Hakim Azfar Ali, MD

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/hakim-azfar-ali-md

Sagittal plane analysis of adolescent idiopathic scoliosis: the effect of anterior versus posterior instrumentation symptoms umbilical hernia order 100 ml duphalac free shipping. Radiographic outcomes of anterior spinal fusion versus posterior spinal fusion with thoracic pedicle screws for treatment of Lenke Type I adolescent idiopathic scoliosis curves medications 126 trusted duphalac 100 ml. Thoracic adolescent idiopathic scoliosis curves between 70 degrees and 100 degrees: is anterior release necessary Direct vertebral rotation: a new technique of three-dimensional deformity correction with segmental pedicle screw fixation in adolescent idiopathic scoliosis 10 medications doctors wont take buy duphalac line. Impact of direct vertebral body derotation on rib prominence: are preoperative factors predictive of changes in rib prominence Direct vertebral body derotation medicine with codeine duphalac 100 ml order on-line, thoracoplasty medicine vs medication 100 ml duphalac order with amex, or both: which is better with respect to inclinometer and scoliosis research society-22 scores Analysis of pulmonary function and axis rotation in adolescent and young adult idiopathic scoliosis patients treated with Cotrel-Dubousset instrumentation. Rotational changes of the vertebral-pelvic axis following Cotrel-Dubousset instrumentation. Analysis of pulmonary function and chest cage dimension changes after thoracoplasty in idiopathic scoliosis. Monaxial versus multiaxial thoracic pedicle screws in the correction of adolescent idiopathic scoliosis. J Bone Joint Surg Am 2007;89(Suppl 2, Pt 2):297­309 Bess S, Boachie-Adjei O, Burton D, et al; International Spine Study Group. Pain and disability determine treatment modality for older patients with adult scoliosis, while deformity guides treatment for younger patients. The incidence and outcomes of vertebral column resection in paediatric patients: a population-based, multicentre, follow-up study. Pseudarthrosis in adult spinal deformity following multisegmental instrumentation and arthrodesis. Biomechanical analysis of sacral screw strain and range of motion in long posterior spinal fixation constructs: effects of lumbosacral fixation strategies in reducing sacral screw strains. Surgeons have responded with en thusiasm after applying various minimally invasive techniques to the correction of spinal deformity and seeing first-hand that the potential benefits are more pronounced. Generally, the indications for treating deformity include back or leg pain that is due to adult idiopathic scoliosis, iatrogenic deformity (flat back syndromes), and lumbar degenerative scoliosis. Curves can be (1) primarily scoliotic with normal sagittal balance, (2) kyphoscoliotic, or (3) primarily ky photic resulting in positive sagittal balance. Open surgical techniques, including osteotomies of various kinds, effectively address the full spectrum of spinal deformities. However, these surgeries involve significant blood loss and long hospitalizations, and a considerable risk of morbidity and com plications. Percutaneous techniques that obviate excessive blood loss and tissue disruption can effectively address primarily coronal curves in adult degenerative scoliosis. Moreover, newer advanced techniques have shown great promise in effectively treating ky photic curves with positive sagittal balance. This algorithm was validated by 11 fellowshiptrained mini mally invasive spine surgeons who applied the algorithm to a set of 20 published deformity cases. It offers large surface areas for interbody fusion, effective indirect decompression of central canal and foraminal stenosis, and excellent clinical outcomes. Likewise, its application for coronal deformity correction has been gaining wide success. Supplemental pedicle screw fixation is done percutaneously and has been shown to offer more stability, improved correction, and decreased risk of graft subsidence. The range of preoperative aver age coronal Cobb angles in these reports range from 18. Following correction, the postoperative average coronal Cobb angle improvement ranges from 6. The second stage consisted of percutaneous pedicle screw fixation spanning T11 through the sacrum/ilium as well as facet fusions at T11-12, L1-2, and L2-3. There is debate on whether to approach the correction from the concavity or the convexity. Proponents of the convexity approach report that it can address multiple levels through one or two incisions, and access to the L4-L5 level is easier if the iliac crest is avoided. Proponents of the concavity approach report that it provides better corrective forces with less stretch injury to the lumbar plexus. Recently, pedicle subtrac tion osteotomies have been performed in minimally invasive or miniopen fashions with promising results. Often this procedure is used as an alternative to lateral interbody fusions for the correction of spondylolisthesis and lateral listhesis in the setting of coronal and sagittal defor mity12. This Kirschner wire (K-wire)-based technique depends entirely on fluoroscopic guidance. Navigation that obvi ates the need for fluoroscopy also has been used in percutaneous pedicle screw placement with comparable accuracy. Lateral fluoroscopic imaging is helpful to ensure appropriate seating of the rod through the tulips or extended tabs prior to the application of the set screws. More over, sequential and stepwise tightening of the set screws is recommended to avoid screw loosening and pullout. Set screws are then applied, and the extended tabs are removed or broken off the screw heads. Conclusion With better understanding and appreciation of the impact of spinopelvic parameters on outcomes following spine surgery, there has been an increase in the number of deformity surgeries performed in the past two decades. These surgeries are often associated with a significant amount of blood loss, morbidity, and even mortality. Minimally invasive techniques that obviate muscle dissection and stripping have shown promise in the cor rection of spinal deformity while minimizing the morbidity in select patients. Management of sagittal balance in adult spinal deformity with mini mally invasive anterolateral lumbar interbody fusion: a preliminary ra diographic study. The minimally invasive spinal deformity surgery algorithm: a reproducible rational framework for decision making in minimally invasive spinal deformity surgery. Biomechanics of lateral plate and pedicle screw constructs in lumbar spines instrumented at two levels with laterally placed interbody cages. Minimally invasive lumbar inter body fusion in patients older than 70 years of age: analysis of peri- and postoperative complications. Anterior longitudinal ligament release using the minimally invasive lateral retro peritoneal transpsoas approach: a cadaveric feasibility study and report of 4 clinical cases. Out come following unilateral versus bilateral instrumentation in patients undergoing minimally invasive transforaminal lumbar interbody fusion: a singlecenter randomized prospective study. Segmental lumbar sagittal correction after bilateral transforaminal lumbar interbody fusion. Effect of steerable cage placement during minimally invasive transforaminal lumbar interbody fusion on lumbar lordosis. Transforaminal lumbar interbody fusion versus an terior lumbar interbody fusion as an adjunct to posterior instrumented correction of degenerative lumbar scoliosis: three year clinical and radio