The cervical spine in the skeletal dysplasias and associated disorders

The cervical spine is an especially important area, not only for the diagnosis of the skeletal dysplasias, but also for the management of the patient. By the "cervical spine" I refer not only to the vertebral bodies and posterior elements of this region, but also to the neural elements contained within, especially the cervical cord. The spine is supported by a group of ligaments both anteriorly and posteriorly, with special fixation of the odontoid and C2 by a ligament which normally affixes it firmly to C1. Multiple things may go wrong with the development of the cervical spine. There may be abnormal development of the "vertebrae" in this region, ranging from hypoplasia to developmental failure and/or abnormal ossification of the cervical vertebrae; associated or unassociated odontoid hypoplasia; poor ligamental fixation of C2 resulting in C1-2 subluxation; abnormal development of the posterior processes; abnormal ligamental development or laxity with abnormal cervical kyphosis or lordosis; and, in the case of more fragile/brittle bone development (osteoporosis or increased bone density), fractures can lead to cervical spine problems. The skeletal dysplasias that involve cervical spine problems constitute about 35 of the 150 well-described disorders. These include certain families of disorders like the type II collagenopathies, as well as many individual disorders. It is very important for the clinician to be able to pilot patients through the various appropriate imaging modalities - conventional radiographs of the cervical spine; lateral flexion/extension views; CT; MRI - so that proper management and therapy will result.     

Analysis of the IgG autoantibody repertoire in endocrine ophthalmopathy using the MegaBlot technique

The cervical spine is frequently involved in rheumatoid arthritis and yet there exists no consensus on the need to screen for cervical spine subluxations preoperatively. We reviewed retrospectively 77 patients who underwent 132 operations under general or regional anaesthesia over a 44-month period. We found that while the majority of patients had received preoperative X-ray screening for cervical spine instability, a third of the X-ray examinations done had been inadequate. Many anaesthetists did not repeat cervical spine X-rays if there were previously performed views available. We showed that a complete X-ray examination of the cervical spine should include flexion and extension stress views in addition to frontal views of the odontoid and entire cervical spine. Anterior atlantoaxial subluxation was the most common subluxation encountered in our study population. The detection of cervical spine instability was found to significantly affect anaesthetic management, favouring techniques that avoided unprotected manipulations of the neck under anaesthesia.     

Pediatric neurosurgical disease

The most common, primary referrals to a pediatric neurosurgeon's office are the evaluation and management of the child with a large head (to rule out hydrocephalus and other space occupying lesions) a mishappen head (to rule out various forms of craniosynostosis), or some form of congenital spinal abnormality (spinal dysraphism). The authors discuss the pathogenesis and clinical features of these disorders, provide a framework for diagnostic evaluation and referral, and discuss the various treatment options available for each.     

Inflammatory disorders of the cervical spine

The most common inflammatory disorders affecting the cervical spine include adult and juvenile rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and psoriatic arthritis. These disorders are characterized by typical deformities and instabilities of the cervical spine that result from the destruction caused by synovitis in bony and ligamentous structures in the neck. The treatment of these inflammatory lesions differs from the treatment of similar lesions found in the posttraumatic or degenerative spine. This article attempts to outline the epidemiology, clinical manifestations, and natural history of these conditions. Various radiographic parameters for evaluating disease progression have been used over the years, and their usefulness is reviewed in the context of recent studies better defining the radiographic natural history of these lesions. An algorithm for the use of the various imaging methods including magnetic resonance scanning is provided, and recent progress in delineating the proper timing of surgical intervention and the predictors of neurologic recovery is presented. The current surgical procedures available to treat these conditions are discussed with emphasis on distinguishing those cases in which stabilization alone is required from those in which a decompression procedure is also necessary.     

