**Part 3**

**Surgical Approaches** 

96 Spine Surgery

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Schwab, F., Patel, A., Ungar, B., Farcy, J. P., & Lafage, V. (2010). "Adult spinal deformity

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Uribe, J. S., Arredondo, N., Dakwar, E., & Vale, F. L. (2010). "Defining the safe working

Uribe, J. S., Vale, F. L., & Dakwar, E. (2010). "Electromyographic monitoring and its

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Wang, M. Y., Anderson, D. G., Poelstra, K. A., & Ludwig, S. C. (2008). "Minimally invasive

Wang, M. Y., & Mummaneni, P. V. (2010). "Minimally invasive surgery for thoracolumbar

Yang, J. J., Yu, C. H., Chang, B. S., Yeom, J. S., Lee, J. H., & Lee, C. K. (2011). "Subsidence and

Youssef, J. A., McAfee, P. C., Patty, C. A., Raley, E., DeBauche, S., Shucosky, E., & Chotikul,

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anatomical implications in minimally invasive spine surgery." Spine (Phila Pa 1976)

the use of rhBMP-2 in PEEK cages for interbody spinal fusions." J Spinal Disord

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L. (2010). "Minimally invasive surgery: lateral approach interbody fusion: results

**7** 

Aydn Nadir

*Türkiye* 

*School of Medicine Sivas-*

**Anterior Approaches to Thoracic** 

*Department of Thoracic Surgery, Cumhuriyet University,* 

Anterior surgical approaches have been used for lower cervical, thoracic, and upper lumbar vertebrae since the beginning of the second half of the 20th century. Hodgson et al. were the first surgeons to perform spinal fusion with anterior approach for the treatment of a paraplegic patient with Pott's disease in 1956. Cauchoix and Binet reported access to vertebral corpuses from C7 to T4 using a median sternotomy in 1957. Moreover, in 1969, Perot and Munro described trans-thoracic removal of a thoracic disc causing compression on the spinal cord. Similarly Dwyer et al. described the use of anterior approach for the surgical treatment of scoliosis (1969) and Harrington anteriorly stabilized vertebral fractures due to tumors with methyl methacrylate. First investigators to describe anterior approach

Surgical interventions for vertebral fractures include anterior, posterior and combined approaches, with the anterior approach providing a very good exposure. Posterior approach poses some technical inadequacy, with recurrence rates higher than the anterior approach. In fractures causing angle deformity, anterior approach has been proposed as the appropriate method. In fragmented fractures of the thoracolumbar spine, corpectomy with anterior approach and grafting is an effective treatment modality (2,5-8). Anterior approach not only provides a very good exposure to allow for decompression of the spinal canal, but also it may help to improve the neurological status in patients with neurological deficits. However, morbidity, which is mostly respiratory (atelectasis, respiratory failure, etc.), is

Anterior approach was first reported by Dwyer and Zielke for scoliosis surgery, with a correction angle between 28,3º-66,6º. The average percentage of patients in whom correction can be achieved is 57.5%. Bilateral approach can be used or posterior approach can be combined with unilateral approach (1,3,9,10). In patients undergoing posterior surgery alone, the likelihood of requiring a second operation is high (11). In cases with scoliosis, the procedure should be performed at the side with widened intercostal spaces and convex deformity. When the thoracotomy is performed at the point of maximum deformity, better

**1. Introduction** 

with VATS were Mack et al. (1993) (1-4).

more frequent with anterior approach (2).

exposure is provided.

**and Thoraco-Lumbar Spine** 

### **Anterior Approaches to Thoracic and Thoraco-Lumbar Spine**

Aydn Nadir

*Department of Thoracic Surgery, Cumhuriyet University, School of Medicine Sivas-Türkiye* 

#### **1. Introduction**

Anterior surgical approaches have been used for lower cervical, thoracic, and upper lumbar vertebrae since the beginning of the second half of the 20th century. Hodgson et al. were the first surgeons to perform spinal fusion with anterior approach for the treatment of a paraplegic patient with Pott's disease in 1956. Cauchoix and Binet reported access to vertebral corpuses from C7 to T4 using a median sternotomy in 1957. Moreover, in 1969, Perot and Munro described trans-thoracic removal of a thoracic disc causing compression on the spinal cord. Similarly Dwyer et al. described the use of anterior approach for the surgical treatment of scoliosis (1969) and Harrington anteriorly stabilized vertebral fractures due to tumors with methyl methacrylate. First investigators to describe anterior approach with VATS were Mack et al. (1993) (1-4).

Surgical interventions for vertebral fractures include anterior, posterior and combined approaches, with the anterior approach providing a very good exposure. Posterior approach poses some technical inadequacy, with recurrence rates higher than the anterior approach. In fractures causing angle deformity, anterior approach has been proposed as the appropriate method. In fragmented fractures of the thoracolumbar spine, corpectomy with anterior approach and grafting is an effective treatment modality (2,5-8). Anterior approach not only provides a very good exposure to allow for decompression of the spinal canal, but also it may help to improve the neurological status in patients with neurological deficits. However, morbidity, which is mostly respiratory (atelectasis, respiratory failure, etc.), is more frequent with anterior approach (2).

Anterior approach was first reported by Dwyer and Zielke for scoliosis surgery, with a correction angle between 28,3º-66,6º. The average percentage of patients in whom correction can be achieved is 57.5%. Bilateral approach can be used or posterior approach can be combined with unilateral approach (1,3,9,10). In patients undergoing posterior surgery alone, the likelihood of requiring a second operation is high (11). In cases with scoliosis, the procedure should be performed at the side with widened intercostal spaces and convex deformity. When the thoracotomy is performed at the point of maximum deformity, better exposure is provided.

Anterior Approaches to Thoracic and Thoraco-Lumbar Spine 101

single-lumen may also be used. In our unit, tubes with a single-lumen are preferred. Retraction of the lung on the same surgical side without collapsing throughout the procedure will provide adequate exposure. This approach allows efficient use of time, and avoids some untoward occurrences such as malpositioning due to a double-lumen tube,

Appropriate positioning of the patient simplifies the surgery, shortens duration of surgery, and reduces the likelihood of morbidity. In cervical procedures the patient is brought to supine position, arms are adducted, and the head is slightly rotated toward the opposite side of the surgery. In case of open surgery between T2-12 or VATS, a standard lateral decubitus position is preferred. In our unit, we also prefer to use lateral decubitus position for anterior surgery in lower thoracic and upper lumber vertebrae during thoracoabdominal procedures. In this case, a backward angulation between 10º-15º toward the operation table

Depending on the position of the lesion, four different anatomical levels may be defined as follows: C7-T2, T2-T6, T6-T12, T12-L3 or L4. For lesions between C7 and T2, the best approach consists of manubrium resection or partial sternotomy in addition to cervical resection, while right thoracotomy is appropriate for T2-T6 lesions. We prefer left thoracotomy starting from T3 level for traumatic vertebral fractures. Due to the close adjacency of the descending aorta, aortic mobilization may be required in anterior approaches at T3 and T4. In the upper thoracic levels between T2 and T6, thoracotomy should be performed at the same level with the lesion. Between T6-T12, procedures are performed via a left thoracotomy. At this level, thoracotomy at one or two level above the lesion may provide better exposure due to downward inclination of the ribs. For lesions between T12-L3, 4 a left thoracoabdominal approach should be undertaken. Removal of the 11th or 12th rib provides wider exposure. Particularly, removal of the 11th or 12th rib provides

Over a 7-year period (2004-2011), 67 patients (17 females, 50 males) were operated on using an anterior approach at our institution (2). The most indication for surgery was trauma fracture in 50 (75%) patients. Distribution of ethiologies of the patients according to access level was detailed in **Table 2**. Mean operation time was about 2 to 3,5 hrs, and estimated blood loss was approximately 1000 mL. Among the 67 patients operated via the anterior approach, we observed four postoperative complications. One patient had empyema postoperatively which was treated with tube thoracotostomy and irrigation. Another patient with vertebral tumor developed hemorrhagic drainage (1100 cc/24 h) during the early postoperative period which resolved with conservative treatment. In two patients, wound

Remainder of this chapter, the procedures will be described detailed with operative pictures

Anterior approach at cervicothoracic vertebrae poses some difficulties associated with the local anatomy and requires a good deal of anatomical knowledge of the bony, ligamentous, muscular, and neurovascular structures of the upper thoracic access routes. Cervical resection, partial resection of the manubrium and clavicle and advances in the surgical

infection developed which were treated with debridement and suturation.

and drawings especially the "thoraco-lumbar" procedure.

**1.3 Anterior approach to the cervicothoracic spine** 

instrumentation provide adequate exposure.

inadequate aspiration, and intolerance to single-lung ventilation.

provides better exposure.

easy extrapleural access to L1-L4 (2,14,15).

#### **1.1 Indications**

The primary indications for anterior approach in vertebral surgery include the conditions associated with the destruction of one or more vertebral corpuses and intervertebral discs, vertebral fractures, and deformities (**Table 1**). Whilst patients with deformities constitute the main patient population in childhood and adolescence, degenerative diseases, malignancies, and infections are the prevailing indications among adults. Recently, traumatic fractures with or without neurologic deficits also represent another very important indication for the anterior approach in spinal surgery. Pain relief, stabilization of the deformity, cosmetic improvement, drainage of spinal infections, and reduction/prevention of neurological deficits are primary objectives of such procedures (1,2,12,13).


Table 1. Indications for anterior approach in spine surgery.

A multidisciplinary team effort involving thoracic surgeons, neurosurgeons, and orthopedic surgeons increases the likelihood of successful outcome with regard to operative results and improves the quality of life postoperatively. Inclusion of a thoracic surgeon in the team facilitates preoperative physiological assessments, determination of the best access route, and postoperative wound care (1,2).

#### **1.2 Preoperative assessments**

The preoperative assessment algorithm is the same as that is used for thoracic surgery. Pulmonary function tests and blood gas analyses are useful both for preoperative and postoperative care and evaluation of the cardiac status may help prevent postoperative complications (1,3,14,15).

Endotracheal general anesthesia with a single-lumen endotracheal tube is adequate for cervical (C7-T2) interventions, while endotracheal tubes with double-lumen should be preferred for thoracic and thoracolumbar procedures. Standard endotracheal tubes with a

The primary indications for anterior approach in vertebral surgery include the conditions associated with the destruction of one or more vertebral corpuses and intervertebral discs, vertebral fractures, and deformities (**Table 1**). Whilst patients with deformities constitute the main patient population in childhood and adolescence, degenerative diseases, malignancies, and infections are the prevailing indications among adults. Recently, traumatic fractures with or without neurologic deficits also represent another very important indication for the anterior approach in spinal surgery. Pain relief, stabilization of the deformity, cosmetic improvement, drainage of spinal infections, and reduction/prevention of neurological

A multidisciplinary team effort involving thoracic surgeons, neurosurgeons, and orthopedic surgeons increases the likelihood of successful outcome with regard to operative results and improves the quality of life postoperatively. Inclusion of a thoracic surgeon in the team facilitates preoperative physiological assessments, determination of the best access route,

The preoperative assessment algorithm is the same as that is used for thoracic surgery. Pulmonary function tests and blood gas analyses are useful both for preoperative and postoperative care and evaluation of the cardiac status may help prevent postoperative

Endotracheal general anesthesia with a single-lumen endotracheal tube is adequate for cervical (C7-T2) interventions, while endotracheal tubes with double-lumen should be preferred for thoracic and thoracolumbar procedures. Standard endotracheal tubes with a

deficits are primary objectives of such procedures (1,2,12,13).

Infection Tuberculosis Pyogenic infections Parasitic infestation

Malignancy

Trauma

 Scoliosis Kyphosis Lordosis

and postoperative wound care (1,2).

**1.2 Preoperative assessments** 

complications (1,3,14,15).

Metastatic disease

 Fracture-dislocation Compresion fracture Spinal deformities

Table 1. Indications for anterior approach in spine surgery.

 Involvement by adjacent tumors Primary tumor of vertebral body Degeneratif disc disease (herniation)

**1.1 Indications** 

single-lumen may also be used. In our unit, tubes with a single-lumen are preferred. Retraction of the lung on the same surgical side without collapsing throughout the procedure will provide adequate exposure. This approach allows efficient use of time, and avoids some untoward occurrences such as malpositioning due to a double-lumen tube, inadequate aspiration, and intolerance to single-lung ventilation.

Appropriate positioning of the patient simplifies the surgery, shortens duration of surgery, and reduces the likelihood of morbidity. In cervical procedures the patient is brought to supine position, arms are adducted, and the head is slightly rotated toward the opposite side of the surgery. In case of open surgery between T2-12 or VATS, a standard lateral decubitus position is preferred. In our unit, we also prefer to use lateral decubitus position for anterior surgery in lower thoracic and upper lumber vertebrae during thoracoabdominal procedures. In this case, a backward angulation between 10º-15º toward the operation table provides better exposure.

