Feasibility of occipital condyle screw placement in patients with Chiari malformation type I

Acta Neurochirurgica (2021) 163:1569–1575

The occipital condyle (OC) screw is an alternative technique for occipitocervical fixation that is especially suitable for revision surgery in patients with Chiari malformation type I (CMI). This study aimed to investigate the feasibility and safety of this technique in patients with CMI.

Methods The CT data of 73 CMI patients and 73 healthy controls were retrospectively analyzed. The dimensions of OCs, including length, width, height, sagittal angle, and screw length, were measured in the axial, sagittal, and coronal planes using CT images. The OC available height was measured in the reconstructed oblique parasagittal plane of the trajectory.

Results The mean length, width, and height of OCs in CMI patients were 17.79   2.31 mm, 11.20   1.28 mm, and 5.87   1.29 mm, respectively. All OC dimensions were significantly smaller in CMI patients compared with healthy controls. The mean screw length and sagittal angle were 19.13   1.97 mm and 33.94    5.43 , respectively. The mean OC available height was 6.36   1.59 mm. According to criteria based on OC available height and width, 52.1% (76/146) of OCs in CMI patients could safely accommodate a 3.5-mm-diameter screw.

Conclusions The OC screw is feasible in approximately half of OCs in CMI patients. Careful morphometric analyses and personalized surgical plans are necessary for the success of this operation in CMI patients.

Stabilization of Tumor-Associated Craniovertebral Junction Instability

Neurosurgery 81:251–258, 2017

Whether primary or metastatic, tumors of the craniovertebral junction (CVJ) are rare and challenging.

OBJECTIVE: To examine the surgical indications, operative variables, and outcomes in patients with tumors of the CVJ undergoing occipitocervical (OC) stabilization.

METHODS: A single-institution, retrospective case series was performed from a prospectively maintained spine database. Patients with primary or metastatic tumors of the CVJ who underwent OC stabilization were identified. Out of 46 patients who underwent OC fusion, 39 were for tumor. Paired t-tests and Wilcoxon rank-sum tests were performed to assess for postoperative changes.

RESULTS: Ten patients (26%) harbored primary tumors, and the remaining 29 (74%) had metastatic disease. Of the metastatic patients, 14 had a neurological deficit, 10 had severe neck pain, and 5 were deemed mechanically unstable. Postoperative visual analog pain scoreswere significantly reduced at all 3 follow-up times (P<.001, 95% confidence interval [CI; 3.2, 6.0]; P = .001, 95% CI [2.6, 7.7]; P = .020, 95% CI [0.6, 5.5]). The percentage of patients who were ambulatory and neurologically improved or intact remained stable postoperatively with no significant declines. There were 2 perioperative mortalities (5%), and 13 patients (33%) experienced a major complication.

CONCLUSIONS: In patients with primary or metastatic tumor of the CVJ, OC stabilization using a cervical screw-rod system affixed to a midline-keel buttress plate, with or without posterior decompression, is a reliable method for CVJ stabilization in the oncologic setting. Improvement in pain and preservation of neurological function was seen.


Management of Operative Complications Related to Occipitocervical Instrumentation


Neurosurgery 72[ONS Suppl 2]:ons214–ons228, 2013

The continued evolution of instrumentation techniques for fusions at the craniovertebral junction has enabled surgical treatment of a wide range of developmental, neoplastic, traumatic, and degenerative conditions. There has been an increased recognition of the morbidity associated with the complications secondary to occipitocervical instrumentation.

OBJECTIVE: To present representative complications secondary to occipitocervical instrumentation in patients who presented to our institution and to emphasize underlying principles in diagnosis and management of craniovertebral disease conditions through illustrative examples of their presentation, management, and follow-up.

METHODS: Clinical records for patients referred to the senior author (A.H.M.) between 2005 and 2010 for evaluation and management of their symptoms arising as a consequence of surgical intervention by a different primary neurosurgeon were reviewed.

RESULTS: Eight patients were identified with representative complications secondary to occipitocervical instrumentation. These complications included incorrect surgical technique, persistent instability, hardware misplacement with potential for vascular injury, associated neural injury, and secondary complications of wound healing resulting from methyl methacrylate use. Surgical revision was required in 2 patients. The remaining patients improved with removal of the offending hardware and acrylic cement. All patients reported symptom resolution, and dynamic imaging studies on follow-up indicated stable alignment and bony fusion.

CONCLUSION: These cases serve as illustrative examples of the spectrum of neural, vascular, biomechanical, and instrument-related complications associated with occipitocervical arthrodesis. Basic principles of occipitocervical instrumentation that enable safe and successful treatment of craniovertebral junction disease conditions have been highlighted. Potential complications and management strategies are discussed.

Axial Spondylectomy and Circumferential Reconstruction via a Posterior Approach

Axial spondylectomy

Neurosurgery 72:300–309, 2013

Spinal metastases of the second cervical vertebra are a subset of tumors that are particularly difficult to address surgically. Previously described techniques require highly morbid circumferential dissection posterior to the pharynx for resection and reconstruction.

OBJECTIVE: To perform a biomechanical analysis of instrumented reconstruction configurations used after axial spondylectomy and to demonstrate safe use of a novel construct in a patient case report.

METHODS: Several different published and novel reconstruction configurations were inserted into 7 occipitocervical spines that underwent axial spondylectomy. A biomechanical analysis of the stiffness of the constructs in flexion and extension, lateral bending, and rotation was performed. A patient then underwent a posterior-only approach for axial spondylectomy and circumferential reconstruction.