The use of bedside fluoroscopy to evaluate the cervical spine in obtunded trauma patients

BACKGROUND: Recognition of a cervical spine injury is important to prevent further injury and in planning for future care. The management of the patient with a possible cervical spine injury who remains unresponsive is controversial. METHODS: A retrospective evaluation of obtunded trauma patients admitted to the surgical intensive care unit who underwent bedside fluoroscopic cervical spine evaluation. Fluoroscopic findings and all complications were noted. RESULTS: Twenty obtunded patients with possible cervical spine injuries underwent bedside fluoroscopic cervical spine evaluation. All patients had at minimum a normal three-view cervical spine series before fluoroscopy. Thirteen patients (65%) had the fluoroscopic examination completed at the bedside and were cleared. The complete cervical spine could not be evaluated in six patients (30%). One patient (5%) was found to have a C4-5 subluxation in the bedside examination. None of the patients had progression of their neurologic symptoms after cervical spine flexion/extension, and none developed evidence of spinal cord injury after being cleared during their hospital course. Cervical collars remained in place for 5.7+/-1.41 days (range, 1- 26 days). Three patients (15%) were noted to have decubiti under the cervical collar. CONCLUSION: In this small study, the use of bedside fluoroscopy to evaluate the cervical spine appears safe and easy to perform. One unrecognized injury was identified. The technique is usually successful and gives reassurance that a significant cervical spine injury is not present.     

Is cervical spine imaging indicated in gunshot wounds to the cranium?

BACKGROUND, MATERIALS AND METHODS: Because there is no consensus regarding the necessity of imaging the cervical spine of patients who sustain a gunshot wound to the cranium, the cervical spinal radiographs of 53 consecutive patients with gunshot wounds to the cranium admitted to Hermann Hospital, a Level I trauma center, from January of 1993 to January of 1996, were reviewed. RESULTS: The cervical spine radiographs of all 53 patients were negative. CONCLUSIONS: Cervical spine injury is not associated with gunshot wound to the cranium. Therefore, patient management decisions/procedures, including endotracheal intubation, should not be delayed pending cervical spine imaging.     

Adequacy and efficacy of lateral cervical spine radiography in alert, high-risk blunt trauma patient

OBJECTIVE: The purpose of this study was to determine the adequacy and accuracy of lateral cervical spine radiographs in the initial evaluation of alert, high-risk trauma patients evaluated at a Level I trauma center. METHODS: Data were obtained retrospectively through review of trauma service admissions from January 1, 1994, to July 31, 1995. Included were all patients triaged to a trauma response team with age > 15 years, Glasgow Coma Scale score > 13, and blunt mechanism of injury. Lateral cervical spine radiograms were obtained routinely before secondary survey and were reviewed for technical adequacy (all seven cervical vertebrae, C7/T1 interspace). The presence of cervical symptoms (pain, tenderness, neurologic deficits) was recorded. Sensitivity and specificity were calculated for lateral cervical spine radiography and cervical symptoms in predicting the presence of cervical spine injury. Bayesian analysis, which allows for the current probability of occurrence to be factored by previously reported probabilities of occurrence, was used to determine the negative predictive probability of lateral cervical spine radiography and absence of cervical symptoms to predict the absence of injury to the cervical spine. RESULTS: Three hundred fifty-three patients received lateral cervical spine radiograms, of which 223 (63%) were determined to be adequate for interpretation. Cervical symptoms were present in 77 patients (20%). Only 32 (42%) of this group's lateral cervical spine radiograms were adequate. Nine patients (2.4%) had acutely fractured cervical vertebrae or ligamentous disruption. Lateral cervical spine radiography showed the injury in only six of these patients. The sensitivity, specificity, and negative predictive probability for lateral cervical spine radiography were 67, 58, and 1.4%, respectively, and for absence of cervical symptoms, 89, 81, and 0.32%, respectively. CONCLUSION: The higher accuracy and lower negative predictive probability make the absence of cervical symptoms in the alert, high-risk, blunt trauma patient a better screening test than lateral cervical spine radiography. We suggest that lateral cervical spine radiography is not needed in the initial evaluation of alert patients who have sustained blunt trauma.     

Labor-induced bladder injuries: historical observations]

Eleven cervical intervertebral space calcifications were studied in ten children (5 boys, 5 girls), with mean age of 9.4 years. The aetiology, symptoms, roentgenographic clinic features were analyzied. All ten patients showed evidence of calcification of the cervical intervertebral disc. One had calcification in two disc spaces of the cervical spine and associated with subluxation of C1,2. Two patients had calcification protruded into the spinal canal without symptoms of spinal cord compression. One had symptom of nerve root irritation. Eight of ten patients had symptoms which disappeared in two weeks after treatment. Eight patients had been followed over one year. The calcification disappeared from 2 to 8 months. The diagnostic criteria for the syndrome of this study are: (1) pediatric age group only; (2) local or referred pain; (3) limited cervical spine motiion; (4) evidence of inflammation; (5) visible calcification of the cervercal intervertebral disc on roentgenogram; (6) self-limited course; (7) good result after conservative treatment and good prognosis.     