graphic outcomes. Intraoperative navigation in minimally invasive transforaminal lumbar interbody fusion and lateral interbody fusion. Smith Compressive lesions in the thoracic spine often present with a gradual onset of symptoms and varied clinical manifestations, making the diagnosis and management challenging. Conservative therapy for thoracic myelopathy secondary to compressive lesions is often ineffective, as these patients invariably have progressive symptoms. In cases involving multiple levels, surgical approach­related morbidity and iatrogenic spinal instability become a concern. Traditionally, the surgical intervention of choice involves multiple consecutive-level laminectomies with resection of the lesion through a large midline incision. This approach exposes the patient to extensive bilateral subperiosteal dissection of the paraspinal musculature and significant removal of the posterior spinal elements to expose the contents of the thoracic spinal canal. It is recognized that these large approaches predispose patients to significant postoperative pain and the potential for chronic pain. Additionally, extensive removal of the bony and ligamentous structures increases stress and loading on the facets of the surgical and adjacent levels. Biomechanical models have shown increased segmental instability following an open laminectomy procedure when compared with a unilateral minimally invasive hemilaminotomy procedure. Furthermore, studies have suggested that the increased spinal instability resulting from multiple consecutive-level laminectomies may predispose patients to degenerative disease and iatrogenic spinal deformity, which is even more pronounced in the pediatric population. The lesions resected were causing symptomatic neural compression spanning one or two levels in the cervical, thoracic, and lumbar spine. Smith et al8 expanded upon this approach by describing a technique used for exposure and resection of extensive multilevel thoracic lesions through a minimally invasive thoracic decompression procedure. This procedure was performed through two small entry points at the cephalad and caudal ends of the pathology. Unilateral hemilaminotomies were performed through each entry point to enable resection of the lesions. The patients in this case series were experiencing myelopathy from lesions spanning five or six levels in the thoracic spine. In contrast to the traditional open procedure, the minimal access approach for multilevel decompression in the thoracic spine limits approach-related soft tissue injury, spares more of the posterior elements and bony anatomy, and decreases the alteration of spinal biomechanics and iatrogenic instability. Patient Selection Patients presenting with clinical myelopathy and radiographic evidence of structural thoracic spinal cord compression as a result of a dorsally located compressive pathology may be considered for this operation. The patient should be securely strapped to the operating table and all pressure points should be well padded. Adequate positioning is essential to avoid pressure points and abdominal compression. Compression of the abdomen may lead to inadequate venous return and engorgement of the epidural venous plexus, leading to excessive intraoperative bleeding. Surgical Procedure Anesthesia and Positioning Minimally invasive thoracic decompression is performed under general anesthesia with endotracheal intubation. Preoperative imaging should be utilized to determine the spinal level at the cephalad and caudal poles of the pathology (T3 and T8 in. Surface landmarks may help to mark the incision by counting from the C7 spinous process; T3 is at the level of the scapular angle, and T7 is at the level of the inferior scapular tip. The lesion was resected and pathology was consistent with an extramedullary hematopoiesis. A 45-year-old woman presented with a 2-year history of progressive thoracic radiculopathy, bilateral foot pain and numbness, and gait imbalance. The patient underwent minimally invasive left T3­T5 hemilaminotomies and right T6­T8 hemila- 83 Minimally Invasive Thoracic Decompression should be utilized to localize the surgical levels by counting cephalad from the sacrum and confirming with anterior-posterior fluoroscopy by counting thoracic ribs. Due to the possibility for patient variation in the number of ribs, and because intraoperative radiographs may not cover all of the ribs, the surgeon should count both up from the bottom rib and down from the top rib to confirm the appropriate operative level. With the appropriate operative levels confirmed, a skin incision should be marked 1. A second skin incision should then be marked in a similar fashion on the contralateral side of the tension band at the caudal pole of the lesion. The skin incisions should then be made, followed by blunt dissection through the fascia. A series of muscle-splitting tubular dilators are docked onto the lamina one level below the cephalad end of the lesion (T4 in. Lateral and anterior-posterior fluoroscopy should be used to confirm docking at the appropriate level. The retractor is then secured to the operating table with a flexible arm and expanded in the rostral-caudal direction to expose the lamina of the superior and inferior surgical border (T3­T5 in. The same steps should be used to position a second Quadrant retractor onto the lamina one level above the caudal end of the lesion (T7 in. The Quadrant retractors should then be expanded in the rostral-caudal direction to expose the lamina of the superior and inferior surgical border (T6­T8 in. Electrocautery is then used to resect residual soft tissue that is obstructing visualization of the lamina. Bleeding from the venous plexus may occur and should be coagulated with electrocautery or absorbable gelatin sponge. Once adequate visualization and hemostasis is obtained, the same steps should be repeated at the contralateral caudal exposure. Contralateral exposure is achieved using a shielded drill and drilling the ventral surface of the spinous process and contralateral lamina to the contralateral pedicle while being cautious not to create an accidental durotomy. The same steps should be repeated to perform the hemilaminotomies on the contralateral side of the posterior tension band at the caudal multilevel segment (T6­T8 in. The ligamentum flavum can then be identified and removed to expose the dorsal epidural pathology. For cases involving extradural pathology, the lesions can be resected with a combination of bipolar electrocautery, pituitary forceps, and microsurgical dissectors. Bipolar electrocautery and Gelfoam (Pharmacia & Upjohn Company, division of Pfizer Inc. For cases involving intradural pathology, the dura is opened at each exposure site and the pathology is resected throughout its rostral-caudal borders. Once hemostasis is obtained, the wound is copiously irrigated with an antibiotic solution. The retractors are then removed to allow the paraspinal muscles to reapproximate in normal anatomic alignment. The subcutaneous layer is reapproximated with 3-0 Vicryl sutures, and the skin is closed using subcutaneous 4-0 sutures followed by Dermabond (Ethicon, Inc. A biomechanical evaluation of graded posterior element removal for treatment of lumbar stenosis: comparison of a minimally invasive approach with two standard laminectomy techniques. Biomechanical effects of a unilateral approach to minimally invasive lumbar decompression. J Spinal Cord Med 2012;35:175­177 de Jonge T, Slullitel H, Dubousset J, Miladi L, Wicart P, Illés T.