RESULTS: Biomechanical analysis of different constructs demonstrated that anterior column reconstruction with bilateral cages spanning the C1 lateral mass to the C3 facet in combination with occipitocervical instrumentation was superior in flexion-extension and equivalent in lateral bending and rotation to currently used constructs. The patient in whom this construct was placed via a posterior-only approach for axial spondylectomy and instrumentation remained at neurological baseline and demonstrated no recurrence of local disease or failure of instrumentation to date.

CONCLUSION: When C1 lateral mass to C3 facet bilateral cage plus occipitocervical instrumentation is compared with existing anterior and posterior constructs, this novel reconstruction is biomechanically equivalent if not superior in performance. In a patient, the posterior-only approach for C2 spondylectomy with the novel reconstruction was safe and durable and avoided the morbidity of the anterior approach.

A systematic review of occipital cervical fusion: techniques and outcomes

J Neurosurg Spine 13:5–16, 2010. DOI: 10.3171/2010.3.SPINE08143

Numerous techniques have been historically used for occipitocervical fusion with varied results. The purpose of this study was to examine outcomes of various surgical techniques used in patients with various disease states to elucidate the most efficacious method of stabilization of the occipitocervical junction.

Methods. A literature search of peer-reviewed articles was performed using PubMed and CINAHL/Ovid. The key words “occipitocervical fusion,” “occipitocervical fixation,” “cervical instrumentation,” and “occipitocervical instrumentation” were used to search for relevant articles. Thirty-four studies were identified that met the search criteria. Within these studies, 799 adult patients who underwent posterior occipitocervical fusion were analyzed for radiographic and clinical outcomes including fusion rate, time to fusion, neurological outcomes, and the rate of adverse events.

Results. No articles stronger than Class IV were identified in the literature. Among the patients identified within the cited articles, the use of posterior screw/rod instrumentation constructs were associated with a lower rate of postoperative adverse events (33.33%) (p < 0.0001), lower rates of instrumentation failure (7.89%) (p < 0.0001), and improved neurological outcomes (81.58%) (p < 0.0001) when compared with posterior wiring/rod, screw/plate, and onlay in situ bone grafting techniques. The surgical technique associated with the highest fusion rate was posterior wiring and rods (95.9%) (p = 0.0484), which also demonstrated the shortest fusion time (p < 0.0064). Screw/rod techniques also had a high fusion rate, fusing in 93.02% of cases. When comparing outcomes of surgical techniques depending on the disease status, inflammatory diseases had the lowest rate of instrumentation failure (0%) and the highest rate of neurological improvement (90.91%) following the use of screw/rod techniques. Occipitocervical fusion performed for the treatment of tumors by using screw/rod techniques had the lowest fusion rate (57.14%) (p = 0.0089). Traumatic causes of occipitocervical instability had the highest percentage of pain improvement with the use of screw/plates (100% improvement) (p < 0.0001).

Conclusions. Based on the existing literature, techniques that use screw/rod constructs in occipitocervical fusion are associated with very favorable outcomes in all categories assessed for all disease processes. For patients requiring occipitocervical arthrodesis for the treatment of inflammatory diseases, screw/rod constructs are associated with the most favorable outcomes, while posterior wiring and onlay in situ bone grafting is associated with the least favorable outcomes. Occipitocervical arthrodesis performed for the diagnosis of tumor is associated with the lowest rate of successful arthrodesis using screw/rod techniques, while posterior wiring and rods have the highest rate of arthrodesis. The nonspecified disease group had the lowest rate of surgical adverse events and the highest rate of neurological improvement.

Occipital condyle fractures: clinical decision rule and surgical management

JNS Spine DOI: 10.3171/2009.5.SPINE08866

Object. Occipital condyle fractures (OCFs) are rare injuries and their treatment remains controversial. Several classification systems have been proposed, first by Anderson and Montesano and more recently by Tuli and colleagues and Hanson and associates, who sought to stratify these fractures in a manner that would guide treatment that has typically ranged from semirigid collar immobilization to halo fixation or occipitocervical fusion. It has been the authors’ impression, based on experience with OCFs at their institution, that classification is cumbersome and contributes little to the clinical decision-making process, while the identification of craniocervical misalignment and neural element compromise is paramount, and sufficient, for the planning of treatment.

Methods. The authors performed a retrospective review of 24,745 consecutive trauma presentations to a single Level I trauma center (UPMC Presbyterian Hospital) over a 6-year period, identifying 100 patients with 106 OCFs. All patients were evaluated by the spine trauma service and underwent imaging of the craniocervical junction using reconstructed CT scans. Patient characteristics, fracture characteristics (including fracture classification according to the 2 major classification systems), initial management, and status at follow-up were recorded.

Results. The incidence of OCF in this trauma population was 0.4%. Two patients had evidence of craniocervical misalignment on reconstructed CT imaging at the time of admission; both patients underwent occipitocervical fusion. One patient underwent occipitocervical fusion for unrelated C1–2 fractures. The remainder of those surviving to discharge, whose fractures represented all fracture subtypes, received treatment with a rigid cervical collar or counseling alone. No patients, including 4 patients with bilateral OCFs, were found to have developed delayed craniocervical instability or misalignment on follow-up, or to require further neurosurgical intervention for an OCF. Neural element compression was not identified in any of the patients, and there were no cases of delayed cranial neuropathy.

Conclusions. Beyond the identification of craniocervical misalignment on reconstructed CT scans at admission, further classification of OCFs is unnecessary. Management should consist of up-front occipitocervical fusion or halo fixation in cases demonstrating occipitocervical misalignment, or of immobilization in a rigid cervical collar followed by delayed clinical and radiographic evaluation in a spine trauma clinic if misalignment is not present.