Psychopathology in children and adolescents with developmental disorders

Children and adolescents with developmental disorders suffer from a wide range of psychopathology. However, there are no published studies examining this subject exclusively in this population using recent diagnostic criteria. The primary purpose of this paper is to report on the diagnosis encountered in a clinical setting using DSM-III-R. The medical records of all individuals assessed in a specialized program during a 1-year period were reviewed looking at their demographic features, diagnoses, and target behaviors. Our sample consisted of 233 subjects and contained significantly more boys than girls. The most common psychiatric diagnoses were oppositional defiant disorder and attention deficit hyperactivity disorder. Pica, organic mental disorder NOS, and Autistic Disorder were more often encountered in individuals with low intellectual functioning. Depressive disorders, posttraumatic stress disorder, and developmental speech/language disorders were diagnosed more in high functioning subjects. The most common symptom was impulsivity. This retrospective study highlights the need for more rigorous examination of current diagnostic concepts and criteria in children and adolescents with developmental disorders. Prospective studies should be conducted with standardized instruments in clinics and community samples to provide more information on psychiatric disorders in this population.     

Work capacity of the upper limbs after mastectomy

A 59-year-old man presented with neck pain and limb numbness. He also had bilateral symmetrical joint deformities of his hands and wrists. Cervical spine radiographs showed C 1/2 instability and features of rheumatoid arthritis. Magnetic resonance imaging demonstrated erosion ofthe odontoid peg by pannus. C 1/2 surgical fusion was performed. The role of imaging in cervical spine involvement by rheumatoid arthritis is reviewed.     

The effect of triple pelvic osteotomy on the articular contact area of the hip joint in dysplastic dogs: an in vitro experimental study

This study compares the frequency of signs and symptoms from the cervical spine in 24 patients diagnosed with Meniere's disease and 24 control subjects from a population sample. From a previous controlled comparative study concerning signs and symptoms of craniomandibular disorders, 24 patients diagnosed with Meniere's disease (10 males and 14 females) and their 24 matched control subjects participated in this investigation on the state of the cervical spine. Symptoms of cervical spine disorders, such as head and neck/shoulder pain, were all significantly more frequent in the patient group than in the control group. Most of the patients (75%) reported a strong association between head neck movements in the atlanto-occipital and atlanto-axial joints and triggered attacks of vertigo. Also, 29% of the patients could influence their tinnitus by mandibular movements. Signs of cervical spine disorders, such as limitations in side-bending and rotation movements, were significantly more frequent in the patient group than in the control group. Tenderness to palpation of the transverse processes of the atlas and the axis, the upper and middle trapezius, and the levator scapulae muscle were also significantly more frequent in the patient group. The study shows a much higher prevalence of signs and symptoms of cervical spine disorders in patients diagnosed with Meniere's disease compared with control subjects from the general population.     

Radiographic evaluation of cervical spine trauma. Procedures to avoid catastrophe

A cervical spine series that includes three views (ie, lateral, open-mouth odontoid, and anteroposterior) is usually adequate to exclude unstable injuries that have the potential for producing spinal cord injury. The films should be of the highest quality and need to be carefully and systematically viewed. Knowledge of cervical spine anatomy and of common types of injuries (including their mechanisms) is essential for accurate interpretation. Conventional tomography, computed tomography, and flexion and extension lateral views may be helpful when findings on the three-view series are equivocal. In patients with neurologic deficits, further radiographic evaluation is also warranted.     

Surgical treatment of the rheumatic neck

This paper reviews rheumatoid cervical spine disease with emphasis on surgical management. The rheumatoid process in the cervical spine is outlined, and the different clinical syndromes are explained according to the underlying pathology. Guidelines for the management of patients with this disease are suggested, and the indications for surgery are discussed. The different surgical approaches and techniques are briefly summarised.     