The platysma muscle layer is then closed treatment zone guiseley cheap duphalac 100 ml visa, and the anterior cervical skin incision is closed with subcuticular suture followed by application of skin glue medicine in the 1800s cheap duphalac 100 ml buy online. Postoperative Care the patient can be mobilized the day of surgery with no need for a collar medications beginning with z cheapest generic duphalac uk, with resumption of activities as tolerated symptoms zenkers diverticulum buy generic duphalac from india. Regular follow-up radiographs should be obtained to ensure proper functioning of the implant and detect any complications treatment 32 for bad breath duphalac 100 ml visa. Positioning the patient with the neck in kyphosis may not allow for selection of the appropriate arthroplasty size and fit. Complete bilateral decompression with uncinate resection should be performed, as persistent nerve root compression may not be well tolerated in the setting of preser- vation of motion. It is vital to ensure that all disk and cartilaginous material is removed from the end plates without completely violating the subchondral bone, to prevent improper fitting of the implant and subsidence. Fluoroscopy should be aligned so as to obtain images without parallax to help choose the appropriate implant size. The lateral image should be carefully visualized to see if there are any radiographic gaps between the trial and the end plates or if there is splaying of the facet joints. Most of the other device-related complications, such as postoperative kyphosis, device migration and subsidence, and vertebral fracture, can be prevented by careful patient selection and adherence to meticulous surgical technique. Biomechanical study on the effect of cervical spine fusion on adjacent-level intradiscal pressure and segmental motion. Posteriorlateral foraminotomy as an exclusive operative technique for cervical radiculopathy: a review of 846 consecutively operated cases. Range of motion change after cervical arthroplasty with ProDisc-C and prestige artificial discs compared with anterior cervical discectomy and fusion. Prospective, randomized, multicenter study of cervical arthroplasty: 269 patients from the Kineflex C artificial disc investigational device exemption study with a minimum 2-year follow-up: clinical article. Cervical total disc replacement with the Mobi-C cervical artificial disc compared with anterior discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease: a prospective, randomized, controlled multicenter clinical trial: clinical article. A prospective, randomized controlled clinical trial of anterior lumbar interbody fusion using a titanium cylindrical threaded fusion device. Cervical total disc replacement, part I: rationale, biomechanics, and implant types. Comparison of biomechanical properties of cervical artificial disc prosthesis: a review. A systematic review of randomized trials on the effect of cervical disc arthroplasty on reducing adjacent-level degeneration. Factors affecting the incidence of symptomatic adjacent level disease in cervical spine after total disc arthroplasty: 2­4 years follow-up of 3 prospective randomized trials. Radiologically documented adjacent-segment degeneration after cervical arthroplasty: characteristics and review of cases. Conclusion Cervical arthroplasty has sustained the initial challenge of demonstrating equivalent clinical success as an anterior cervical fusion, at the same time preserving normal motion at the affected level. Short- and intermediate-term results with good clinical success and preserved range of motion favors the use of cervical spinal arthroplasty. Box 29-1 Key Operative Points and Avoiding Complications Patient positioning is critical. Perform complete bilateral decompression with uncinate resection to avoid postoperative nerve root impingement. Ensure removal of all disk and cartilaginous material from the end plates without completely violating the subchondral bone, to prevent improper fitting of the implant and subsidence. Fluoroscopy should be aligned to obtain images without parallax, so that an appropriate-sized implant can be chosen. Obtain anteroposterior and lateral fluoroscopic images after final implant positioning to ensure that the implant is seated properly in both the coronal and the sagittal planes. Adjacent segment disease after anterior cervical discectomy and fusion in a large series. Neurosurgery 2014;74: 139­146, discussion 146 Goffin J, Geusens E, Vantomme N, et al. Long-term clinical and radiographic outcomes of cervical disc replacement with the Prestige disc: results from a prospective randomized controlled clinical trial. Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: single-level and bi-level. A clinical analysis of 4- and 6-year follow-up results after cervical disc replacement surgery using the Bryan Cervical Disc Prosthesis. The history of anterior microforaminotomy for cervical radiculopathy dates back to 1968,1­3 when attempts were made to achieve decom pression by partial removal of the offending disk material. Ante rior cervical foraminotomy was described by Jho in 1996,4 and the results of this technique were reported in 2002. We have modified the technique of upper vertebral transcorporeal anterior foraminotomy for the treat ment of cervical radiculopathy by avoiding breaching the me dial wall of the transverse foramen and attempting to preserve the lower end plate. Their principle was based on the simple idea of direct anterior decompression of the offending structure, but was associated with either loss of disk height (in patients without fusion) or loss of a mobile segment (in patients with interbody fusion). Furthermore, patients undergoing anterior decompression and fusion in the long run developed fusion related complications, namely adjacent segment disease, pseu darthrosis, and other graftrelated problems. Also, the difficulty in maneuvering a scope in the narrow con fines of the cervical foramen restricts its use to a few indicated cases. In an attempt to solve this problem, Choi et al10,11 devel oped the transcorporeal tunnel approach for unilateral cervical spondylotic radiculopathy. Anatomic Considerations the lower five cervical levels (C3 to C7) are known as the typical cervical vertebrae and they are all alike in that they are small and their anterior body length is usually slightly less than the poste rior length, whereas the cervical disks are wider anteriorly and narrower posteriorly. The superior and inferior surfaces of the bodies are saddle shaped due to the laterally placed uncovertebral joints (a. In the foramen, the cervical nerve root passes anterior to the facet joint and posterior to the unco vertebral joints, and this special joint arrangement frequently prevent a disk rupture from directly pressing on the nerve root. In contrast, osteophytes arising from these joints may cause compression on the nerve root,12 and are a major etiologic factor in unilateral cervical radiculopathy. Contraindications · · · Dominant axial neck pain Cervical instability Cervical infections or tumors Anesthesia and Patient Positioning After induction of intubated general anesthesia, the patient is placed in the supine position on a surgical table with a small roll below the neck to maintain cervical lordosis. The intended skin incision level is marked on the skin using a marker X-ray or fluoroscopy, and the standard Smith-Robinson ap proach is made from the affected side as in an anterior cervical diskectomy. Once the prevertebral fascia is opened, the midline is marked in rela tion to the two longus coli muscles, and the level is confirmed under fluoroscopy. The longus coli muscle is then lifted off its medial attachment subperiosteally, and selfretaining retractors are applied under the muscle. This prevents unnecessary han dling of the anterior longitudinal ligament and ultimately its ossification. Level confirmation is done at this stage, and an operating microscope is brought in the field. Before the drilling is begun, indigo-carmine dye is injected in the affected disk to facilitate the orientation of the disk space while drilling. The position of the drill hole is 4 to 6 mm above the lower border of the proxi mal vertebra, at the level of the medial border of the longus coli muscle. The trajectory depends on the location of the target, which is determined preoperatively on the radiological imaging. If needed, intraoperative fluoroscopy can be used to confirm the hole position and trajectory. A 6 × 7 mm drill hole is made from medial to lateral, and because of the oblique trajectory of the cervical disk, this leads directly to the pathological site in the foramen. Drilling can be done using a 4mm diamond bur initially and later with a 3mm bur for better visualization and fine drilling. At a one-third depth of the drilling, the bluish discoloration of the stained disk can be seen. Drilling can be safely continued, keeping the blue stained material in the center of the hole so as to maintain