The craniovertebral junction (CVJ) has attracted more attention in pediatric medicine in recent years due to the progress in surgical technologies allowing a direct approach to the CVJ in children. The CVJ is the site of numerous pathologies, most originating in bone anomalies resulting from abnormal CVJ development. Before discussing the surgical approaches to CVJ, three points should be borne in mind: first, that developmental anatomy demonstrates age-dependent mechanisms and the pathophysiology of pediatric CVJ anomalies; second, that CT-based dynamic simulations have improved our knowledge of functional anatomy, enabling us to locate CVJ lesions with greater certainty; and third, understanding the complex structure of the pediatric CVJ also clarifies the surgical anatomy. This review begins with a description of the embryonic developmental process of the CVJ, comprising ossification and resegmentation of the somite. From the clinical perspective, pediatric CVJ lesions can be divided into three categories: developmental bony anomalies with or without instability, stenotic CVJ lesions, and others. After discussing surgery and management based on this classification, the author describes surgical outcomes on his hands, and finally proceeds to address controversial issues specific for pediatric CVJ surgery. The lessons, which the author has gleaned from his experience in pediatric CVJ surgery, are also presented briefly in this review. Recent technological progress has facilitated pediatric surgery of the CVJ. However, it is important to recognize that we are still far from reliably and consistently obtaining satisfactory results. Further progress in this area awaits contributions of the coming generations of pediatric surgeons.
The spinal canal diameter (SCD) is one of the most studied factors for the assessment of cervical spinal canal stenosis. The inner anteroposterior diameter (IAP), the SCD, and the cross-sectional area (CSA) of the atlas have been used for the evaluation of the size of the atlas in patients with atlas hypoplasia, a rare form of developmental spinal canal stenosis, however, there is little information on their relationship. The aim of this study was to identify the most useful parameter for depicting the size of the atlas. The CSA, the IAP, and the SCD were measured on computed tomography (CT) images at the C1 level of 213 patients and compared in this retrospective study. These three parameters increased with increasing patient height and weight. There was a strong correlation between IAP and SCD (r = 0.853) or CSA (r = 0.822), while correlation between SCD and CSA (r = 0.695) was weaker than between IAP and CSA. Partial correlation analysis showed that IAP was positively correlated with SCD (r = 0.687) and CSA (r = 0.612) when CSA or SCD were controlled. SCD was negatively correlated with CSA when IAP was controlled (r = −0.21). The IAP can serve as the CSA for the evaluation of the size of the atlas ring, while the SCD does not correlate with the CSA. As the patient height and weight affect the size of the atlas, analysis of the spinal canal at the C1 level should take into account physiologic patient data.
The aim of this study was to highlight the walking recovery after surgical management of traumatic burst fractures at the thoracolumbar junction (T10 or T11 or T12 or L1) in paraplegic patients to decide what surgeons should tell their patients to help them develop realistic expectations and potentially improve their outcome. This is a series of adult patients presented with paraplegia from isolated thoracolumbar fracture and underwent surgical intervention from August 2009 to August 2015. Patients with preexisting disability from previous neurologic condition, patients with associated severe head injury or major medical comorbidities or life-threatening injuries were excluded. Neurological status was assessed on admission using the American Spinal Injury Association (ASIA) impairment scale (AIS). The walking ability was assessed 12 months after surgery using the modified Benzel scale. This study included 53 patients with a mean age of 39.4 years (ranging from 18 years to 58 years). Patients presented with AIS grade A are 6, 18 patients with AIS grade B, and 29 patients with AIS grade C. All the patients with L1 fracture and 70.96% of the patients with T12 fracture regained the ability to walk, but unfortunately all the patients with T10 and T11 fractures didn’t regain the walking ability 12 months after surgery. The severity of spinal cord injury and hence the walking recovery were related to the spinal level of fracture. A prospectively controlled study with more patients is needed to reevaluate the walking recovery in paraplegic patients with T10 and T11 fractures.