Depending on the position of the lesion, four different anatomical levels may be defined as follows: C7-T2, T2-T6, T6-T12, T12-L3 or L4. For lesions between C7 and T2, the best approach consists of manubrium resection or partial sternotomy in addition to cervical resection, while right thoracotomy is appropriate for T2-T6 lesions. We prefer left thoracotomy starting from T3 level for traumatic vertebral fractures. Due to the close adjacency of the descending aorta, aortic mobilization may be required in anterior approaches at T3 and T4. In the upper thoracic levels between T2 and T6, thoracotomy should be performed at the same level with the lesion. Between T6-T12, procedures are performed via a left thoracotomy. At this level, thoracotomy at one or two level above the lesion may provide better exposure due to downward inclination of the ribs. For lesions between T12-L3, 4 a left thoracoabdominal approach should be undertaken. Removal of the 11th or 12th rib provides wider exposure. Particularly, removal of the 11th or 12th rib provides easy extrapleural access to L1-L4 (2,14,15).

Over a 7-year period (2004-2011), 67 patients (17 females, 50 males) were operated on using an anterior approach at our institution (2). The most indication for surgery was trauma fracture in 50 (75%) patients. Distribution of ethiologies of the patients according to access level was detailed in **Table 2**. Mean operation time was about 2 to 3,5 hrs, and estimated blood loss was approximately 1000 mL. Among the 67 patients operated via the anterior approach, we observed four postoperative complications. One patient had empyema postoperatively which was treated with tube thoracotostomy and irrigation. Another patient with vertebral tumor developed hemorrhagic drainage (1100 cc/24 h) during the early postoperative period which resolved with conservative treatment. In two patients, wound infection developed which were treated with debridement and suturation.

Remainder of this chapter, the procedures will be described detailed with operative pictures and drawings especially the "thoraco-lumbar" procedure.

#### **1.3 Anterior approach to the cervicothoracic spine**

Anterior approach at cervicothoracic vertebrae poses some difficulties associated with the local anatomy and requires a good deal of anatomical knowledge of the bony, ligamentous, muscular, and neurovascular structures of the upper thoracic access routes. Cervical resection, partial resection of the manubrium and clavicle and advances in the surgical instrumentation provide adequate exposure.

Anterior Approaches to Thoracic and Thoraco-Lumbar Spine 103

muscle is cut with cautery, strap muscles are divided and pulled upward, the sternal part of the pectoralis major is stripped toward lateral side, clavicle is stripped subperiosteally, and disarticulated from sternum. In this way, vascular structures are pulled more laterally. If required, inferior thyroid vein is ligated and manubrium is partially removed. A Hemovac drainage tube is placed into the operation area and the layers are closed in accordance with

The access route is determined by the spinal level and length of the procedure. In deformities such as scoliosis, a thoracotomy is performed at the side with the wider intercostal space where the deformity reaches its apex, which is defined as the most prominent site of deformity. When required, the rib at the level of the incision can be removed. Removal of the third rib provides a good exposure in T1-T4 lesions (1,2,6). Presence of the liver on the right side may result in technical problems; for this reason, we prefer left thoracotomy both for thoracic and lumbar procedures unless a contraindication exists. In situations such as the presence of a tumor or hydatid cyst, a left or right

After intubation in supine position, a lateral decubitus position with the left side on top is used. A skin incision from the appropriate intercostal space and extending up to paraspinal muscles is made and thoracotomy is commenced. Care should be experienced to provide congruity between the incision and the costal margin. The anterior edge of the latissimus dorsi is determined and cut by cauterization in the posterior direction. Serratus anterior is cut toward anterior direction starting from its posterior side along the ribs. The first rib is palpated under the scapula, ribs are counted, and intercostals muscles are cut at the preferred level and thoracic cavity is accessed. We do not perform rib resection in middle and lower thoracic procedures, since adequate exposure is achieved. If pleural adhesions are present, they are released by blunt or sharp dissection. In case of intubation with a singlelumen tube, a compression is placed upon the lung to provide mild compression. The parietal pleura is opened in cephalad and caudad directions. The perforating arteries from the aorta, if required, intercostal artery and vein are ligated and the vertebrae are accessed (**Figure 2**). Following the procedure, bleeding control is achieved and a 32F or 36F chest tube is placed in the pleural cavity before the layers are closed according to normal anatomical alignment. After a daily drainage volume of 50 to 100 ml and expansion of the lungs, the

Anatomy of the diaphragm is important for thoracolumbar approaches. The apex of the dome of diaphragm may reach T7 level. It is attached to the xiphoid bone anteriorly; to the ribs and costal cartilages laterally (ribs 6 to 12); and to the corpuses and transverse processes of L1, L2, and L3 vertebrae with the lumbosacral arch via the crura posteriorly. The right and left diaphragmatic crura reach the upper lumbar vertebrae by forming the aortic hiatus. Since the diaphragm is innervated centrally, the incisions on the diaphragm should be

The Adamkiewicz artery is the principal arterial supply to the spinal cord in the lumbar area and its injury leads to paraplegia. It arises from the intercostal artery from the left and right

thoracotomy may be preferred depending on the location of the lesion (13,16-18).

normal anatomic alignment.

**1.4 Anterior Approach to the Thoracic Spine** 

chest tube is usually withdrawn within 48-72 hours.

**1.5 Anterior Approach to the Thoracolumbar Spine** 

peripheral and circular.


Table 2. Distribution of ethiologies of the patients according to access levels.

A neck incision parallel to the sternocleidomastoid and extending up to the suprasternal notch is made in addition to partial sternotomy reaching T4 level (**Figure 1a-b**).

Fig. 1. Oblique neck and upper sternotomi incision is showing in figure 1a, and surgical exposure of C2 to T2 after the retraction of the vascular structures (Figure 1b). If clavicle is disarticulated form the manubrium, exposure can now be carried out to the T3.

A subplatysmal flap is prepared and strep muscles are pulled upwards to expose the sternoclavicular joint. Sternomastoid muscle is pulled laterally together with the jugular vein, and strap muscles are pulled toward medial side. Thus, the carotid sheath is positioned laterally, while the trachea and esophagus are positioned medially. Recurrent laryngeal nerve injury is avoided at the tracheoesophageal canal. Trachea and esophagus are pulled medially and the prevertebral fascia is exposed. Walsh et al recommend left sided neck incision due to decreased likelihood of injury to the contralateral laryngeal nerve, provided that there are no contraindications. Moreover, this approach provides better exposure from C4 to T3 (1,14,15).

Sternotomy may not be necessary to access T1 vertebra. In that case, partial excision of the manubrium and/or clavicle may provide adequate exposure. The sternocleidomastoid

T7-10 n

T3-6 n

Table 2. Distribution of ethiologies of the patients according to access levels.

notch is made in addition to partial sternotomy reaching T4 level (**Figure 1a-b**).

Trauma 3 6 **41 50**  Tumor 1 **4** 1 **6**  Tuberculosis **3** 1 **4**  Scoliosis 2 **2**  Hydatid cyst 3 **3**  Kyphosis 1 **1**  Kyphoscoliosis 1 **1**  Total **10 14 43 67** 

A neck incision parallel to the sternocleidomastoid and extending up to the suprasternal

Fig. 1. Oblique neck and upper sternotomi incision is showing in figure 1a, and surgical exposure of C2 to T2 after the retraction of the vascular structures (Figure 1b). If clavicle is

A subplatysmal flap is prepared and strep muscles are pulled upwards to expose the sternoclavicular joint. Sternomastoid muscle is pulled laterally together with the jugular vein, and strap muscles are pulled toward medial side. Thus, the carotid sheath is positioned laterally, while the trachea and esophagus are positioned medially. Recurrent laryngeal nerve injury is avoided at the tracheoesophageal canal. Trachea and esophagus are pulled medially and the prevertebral fascia is exposed. Walsh et al recommend left sided neck incision due to decreased likelihood of injury to the contralateral laryngeal nerve, provided that there are no contraindications. Moreover, this approach provides better

Sternotomy may not be necessary to access T1 vertebra. In that case, partial excision of the manubrium and/or clavicle may provide adequate exposure. The sternocleidomastoid

disarticulated form the manubrium, exposure can now be carried out to the T3.

Access level

T11-L3 n

**Total n** 

**Etiology** 

exposure from C4 to T3 (1,14,15).

muscle is cut with cautery, strap muscles are divided and pulled upward, the sternal part of the pectoralis major is stripped toward lateral side, clavicle is stripped subperiosteally, and disarticulated from sternum. In this way, vascular structures are pulled more laterally. If required, inferior thyroid vein is ligated and manubrium is partially removed. A Hemovac drainage tube is placed into the operation area and the layers are closed in accordance with normal anatomic alignment.

#### **1.4 Anterior Approach to the Thoracic Spine**

The access route is determined by the spinal level and length of the procedure. In deformities such as scoliosis, a thoracotomy is performed at the side with the wider intercostal space where the deformity reaches its apex, which is defined as the most prominent site of deformity. When required, the rib at the level of the incision can be removed. Removal of the third rib provides a good exposure in T1-T4 lesions (1,2,6). Presence of the liver on the right side may result in technical problems; for this reason, we prefer left thoracotomy both for thoracic and lumbar procedures unless a contraindication exists. In situations such as the presence of a tumor or hydatid cyst, a left or right thoracotomy may be preferred depending on the location of the lesion (13,16-18).

After intubation in supine position, a lateral decubitus position with the left side on top is used. A skin incision from the appropriate intercostal space and extending up to paraspinal muscles is made and thoracotomy is commenced. Care should be experienced to provide congruity between the incision and the costal margin. The anterior edge of the latissimus dorsi is determined and cut by cauterization in the posterior direction. Serratus anterior is cut toward anterior direction starting from its posterior side along the ribs. The first rib is palpated under the scapula, ribs are counted, and intercostals muscles are cut at the preferred level and thoracic cavity is accessed. We do not perform rib resection in middle and lower thoracic procedures, since adequate exposure is achieved. If pleural adhesions are present, they are released by blunt or sharp dissection. In case of intubation with a singlelumen tube, a compression is placed upon the lung to provide mild compression. The parietal pleura is opened in cephalad and caudad directions. The perforating arteries from the aorta, if required, intercostal artery and vein are ligated and the vertebrae are accessed (**Figure 2**). Following the procedure, bleeding control is achieved and a 32F or 36F chest tube is placed in the pleural cavity before the layers are closed according to normal anatomical alignment. After a daily drainage volume of 50 to 100 ml and expansion of the lungs, the chest tube is usually withdrawn within 48-72 hours.

#### **1.5 Anterior Approach to the Thoracolumbar Spine**

Anatomy of the diaphragm is important for thoracolumbar approaches. The apex of the dome of diaphragm may reach T7 level. It is attached to the xiphoid bone anteriorly; to the ribs and costal cartilages laterally (ribs 6 to 12); and to the corpuses and transverse processes of L1, L2, and L3 vertebrae with the lumbosacral arch via the crura posteriorly. The right and left diaphragmatic crura reach the upper lumbar vertebrae by forming the aortic hiatus. Since the diaphragm is innervated centrally, the incisions on the diaphragm should be peripheral and circular.

The Adamkiewicz artery is the principal arterial supply to the spinal cord in the lumbar area and its injury leads to paraplegia. It arises from the intercostal artery from the left and right

Anterior Approaches to Thoracic and Thoraco-Lumbar Spine 105

Fig. 3. The dotted lines showing the dissection plane either in radioloque (a), or schematic

(b) illustration (The zig-zag lines in the b frame represents vertebral fractures).

Fig. 4. White arrow indicating the pathway for reaching lumbal vertebrae during

entering the abdomen, which allows access up to level L3.

facilitates the postoperative drainage in the field of surgery.

thoracotomy, in a sagittal section of a computed tomography. The diaphragm was separated from the antero-lateral vertebral corpus and the retroperitoneal space was reached without

the abdominal cavity. During the closure of diaphragm, infrequent sutures are usually adequate. Abdominal herniation is not expected, as only the retroperitoneal area has close association with the pleural cavity. In addition, the chest tube placed into the pleural cavity

For lesions at L2, a thoracoabdominal cut at the 11th or 12th costal region is performed (**Figure 6-9**). Removal of the 12th rib results in simple access to L3 (**Figure 10**), and if required, to L4. If necessary, lateral fibers of the abdominal muscles (external oblique, internal oblique, and abdominal transverse) can be opened carefully (14-16,19). Retroperitoneal area is reached without entering the pleural cavity. The porous tissues of the

Fig. 2. The postero-anterior roentgenogram is showing fixating plates from T5 to T7 that is placed via left thoracotomy (Department of Neurosurgery, Cumhuriyet University, with permission).

side in 75% and 25% of the individuals, respectively (1,14,15). Maximum effort should be carried out to avoid injuring this artery in the critical vascular zone of the spinal cord, i.e. between T7-L4, and particularly between T8-T10. If required, a preoperative selective angiography may be helpful in deciding on the surgical approach and preventing paraplegia. Somato-sensory potentials monitoring is useful to minimize the risk of cordal ischemia, particularly when performing an anterior approach through the left side.