the direction of the trajectory. After the desired depth is achieved, a blunt probe is used to palpate the base of the tunnel so that the thin ivorywhite shell of the posterior vertebral wall can be care fully lifted with a fine bone punch or curette. The posterior lon gitudinal ligament still acts as a protective barrier between the instruments and the neural structures. Bone wax can be used to stop the bleeding from the spongy bone, and epidural bleeds can be managed with thrombin-soaked Gelfoam or FloSeal. After opening the posterior wall, the herniated disk stained blue with indigocarmine and the hypertrophied uncovertebral region can be visualized. Foraminal decompression can be achieved by undercutting the bony prominences with a rongeur, taking care not to breach the medial foraminal wall. Dominance of the vertebral artery and the distance of the transverse foramen from the uncovertebral joint should be noted preoperatively. Subperiosteal retraction of the longus coli minimizes bleeding and protects the carotid artery. The use of indigocarmine dye facilitates the approach by identifying the disk space as well as any herniated disk fragments. While using a long bur, wobbling may be encountered, so extra care should be taken to avoid untoward injury. The surgeon should attempt to follow the direction of the previously planned trajectory. Note the narrow anterior window and the wider base posteriorly, which were done to decompress the left C6-C7 foramen. Conclusion the transcorporeal tunnel approach enables the surgeon to per form a direct anterior decompression without the need for inter body fusion. Meticulous planning and a cautious approach can provide an excellent surgical outcome. Anterior microforaminotomy for treatment of cervical radiculopathy: part 1-discpreserving "functional cervical disc surgery". Neurosurgery 2002;51(5, Suppl):S46­S53 Saringer W, Nöbauer I, Reddy M, Tschabitscher M, Horaczek A. Microsur gical anterior cervical foraminotomy (uncoforaminotomy) for unilateral radiculopathy: clinical results of a new technique. The treatment of certain cervicalspine disor ders by anterior removal of the intervertebral disc and interbody fusion. Transcorporeal tunnel approach for unilateral cervical radiculopathy: a 2year followup review and results. Multilevel cervical fusion and its effect on disc degeneration and osteophyte formation. Modified transcorporeal anterior cervical microforaminotomy for cervical radiculopathy: a tech nical note and early results. Posterior Approach 31 Cervical Spine: Posterior Exposure Sean Christie and Janet Martin Historically, the initial operations on the cervical spine utilized a posterior approach. However, with the advent of anterior approaches and subsequent advancement of those techniques, the posterior exposure has lost some of its favor. Concerns about relatively more postoperative neck discomfort, longer hospital stays, and the development of postlaminectomy kyphosis have contributed to this trend. Nonetheless, the posterior approach is a familiar exposure to the cervical spine, and there are several pathological conditions that favor its use (Table 31. Advantages · · Familiar to neurosurgeons Avoids risk to the anterior vascular and visceral structures and short rotator muscles, including the semispinalis capitis, semispinalis cervicis, longissimus, and oblique capitis muscles. These areas are extensively vascularized, and good hemostatic control is of necessity for proper visualization; however, dissection through the ligamentum nuchae in the midline affords a plane of relative avascularity. The vertebral arteries run through the transverse foramen of the cervical vertebrae and are generally beyond the typical exposure from the posterior approach. Morphologically, the cervical vertebrae are smaller, with bifid spinous processes, generally, to the level of C6 connected by the ligamentum flavum. As a rule, the cervical vertebrae display less shingling, enabling clear visualization of the interlaminar space. Clear distinction may be made between the lamina and the lateral mass/facet joints to the level of C6. At C7, this distinction becomes somewhat less apparent due to additional muscle attachments at this level. It should be noted that the lateral mass, also known as the zygapophyseal capsule, provides a readily visible landmark for the lateral extent of dissection in a majority of cases when instrumentation is not indicated. Disadvantages · · Potentially more postoperative discomfort and longer hospital stays Potential for postoperative kyphosis Surgical Technique Anesthesia General endotracheal anesthesia is required for posterior cervical approaches. If there are concerns about cord compression during intubation or positioning, awake fiberoptic intubation may be used. Situations in which awake intubation should be considered include spinal trauma and pronounced spondylotic myelopathy in a cooperative patient1; if fiberoptic intubation is not available, intubation may be managed by maintaining the neck in a neutral position, with or without traction. In addition, several devices have been developed that utilize video assistance to safely intubate a patient without manipulating the neck. Realtime evoked potential monitoring may be extremely useful in monitoring the status of a patient during both the pre- and perioperative phases of surgery. Anatomy and Landmarks of the Posterior Spine Although the regional anatomy of the anterior cervical spine was discussed in Chapter 28, several surface landmarks are of particular clinical utility with the posterior approach. Palpating downward from the base of the skull, the spinous process of the C2 vertebra may be identified as the most superior bony prominence encountered. Below C2, the vertebrae are frequently obscured by soft tissue to the level of C7, which is usually palpable in the midline of the base of the neck, and may be visible as an outward protuberance in nonobese patients. Placing the neck into flexion enables visualizing the ligamentum nuchae as a longitudinal ridge running between the spinous process of C7 and the external occipital protuberance, continuous inferiorly with the supraspinous ligament, and providing attachment to the trapezius and splenius capitis muscles. The musculature of the cervical spine is best visualized as three layers from superficial to deep.

Duphalac 100 ml buy online. Do you have anxiety? (TEST).

The cost of the titanium clips and the presence of metal artifact on postoperative imaging are a few of the drawbacks associated with clipping a durotomy medications pancreatitis discount duphalac on line. Also medicine 93 948 cheap duphalac 100 ml line, fat or fascial grafts are useful in situations where dural substitutes are not available or economically feasible medications used to treat fibromyalgia purchase genuine duphalac online. Fascial grafts can sometimes be harvested from the tensor fascia lata or the surgical wound itself medicine used to induce labor order duphalac line. However treatments order cheap duphalac online, caution must be taken with surgical-site fascia harvesting, as this may compromise approximation of the fascia during wound closure, which is important in maintaining a leak-free closure. Harvesting fascia from the tensor fascia lata risks causing weakness in leg abduction. Another disadvantage of fat and fascial grafts is that a second surgical wound may be needed for harvesting. Polymerizing sealants can also be used as adjuncts to primary closures of dural repairs. The most common sealant is a mixture of polyethylene glycol and trilysine amine, which polymerizes when the two compounds are mixed. These sealants occupy spaces in which primary closure was insufficient, and eventually dissolve in 4 to 8 weeks. Therehavebeen case reports in the literature of compression on the spinal cord, causing quadriparesis and cauda equina syndrome following its use in cervical and lumbar surgeries, respectively. Theoretically, the use of postoperative steroids arrests the process of fibroblast proliferation and incorporation; therefore, avoidance of postoperative steroids is recommended. Although some manufacturers claim that their dural substitutes do not need to be sutured down, we recommend as close to a watertight suture with the dural substitutes as possible. Following any repair, the dural closure can be tested by requesting a Valsalva maneuver of 40 mm H2O pressure from the anesthesia team. Any evidence of a seeping wound would be an indication for reopening the lumbar drain for a prolonged drainage period, or even considering permanent lumbar-peritoneal shunting. Similar to the use of lumbar drains, some institutions favor a weaning process by which the subfascial drain is clamped and the surgical wound is monitored for leaking before committing todiscontinuingthedrain. Immediately following surgery, the dural repair should be discussed with the anesthesia team, to ensure that the team is aware of the importance of a careful extubation to prevent intrathecal pressure elevation with violent coughs and vomiting. In the recovery period, vomiting can be controlled by steroids or antiemetics, and the surgeon should have a low threshold to prescribe antiemetics to stay ahead of vomiting episodes postoperatively. Pain may lead to writhing, which can increase intrathecal pressure; therefore, adequate pain control should be provided in the form of opioids and antispasmodics. Thecommonadverseeffectof constipation from use of opioid medications can raise intrathecal pressures if the patient is straining to have a bowel movement. Aggressive bowel regimens to include laxatives, stool softeners, and even more aggressive measures like enemas should be considered in the postoperative period. Flat-in-bed positioning to 686 V Lumbar and Lumbosacral Spine reduce the hydrostatic tension on the dural repair may be contraindicated in patients with positional orthopnea, and can be cumbersome for meals and rehabilitation. However, the prophylactic use of antibiotics (cefazolin or vancomycin) while a lumbar or a subfascial drain is present is essential. Postoperative cervical cord compression induced by hydrogel dural sealant (DuraSeal). Postoperative cervical cord compression induced by hydrogel (DuraSeal): a possible complication. Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks. Managing the Cerebrospinal Fluid Leaks After Spinal Surgery By Prolonged Subfascial Drainage. Management and results after a two-year-minimum follow-up of eighty-eight patients. We recommend starting the approach from normal anatomy in the cranial-caudal dimension, and working toward the previous surgical site to build planes from normal anatomy to abnormal, postsurgical anatomy. In the case of the traumatic dural violation from a spine fracture, the surgeon should anticipate the materials and procedures required to address the fracture if instability is a concern. In the setting of a suspected infection, wound cultures should be sent to the lab for analysis, and antibiotics should be held preoperatively, if tolerated, to increase diagnostic yield. Once culture specimens are obtained, empiric antibiotics should be started without delay. When conservative management fails or is deemed contraindicated, surgical correction is essential in rectifying this common problem. Conceptually, drainage from the spinal intrathecal compartment in so-called communicating hydrocephalus states could have some advantages. With a mean follow-up of 19 months, however, the revision rate was 27% with an average time to failure of 11 months. This can result in difficulty cannulating the intrathecal space, accessing the peritoneal space in the lateral body position, and assessing the patency of the shunt. In our experience, shunt patency becomes an automatic concern for patients with any return or continuance of headache symptoms, leading to frequent office or emergency room visits. Nuclear medicine shunt studies and lumbar puncture opening pressures can provide unreliable indicators of shunt failure. However, 56% of the cohort required at least one shunt revision, with the number of revisions ranging from 1 to 13. In selected cases, adjustable valves are used, but with the knowledge that it will likely be difficult to change the settings once the system is implanted. Over the flank or abdomen, the valve may not be palpable due to the degree of overlying subcutaneous fat. It has been theorized that "equal drainage" for the ventricular and cranial subarachnoid spaces would lessen the risk of subdural hematoma, but this has not been demonstrated by any clinical study. As in all procedures involving implantable hardware, there is a risk of infection of the implanted system. Overall, up to 90% of the implanted systems require revision for mechanical failure with long-term follow-up. Technique the patient is placed in the lateral decubitus position, with as much flexion as possible without obstructing access to the abdomen (Video 111. Three separate incisions are made: (1) for thecal sac access, (2) for peritoneal access, and (3) for placement of the valve in the flank area. Lack of flow typically indicates a kinked catheter or other problem (such as a broken catheter, reversed valve, etc. The lumbar incision is vertical (parallel to the spinous processes) and either in the midline or slightly paramedian at the level of the L3-4 or L4-5 interspace, which roughly corresponds to the level of the iliac crest. A paramedian location decreases frictional wear of the catheter with the spinous processes. The peritoneal cavity is accessed via a mini-laparotomy using a standard approach. In obese patients, care must be taken not to stray obliquely downward in the subcutaneous fat, missing the rectus fascia completely. At our center, laparoscopic bariatric surgeons have successfully accessed the peritoneum, although using caution because laparoscopic surgery is typically performed with the patient in the supine position. This incision has to be long enough to be able to anchor catheters on both sides of the H-V valve and accommodate the H-V valve so that it is in the vertical position when the patient is upright. A tunneler is used to pass the peritoneal catheter from the flank to the abdominal incision. The valve is secured to the subcutaneous fat with 2-0 silk sutures to ensure that the long axis of the valve is in line with the long axis of the patient. The peritoneal catheter is connected to the valve and secured with a 2-0 silk tie. If the surgeon wishes to leave a tapping reservoir, this device is typically situated near the lumbar incision in a pocket. A 14-gauge Tuohy needle is used to access the lumbar cistern, aiming medially toward midline and 30 to 45 degrees cephalad. Approximately 10 cm of catheter is advanced into the lumbar cistern, and then the needle is withdrawn, taking care not to lacerate the catheter with the sharp tip. The catheter is sutured to the lumbosacral fascia using a silicone butterfly suture clamp. All incisions are irrigated copiously with antibiotic irrigation and closed in layers in the standard fashion. Preoperative Planning There are several factors to consider prior to proceeding with operation. It is technically difficult and relatively contraindicated in patients with history of lumbar fusions or extensive abdominal operations. In those cases, fluoroscopic guidance may be required for accessing the thecal sac, and general surgery assistance may be required for accessing the peritoneum. Occult spinal pseudomeningocele following a trivial injury successfully treated with a lumboperitoneal shunt: a case report. Treatment of cerebrospinal fluid rhinorrhea by percutaneous lumboperitoneal shunting: review of 15 cases. J Neurosurg Spine 2010;13:133­138 Kanazawa R, Ishihara S, Sato S, Teramoto A, Kuniyoshi N. Acute subdural hematoma after lumboperitoneal shunt placement in patients with normal pressure hydrocephalus. Tonsillar herniation: the rule rather than the exception after lumboperitoneal shunting in the pediatric population. By limiting passive and active motion and in the extreme by leading to irreducible contractures and deformities, an excess of muscular tone contributes to further incapacity. When hyperspasticity becomes refractory to medical treatment and physical therapy, the recourse to functional neurosurgery may be justified. The technique consisted of dividing the entire dorsal roots from L2 to S2, excluding the "antigravity root" L4. He used intraoperative electrical stimulation to identify segmental levels and to distinguish between ventral and dorsal roots. In the 1960s, Gros and coworkers3 in Montpellier, France, separated the dorsal roots into rootlets and performed partial dorsal rhizotomies with nonselective sectioning of 80% of the rootlets of each root to limit postoperative sensory deficits. In 1976, Fasano et al5 in Turin, Italy, introduced a different concept of dorsal rhizotomy-the functional posterior rhizotomy-based on identification of abnormal muscular responses to electrical stimulation of roots and rootlets. Responses were categorized as abnormal when repetitive dorsal root and rootlets stimulation with a train at a frequency of 50 Hz and a duration of 1 second provoked sustained responses in the corresponding segmental muscles or the spread of response to other territories either ipsilaterally or contralaterally. At the beginning of the 1980s, to achieve more precise identification of the whole lumbar and sacral rootlets, Peacock and Arens6 and Abbott et al7 extended the exposure to the entire cauda equina through an L1­S2 laminotomy. Limited Approaches In the 1980s and 1990s we commonly used osteoplastic laminotomy limited to the T11, T12, and L1 vertebrae. Through this approach, the ventral and corresponding dorsal L2 and L3 roots can be reached just before they exit at their respective dural sheaths. The other (dorsal) lumbar and sacral roots/rootlets can be identified at their entry into the dorsolateral sulcus at the conus medullaris. At the conus medullaris, the