Use of cervicothoracic junction pedicle screws for reconstruction of complex cervical spine pathology

STUDY DESIGN: A retrospective review of 21 patients in which cervical pedicle screw fixation was used at C7 with or without upper thoracic pedicle screw fixation. OBJECTIVE: To evaluate the use of pedicle screw placement in the lower cervical spine. SUMMARY OF BACKGROUND DATA: The use of posterior cervical spine fixation, including lateral mass fixation, has become increasingly popular in recent years. However, lateral mass fixation at C7 is often hindered by lack of substantial high quality bone. The end level of long cervical spine constructs is frequently C7 or T1. Dissatisfaction with lateral mass fixation at C7 and T1 led the authors to use lower cervical pedicle screw fixation for several cervical spine disorders. METHODS: Twenty-one patients who had undergone cervical pedicle screw fixation at C7 were reviewed retrospectively. There were 12 males and 9 females, with an average age of 52 years. All pedicle screws were placed, after direct palpation of the pedicle, with a right angle nerve hook after laminoforaminotomy at C7. RESULTS: There were no neurologic complications related to pedicle screw placement, and no patient was symptomatically worse after the operation. Six patients with root pathology improved. Of 14 patients with cervical myelopathy, 12 improved at least one Nurick grade, and 2 had no improvement. There were no failures of fixation or complications related to pedicle fixation at a minimum of 1 year follow-up. CONCLUSION: Pedicle screws in C7 placed with laminoforaminotomy and palpation technique appears to be safe and efficacious. Excellent fixation can be achieved.     

Ovarian masses in the pediatric patient

Ovarian masses in the pediatric patient are uncommon. Children with ovarian tumors, however, pose diagnostic and therapeutic challenges because their presentation can mimic other more common intraabdominal disorders and their tumor histology varies widely. The refinement of surgical techniques and the advent of more effective chemotherapy in the past 25 years has increased overall survival rates from approximately 20% to 70%, thus improving the outcome for girls with malignant tumors. This article summarizes the current evaluation and management of ovarian masses in childhood and reviews pertinent pathology.     

Pathologic features of spinal disorders in patients treated with long-term hemodialysis

STUDY DESIGN: Pathologic features of hemodialysis-associated spinal disorders were evaluated using preoperative radiographic images and histologic findings of the spinal lesions resected during surgery. OBJECTIVES: To investigate the pathology of hemodialysis-related spinal disorders and to determine the role of amyloidosis in the establishment of severe destruction of the spine. SUMMARY OF BACKGROUND DATA: The pathologic events leading to hemodialysis-associated spinal disorders are poorly understood. The distribution of amyloid deposits in the spine also has not been clarified. METHODS: Twenty patients with hemodialysis-associated spinal disorders were investigated regarding pathologic features of neural compression and spinal destruction. Preoperative radiographic images such as plain radiography, tomography, computed tomography, magnetic resonance imaging, and scintigraphy were assessed for the existence of an intracanal mass, hypertrophy of the ligamentum flavum, and destructive changes of the spinal components. Histologic examination also was conducted by light microscopy and scanning electron microscopy to determine the distribution pattern of amyloid deposits in the spinal components. RESULTS: Six patients with no destructive changes in the spine showed spinal canal stenosis. In the cervical spine, a main factor associated with spinal canal stenosis was the presence of intracanal amyloid deposits in three patients. In the lumbar spine, a main factor associated with spinal canal stenosis was hypertrophied ligamentum flavum in three patients. Destructive changes of the facet joints, intervertebral disc, and vertebral body were seen in the other 14 patients. Amyloid deposits were densely distributed at the enthesis of capsular fibers to the bone and in anular tears in the intervertebral discs. Vertebral end plates were destroyed by penetration of amyloid granulation into the vertebral body. Osteoclast activity in the destroyed vertebral bodies was enhanced, with no evidence of new bone formation. CONCLUSIONS: Amyloid deposits played an important role in the progression of spinal destruction and severe instability.     