An incision along the 10th costal margin should be made for procedures between T10 and L1. In this regard, Hodgson recommends resection of the 9th rib, while Dwyer recommends the 10th. We prefer a transthoracic approach from the 9th intercostal space for T11-T12 lesions, while we access the thoracic cavity through the 10th intercostal space for T12-L1 lesions (2). For T12-L1, we access the retroperitoneal area with a transthoracic approach (**Figure 3a-b**). For the majority of cases this negates the need for costal resections. The diaphragm is stripped anteriorly-laterally over the vertebral corpus to reach L1 without disrupting the integrity of the diaphragm (**Figure 3,4**). If access to L2 is required in this approach, an additional circumferential resection 4 to 5 cm in length is made in the costal diaphragm. For L2 lesions, a resection at the 12th rib is performed to reach L1-L2 extrapleurally.

In lateral decubitus position, a posterior angulation of 10º-15º is provided for better exposure when the patient lies. In deformities such as scoliosis or kyphoscoliosis, the side of convexity is preferred for surgery. Otherwise, a left thoracotomy is performed based on simpler mobilization of the aorta and spleen as compared to inferior vena cava and liver. A skin incision along the appropriate costal margin is made and extended anteriorly toward the iliac crest. After the muscles are severed by cautery, ribs are accessed and removed up to the costal cartilage by deperiostization. Thoracic cavity is accessed. If access to L1 level suffices for the procedure, then diaphragm is stripped anteriorly-laterally without disrupting its integrity and the retroperitoneal area is accessed (**Figure 3-5**) without entering

Fig. 2. The postero-anterior roentgenogram is showing fixating plates from T5 to T7 that is placed via left thoracotomy (Department of Neurosurgery, Cumhuriyet University, with

side in 75% and 25% of the individuals, respectively (1,14,15). Maximum effort should be carried out to avoid injuring this artery in the critical vascular zone of the spinal cord, i.e. between T7-L4, and particularly between T8-T10. If required, a preoperative selective angiography may be helpful in deciding on the surgical approach and preventing paraplegia. Somato-sensory potentials monitoring is useful to minimize the risk of cordal

An incision along the 10th costal margin should be made for procedures between T10 and L1. In this regard, Hodgson recommends resection of the 9th rib, while Dwyer recommends the 10th. We prefer a transthoracic approach from the 9th intercostal space for T11-T12 lesions, while we access the thoracic cavity through the 10th intercostal space for T12-L1 lesions (2). For T12-L1, we access the retroperitoneal area with a transthoracic approach (**Figure 3a-b**). For the majority of cases this negates the need for costal resections. The diaphragm is stripped anteriorly-laterally over the vertebral corpus to reach L1 without disrupting the integrity of the diaphragm (**Figure 3,4**). If access to L2 is required in this approach, an additional circumferential resection 4 to 5 cm in length is made in the costal diaphragm. For L2 lesions, a resection at the 12th rib is performed to reach L1-L2

In lateral decubitus position, a posterior angulation of 10º-15º is provided for better exposure when the patient lies. In deformities such as scoliosis or kyphoscoliosis, the side of convexity is preferred for surgery. Otherwise, a left thoracotomy is performed based on simpler mobilization of the aorta and spleen as compared to inferior vena cava and liver. A skin incision along the appropriate costal margin is made and extended anteriorly toward the iliac crest. After the muscles are severed by cautery, ribs are accessed and removed up to the costal cartilage by deperiostization. Thoracic cavity is accessed. If access to L1 level suffices for the procedure, then diaphragm is stripped anteriorly-laterally without disrupting its integrity and the retroperitoneal area is accessed (**Figure 3-5**) without entering

ischemia, particularly when performing an anterior approach through the left side.

permission).

extrapleurally.

Fig. 3. The dotted lines showing the dissection plane either in radioloque (a), or schematic (b) illustration (The zig-zag lines in the b frame represents vertebral fractures).

Fig. 4. White arrow indicating the pathway for reaching lumbal vertebrae during thoracotomy, in a sagittal section of a computed tomography. The diaphragm was separated from the antero-lateral vertebral corpus and the retroperitoneal space was reached without entering the abdomen, which allows access up to level L3.

the abdominal cavity. During the closure of diaphragm, infrequent sutures are usually adequate. Abdominal herniation is not expected, as only the retroperitoneal area has close association with the pleural cavity. In addition, the chest tube placed into the pleural cavity facilitates the postoperative drainage in the field of surgery.

For lesions at L2, a thoracoabdominal cut at the 11th or 12th costal region is performed (**Figure 6-9**). Removal of the 12th rib results in simple access to L3 (**Figure 10**), and if required, to L4. If necessary, lateral fibers of the abdominal muscles (external oblique, internal oblique, and abdominal transverse) can be opened carefully (14-16,19). Retroperitoneal area is reached without entering the pleural cavity. The porous tissues of the

Anterior Approaches to Thoracic and Thoraco-Lumbar Spine 107

Fig. 7. The patient is placed in the lateral decubitus position with the left side up and is positioned in 10º-15º oblique chest position rotated to the posteriorly. The skin and subcutaneous tissue are opened from the lateral border of the paraspinous musculature to

costal cartilage junction over the rib to be resected (Department of Neurosurgery,

Fig. 8. The Periosteum is elevated first from the outer surface of the rib, then from the superior surface, followed by the inferior surface of the rib. The rib is cut as far anteriorly as between the costal cartilage junction and posteriorly at costotransverse joint (Department of

Neurosurgery, Cumhuriyet University, with permission).

Cumhuriyet University, with permission).

Fig. 5. The postero-anterior roentgenogram is showing the stabilization from T11 to L1. The diaphragm is divided from the vertebral corpus and reached the level L1 (Department of Neurosurgery, Cumhuriyet University, with permission).

retroperitoneum are retracted anteriorly and medially. The psoas muscle is stripped from its attachments to the L1 and L2 vertebrae using the vertebral column as a guide. Vertebrae are accessed. Sometimes thorax retractors may cause diaphragmatic injury, which can be closed by non-absorbable sutures for smaller defects. The lungs are fully expanded in coordination with the anesthesiologist. After absence of air in the pleural cavity is ascertained, the sutures placed on the diaphragm are ligated and the pleural cavity is closed without the need for a chest tube. Hemovac drains are placed in the field of surgery and under paraspinous muscles, and the layers are closed according to anatomy.

Fig. 6. The traumatic fracture in L1 vertebrae is revealed in the magnetic resonance imaging (Department of Neurosurgery, Cumhuriyet University, with permission).

Fig. 5. The postero-anterior roentgenogram is showing the stabilization from T11 to L1. The diaphragm is divided from the vertebral corpus and reached the level L1 (Department of

retroperitoneum are retracted anteriorly and medially. The psoas muscle is stripped from its attachments to the L1 and L2 vertebrae using the vertebral column as a guide. Vertebrae are accessed. Sometimes thorax retractors may cause diaphragmatic injury, which can be closed by non-absorbable sutures for smaller defects. The lungs are fully expanded in coordination with the anesthesiologist. After absence of air in the pleural cavity is ascertained, the sutures placed on the diaphragm are ligated and the pleural cavity is closed without the need for a chest tube. Hemovac drains are placed in the field of surgery and under paraspinous

Fig. 6. The traumatic fracture in L1 vertebrae is revealed in the magnetic resonance imaging

(Department of Neurosurgery, Cumhuriyet University, with permission).

Neurosurgery, Cumhuriyet University, with permission).

muscles, and the layers are closed according to anatomy.

Fig. 7. The patient is placed in the lateral decubitus position with the left side up and is positioned in 10º-15º oblique chest position rotated to the posteriorly. The skin and subcutaneous tissue are opened from the lateral border of the paraspinous musculature to costal cartilage junction over the rib to be resected (Department of Neurosurgery, Cumhuriyet University, with permission).

Fig. 8. The Periosteum is elevated first from the outer surface of the rib, then from the superior surface, followed by the inferior surface of the rib. The rib is cut as far anteriorly as between the costal cartilage junction and posteriorly at costotransverse joint (Department of Neurosurgery, Cumhuriyet University, with permission).

Anterior Approaches to Thoracic and Thoraco-Lumbar Spine 109

[1] Mansour KA, DeLaRosa J. Anterior transthoracic approaches to the spine. In Shields TW,

[2] Nadir A, Sahin E, Ozum U, Karadag O, Tezeren G, Kaptanoglu M. Thoracotomy in spine

[3] Dwyer AF, Newton NC, Sherwood AA. An anterior approach to scoliosis. A preliminary

[4] Levin R, Matusz D, Hasharoni A, Scharf C, Lonner B, Errico T. Mini-open

[5] Hitchon PW, Tomer J, Eichholz KM, Beeler SM. Comparison of anterolateral and

[6] Muschik MT, Kimmich H, Demmel T. Comparison of anterior and posterior double-rod

[7] Schnee CL, Ansell LV. Selection criteria and outcome of operative approaches for

[8] Denis F, Amstrong GW, Searls K, Matta L. Acute thoracolombar burst fractures in the

[9] Liljengvist UR, Bullmann V, Schulte TL, Hackenverg L, Halm HF. Anterior dual rod instrumentation in idiopathic scoliosis. Eur Spine J 2006;15:1118-27. [10] Jochen SH, Laurel B, Connie PK, George T. Video assisted thoracoscopic surgery in idiopathic scoliosis: evaluation of the learning curve. Spine 2007;32:703-7. [11] Lapinsky AS, Richards BS. Preventing the crankshaft phenomenon by combining

[12] Dai LY, Jiang SD, Wang XY, Jiang SY. A review of the management of thoracolumbar

[13] Gurelik M, Goksel HM, Nadir A. Posterior mediastinal paravertebral hydatid cyst

[14] Watkins R. Thoracic spine:anterior. In Herkowitz HN, Garfin SR, Eismont FJ, Bell GR,

[15] Thongtrangan I, Le HN, Park J, Kim DH. Thoracic and thoracolumar fractures. In Kim

[16] Pettiford BL, Schuchert MJ, Jeyabalan G, Landreneau JR, Kilic A, Landreneau JP,

operative and radiographic results. The Spine Journal 2005;5:632-8.

Philadelphia: Lippincott Williams and Wilkins; 2005:703-709.

surgery. Thorac Cardiovasc Surg 2008;56:482-84.

report. Clin Orthop 1969;62:192.

Neurosurg Spine. 2006;5:117-25.

treatment. Clin Orthop 1984;189:142-9.

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Sunders Elsevier; 2006: 290-307.

Ann Thorac Surg. 2008;86:1762-68.

causing severe paraparesis. Br J Neurosurg. 2002; 16:605-6.

spine 9th ed, Philadelphia: Sunders Elsevier; 2006:352-363.

2006;1128-38.

1997;86:48-55.

LoCicero J, Ponn RB, Rusch VW, ed. General Thoracic Surgery, vol 1, 6th ed.

thoracoscopically assisted thoracotomy versus video-assisted thoracoscopic surgery for anterior release in thoracic scoliosis and kyphosis: a comparison of

posterior approaches in the management of thoracolumbar burst fractures. J

instrumentation for thoracic idiopathic scoliosis:results of 141 patients. Eur Spine J

thoracolumbar burst fractures with and without neurological deficit. J Neurosurg

absence of neurologic deficit: a comparison between operative and nonoperative

anterior fusion with posterior instrumentation. Does it work? Spine 1995;20:1392-8.

Balderston RA, ed. Rothman-Simeone Spine Surgery, vol 1, 5th ed, Philadelphia:

DH, Henn JS, Vaccaro AR, Dickman CA, ed Surgical anatomy&Techniques to the

Awais O, Kent MS, Ferson PF, Luketich JD, Peitzman AB, Landreneau RJ. Technical challenges and utility of anterior exposure for thoracic spine pathology.

**2. References** 

Fig. 9. Retroperitoneal area is accessed extrapleurally by the resection of 11th or 12th ribs depending on the location of the diaphragm. The intraoperative image of a patient following L1 corpectomy and stabilization by the aid of excellent exposure provided with the resection of 11th rib (Department of Neurosurgery, Cumhuriyet University, with permission).