landmark between the S1 and the S2 medullary segments is located ~ 30 mm from the exit of the (tiny) coccygeal root from the conus. The quantity per root differs with respect to the root level and function and to its involvement in the (harmful) components of the spasticity. By their technique, which they called the "single-level immediately caudal to conus medullaris approach," at the T12-L1-L2 level, the dural sac is exposed. Localization of the conus and adjacent cauda equina are confirmed by an ultrasound probe through the exposed space. The conus appears hypoechogenic and cylindrical, and the cauda equina hyperechogenic and inhomogeneous. Once identification is completed, a single-level laminectomy, or more levels if necessary, is performed. After dural and arachnoid opening, the L1 and L2 roots are identified at the exit of their corresponding foramina. The dorsal root of L2 is separated from the ventral root and followed up to the conus. From the L2 dorsal root at the dorsolateral sulcus, the subjacent dorsal rootlets, from L3 to supposedly S2, are then progressively retracted medially, while being separated from their corresponding ventral roots. Then the S3 to S5 roots are identified at their exit from the most caudal part of the conus so that they are spared. We recently developed a modality that we have termed keyhole interlaminar dorsal rhizotomy. To access the roots to be targeted individually at their exit from the intradural space to the corresponding dural sheath. Under direct vision, identification of the anatomic/topographic level can be precisely verified by electrical stimulation of the (ventral) root. Stimulation of the dorsal root can test its physiological implication in the harmful components of the spasticity and help quantify sectioning. For diplegic children who are able to ambulate, generally with the so-called scheme of Little,15 the goals are to improve functional status and autonomy, and prevent or stop the evolution of the deformities. For nonambulatory diplegic or quadriplegic children, the only realistic goal is to facilitate care, provide comfort, and ease pain. In diplegic patients the main muscles involved are the psoas-iliacus and adductors of thigh (whose corresponding roots are L2 and L3), hamstrings (L5, S1, and S2), triceps surae and tibialis posterioris (S1). Too early would be imprudent, as younger children still have the potential for developmental maturation of their central nervous system and the capacity for further locomotion skills. Too late would be unwise, due to the appearance of potentially irreducible contractures and deformities.

Combined C1 and C2 Fractures Combined atlantoaxial fractures are also common treatment norovirus 100 ml duphalac fast delivery, but entail a higher rate of neurologic dysfunction and instability due to the relatively higher kinetic energy delivered than with an isolated Conclusion Occipitocervical junction trauma can often be lethal medicine 1700s discount duphalac 100 ml visa, and at best symptoms 7 days pregnant buy duphalac 100 ml otc, carries a high morbidity symptoms for pink eye duphalac 100 ml overnight delivery. The ligament is contrasted by high-signal intensity on both sides-anteriorly by synovium and posteriorly by cerebrospinal fluid treatment 1st degree burns generic duphalac 100 ml fast delivery. The disrupted ligaments demonstrate high-signal intensity within the ligament, loss of anatomic continuity, and blood at the insertion of the ligament (arrows). The majority of patients are treated successfully with reduction and immobilization without surgery. Therefore, an awareness of the clinical presentation, underlying anatomy, radiographic features, and the implications of each type of injury are vital in achieving a successful outcome for the patient. Fractures of the neural arch and odontoid process of the axis: a study of their causation. Injuries involving the transverse atlantal ligament: classification and treatment guidelines based upon experience with 39 injuries. The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine. High cervical spine and craniocervical junction injuries in fatal traffic accidents: a radiological study. Paralysis of both arms from injury of the upper portion of the pyramidal decussation: "cruciate paralysis". Magnetic resonance imaging of the transverse atlantal ligament for the evaluation of atlantoaxial instability. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. The cervicomedullary junction is the crossroads of the central nervous system as the brainstem transitions to the upper cervical spinal cord. The medulla contains the nuclei required for breathing and cardiovascular function, and the cervicomedullary junction contains the descending motor fibers to the spinal cord and ascending sensory fibers. However, this complexity also creates the potential for a wide range of congenital, developmental, and acquired pathology. In 1957, Southwick and Robinson13 resected an osteoma of the body of the axis through a transoral-transpharyngeal approach. However, it was not until 1962 that Fang and Ong14 described the approach in detail, utilizing it in five cases of chronic irreducible atlantoaxial dislocations and one case of tuberculosis of the atlas and axis. In this small series, the complication rate was high, with four cases resulting in infection and one infection leading to death. However, in their discussion of the approach, Fang and Ong suggested that infection could be reduced with meticulous closure of the posterior pharyngeal wall, proper preoperative oral preparation, and preoperative and postoperative antibiotics. Despite this suggestion, the approach was reported only sporadically in case series in the 1960s15,16 and early 1970s. This was the first large series that demonstrated that the transoral approach was not fraught with complications, as suggested by the series from Fang and Ong. In 1988, Menezes reported on 72 transoral cases over a period of 10 years-the largest series at that time. Subsequently, the report of 14 transoral cases by Crockard et al20,21 in 1985 and 53 transoral cases by Hadley et al22 in 1989 helped solidify the support for this approach. The transoral approaches are categorized as standard and extended, and each variation provides a different degree of exposure (Table 5. The standard transoral approach, as popularized by the pioneers cited above, includes the transoral-transpharyngeal approach and the transoral-transpalatopharyngeal approach (see Box 1. We prefer to divide the soft palate (transoral-transpalatopharyngeal) when necessary, as it increases exposure superiorly to the inferior one third of the clivus (Table 5. Many other surgeons have suggested that elevation and retraction of the soft palate provides similar access to dividing the soft palate. However, with normal clival anatomy we have found that elevation and retraction of the soft palate usually only provides rostral access to the inferior tip of the clivus. Additionally, in congenital pathological states, such as with a foreshortened clivus or basioccipital hypoplasia, the clivus tends to be more horizontal in position than vertical. Thus, it becomes essential to divide the soft palate (transoral-transpalatopharyngeal approach) and at times resect the posterior-inferior portion of the posterior hard palate to gain clival exposure. In an anatomic cadaver study by Balasingam et al,24 division of the soft palate provided nearly 1 cm of clival exposure. In contrast, retraction of the soft palate into the nasopharynx did not provide adequate exposure of the clivus superior to the foramen magnum, but did provide adequate exposure of the atlantoaxial complex. In general, it is imperative to review the imaging studies preoperatively to determine the adequacy of a clival exposure with or without a soft palate split and to determine whether this exposure is even needed for ventral decompression. The inferior extent of the exposure, which is limited by the degree of depression of the tongue, is the C2­3 interspace. The lateral extent of the exposure is limited by the condylar canals of the hypoglossal nerve, the eustachian tubes, and the vertebral arteries before they enter the intradural space. However, when a tumor, such as a chordoma, is present, the tumor displaces normal anatomy, creating working space and greater exposure than normal. Transoral-Transpalatopharyngeal Approach (Standard Transoral) Degree of Craniovertebral Junction Exposure the transoral-transpharyngeal approach provides exposure from the clivus to the C2­3 interspace and laterally for 2 cm to either side of the midline (Table 5. Laterally situated lesions may involve the occipital condyles, as well as the lateral portions of the posterior fossa, the transverse processes of the atlas, and the axis vertebrae. A midline ventral approach enables exposure of the anterior 45 degrees of the circumference of the foramen magnum, to either side of the midline, thus providing a 90-degree exposure. Reduction pertains to