The significance of hardware failure in anterior cervical plate fixation. Patients with 2- to 7-year follow-up

STUDY DESIGN: In this retrospective study, the incidence of anterior cervical hardware failure was reviewed in 109 patients with degenerative disorders treated by one surgeon. OBJECTIVES: To evaluate the risk of injury caused by hardware failure in anterior cervical spine reconstruction. SUMMARY OF BACKGROUND DATA: Anterior plating is used for stabilization after cervical spine trauma and other conditions of instability. There has been a concern among surgeons about the risks involved when anterior cervical plating fails (fracturing or loosening of the construct). METHODS: The series included placement of 70 nonconstrained plates and 39 constrained plates. The average length of follow-up was 43 months. Hardware failure was defined as any broken or loosened screw or plate, regardless of clinical significance. RESULTS: There were 32 Orozco (Synthes, Inc., Paoli, PA) failures, 5 cervical spine locking plate failures, and 2 Orion (Sofamor Danek USA, Inc., Memphis, TN) failures. There were no injuries to tracheoesophageal or neurovascular structures as a result of hardware implantation or failure. CONCLUSIONS: The incidence of prominent hardware that endangers tracheoesophageal structures is minimal. In most cases, careful and long-term follow-up can ensure that failed hardware has not progressed and can confirm that late failure has not occurred. Hardware failure should increase the surgeon's suspicion of a nonunion, but immediate removal of the failed hardware is rarely necessary. If reoperation is necessary for nonunion repair, kyphosis correction, or other secondary procedures, the hardware can be removed at that time. Constrained systems (cervical spine locking plate, Orion) had significantly (P2 = 7.65, P < 0.01) fewer failures than the nonconstrained Orozco system.     

Surgical evaluation and management of refractory constipation in older children

Chronic constipation is a common childhood problem that accounts for 3% to 5% of pediatric visits and 10% to 25% of referrals to pediatric gastroenterologists. The etiology of constipation can be elusive, and extensive investigation often fails to identify a specific cause. The authors conducted a 5-year retrospective review of the patients referred for deep transanal rectal biopsy to determine the usefulness of this procedure in the evaluation and subsequent surgical management of refractory constipation. Specimens obtained by transanal rectal biopsy established a diagnosis for 30 of the 70 patients, and 17 of these 30 had subsequent procedures in the treatment of their constipation. The authors conclude that transanal rectal biopsy identifies a significant number of patients with previously unidentified neuroenteric disorders who may benefit from additional surgery in the treatment of constipation refractory to medical management.     

Cervical spine fractures in the elderly

BACKGROUND: Cervical spine fractures in the elderly are relatively common. The management of such injuries may be complicated by underlying medical debility and osteopenia as well as reduced tolerance to halo immobilization. METHODS: Over a 1-year period, 43 cervical spine fractures were treated at our institution. Ten (23%) were in persons 70 years of age or older. This retrospective analysis describe the clinical features, treatment, and outcome of these 10 elderly patients. All fractures in this patient population involved the atlantoaxial complex, including five combination C1-C2 fractures. Six patients were treated with early halo immobilization and three were initially managed with a rigid cervical collar. Three patients required posterior cervical fusion. RESULTS: Of the six patients undergoing halo immobilization, five progressed to osseous union. Three patients were immobilized in a Philadelphia collar resulting in one osseous union, one nonunion, and one death. Three patients underwent posterior cervical fusion with subsequent osseous union in all three. CONCLUSIONS: Although external immobilization with a halo device is our treatment of choice for most C1 and C2 fractures in elderly patients, a Philadelphia collar is useful in select cases when halo immobilization or early surgical fusion is contraindicated. Posterior cervical fusion can be safely and effectively performed in elderly patients and should be strongly considered for initial therapy in the elderly with fracture types unlikely to progress to osseous union with external immobilization alone.     

Relation of intelligence to childhood depression in children referred to an educational diagnostic center

Basing on literature and 230 own functional examinations of the cervical spine, the author reports on a roentgenological method which satisfies practical requirements. In patients with degenerative and post-traumatic changes, the extent and localisation of the disorders of function and structure of the vertebrae can be determined by this method, enabling discovery of functional disorders in a large number of patients with clinical cervical spine syndrome. X-ray functional testing is shown to be a necessary complement to conventional x-ray diagnosis and clinical examination.