Fig. 10. Magnetic resonance imaging is showing traumatic vertebral fracture in L2 (a) and L2 corpectomy and stabilization was performed by the assistance with the resection of 12th rib (b) (Department of Neurosurgery, Cumhuriyet University, with permission).

Apart from the patients requiring vertebral resection due to metastasis of lung cancer, anterior approach with thoracotomy is required in spine surgery for conditions such as trauma, tumor, hydatid cyst etc. A good preoperative assessment of the vertebrae to be intervened is important for good exposure during surgery. Our experience showed us, thoracotomy levels should be placed according to the level of T6-7. If the lesion placed above that limit, then thoracotomy should be performed at the lesion point. If the lesion placed below that level, then thoracotomy should be performed one or two vertebrae higher than the lesion point.

#### **2. References**

108 Spine Surgery

Fig. 9. Retroperitoneal area is accessed extrapleurally by the resection of 11th or 12th ribs depending on the location of the diaphragm. The intraoperative image of a patient following L1 corpectomy and stabilization by the aid of excellent exposure provided with the resection

Fig. 10. Magnetic resonance imaging is showing traumatic vertebral fracture in L2 (a) and L2 corpectomy and stabilization was performed by the assistance with the resection of 12th rib

Apart from the patients requiring vertebral resection due to metastasis of lung cancer, anterior approach with thoracotomy is required in spine surgery for conditions such as trauma, tumor, hydatid cyst etc. A good preoperative assessment of the vertebrae to be intervened is important for good exposure during surgery. Our experience showed us, thoracotomy levels should be placed according to the level of T6-7. If the lesion placed above that limit, then thoracotomy should be performed at the lesion point. If the lesion placed below that level, then thoracotomy should be performed one or two vertebrae higher

(b) (Department of Neurosurgery, Cumhuriyet University, with permission).

than the lesion point.

of 11th rib (Department of Neurosurgery, Cumhuriyet University, with permission).


**Part 4** 

**Cervical Spine** 



## **Part 4**

**Cervical Spine** 

110 Spine Surgery

[17] Lu DC, Lau D, Lee JG, Chou D. The transpedicular approach compared with the

[18] Janik JS, Burrington JD, Janik JE, Wayne ER, Chang JH, Rothenberg SS. Anterior

[19] Naunheim KS, Barnett MG, Crandall DG, Vaca KJ, Burkus JK. Anterior exposure of the

Neurosurg-Spine 2010;12(6);583-591.

thoracic spine. Ann Thorac Surg 1994;57:1436-9.

1997;32:852-9.

anterior approach:an analysis of 80 thoracolumbar corpectomies: clinical article. J

exposure of spinal deformities and tumors: a 20 year experienceJ Pediatr Surg

**8** 

**of 14 Years -** 

*Matsumoto-City, Nagano,* 

*Japan* 

**Perforation Rates of Cervical Pedicle Screw** 

**Inserted from C3 to C6 - A Retrospective** 

*Department of Orthopaedic Surgery, Shinshu University School of Medicine,* 

Cervical spine fixation using cervical pedicle screw (CPS) was first reported by Abumi [1] and Jeanneret [2] in 1994. Both reports described cases of cervical instability caused by cervical trauma. Cervical spine fixation by CPS was introduced as a procedure for the cervical instability of middle and/or lower cervical spine caused by trauma, and the importance of fixation by CPS for posterior cervical decompression and reconstruction was later reported [3,4]. Cervical pedicle screws can achieve rigid fixation compared to other cervical pedicle fixation methods [5, 6], and enable posterior cervical cord decompression. However, cervical pedicle screw insertion is technically demanding because of the narrow pedicle diameter and the risk of serious neurovascular complications including vertebral artery tear, spinal cord injury, and nerve root injury [7]. To achieve more accurate and safe pedicle screw insertion, navigation by two-dimensional imaging system or CT has been employed in recent years [9-12]. However, CPS insertion from C3 to C6 is technically demanding. The purpose of this study was to evaluate the perforation rates and direction of

We evaluated 78 subjects (49 men and 29 women; mean age, 61.1 14.2 years) who had undergone CPS insertion from C3 to C6 by using a CT-based navigation system from September 1997 to March 2011. A frameless stereotactic image-guidance system (StealthStation and Stealth Station TREONTM; Medtronic, Sofamor Danek, Memphis, TN, USA) was used in screw placement and fixation of the cervical spine. The profile of cervical pedicle screw system was as follows; SUMMIT SI Occipito-cervico-thoracic (OCT) spinal fixation system (Depuy Spine, Inc., Raynham, MA), Olerud cervical system (Nord Opedic, Askim, Sweden), RRS Loop Spinal System (Robert Leid, Tokyo, Japan), Vertex Max system

screw perforations in these insertions using CT-based navigation system.

**1. Introduction** 

**2. Materials and methods** 

**Analysis of 78 Patients over a Period 5** 

Jun Takahashi, Hiroki Hirabayashi, Hiroyuki Hashidate, Nobuhide Ogihara, Keijiro Mukaiyama, Syuugo Kuraishi, Masayuki Shimizu, Masashi Uehara and Hiroyuki Kato

### **Perforation Rates of Cervical Pedicle Screw Inserted from C3 to C6 - A Retrospective Analysis of 78 Patients over a Period 5 of 14 Years -**

Jun Takahashi, Hiroki Hirabayashi, Hiroyuki Hashidate, Nobuhide Ogihara, Keijiro Mukaiyama, Syuugo Kuraishi, Masayuki Shimizu, Masashi Uehara and Hiroyuki Kato *Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto-City, Nagano, Japan* 

#### **1. Introduction**

Cervical spine fixation using cervical pedicle screw (CPS) was first reported by Abumi [1] and Jeanneret [2] in 1994. Both reports described cases of cervical instability caused by cervical trauma. Cervical spine fixation by CPS was introduced as a procedure for the cervical instability of middle and/or lower cervical spine caused by trauma, and the importance of fixation by CPS for posterior cervical decompression and reconstruction was later reported [3,4]. Cervical pedicle screws can achieve rigid fixation compared to other cervical pedicle fixation methods [5, 6], and enable posterior cervical cord decompression. However, cervical pedicle screw insertion is technically demanding because of the narrow pedicle diameter and the risk of serious neurovascular complications including vertebral artery tear, spinal cord injury, and nerve root injury [7]. To achieve more accurate and safe pedicle screw insertion, navigation by two-dimensional imaging system or CT has been employed in recent years [9-12]. However, CPS insertion from C3 to C6 is technically demanding. The purpose of this study was to evaluate the perforation rates and direction of screw perforations in these insertions using CT-based navigation system.

#### **2. Materials and methods**

We evaluated 78 subjects (49 men and 29 women; mean age, 61.1 14.2 years) who had undergone CPS insertion from C3 to C6 by using a CT-based navigation system from September 1997 to March 2011. A frameless stereotactic image-guidance system (StealthStation and Stealth Station TREONTM; Medtronic, Sofamor Danek, Memphis, TN, USA) was used in screw placement and fixation of the cervical spine. The profile of cervical pedicle screw system was as follows; SUMMIT SI Occipito-cervico-thoracic (OCT) spinal fixation system (Depuy Spine, Inc., Raynham, MA), Olerud cervical system (Nord Opedic, Askim, Sweden), RRS Loop Spinal System (Robert Leid, Tokyo, Japan), Vertex Max system

Perforation Rates of Cervical Pedicle Screw Inserted

(CP), and 2 (2 males; mean age 45.5±10.6 years).

**3. Results** 

and grade 2) was 17.9% (49/274).

IBM company, Tokyo, Japan), with p<0.05 defined as significant.

from C3 to C6 - A Retrospective Analysis of 78 Patients over a Period 5 of 14 Years - 115

males, 2 females; mean age 62.3±9.1 years) of spine tumor, 5 cases (4 males; mean age 53.6±15.2 years) of cervical spondylotic myelopathy associated with athetoid cerebral palsy

Using postoperative axial CT, the screw insertion status was classified as follows: grade 1 (no perforation), screw is accurately inserted in the pedicle; grade 2 (minor perforation), perforation of less than 50% of screw diameter; grade 3 (major perforation), perforation of 50% of screw diameter or more. The directions of perforations were evaluated as well.

The data were analyzed by a paired-sample Student *t* test using SPSS (SPSS Japan Inc., an

Mean surgical time was 239±109 (range; 90 – 505) minutes. Mean blood loss volume was 352±327 (range; 20 – 1500) grams. For grade 3 (major perforation), the screw perforation rates by vertebral level were as follows: C3 (4/65, 6.2%), C4 (5/65, 7.7%), C5 (2/68, 3.1%), and C6 (1/76, 1.3%); therefore, higher perforation rates were observed for C4 and C3. For grade 3 and grade 2, the screw perforation rates by vertebral level were as follows: C3 (12/65, 18.5%), C4 (14/65, 21.5%), C5 (15/68, 22.1%), and C6 (8/76, 10.5%); therefore, higher perforation rates were observed for C5, C4, and C3, in this order (Fig. 1). For all the screws, the major perforation rate (only grade 3) was 4.4% (12/274) and perforation rate (grade 3

Fig. 1. Position of the cervical pedicle screw at different vertebral levels, observed by postoperative CT. Grade 1 (no perforation), screw is accurately inserted in the pedicle; Grade 2 (minor perforation), perforation of less than 50% of screw diameter; Grade 3 (major

perforation), perforation of 50% of screw diameter or more.

(Medtronic, Sofamor Danek, Memphis, TN, USA) , Axon system (Synthes, Inc., West Chester, PA, USA), and Oasys (Optimal Aignment System) (Stryker Spine Allendale, NJ, USA).

#### **Pedicle screw insertion technique assisted with navigation system**

The basic data used for navigation were preoperative CT scan imaging data, consisting of consecutive axial slices 1 mm in thickness of the patients. The data were transferred to the system computer and were reconstructed into two-dimensional (2-D) and three-dimensional (3-D) images on a video monitor. Other mechanical components consisted of a computer workstation, a surgical reference frame, a probe rod to indicate the position in the surgical field, infrared light-emitting diodes (LEDs) that were attached to the probe rod, an electrooptical camera as a position sensor connected to the computer, and a drill guide. Infrared beams were tracked by the electro-optical camera system and the position of the respective LEDs was identified in real time in the surgical field.

Registration was performed in order to accurately match the computer-reconstructed 3-D surgical space with the real surgical space, by identifying four or more points on the vertebrae and the corresponding points of the vertebrae on the 3-D CT image on the monitor (matched-pair point registration). Though more precise matching of the two spaces is usually obtained by repeated registration procedures with 30 or more randomized points indicated by the probe on the surface of the vertebral body (surface registration), this group's procedure employs only 5 to 6 registration points for two consecutive lamina, to shorten the surgical time. More accurate positioning is possible by using the top of the spinous process and bilateral inferior facet caudal tip as points.

We established a surgical plan a day before surgery and confirmed insertion point of screws, applicability of 3.5 mm screws, point-for-point registration, screw position in relation to vertebral artery. This planning procedure took 20 to 40 min. Evaluation during the surgical plan for navigation provides further benefit by identifying pedicles with insertion risks and excluding such pedicles from operation (about 10% of all pedicles were excluded). Then, the entrance holes, direction, diameter, and depth of the screws were depicted with a cursor on the monitor, and the surgery was initiated. After exposure of the posterior bony elements of the spine, the reference frame was fixed to the spinous processes and the registration procedures described above were performed. After completion of the registration by matched-pair point and surface registration, the screws were inserted under the guidance of the navigation system. The position of the probe or drill guide was superimposed in realtime on CT images on the monitor, and the screws were introduced into the pedicles at the planned position indicated on the monitor. The required time between fixation of reference frame to spinous process and insertion of pedicle screw to each segment (1 or 2 vertebrae) was 10 to 15 min. After all screws were set, the reference frame for registration was removed and additional surgical procedures including decompression or bone graft were followed. If pedicle screw insertion was ineligible, sublaminar cable fixation by SecureStrand was performed.

Diseases included 22 cases (16 males, 6 females; mean age 52.2±18.8 years) of spinal trauma, 19 cases (8 males, 11 females; mean age 65.0±8.9 years) of rheumatoid arthritis (RA), 13 (7 males, 6 females; mean age 69.9±7.6 years) of cervical spondylotic myelopathy (CSM), 11 (7 males, 4 females; mean age 65.2±7.0 years) of destructive spondyloarthropathy (DSA), 6 (4 males, 2 females; mean age 62.3±9.1 years) of spine tumor, 5 cases (4 males; mean age 53.6±15.2 years) of cervical spondylotic myelopathy associated with athetoid cerebral palsy (CP), and 2 (2 males; mean age 45.5±10.6 years).

