Transoral digital reduction of complete anterior odontoid dislocation followed by fiducial-based navigated transcondylar screw fixation: illustrative case

BACKGROUND Posterior atlantoaxial dislocations (i.e., complete anterior odontoid dislocation) without C1 arch fractures are a rare hyperextension injury most often found in high-velocity trauma patients. Treatment options include either closed or open reduction and optional spinal fusion to address atlantoaxial instability due to ligamentous injury. OBSERVATIONS A 60-year-old male was struck while on his bicycle by a truck and sustained an odontoid dislocation without C1 arch fracture. Imaging findings additionally delineated a high suspicion for craniocervical instability. The patient had neurological issues due to both a head injury and ischemia secondary to an injured vertebral artery. He was stabilized and transferred to our facility for definitive neurosurgical care. LESSONS The patient underwent a successful transoral digital closed reduction and posterior occipital spinal fusion via a fiducial-based transcondylar, C1 lateral mass, C2 pedicle, and C3 lateral mass construct. This unique reduction technique has not been recorded in the literature before and avoided potential complications of overdistraction and the need for odontoidectomy. Furthermore, the use of bone fiducials for navigated screw fixation at the craniocervical junction is a novel technique and recommended particularly for placement of technically demanding transcondylar screws and C2 pedicle screws where pars anatomy is potentially unfavorable.

Effectiveness of Percutaneous Pedicle Screw Fixation for Traumatic Thoracolumbar Spine Fracture

Introduction: Surgical treatment of thoracolumbar fracture without neurological damage has resulted in better clinical and radiological outcome than conservative treatment. Traditional open approach is associated with extensive paravertebral muscle damage and postoperative morbidity so percutaneous pedicle screw fixation is highly valuable alternatives. Aims: to evaluate the efficacy and outcome of percutaneous pedicle screw fixation in the treatment of traumatic thoracolumbar fracture without neurological deficit. Methods: This study was conducted in Nepalgunj Medical College, Nepalgunj in a time span of one year; total of 40 patients were included and treated with percutaneous pedicle screw fixation and followed up for 6months. They were evaluated clinically and radiologically. Results: 40 patients with thoracolumbar fractures were managed with percutaneous pedicle screw fixation with a mean operative time of 77.30 min and intraoperative blood loss was 88.38ml. There was significant improvement in cobb’s angle (mean difference 13.92 degree), vertebral body height loss (mean difference 37.7%) and visual analogue scale (mean difference 3.55) postoperatively. These improvements remained statically significant at 6months follow up. Conclusion: Percutaneous pedicle screw fixation is safe, valid and effective treatment of thoracolumbar fracture without neurological deficit.

Medial Pedicle Pivot Point Using Preoperative Computed Tomography Morphometric Measurements for Cervical Pedicle Screw Insertion: A Novel Technique and Case Series

This study describes a new and safe freehand cervical pedicle screw insertion technique using preoperative computed tomography (CT) morphometric measurements as a guide and a medial pedicle pivot point (MPPP) during the procedure. This study included 271 pedicles at 216 cervical spine levels (mean: 4.75 pedicles per patient). A pedicle diameter (PD) ≥ 3.5 mm was the cut-off for pedicle screw fixation. The presence and grade of perforation were detected using postoperative CT scans, where perforations were graded as follows: 0, no perforation; 1, perforation < 0.875 mm; 2, perforation 0.875–1.75 mm; and 3, perforation > 1.75 mm. The surgical technique involved the use of an MPPP, which was the point at which the lines representing the depth of the lateral mass and total length of the pedicle intersected, deep in the lateral mass. The overall success rate was 96.3% (261/271, Grade 0 or 1 perforations). In total, 54 perforations occurred, among which 44 (81.5%) were Grade 1 and 10 (18.5%) were Grade 2. The most common perforation direction was medial (39/54, 72.2%). The freehand technique for cervical pedicle screw fixation using the MPPP may allow for a safe and accurate procedure in patients with a PD ≥3.5 mm.

Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries

Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.