An electrophysiological study is commonly used to decide a therapeutic strategy for carpal tunnel syndrome (CTS). In this study, the electrophysiological parameter measurement as a prognostic indicator for CTS after wrist splinting was assessed to identify appropriate candidates for wrist splinting for CTS. One hundred and six hands in 78 patients with CTS were treated by wrist splinting, and three electrophysiological parameters; median distal motor latency (DML) of the abductor pollicis brevis (APB) muscle, median distal sensory latency (DSL) of the index finger, and second lumbrical-interossei latency difference (2L-INT LD); were statistically analyzed to compare with clinical results by Kelly’s evaluation respectively. Clinical results were excellent in 15 hands, good in 51 hands, fair in 19 hands, and poor in 21 hands. The recordable rate in 2L-INT LD (99.1%) was higher than DML (96.2%) and DSL (79.2%). Patients with DML less than 6.5 ms, DSL less than 5.7 ms, or 2L-INT LD less than 2.5 ms had significantly excellent or good clinical results. The odds ratios of the DML, DSL, and the 2L-INT LD were 7.93, 8.81, and 12.8, respectively. This study demonstrated that CTS patients with DML less than 6.5 ms, DSL less than 5.7 ms, or 2L-INT less than 2.5 ms were good candidates for wrist splinting. Especially, the 2L-INT LD could be the most reliable indicator to predict clinical results for all grades of CTS. This electrophysiological information could be useful in further improvement of accurate diagnosis of CTS, and may help in the assessment of appropriate treatment for CTS with wrist splinting.
We analyzed clinical usefulness of the high resolution imaging system in a hybrid operation room (OR) for posterior lumbar interbody fusion. A total of 17 patients with lumbar spondylolisthesis between February 2014 and August 2016 were included. Multi-axis imaging system in a hybrid OR was used in 12 patients (hybrid OR group); the conventional C-arm fluoroscopy, in 5 patients (C-arm group). The time to confirm the first percutaneous pedicle screw (PPS) angle (hybrid OR, 80 vs C-arm, 249 s; P = 0.0026) and the second to the last PPS angle (77 vs 90 s; P = 0.040) were shorter in the hybrid OR group. Placement accuracy was higher in the hybrid OR group (88.0 vs 59.1%; P = 0.010). Irradiation dose was significantly lower in the C-arm group (462 vs 102 mGy; P = 0.0013). This study suggested that the accuracy of PPS placement and time to confirm the PPS angle are the advantages in a hybrid OR.
Percutaneous balloon kyphoplasty (PBKP) is generally performed under two-dimensional (2D) radiography guidance (lateral- and anteroposterior (A-P) views) using C-arm fluoroscopy. However, 2D images taken by single-plane or bi-plane fluoroscopy cannot provide information regarding axial views, particularly the Z axis. Lack of information regarding the Z axis prevents the creation of three-dimensional (3D) images. Currently, there has been a progress in interventional X-ray systems, and they are capable of providing 3D radiographic images using a rotational angiography mode which is used to create 3D angiographies. In this report, we described the usefulness of 3D radiography guidance. Patients treated by PBKP was designed to evaluate the efficacy of 3D radiography guidance. These patients experienced osteoporotic vertebral fractures with severe pain. We retrospectively analyzed patients who underwent PBKP from February to December 2016. All patients had a single-level vertebral fracture and underwent surgery by 2D or 3D radiography guidance. We performed 16 patients in 3D radiography guidance, and 10 patients in traditional 2D radiography guidance. This 3D radiography guided PBKP increase the amount of the polymethyl methacrylate (PMMA) injection compared with ordinary 2D method. As a result, postoperative vertebral height and alignment were significantly improved. Both groups have no complication. To confirm the final results and make PBKP more effective, 3D radiography guidance is feasible and safe for balloon kyphoplasty.
Stereoelectroencephalography (SEEG) is an invasive surgical procedure used to identify epileptogenic zones. The combination of both subdural grids and depth electrodes (DEs) is currently used for invasive intracranial monitoring in many epilepsy centers. To perform DE implantation, some centers use frame-based stereotactic techniques and others use stereotactic robotic techniques. However, not all epilepsy centers have access to these tools. We hypothesized that DE implantation using a neuronavigation system can be utilized for subsequent epilepsy surgery. Between April 2016 and April 2017, we performed invasive monitoring for 26 patients. Among these, 17 patients (8 females, 9 males; mean age, 21.2 years; range, 3–51 years) underwent DE implantation. We divided patients into three groups: Group 1 (7 patients), a free-hand implantation group; Group 2 (7 patients), a frameless stereotactic implantation group; and Group 3 (3 patients), a computed tomography (CT)-guided auto image registration system with the stereotactic implantation group. Group 3 showed the closest distance from planned target to DE tip, followed by Group 2. Fourteen of the 17 patients underwent subsequent epilepsy surgery referring to the results of DE studies. DE placement using a neuronavigation system without stereotactic robotic equipment or frame-based stereotactic techniques can be utilized for subsequent epilepsy surgery.