Using postoperative axial CT, the screw insertion status was classified as follows: grade 1 (no perforation), screw is accurately inserted in the pedicle; grade 2 (minor perforation), perforation of less than 50% of screw diameter; grade 3 (major perforation), perforation of 50% of screw diameter or more. The directions of perforations were evaluated as well.

The data were analyzed by a paired-sample Student *t* test using SPSS (SPSS Japan Inc., an IBM company, Tokyo, Japan), with p<0.05 defined as significant.

#### **3. Results**

114 Spine Surgery

(Medtronic, Sofamor Danek, Memphis, TN, USA) , Axon system (Synthes, Inc., West Chester, PA, USA), and Oasys (Optimal Aignment System) (Stryker Spine Allendale, NJ,

The basic data used for navigation were preoperative CT scan imaging data, consisting of consecutive axial slices 1 mm in thickness of the patients. The data were transferred to the system computer and were reconstructed into two-dimensional (2-D) and three-dimensional (3-D) images on a video monitor. Other mechanical components consisted of a computer workstation, a surgical reference frame, a probe rod to indicate the position in the surgical field, infrared light-emitting diodes (LEDs) that were attached to the probe rod, an electrooptical camera as a position sensor connected to the computer, and a drill guide. Infrared beams were tracked by the electro-optical camera system and the position of the respective

Registration was performed in order to accurately match the computer-reconstructed 3-D surgical space with the real surgical space, by identifying four or more points on the vertebrae and the corresponding points of the vertebrae on the 3-D CT image on the monitor (matched-pair point registration). Though more precise matching of the two spaces is usually obtained by repeated registration procedures with 30 or more randomized points indicated by the probe on the surface of the vertebral body (surface registration), this group's procedure employs only 5 to 6 registration points for two consecutive lamina, to shorten the surgical time. More accurate positioning is possible by using the top of the

We established a surgical plan a day before surgery and confirmed insertion point of screws, applicability of 3.5 mm screws, point-for-point registration, screw position in relation to vertebral artery. This planning procedure took 20 to 40 min. Evaluation during the surgical plan for navigation provides further benefit by identifying pedicles with insertion risks and excluding such pedicles from operation (about 10% of all pedicles were excluded). Then, the entrance holes, direction, diameter, and depth of the screws were depicted with a cursor on the monitor, and the surgery was initiated. After exposure of the posterior bony elements of the spine, the reference frame was fixed to the spinous processes and the registration procedures described above were performed. After completion of the registration by matched-pair point and surface registration, the screws were inserted under the guidance of the navigation system. The position of the probe or drill guide was superimposed in realtime on CT images on the monitor, and the screws were introduced into the pedicles at the planned position indicated on the monitor. The required time between fixation of reference frame to spinous process and insertion of pedicle screw to each segment (1 or 2 vertebrae) was 10 to 15 min. After all screws were set, the reference frame for registration was removed and additional surgical procedures including decompression or bone graft were followed. If pedicle screw insertion was ineligible, sublaminar cable fixation by SecureStrand was

Diseases included 22 cases (16 males, 6 females; mean age 52.2±18.8 years) of spinal trauma, 19 cases (8 males, 11 females; mean age 65.0±8.9 years) of rheumatoid arthritis (RA), 13 (7 males, 6 females; mean age 69.9±7.6 years) of cervical spondylotic myelopathy (CSM), 11 (7 males, 4 females; mean age 65.2±7.0 years) of destructive spondyloarthropathy (DSA), 6 (4

**Pedicle screw insertion technique assisted with navigation system** 

LEDs was identified in real time in the surgical field.

spinous process and bilateral inferior facet caudal tip as points.

USA).

performed.

Mean surgical time was 239±109 (range; 90 – 505) minutes. Mean blood loss volume was 352±327 (range; 20 – 1500) grams. For grade 3 (major perforation), the screw perforation rates by vertebral level were as follows: C3 (4/65, 6.2%), C4 (5/65, 7.7%), C5 (2/68, 3.1%), and C6 (1/76, 1.3%); therefore, higher perforation rates were observed for C4 and C3. For grade 3 and grade 2, the screw perforation rates by vertebral level were as follows: C3 (12/65, 18.5%), C4 (14/65, 21.5%), C5 (15/68, 22.1%), and C6 (8/76, 10.5%); therefore, higher perforation rates were observed for C5, C4, and C3, in this order (Fig. 1). For all the screws, the major perforation rate (only grade 3) was 4.4% (12/274) and perforation rate (grade 3 and grade 2) was 17.9% (49/274).

Fig. 1. Position of the cervical pedicle screw at different vertebral levels, observed by postoperative CT. Grade 1 (no perforation), screw is accurately inserted in the pedicle; Grade 2 (minor perforation), perforation of less than 50% of screw diameter; Grade 3 (major perforation), perforation of 50% of screw diameter or more.

Perforation Rates of Cervical Pedicle Screw Inserted

**4. Case report** 

6).

from C3 to C6 - A Retrospective Analysis of 78 Patients over a Period 5 of 14 Years - 117

67 year-old male with rheumatoid cervical spine. The subject presented with spinal cord compression and instability at the C3-C4 and C4-C5 levels and showed myelopathy (Fig. 4) Laminoplasy and posterior fusion with CPS from C3 to C5 was performed (Fig. 5). Postoperative axial CT indicated the screw insertion status, which was as follows: bilateral C3, grade 2; right side of C4, grade 3; left side of C4, grade 2; and bilateral C5, grade 1 (Fig.

a b c

compression was observed at the C3-C4 and C4-C5 levels.

Fig. 4. a,b) Preoperative maximum flexion and extension lateral X-ray. Instability was observed at the C3-C4 and C4-C5 levels. c) MRI scan (T2-WI sagittal view). Spinal cord

Fig. 5. Laminoplasy and posterior fusion with CPS from C3 to C5 was performed.

The percentage of total lateral and medial perforations were 76% (37/49) and 24% (12/49), respectively. Grade 3 lateral and medial perforations were observed in 6 and 5 pedicles, respectively (Fig. 2). Grade 2 lateral and medial perforations were observed in 31 and 7 pedicles, respectively (Fig. 3). No vertebral artery tear, spinal cord injury, and nerve root injury were observed.

Fig. 2. Direction of grade 3 cervical pedicle screw perforation at different vertebral levels.

Fig. 3. Direction of grade 2 cervical pedicle screw perforation at different vertebral levels.

### **4. Case report**

116 Spine Surgery

The percentage of total lateral and medial perforations were 76% (37/49) and 24% (12/49), respectively. Grade 3 lateral and medial perforations were observed in 6 and 5 pedicles, respectively (Fig. 2). Grade 2 lateral and medial perforations were observed in 31 and 7 pedicles, respectively (Fig. 3). No vertebral artery tear, spinal cord injury, and nerve root

Fig. 2. Direction of grade 3 cervical pedicle screw perforation at different vertebral levels.

Fig. 3. Direction of grade 2 cervical pedicle screw perforation at different vertebral levels.

injury were observed.

67 year-old male with rheumatoid cervical spine. The subject presented with spinal cord compression and instability at the C3-C4 and C4-C5 levels and showed myelopathy (Fig. 4) Laminoplasy and posterior fusion with CPS from C3 to C5 was performed (Fig. 5). Postoperative axial CT indicated the screw insertion status, which was as follows: bilateral C3, grade 2; right side of C4, grade 3; left side of C4, grade 2; and bilateral C5, grade 1 (Fig. 6).

Fig. 4. a,b) Preoperative maximum flexion and extension lateral X-ray. Instability was observed at the C3-C4 and C4-C5 levels. c) MRI scan (T2-WI sagittal view). Spinal cord compression was observed at the C3-C4 and C4-C5 levels.

Fig. 5. Laminoplasy and posterior fusion with CPS from C3 to C5 was performed.

Perforation Rates of Cervical Pedicle Screw Inserted

the case of the C3 and C4 pedicles.

direction in 76% of the cases.

**6. Conclusions** 

**7. References** 

from C3 to C6 - A Retrospective Analysis of 78 Patients over a Period 5 of 14 Years - 119

et al. [19] studied the transverse pedicle diameter of the C2-C7 of the cervical spine in a Malaysian population using computerized tomography (CT) measurements. The mean transverse diameters of the cervical pedicle of C3, C4, C5, and C6 in males were 5.2, 5.1, 5.2, and 5.5mm, respectively. In females, the mean transverse diameter of the cervical pedicle of C3, C4, C5, and C6 were 4.6, 4.7, 4.9, and 5.2mm, respectively. Our data on CPS perforation supported the results of the abovementioned studies in that pedicles with smaller diameters were found to have a larger number of perforations. The reason for the large number of minor perforations at C5 is unclear. C3 and C4 pedicles are generally narrow and hence, screw insertion is performed carefully. However, C5 is wider than C3 and C4; thus, the surgeon might be less attentive during the screw insertion for C5, which could contribute to this finding. Therefore, careful attention should be paid with respect to major perforations in

We found that a larger number of minor perforations occurred in the lateral direction than in the medial direction and that many major perforations were observed in the medial direction at the C3 level. During screw insertion in the cervical pedicle, the cortex is thicker in the medial direction and thinner in the lateral direction, and therefore, the CPS is likely to cause perforation in the lateral direction. In this study, perforation occurred in the lateral

The possible causes of perforation of pedicle screw are as follows: Deviation of CT-based navigation system caused from unintentional movement of reference frame during operation etc.; lateral perforation caused by pressure from paravertebral muscle to probe, tap, or screw; narrow osteosclerotic pedicle that has no cancellous bone. To avoid perforation under such conditions, countermeasures as follows are required: If the practitioner judges the insertion point or screw direction shown by the navigation system is incorrect, intraoperative x-ray image or fluoroscopy shall be used. If screw direction could not be set sufficiently in the medial orientation, prepare a skin incision externally and insert probe, tap, and screw from the incision. In the case of narrow or osteosclerotic pedicle, skip the pedicle or change the fixation method to lateral mass screw, sublaminar cable, or other.

Major perforations were mostly observed in C4 and C3 pedicles. However, the number of C5 pedicle perforations was as large as C4 or C3 pedicle perforations when the total perforations, i.e., both major and minor perforations, were considered. The perforation rate of C6 pedicle was lesser than that for pedicles from C3 to C5. The major perforation rate for lateral and medial perforations was comparable. CPS insertion from C3 to C5 should be

[1] Abumi K, Itoh H, Taneichi H, Kaneda K. Transpedicular screw fixation for traumatic

[2] Janneret B, Gebhard JS, Magerl F. Transpedicular screw fixation of articular mass

lesions of the middle and lower cervical spine: Description of the techniques and

fractureseparation: Results of an anatomical study and operative technique. J

performed with extreme caution even under the CT-based navigation system.

preliminary report. J Spinal Disord 1994;7:19-28.

Spinal Disord 1994;7:222-9.

Fig. 6. Postoperative axial CT showed the following screw insertion status: bilateral C3, grade 2; right side of C4, grade 3; left side of C4, grade 2; and bilateral C5, grade 1.

#### **5. Discussion**

Cervical pedicle screws can achieve rigid fixation compared to other cervical pedicle fixation methods [13, 14], and enable posterior cervical cord decompression. However, cervical pedicle screw insertion is technically demanding because of the narrow pedicle diameter and the risk of serious neurovascular complications including vertebral artery tear, spinal cord injury, and nerve root injury [15]. Indication of cervical pedicle screw technique is as follows: destructive lesions including RA, DSA, and spine tumor; procedures that include both spinal cord decompression and posterior fusion. For rheumatoid cervical spine, this technique is especially useful because the strong initial fixation eliminates the necessity of postoperative external fixation such as halo vest or collar.

To achieve more accurate and safe pedicle screw insertion, navigation by two-dimensional imaging system or CT has been employed in recent years. In the meta-analysis reported by Tian et al., the accuracy of pedicle screw insertion by CT navigation (90.76%) was significantly improved compared to the two-dimensional imaging system (85.48%) [16]. Our institution employs a CT-based navigation system for the cervical pedicle screw insertion [9- 12]. The result of this paper was that the percentage of major perforations were 4.4%, total perforation rates were 17.9% for all cervical pedicle screws. Richter et al. [17] reported comparative study of cervical pedicle screw fixation with conventional versus computer assisted surgery (CAS). In their result, pedicle perforation was 8.6% in conventional group and 3.0% in CAS group. Richter et al. indeed reported an excellent surgical outcome. The study of Richter et al. involved screw insertion for the upper thoracic vertebrae that have a larger vertebrae width as compared to the C3–C6 vertebrae that we studied, and vertebrae sizes could be larger in German individuals than in Japanese individuals. The reason for the larger perforation rate in our study could have resulted from the presence of a smaller pedicle in Japanese people and the narrow pedicle sizes of C3–C6 vertebrae.

