventeen patients noticed C-2 distribution numbness only during examination in the clinic, and 2 patients reported C-2 numbness, but it did not affect their daily function.Conclusions
In this series of C1-2 instrumented arthrodesis in elderly patients, excellent fusion rates were achieved, and patient satisfaction was not negatively affected by C-2 neurectomy. In the authors' experience, C-2 neurectomy enhanced surgical exposure of the C1-2 joint, thereby facilitating hemostasis, placement of instrumentation, and decortication of the joint space for arthrodesis. Importantly, with C-2 neurectomy in the present series, no cases of new onset postoperative C-2 neuralgia occurred, in contrast to a growing number of reports in the literature documenting new-onset C-2 neuralgia without C-2 neurectomy. On the contrary, 80% of patients in the present series had preoperative occipital neuralgia and in all of these patients this neuralgia was relieved following C1-2 instrumented arthrodesis with C-2 neurectomy.Item Open Access Faced joint locking.(Journal of neurosurgery. Spine, 2011-01) Shaffrey, Christopher IItem Open Access The use of allograft and recombinant human bone morphogenetic protein for instrumented atlantoaxial fusions.(World neurosurgery, 2014-12) Hood, Brian; Hamilton, D Kojo; Smith, Justin S; Dididze, Marine; Shaffrey, Christopher; Levi, Allan DBackground
Iliac crest autograft is the historic gold standard for bone grafting, but is associated with a significant patient morbidity. Fusion rates of C1-C2 up to 88.9% using allograft and 96.7% using autologous iliac crest bone graft can be achieved when combined with rigid screw fixation. We sought to determine our fusion rate when combining allograft with recombinant human bone morphogenetic protein-2 (rh-BMP2) and rigid screw fixation.Methods
We reviewed our experience using allograft, bone morphogenetic protein (rh-BMP2) and screw fixation of C1-C2 in 52 patients and examined indications, surgical technique, fusion rates, and complications. In 28 patients, corticocancellous allograft pieces were laid along decorticated bone after a C2 neurectomy was performed. In 24 patients, unicortical iliac crest allograft was precision-cut to fit between the C1 lamina and C2 spinous processes.Results
Fifty-two C1-C2 fusions were performed with allograft, rh-BMP2, and rigid screw fixation. There were 25 female and 27 male patients ranging in age from 6 to 92 years (mean, 65.8 years). Operative indications included trauma (56%), degenerative disease (21%), rheumatoid arthritis (15%), congenital anomalies (6%), and synovial cyst (2%). The mean follow-up was 23.9 ± 2.1 months (range, 2-55 months). The mean dose of rh-BMP2 used for all patients was 4.5 mg (range, 2.2-12 mg). In patients who achieved sufficient follow-up, 100% achieved solid fusion: 45/50 Lenke A, 5/50 Lenke B. There were no known complications attributable to the use of rh-BMP2.Conclusions
The use of small doses of rh-BMP2 added to allograft in addition to rigid screw fixation is a safe and highly effective means of promoting a solid fusion of the atlantoaxial complex and spares the patient the morbidity of iliac crest harvest.