the reestablishment of anatomic alignment to relieve compression of neural structures. In children as well as adults, adequate access to the craniocervical junction and upper cervical vertebrae can usually be achieved with a transoral­transpalatopharyngeal route. In some children, however, young age or small size preclude adequate exposure with a soft palatal split alone. Tracheotomy provides an unobstructed view of the oral cavity and posterior pharyngeal wall and prevents upper airway obstruction secondary to tongue and pharyngeal edema in the perioperative phase. By splitting the mandible, the surgeon also has a shorter working distance to the spine. Limitations In some young children, the ability to sufficiently open the mouth is extremely limited. This is further assessed once the child is asleep and paralysis induced by the anesthesiologist. An extended transoral approach via the transmandibular route can be used in such extreme cases, but this is rare (see next section). In general, with proper closure and good surgical technique, the facial scarring is minimal. Extending the Transoral Approach the emergence of the transoral approach provided exposure to a previously inaccessible region. Combining the standard transoral approach with previously described techniques of craniofacial osteotomies that split the mandible and divided the tongue29,30 or opened the maxilla and divided the hard palate31 enhances access inferiorly to the C4­5 interspace and superiorly to the upper aspect of the clivus, respectively (Table 5. Transmaxillary­Le Fort I Osteotomy with Down-Fracture of the Maxilla Degree of Craniovertebral Junction Exposure the Le Fort I osteotomy (maxillotomy) with down-fracture of the maxilla is an approach onto itself rather than an extension of the standard transoral approaches. However, the inferior displacement of the hard palate obstructs caudal access to C1­2. Transmandibular­Median Labiomandibular Approach and Variations Degree of Craniovertebral Junction Exposure A combined transoral-transpalatopharyngeal approach with a median mandibulotomy (median labiomandibular approach) provides increased caudal exposure to the C3­4 interspace and maintains the superior exposure to the inferior third of the clivus. Indications and Limitations the Le Fort I maxillotomy approach is indicated for extensive lesions that are too wide and too inferior for an endoscopic endonasal approach and too rostral for a standard transoral approach. An endoscopic endonasal approach can provide similar access above the hard palate without the morbidity of this approach. However, the Le Fort I osteotomy with down-fracture has advantages over the endoscopic endonasal approach in that it provides wider exposure as well as more inferior viewing past the plane of the hard palate. With advancements of the endoscopic endonasal approach, the use of a Le Fort osteotomy is becoming increasingly rare. As mentioned above, this approach is not really an extended transoral approach, as the extension from the mouth is not used to gain exposure. Others have described this as the transmaxillary palatal split approach or the extended "open-door" maxillotomy. Complications Associated with Transoral Approaches In the hands of experienced surgeons, transoral complications are minimal. In the second case, infection occurred requiring intravenous antibiotics and drainage into the pharynx. It was thought to be secondary to fibrosis that took place in the soft palate or in the pharyngeal wall. Pharyngeal retraining in three children and an obturator in the other two circumvented the problem. In one child, fat emulsion was injected into the posterior pharyngeal wall to bring it forward and close off the incompetence. Indications and Limitations the Le Fort I osteotomy with palatal split is indicated for extensive lesions from the superior aspect of the clivus to the body of C2. However, again, with advancements in the endoscopic endonasal approach, the use of a Le Fort osteotomy is becoming increasingly rare. Even in rare cases of such an extensive lesion, an extended endoscopic endonasal approach is effective. The endoscopic endonasal approach is limited by the hard palate, but for extensive lesions from the top of the clivus to the body of C2 and below the nasopalatine line, a combined endoscopic endonasal approach with a standard transoral approach would provide adequate exposure and limit the morbidity of a Le Fort I osteotomy with palatal split. Specific entities affecting the craniocervical region: syndromes affecting the craniocervical junction. The transoral approach for the management of intradural lesions at the craniovertebral junction: review of 7 cases. Transoral Approaches for Intradural Pathology With popularization of the transoral approach for extradural bony decompression in the late 1980s, some surgeons expanded the indications of the approach to include resection of purely intradural tumors located ventrally at the level of the clivus or foramen magnum. Bullet located between the atlas and the base of the skull- technic of removal through the mouth. Surgical approaches: postoperative care and complications "transoral-transpalatopharyngeal approach to the craniocervical junction". Am J Surg 1961; 102:753­759 Transoral Approaches to the Craniovertebral Junction 30. The transfacial approaches to midline skull base lesions: a classification scheme. Labiomandibular, transoral approach to chordomas in the clivus and upper cervical spine. Transoral approach and extended modifications for lesions of the ventral foramen magnum and craniovertebral junction. Trans oral approach to the nasopharynx and clivus using the Le Fort I osteotomy with midpalatal split. Surgical approaches: postoperative care and complications "posterolateral-far lateral transcondylar approach to the ventral foramen magnum and upper cervical spinal canal". Evolution of transoral surgery: three decades of change in patients, pathologies, and indications. Other pathological conditions such as proatlas segmentation abnormalities, atlantoaxial tumors, clival tumors, and rare congenital osseous abnormalities can also result in ventral cervicomedullary compression. Contraindications In some children and adults, the ability to sufficiently open the mouth is extremely limited. However, this is further assessed once the patient is under general anesthesia and paralysis induced by the anesthesiologist. The flexed and extended positions provide a dynamic view of the bony anatomy in relationship to the neural structures, specifically the medulla and upper cervical spine. In the neutral position, ventral compression may not be present, but when the neck is flexed, compression from the odontoid process may be much more evident. This can determine if vascular occlusions occur when the patient changes neck position. For example, in irreducible basilar invagination, the ventral transoral­transpalatopharyngeal route to the craniocervical junction1­3 enables removal of the superiorly displaced odontoid process and therefore ventral decompression of the cervicomedullary junction. Committing to a posterior-only approach necessitates proper reduction prior to occipital cervical fusion. Instrumentation with fusion without proper reduction and ventral decompression can be catastrophic. Proper intraoperative imaging must provide evidence of reduction and decompression. If reduction cannot be achieved, a 540-degree procedure may be necessary in some cases (depending on the pathology), whereby the posterior approach and incision is temporarily closed and the patient is moved to a supine position for a ventral decompression followed by reopening of the posterior incision and posterior fixation. Preoperative imaging after previous posterior fusion by an outside institution demonstrating irreducible and severe cervicomedullary compression. Dental hygiene is addressed to remove causes of bacterial contamination such as dental caries and gingivitis in the operative field. In one study, loss of vagal, hypoglossal, and glossopharyngeal nerve function mandated a tracheostomy at the start of the operation in 12 patients. As a precaution, nystatin rinses and Peridex gargles are performed three times a day 2 days before the operative procedure. Mupirocin nasal ointment is used in the nasal passages for 2 days prior to the operative procedure. Preoperative Reduction via Craniocervical Traction "Reduction" through skeletal traction is attempted in children, because 80% of children younger than 12 to 14 years of age with atlantoaxial dislocation or basilar invagination can be reduced, thereby relieving compression on neural structures and thus avoiding a ventral procedure. A dorsal occipitocervical fixation can then be performed in the reduced position with or without decompression. In this approach, the child is placed in the supine position with a pad underneath the shoulders and head. A crown halo is positioned at the equator of the cranium (pins placed above this plane have a tendency to pull out).