Higher perforation rates for grade 3 (major perforation) were observed for C4 and C3. Furthermore, higher perforation rates for grade 2 and 3 (including minor perforation) were observed for C5, C4, and C3, in this order. For C6, the number of both major and minor perforations was small. Rheinhold et al. [18] measured the mean outer pedicle width for C3- C6 in human cadavers (mean age, 85 years), and the values for C3, C4, C5, and C6 were found to be 5.7 0.4 mm, 5.6 0.6 mm, 6.2 0.6 mm, and 6.7 0.6 mm, respectively. Yusof et al. [19] studied the transverse pedicle diameter of the C2-C7 of the cervical spine in a Malaysian population using computerized tomography (CT) measurements. The mean transverse diameters of the cervical pedicle of C3, C4, C5, and C6 in males were 5.2, 5.1, 5.2, and 5.5mm, respectively. In females, the mean transverse diameter of the cervical pedicle of C3, C4, C5, and C6 were 4.6, 4.7, 4.9, and 5.2mm, respectively. Our data on CPS perforation supported the results of the abovementioned studies in that pedicles with smaller diameters were found to have a larger number of perforations. The reason for the large number of minor perforations at C5 is unclear. C3 and C4 pedicles are generally narrow and hence, screw insertion is performed carefully. However, C5 is wider than C3 and C4; thus, the surgeon might be less attentive during the screw insertion for C5, which could contribute to this finding. Therefore, careful attention should be paid with respect to major perforations in the case of the C3 and C4 pedicles.

We found that a larger number of minor perforations occurred in the lateral direction than in the medial direction and that many major perforations were observed in the medial direction at the C3 level. During screw insertion in the cervical pedicle, the cortex is thicker in the medial direction and thinner in the lateral direction, and therefore, the CPS is likely to cause perforation in the lateral direction. In this study, perforation occurred in the lateral direction in 76% of the cases.

The possible causes of perforation of pedicle screw are as follows: Deviation of CT-based navigation system caused from unintentional movement of reference frame during operation etc.; lateral perforation caused by pressure from paravertebral muscle to probe, tap, or screw; narrow osteosclerotic pedicle that has no cancellous bone. To avoid perforation under such conditions, countermeasures as follows are required: If the practitioner judges the insertion point or screw direction shown by the navigation system is incorrect, intraoperative x-ray image or fluoroscopy shall be used. If screw direction could not be set sufficiently in the medial orientation, prepare a skin incision externally and insert probe, tap, and screw from the incision. In the case of narrow or osteosclerotic pedicle, skip the pedicle or change the fixation method to lateral mass screw, sublaminar cable, or other.

#### **6. Conclusions**

118 Spine Surgery

C3 C4 C5

postoperative external fixation such as halo vest or collar.

**5. Discussion** 

Fig. 6. Postoperative axial CT showed the following screw insertion status: bilateral C3, grade 2; right side of C4, grade 3; left side of C4, grade 2; and bilateral C5, grade 1.

Cervical pedicle screws can achieve rigid fixation compared to other cervical pedicle fixation methods [13, 14], and enable posterior cervical cord decompression. However, cervical pedicle screw insertion is technically demanding because of the narrow pedicle diameter and the risk of serious neurovascular complications including vertebral artery tear, spinal cord injury, and nerve root injury [15]. Indication of cervical pedicle screw technique is as follows: destructive lesions including RA, DSA, and spine tumor; procedures that include both spinal cord decompression and posterior fusion. For rheumatoid cervical spine, this technique is especially useful because the strong initial fixation eliminates the necessity of

To achieve more accurate and safe pedicle screw insertion, navigation by two-dimensional imaging system or CT has been employed in recent years. In the meta-analysis reported by Tian et al., the accuracy of pedicle screw insertion by CT navigation (90.76%) was significantly improved compared to the two-dimensional imaging system (85.48%) [16]. Our institution employs a CT-based navigation system for the cervical pedicle screw insertion [9- 12]. The result of this paper was that the percentage of major perforations were 4.4%, total perforation rates were 17.9% for all cervical pedicle screws. Richter et al. [17] reported comparative study of cervical pedicle screw fixation with conventional versus computer assisted surgery (CAS). In their result, pedicle perforation was 8.6% in conventional group and 3.0% in CAS group. Richter et al. indeed reported an excellent surgical outcome. The study of Richter et al. involved screw insertion for the upper thoracic vertebrae that have a larger vertebrae width as compared to the C3–C6 vertebrae that we studied, and vertebrae sizes could be larger in German individuals than in Japanese individuals. The reason for the larger perforation rate in our study could have resulted from the presence of a smaller

Higher perforation rates for grade 3 (major perforation) were observed for C4 and C3. Furthermore, higher perforation rates for grade 2 and 3 (including minor perforation) were observed for C5, C4, and C3, in this order. For C6, the number of both major and minor perforations was small. Rheinhold et al. [18] measured the mean outer pedicle width for C3- C6 in human cadavers (mean age, 85 years), and the values for C3, C4, C5, and C6 were found to be 5.7 0.4 mm, 5.6 0.6 mm, 6.2 0.6 mm, and 6.7 0.6 mm, respectively. Yusof

pedicle in Japanese people and the narrow pedicle sizes of C3–C6 vertebrae.

Major perforations were mostly observed in C4 and C3 pedicles. However, the number of C5 pedicle perforations was as large as C4 or C3 pedicle perforations when the total perforations, i.e., both major and minor perforations, were considered. The perforation rate of C6 pedicle was lesser than that for pedicles from C3 to C5. The major perforation rate for lateral and medial perforations was comparable. CPS insertion from C3 to C5 should be performed with extreme caution even under the CT-based navigation system.

#### **7. References**


**1. Introduction** 

**9** 

*Russia* 

**General Description** 

*St. Petersburg State Pediatric Medical Academy,* 

Alexander Gubin

**of Pediatric Acute Wryneck Condition** 

At least 80 causes of torticollis have been documented in the literature [1]. Acutely developed torticollis may mask severe pathology requiring treatment including surgical one. First of all, it is necessary to rule out trauma as well as the destructive process of tumoral or inflammatory nature. General differential-and-diagnostic algorithms required for

examination of children with torticollis have been proposed (Fig. 1).

Fig. 1. Algorithm for examination of children with torticollis (cit. by [2]).


### **General Description of Pediatric Acute Wryneck Condition**

Alexander Gubin

*St. Petersburg State Pediatric Medical Academy, Russia* 

#### **1. Introduction**

120 Spine Surgery

[3] Abumi K, Kaneda K. Pedicle screw fixation for nontraumatic lesions of the spine. Spine

[4] Abumi K, Kaneda K, Shono Y, Fujiyama M. One-stage posterior decompression and

[5] Jones EI, Heller JG, Silcox DH, Hutton WC. Cervical pedicle screws versus lateral mass

[6] Kotani Y, Cunningham BW, Abumi K, McAfee PC. Biomechanical analysis of cervical

[7] Karaikovic EE, Kunakornsawat S, Daubs MD, Madsen TW, Gaines RW Jr. Surgical

[9] Takahashi J, Shono Y, Nakamura I, et al. Computer-assisted screw insertion for cervical

[10] Yuzawa Y, Kamimura M, Nakagawa H, et al. Surgical treatment with instrumen- tation

[11] Ogihara N, Takahashi J, Hirabayashi H, Hashidate H, Kato H. Long-term results of

[12] Uehara M, Takahashi J, Hirabayashi H, Hashidate H, Ogihara N, Mukaiyama K,

[13] Jones EI, Heller JG, Silcox DH, Hutton WC. Cervical pedicle screws versus lateral mass

[14] Kotani Y, Cunningham BW, Abumi K, McAfee PC. Biomechanical analysis of cervical

[15] Karaikovic EE, Kunakornsawat S, Daubs MD, Madsen TW, Gaines RW Jr. Surgical

[16] Tian NF, Xu HZ. Image-guided pedicle screw insertion accuracy: a meta-analysis. Int

[17] Richter M, Cakir B, Schmidt R. Cervical pedicle screws: conventional versus computer-

[18] Reinhold M, Magerl F, Rieger M, Blauth M. Cervical pedicle screw placement: feasibility

[19] Yusof MI, Ming LK, Abdullah MS, Yusof AH. Computerized tomographic

assisted placement of cannulated screws. Spine 2005;30:2280-7.

feasibility for transpedicular fixation. Spine 2006;31(8):E221-4.

disorders in rheumatoid arthritis. Eur Spine J 2007;16:485-494.

reconstruction of the cervical spine by using pedicle screw fixation systems. J

screws: Anatomic feasibility and biomechanical comparison. Spine 1997; 22:977-82.

stabilization systems: An assessment of transpedicular screw fixation in the cervical

anatomy of the cervical pedicles: Landmarks for posterior cervical pedicle entrance

for severely destructive spondyloarthropathy of cervical spine. J Spinal Disord

computer-assisted posterior occipitocervical reconstruction.World Neurosurg.

Ikegami S, Kato H. Perforation rates of cervical pedicle screw insertion by disease

screws: Anatomic feasibility and biomechanical comparison. Spine 1997; 22:977-82.

stabilization systems: An assessment of transpedicular screw fixation in the cervical

anatomy of the cervical pedicles: Landmarks for posterior cervical pedicle entrance

and accuracy of two new insertion techniques based on morphometric data. Eur

measurement of the cervical pedicles diameter in a Malaysian population and the

1997;22:1853-63.

Neurosurg 1999 ;90:19-26.

spine. Spine 1994;19:2529-39.

spine. Spine 1994;19:2529-39.

Orthop. 2009; 33:895-903.

Spine J. 2007 ;16:47-56.

Tech 2005; 18: 23-8.

2010; 73: 722-8.

localization. J Spinal Disord 2000; 13: 63-72.

and vertebral level. Open Orthop J. 2010; 4: 142-6.

localization. J Spinal Disord 2000;13:63-72.

At least 80 causes of torticollis have been documented in the literature [1]. Acutely developed torticollis may mask severe pathology requiring treatment including surgical one. First of all, it is necessary to rule out trauma as well as the destructive process of tumoral or inflammatory nature. General differential-and-diagnostic algorithms required for examination of children with torticollis have been proposed (Fig. 1).

Fig. 1. Algorithm for examination of children with torticollis (cit. by [2]).

General Description of Pediatric Acute Wryneck Condition 123

Fig. 2. Typical head position in a boy with wryneck.

knowledge is difficult [8].

**2. Etiology and pathogenesis of acute torticollis in children** 

process dissemination to the lymph nodes behind the pharynx.

beyond-range rotatory motion of the neck with head tilt [11,12].

In N. Schwarz et al. opinion, the final decision on the direct pathogenetic cause of acute atlantoaxial rotatory subluxation (AARSL) in view of the current scope of scientific

The inflammatory theory of CI subluxation was the principal until the middle of the XX century [9]. The Grisel syndrome was explained by the contracture of paravertebral muscles due to the pathological impulses from the focus of inflammation, or the inflammatory

Most contemporary authors consider the Grisel syndrome cause as a direct inflammatory involvement of the soft-tissue structures of the atlantoaxial joint. The system of veins with frequent lymph-venous anastomoses between the periodontal venous plexus and the suboccipital epidural sinus may be a hematogenous intermediary to transfer the

The theory of the entrapment of meniscoid bodies and torn ligaments in the cavity of the lateral atlantoaxial joints is more popular, and according to researchers it takes place for

After performing a series of experiments on the anatomical preparations of atlantoaxial complexes with their subsequent freezing and making frontal and sagittal saw-cuts M.N. Nikitin (1965) put forward his theory [13,14]: «In case of uncoordinated movement of the head its lateral tilt occurs which leads to the expansion of the lateral atlantoaxial joint gap contralaterally, as a result of which the anterior and posterior parts of the joint capsule go

peripharyngeal inflammatory exudate to the zone of the atlantoaxial joint [10].

In case of acutely developed torticollis without traumatic effect the working diagnosis is made as acute torticollis or suspicion of rotatory subluxation, and in case of inflammation presence in nasopharynx it is made as the Grisel syndrome.

Such a child should be observed under out-patient conditions with prescription of immobilization and non-steroid anti-inflammatory medications. X-rays should not be made because torticollis prevents patient's proper positioning. In case of the pain syndrome and forced head position retention the patient should be hospitalized for examination and treatment. Thus, the acutely developed pathological head position and the pain syndrome in a child provided for ruling out traumatic and destructive causes is considered as a condition, the basis of which, according to most authors, is idiopathic atlantoaxial fixation or subluxation of СI.

Blankstein et al. (1997), who had analyzed the data of 33 patients over four years, found a clear seasonal trend – 58% cases accounted for the period from November to February, 33% of them – for the period from April to July [4]. Nemet et al. (2002) reported that 73% of cases in their group occurred in autumn and winter [5]. None of the authors mentioned could explain the phenomenon observed.

In our group (264 patients) the appearance of acute wryneck was the most characteristic for winter/spring period (70%). In the summer time mainly pre-school children were hospitalized with acute torticollis, while in the autumn children of the older school age prevail.

In majority of patients head side bending contra lateral to painful side has prevailed (Fig. 2). The «cock-robin position» with rotational motions block, classical for atlas-axial rotational subluxation description, is observed very rarely. Head side bending has varied from 10 to 45 degrees. The amount of rotational movements is restricted towards the painful side but had always prevailed over possibility for proper head positioning.

None of the authors tried to assess the pain syndrome intensity objectively. We found no attempts to connect the manifestation degree of the pathological head position with the characteristic features of x-ray picture. Despite the fact that some authors tried to characterize the range of motion in patients, it had no effect on the final diagnosis making or treatment character.

No relationship was found in the literature between the patient's age and the pain syndrome duration as well. In general, neck pain lasts from several hours to several days [5,6].

In our group minimal time needed to cut off pain syndrome is 24 hours; maximal one – is 10 days.

We've found the direct relationship between age of patients with acute torticollis and pain syndrome duration: the older a child, the longer is pain. So in children of babyhood the maximal duration of pain syndrome was 5 days and in older schoolchildren – 10 days.

With regard to neurological status, some authors consider complete neurological intactness [7] while others point to mild neurological symptoms as weakness in the limbs and headaches [4].

In case of acutely developed torticollis without traumatic effect the working diagnosis is made as acute torticollis or suspicion of rotatory subluxation, and in case of inflammation

Such a child should be observed under out-patient conditions with prescription of immobilization and non-steroid anti-inflammatory medications. X-rays should not be made because torticollis prevents patient's proper positioning. In case of the pain syndrome and forced head position retention the patient should be hospitalized for examination and treatment. Thus, the acutely developed pathological head position and the pain syndrome in a child provided for ruling out traumatic and destructive causes is considered as a condition, the basis of which, according to most authors, is idiopathic atlantoaxial fixation or

Blankstein et al. (1997), who had analyzed the data of 33 patients over four years, found a clear seasonal trend – 58% cases accounted for the period from November to February, 33% of them – for the period from April to July [4]. Nemet et al. (2002) reported that 73% of cases in their group occurred in autumn and winter [5]. None of the authors mentioned could

In our group (264 patients) the appearance of acute wryneck was the most characteristic for winter/spring period (70%). In the summer time mainly pre-school children were hospitalized with acute torticollis, while in the autumn children of the older school age

In majority of patients head side bending contra lateral to painful side has prevailed (Fig. 2). The «cock-robin position» with rotational motions block, classical for atlas-axial rotational subluxation description, is observed very rarely. Head side bending has varied from 10 to 45 degrees. The amount of rotational movements is restricted towards the painful side but had

None of the authors tried to assess the pain syndrome intensity objectively. We found no attempts to connect the manifestation degree of the pathological head position with the characteristic features of x-ray picture. Despite the fact that some authors tried to characterize the range of motion in patients, it had no effect on the final diagnosis making or

No relationship was found in the literature between the patient's age and the pain syndrome duration as well. In general, neck pain lasts from several hours to several days

In our group minimal time needed to cut off pain syndrome is 24 hours; maximal one – is 10

We've found the direct relationship between age of patients with acute torticollis and pain syndrome duration: the older a child, the longer is pain. So in children of babyhood the maximal duration of pain syndrome was 5 days and in older schoolchildren – 10 days.

With regard to neurological status, some authors consider complete neurological intactness [7] while others point to mild neurological symptoms as weakness in the limbs and

presence in nasopharynx it is made as the Grisel syndrome.

always prevailed over possibility for proper head positioning.

subluxation of СI.

prevail.

treatment character.

[5,6].

days.

headaches [4].

explain the phenomenon observed.

Fig. 2. Typical head position in a boy with wryneck.

#### **2. Etiology and pathogenesis of acute torticollis in children**

In N. Schwarz et al. opinion, the final decision on the direct pathogenetic cause of acute atlantoaxial rotatory subluxation (AARSL) in view of the current scope of scientific knowledge is difficult [8].

The inflammatory theory of CI subluxation was the principal until the middle of the XX century [9]. The Grisel syndrome was explained by the contracture of paravertebral muscles due to the pathological impulses from the focus of inflammation, or the inflammatory process dissemination to the lymph nodes behind the pharynx.

Most contemporary authors consider the Grisel syndrome cause as a direct inflammatory involvement of the soft-tissue structures of the atlantoaxial joint. The system of veins with frequent lymph-venous anastomoses between the periodontal venous plexus and the suboccipital epidural sinus may be a hematogenous intermediary to transfer the peripharyngeal inflammatory exudate to the zone of the atlantoaxial joint [10].

The theory of the entrapment of meniscoid bodies and torn ligaments in the cavity of the lateral atlantoaxial joints is more popular, and according to researchers it takes place for beyond-range rotatory motion of the neck with head tilt [11,12].

After performing a series of experiments on the anatomical preparations of atlantoaxial complexes with their subsequent freezing and making frontal and sagittal saw-cuts M.N. Nikitin (1965) put forward his theory [13,14]: «In case of uncoordinated movement of the head its lateral tilt occurs which leads to the expansion of the lateral atlantoaxial joint gap contralaterally, as a result of which the anterior and posterior parts of the joint capsule go

General Description of Pediatric Acute Wryneck Condition 125

Fig. 4. 3-D CT of a child with AARSL. The getting of CI left articular surface to CII is clearly

The theory of acute muscular torticollis is considered in the literature as well. It is assumed that the pathological displacement of cervical vertebrae occurs due to muscle spasm [22].

The literature analysis allows to note that all the existing theories dealing with acute torticollis and AARSL development aside from intervertebral blocking are not confirmed by modern research methods (CT, MRI) and are the result of the authors' assumptions only. The lack of clarity in determining the causal relationships of all the theories proposed is not unimportant. No assumption clearly answers the question, what is the starting point for

Maigne et al. (2003) have performed MRI of cervical spine in a 15-year adolescent in the early hours from the onset of typical acute torticollis developed after night sleep [23]. The authors did not rule out the disorder of СI-CII relation, but the signs of signal intensification were not found there. A hyperintensive wedge-shaped signal was determined by them in the zone of CII-CIII uncovertebral articulation on the side of pains (Fig. 5). It disappeared after three weeks by control MRI data. Torticollis quickly resolved by conservative treatment. The authors explained the finding by acutely occurred rupture of the

suffering beginning. Is CI subluxation the cause of the problem or its consequence ?

determined (our case).

intervertebral disc.

deeply into the joint cavity as folds by 2/3 of the joint sagittal length at the expense of negative pressure (normally this hollow amounts to ½ of the joint sagittal length). The tension of the joint capsule lateral part, which occurs at that, causes irritation of nerve endings, thereby leading to reflex protective contraction of the muscles around the atlantoaxial complex, with entrapment of the capsule folds deepened and development of the joint blockade». This theory explains frequent beginning of acute AARSL from a sharp spasm of muscles during movements.

Another theory consists in atlas lateral mass getting on the side of its forward rotation to axis underlying part with joint gap overlapping (intervertebral blocking) [15-21]. This manifests itself as the radiological symptom of «winking». The coupling of the adjacent articular facets of the lateral atlantoaxial joints takes place in case of their getting (Fig. 3).

Fig. 3. «Winking» symptom in a child with AARSL. Marked СI-CII articulation locked (our case).

It should be noted that the analysis of the works demonstrating AARSL picture by dynamic 3-D CT confirms this point of view (Fig. 4).

deeply into the joint cavity as folds by 2/3 of the joint sagittal length at the expense of negative pressure (normally this hollow amounts to ½ of the joint sagittal length). The tension of the joint capsule lateral part, which occurs at that, causes irritation of nerve endings, thereby leading to reflex protective contraction of the muscles around the atlantoaxial complex, with entrapment of the capsule folds deepened and development of the joint blockade». This theory explains frequent beginning of acute AARSL from a sharp

Another theory consists in atlas lateral mass getting on the side of its forward rotation to axis underlying part with joint gap overlapping (intervertebral blocking) [15-21]. This manifests itself as the radiological symptom of «winking». The coupling of the adjacent articular facets of the lateral atlantoaxial joints takes place in case of their getting (Fig. 3).

Fig. 3. «Winking» symptom in a child with AARSL. Marked СI-CII articulation locked (our

It should be noted that the analysis of the works demonstrating AARSL picture by dynamic

spasm of muscles during movements.

case).

3-D CT confirms this point of view (Fig. 4).

Fig. 4. 3-D CT of a child with AARSL. The getting of CI left articular surface to CII is clearly determined (our case).

The theory of acute muscular torticollis is considered in the literature as well. It is assumed that the pathological displacement of cervical vertebrae occurs due to muscle spasm [22].

The literature analysis allows to note that all the existing theories dealing with acute torticollis and AARSL development aside from intervertebral blocking are not confirmed by modern research methods (CT, MRI) and are the result of the authors' assumptions only. The lack of clarity in determining the causal relationships of all the theories proposed is not unimportant. No assumption clearly answers the question, what is the starting point for suffering beginning. Is CI subluxation the cause of the problem or its consequence ?

Maigne et al. (2003) have performed MRI of cervical spine in a 15-year adolescent in the early hours from the onset of typical acute torticollis developed after night sleep [23]. The authors did not rule out the disorder of СI-CII relation, but the signs of signal intensification were not found there. A hyperintensive wedge-shaped signal was determined by them in the zone of CII-CIII uncovertebral articulation on the side of pains (Fig. 5). It disappeared after three weeks by control MRI data. Torticollis quickly resolved by conservative treatment. The authors explained the finding by acutely occurred rupture of the intervertebral disc.

General Description of Pediatric Acute Wryneck Condition 127

Fig. 6. MRI in the fat inhibition mode in 10 children with acute torticollis. The triangular area of hyperintensive signal is clearly seen in posterior-lateral parts of intervertebral space.

We propose the following mechanism of the syndrome development called "the uncovertebral wedge" [24,25]. Periosteal-facsial tissue in the area of uncovertebral joint is restricted by: hard borders of the disk fibrous ring from interiorly, posterior longitudinal ligament from posterior, hamus of caudal vertebra laterally and lamina of cranial vertebra from anterior. The reason of acute torticollis in children is in sharp or gradual compression of periosteal-facsial tissue in the uncovertebral fissure resulting from head movement or from long neck sidebending (sleep) with formation of a "wedge" from edematous tissue which irritates posterior longitudinal ligament. It leads to antalgic head position and, in some cases, to atlas-axial block. That's why traction reducing pressure in the uncovertebral fissure and contributing in venous drainage improvement and problem resolution is so efficient. Following arguments in favor of the given supposition seem to be equally

1. Uncovertebral joint is an exclusive anatomical neck specific, that's why similar

2. Pain appearance and its amplification in vertical posture, for here the pressure applied to intervertebral disk and correspondingly to uncovertebral "fissure" is increased.

conditions in children occur neither in lumbar nor in thoracic spine.

The disk outline is separated from this area.

important:

Fig. 5. A hyperintensive wedge-shaped signal in the zone of CII-CIII uncovertebral articulation (cit. [23]).

For identification of given pathological condition reasons we accepted a tactics of special MRI mode use in first hours after the patient's submission [24] .

We have made randomized sampling of patients with acute torticollis and atlas-axial block with a single selection criteria – first 12 hours after disease appearance. It has found to be reasonable for in 10 patients examined in succession, typical alteration were detected. They consisted in area of marked glowing of triangular or longitudinal shape in the area of external edge of C2-C3 or C3-C4 disk, and this glowing was always on the painful side (Fig. 6). The same findings that was presented by Maigne et al.

Fig. 5. A hyperintensive wedge-shaped signal in the zone of CII-CIII uncovertebral

MRI mode use in first hours after the patient's submission [24] .

6). The same findings that was presented by Maigne et al.

For identification of given pathological condition reasons we accepted a tactics of special

We have made randomized sampling of patients with acute torticollis and atlas-axial block with a single selection criteria – first 12 hours after disease appearance. It has found to be reasonable for in 10 patients examined in succession, typical alteration were detected. They consisted in area of marked glowing of triangular or longitudinal shape in the area of external edge of C2-C3 or C3-C4 disk, and this glowing was always on the painful side (Fig.

articulation (cit. [23]).

Fig. 6. MRI in the fat inhibition mode in 10 children with acute torticollis. The triangular area of hyperintensive signal is clearly seen in posterior-lateral parts of intervertebral space. The disk outline is separated from this area.

We propose the following mechanism of the syndrome development called "the uncovertebral wedge" [24,25]. Periosteal-facsial tissue in the area of uncovertebral joint is restricted by: hard borders of the disk fibrous ring from interiorly, posterior longitudinal ligament from posterior, hamus of caudal vertebra laterally and lamina of cranial vertebra from anterior. The reason of acute torticollis in children is in sharp or gradual compression of periosteal-facsial tissue in the uncovertebral fissure resulting from head movement or from long neck sidebending (sleep) with formation of a "wedge" from edematous tissue which irritates posterior longitudinal ligament. It leads to antalgic head position and, in some cases, to atlas-axial block. That's why traction reducing pressure in the uncovertebral fissure and contributing in venous drainage improvement and problem resolution is so efficient. Following arguments in favor of the given supposition seem to be equally important:


General Description of Pediatric Acute Wryneck Condition 129

Type I Type II

Type III Type IV

Type of acute AARSL CI sagittal displacement Size of Cruveilhier joint gap

Type I Absent 3 mm Type II Anterior 3-5 mm Type III Anterior › 5 mm Type IV Posterior -

Fig. 7. Acute AARSL classification (cit. by [32]).


We suppose that age-related reduction and disappearance of acute torticollis and atlas-axial subluxations in adults is related to decrease of intervertebral disks resilience, to presence of powerful motion restrictors in the form of well-developed uncovertebral joints and to degenerative changes in Luschka joints.

#### **3. Radiological findings in children with acute wryneck.**

The vast majority of works deals with studying the atlantoaxial articulation X-rays. Some authors believe that the sign of asymmetric axis odontoid process location relative to atlas lateral masses is quite sufficient to make the diagnosis [26,27]. Others have doubts about the reliability of the most x-ray signs observed connecting them with the inability to achieve proper positioning in the process of x-ray study [28,29] or consider them as a variant of the norm [30]. While performing plane radiography Nicholson et al. (1999) reported that acute AARSL was not diagnosed in 67% of cases in their group of patients, and hyperdiagnosis had place in 29% of the cases [31]. That is to say, the radiological method has been recognized to be questionable in terms of assessing CI-CII relation for acute torticollis! Nevertheless, the most widely used classification of acute atlantoaxial rotatory subluxation has been proposed based on the clinical picture and radiological technique (Fig. 7). There are no Types III and IV in children.

The methods of dynamic radiography and cineradiography have not become popular because of the high level of radiation exposure [33].

The appearance of computer tomography in the 70-s of the ХХ century allowed researchers to define the details of atlas displacement more accurately [34-36]

At present dynamic and 3-D CT are mainly used [37]. Li et Pang (1995) have developed the criteria of 3-D dynamic CT using to define the diagnosis more exactly and develop the tactics for treating the atlantoaxial fixation [38]. They have refined the classification of Fielding J.W. et Hawkins R.J:

Type I – CI-CII is blocked with corrective rotation of the head;

Type II – СI-CII relation is improved with corrective rotation of the head:

Type IIА – СI-CII relation does not reach 0º with corrective rotation of the head;

Type IIB – СI-CII relation reaches 10º of rotation not more in the direction opposite blocking.

The more perfect tomography methods became and the more material collected, the more frequent were the data of the absence of visualization of the pathology in the atlantoaxial segment for the typical clinical picture of acute torticollis. Thus, Alanay et al. (2002) examined 15 girls and 21 boys at the age of 4-16 years with acute torticollis using dynamic CT, and they did not find the difference in СI-CII relations between them and normal children subjected to the similar study [39].

3. Larger occurrence of acute torticollis in autumn/winter period may be explained by large amount of inflammatory alterations from the side of nasopharynx, that leads to

We suppose that age-related reduction and disappearance of acute torticollis and atlas-axial subluxations in adults is related to decrease of intervertebral disks resilience, to presence of powerful motion restrictors in the form of well-developed uncovertebral joints and to

The vast majority of works deals with studying the atlantoaxial articulation X-rays. Some authors believe that the sign of asymmetric axis odontoid process location relative to atlas lateral masses is quite sufficient to make the diagnosis [26,27]. Others have doubts about the reliability of the most x-ray signs observed connecting them with the inability to achieve proper positioning in the process of x-ray study [28,29] or consider them as a variant of the norm [30]. While performing plane radiography Nicholson et al. (1999) reported that acute AARSL was not diagnosed in 67% of cases in their group of patients, and hyperdiagnosis had place in 29% of the cases [31]. That is to say, the radiological method has been recognized to be questionable in terms of assessing CI-CII relation for acute torticollis! Nevertheless, the most widely used classification of acute atlantoaxial rotatory subluxation has been proposed based on the clinical picture and radiological technique (Fig. 7). There are

The methods of dynamic radiography and cineradiography have not become popular

The appearance of computer tomography in the 70-s of the ХХ century allowed researchers

At present dynamic and 3-D CT are mainly used [37]. Li et Pang (1995) have developed the criteria of 3-D dynamic CT using to define the diagnosis more exactly and develop the tactics for treating the atlantoaxial fixation [38]. They have refined the classification of

Type IIB – СI-CII relation reaches 10º of rotation not more in the direction opposite blocking. The more perfect tomography methods became and the more material collected, the more frequent were the data of the absence of visualization of the pathology in the atlantoaxial segment for the typical clinical picture of acute torticollis. Thus, Alanay et al. (2002) examined 15 girls and 21 boys at the age of 4-16 years with acute torticollis using dynamic CT, and they did not find the difference in СI-CII relations between them and normal

venous drainage and adjacent tissue deterioration and edema complications. 4. Pathologically explainable becomes not only antalgic scoliosis (torticollis), but

frequently observed kyphotic deformities in the cervical spine.

**3. Radiological findings in children with acute wryneck.** 

degenerative changes in Luschka joints.

no Types III and IV in children.

Fielding J.W. et Hawkins R.J:

children subjected to the similar study [39].

because of the high level of radiation exposure [33].

to define the details of atlas displacement more accurately [34-36]

Type I – CI-CII is blocked with corrective rotation of the head;

Type II – СI-CII relation is improved with corrective rotation of the head:

Type IIА – СI-CII relation does not reach 0º with corrective rotation of the head;

Type I Type II

Type III Type IV


Fig. 7. Acute AARSL classification (cit. by [32]).

General Description of Pediatric Acute Wryneck Condition 131

Fig. 8. Algorithm of surgeon's actions in case of admission of patients with acute pain syndrome and constrained head position. 3 incremental "danger levels". The pyramid

[1] Staheli, L.T. Practice of pediatric orthopedics / L.T. Staheli. – Philadelphia : Lippincot

[2] Ballock, R. The Prevalence of Nonmuscular Causes of Torticollis in Children / R. Ballock,

[3] Clark Ch.R. The сervical spine / Ch.R. Clark. – 4th ed. – Philadelphia : Lippincot and

[4] Blankstein, A. Acquired torticollis in hospitalized children / A. Blankstein [et al.] //

[5] Nemet D. Acute acquired non-traumatic torticollis in hospitalized children / D. Nemet

[6] Phillips, W.A. The management of rotatory atlanto-axial subluxation in children / W.A. Phillips, R. Hensinger // J. Bone Joint Surg. – 1989. – Vol. 71-A, N5. – P. 664–668.

K. Song // J. Pediatr. Orthop. – 1996. – Vol. 16, N 4. – P. 500–504.

narrowing to the 3rd level symbolically reflects amount of patients.

Harefuah. – 1997. – Vol. 133. – N 12. – P. 616–619.

[et al.] // Harefuah. – 2002. – Vol. 141, N 6. – P. 519–521.

and Wilkins, 2006. – 460 p.

Wilkins, 2005. – 1250 p.

**6. References** 

In the authors' opinion, there is no need to use dynamic CT in case of the fundamentally good-quality condition with spontaneous recovery which is represented by acute torticollis. They propose to use tomography in the cases of prolonged (more than one week) pain syndrome only. They have confirmed their first work by the second one with mathematical analysis and come to the same conclusions [40]. Other researches also had difficulties in the interpretation of CT picture for acute torticollis in children [41]. The main answer is absent in all the CT observations found in the literature: whether СI-CII relation disorder is a primary problem or a secondary positioning of the head. First of all, its use is justified for chronic AARSL [42].

Mainly MRI for torticollis is used to rule out a traumatic or destructive process [43].

#### **4. Management of acute wryneck**

Some authors within the end of the XIX century-first half of the XX century recommended to perform acute manual reduction for the purpose of subluxation elimination. The technique developed by Heister and Richet-Hueter was used for this purpose [44]. However, by the 60-s of the XX century this technique has lost its popularity, and most of the authors has recommended to perform loop traction.

The standard treatment regimen for patients with acute torticollis (suspicion of acute AARSL) has been reflected in most guides to Orthopedics (cit. by [3]):


#### **5. Conclusion**

Children with sudden pain in the neck and constrained head position are frequent pediatric patients. It is reasonable to make a syndrome-related diagnosis on the stage of initial examination. The main task for a doctor is to separate those from the patients whose condition demands more profound examination, observation and treatment.

It is impossible to provide each patient with acute torticollis with full radiological examination and long observation in the hospital. That's why it is necessary to single out "danger levels" to provide this patients' group with adequate management [45]. We propose to single out 3 levels built by exclusion method (Fig. 8).

First level represents main flow of patients with multietiological and, in majority of cases, with "innocent" damages of cervical spine.

Second level represents patients with true atlas-axial subluxations demanding obligatory traction treatment to prevent pathology transition to chronic stage.

Third level includes patients with risk of mechanical and neurological instability demanding, as a rule, operative treatment. Besides usual injury it includes children with cervical developmental defects manifestation.

In the authors' opinion, there is no need to use dynamic CT in case of the fundamentally good-quality condition with spontaneous recovery which is represented by acute torticollis. They propose to use tomography in the cases of prolonged (more than one week) pain syndrome only. They have confirmed their first work by the second one with mathematical analysis and come to the same conclusions [40]. Other researches also had difficulties in the interpretation of CT picture for acute torticollis in children [41]. The main answer is absent in all the CT observations found in the literature: whether СI-CII relation disorder is a primary problem or a secondary positioning of the head. First of all, its use is justified for

Mainly MRI for torticollis is used to rule out a traumatic or destructive process [43].

Some authors within the end of the XIX century-first half of the XX century recommended to perform acute manual reduction for the purpose of subluxation elimination. The technique developed by Heister and Richet-Hueter was used for this purpose [44]. However, by the 60-s of the XX century this technique has lost its popularity, and most of the authors has

The standard treatment regimen for patients with acute torticollis (suspicion of acute

1. Below one week: immobilization with soft collar, analgesics, bed rest; in case of

2. Above one week, but below one month: hospitalization, loop traction, cervical collar for

Children with sudden pain in the neck and constrained head position are frequent pediatric patients. It is reasonable to make a syndrome-related diagnosis on the stage of initial examination. The main task for a doctor is to separate those from the patients whose

It is impossible to provide each patient with acute torticollis with full radiological examination and long observation in the hospital. That's why it is necessary to single out "danger levels" to provide this patients' group with adequate management [45]. We

First level represents main flow of patients with multietiological and, in majority of cases,

Second level represents patients with true atlas-axial subluxations demanding obligatory

Third level includes patients with risk of mechanical and neurological instability demanding, as a rule, operative treatment. Besides usual injury it includes children with

3. Above one month: hospitalization, skeletal traction, cervical collar for 4-6 weeks.

condition demands more profound examination, observation and treatment.

propose to single out 3 levels built by exclusion method (Fig. 8).

traction treatment to prevent pathology transition to chronic stage.

with "innocent" damages of cervical spine.

cervical developmental defects manifestation.

AARSL) has been reflected in most guides to Orthopedics (cit. by [3]):

chronic AARSL [42].

4-6 weeks;

**5. Conclusion** 

**4. Management of acute wryneck** 

recommended to perform loop traction.

recovery absence: hospitalization, traction;

Fig. 8. Algorithm of surgeon's actions in case of admission of patients with acute pain syndrome and constrained head position. 3 incremental "danger levels". The pyramid narrowing to the 3rd level symbolically reflects amount of patients.

#### **6. References**


General Description of Pediatric Acute Wryneck Condition 133

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**Part 5** 

**Spinal Cord Injury** 