A study by Tashjian et al41 found a 42% and 20% mortality rate in the halo-treated and non­halo-treated groups symptoms gastritis duphalac 100 ml purchase, respectively medicine cabinets with lights duphalac 100 ml cheap. However treatment plan for ptsd duphalac 100 ml buy overnight delivery, the surgical group had a significantly lower rate of nonunion (5% versus 21%) and a lower mortality than the group that was nonsurgically managed medicine 1900s spruce cough balsam fir 100 ml duphalac order with visa. As expected medication 3 checks duphalac 100 ml on-line, C1-C2 fractures entail a relatively greater risk of instability than an isolated fracture of either the atlas or axis, and a higher index of suspicion for instability should be maintained clinically. Many of the prior methods of C1-C2 posterior fixation such as the Brooks-Gallie methods, Halifax clamping, or other variants of interspinous and posterior column fusions require intact posterior elements. More modern techniques using segmental instrumentation, such as pars, pedicle, lateral mass, laminar, or transarticular screws, have supplanted these older techniques and have enabled the surgeon to match the anatomy to the technique and to provide the patient with a higher rate of fusion. Clinical Presentation Although these injuries used to entail a high rate of mortality, improvements in care and triage have enabled a higher survival rate. Radiographic Presentation Although lateral radiographs can be initially useful in recognizing severe dislocations, they usually fail to diagnose less severe injuries. In motor vehicle accidents, force is delivered in a pattern that causes hyperextension and compression, typically resulting in sparing of the C2­3 disk space and ligamentous structures, decreasing the lethality. Over time there have been many classification schemes, and in 1981 a three-pattern system became widely accepted, reported first by Effendi and colleagues. The Wackenheim line is drawn to extend along the dorsal surface of the clivus in the midsagittal plane. This line should be tangential to the tip of the dens and is not altered by flexion or extension. Occipitocervical fusion: posterior stabilization of the craniovertebral junction and upper cervical spine. Transverse Ligament Disruption C1-C2 subluxation can occur with or without the disruption of the transverse atlantal ligament. However, C1-C2 subluxation occurs most commonly from odontoid fractures, which less commonly involve disruption of the transverse ligament. Os odontoideum is also a cause of C1-C2 subluxation but is rela- tively less common, being an uncommon congenital finding. This patient arrived in the emergency department with a Philadelphia collar that was applied at the scene of the accident (right). The collar reproduced the distractive mechanism of injury and can cause decompensation of this highly unstable injury. The relative position of the occipital condyles and C1 was immediately improved by removing the cervical collar and immobilizing the head in a neutral position on a spine board (left). Atlantoaxial Rotatory Subluxation Atlantoaxial rotatory subluxation is more commonly seen in children and adolescents. Fracture displacement is a major determinant in the decision to perform internal fixation. Many combined nondisplaced fractures will heal in a brace and can be followed in the office with serial radiographs, including flexion-extension views. Atlantal-Occipital Dislocation A confirmed atlantal-occipital dislocation is an unstable injury, as the force involved in a dislocation is associated with significant ligamentous injury. Traction and closed reduction should be undertaken under fluoroscopic guidance, preferably in the operating room with neurophysiological monitoring. Treatment Options the initial management of these injuries is focused on the general principles of basic trauma management, including establishing and maintaining a clear airway, breathing, and circulation, and carefully immobilizing and transferring the patient to a treatment facility. Hence, they usually require surgery to restore stability and preserve the functional integrity of the spine. Transverse Ligament Disruption Type I or Ia disruptions of the transverse ligament will not heal and therefore require surgery because of the inability of the transverse ligament to repair itself. Displacement is an indirect indicator of ligamentous disruption, and as a result most ascending grading scales relate instability to displacement. Isolated atlas fractures heal in most cases with an orthosis, except in the case of disruption of the tubercle. As previously mentioned, this is successfully treated nonsurgically in most cases, and can be reduced with traction followed by immobilization with a cervical collar for 12 weeks, and occasionally requiring the use of halo placement. In children of ages 8 to 16 years, a total of four pins are utilized, two pins on each side, and they are tightened to 6 to 8 lb of pressure. In children of ages 4 to 6 years, six to eight pin fixation is used under general anesthesia. The maximum tightening pressure for a 6-year-old is 5 to 6 lb and for a 4-year-old is 4 lb. Preoperative traction is maintained with mild elevation of the head-15 to 20 degrees above the horizontal. Cervical traction is started at 5 to 6 lb in an 8-year-old and increased to 9 lb by the end of the first day. In the child in whom an operative procedure is being done for a tumor or a noncongenital abnormality, the crown-halo traction is applied intraoperatively. Although other retractors have been used for the transoral approach, all are a modification or variation of the Dingman retractor. If needed, the mandible can be dislocated under general anesthesia to provide a greater oral opening. The crown halo is applied with the patient in the supine position and the head placed on a horseshoe headrest with 8 lb of traction. If there is adequate reduction and decompression in proper alignment, a transoral resection of the odontoid process is not needed. We have described dorsal occipitocervical fusion and its variations in a previously published report. The soft palate is split in procedures that involve the foramen magnum and the inferior clivus. To divide the soft palate, an incision is made starting at the right of the uvula and extends along the median raphe up to the hard palate. Stay sutures that are attached to the edge of the palate divide and fastened between the coiled springs of the Dingman retractor hold apart the exposure. At times, it is necessary to remove a portion of the hard palate to gain exposure of the high nasopharynx. The longus colli and longus capitis muscles are detached from their medial origin on the ventral surface of the cervical vertebrae and mobilized laterally in a subperiosteal fashion using bipolar electrocuting cautery and blunt dissection. These muscles can be held in place with tooth-bladed lateral pharyngeal retractors if needed or held in place with stay sutures. Surgical Technique Positioning and Preparation the patient, either child or adult, is brought to the operating room with a cervical collar in place as a precaution during intubation, maneuvers, and positioning. However, in children younger than 10 years of age or in an older child who cannot tolerate the procedure, general anesthesia is utilized and fiberoptic intubation is performed through the mask. The patient is positioned supine on the operating table with the head and crown halo resting on a horseshoe headrest with traction being maintained at 5 to 7 lb in children and 7 lb in adults. The endotracheal tube is secured to the skin overlying the mandible with suture, and the nasal passages anesthetized with topical cocaine. A throat pack is used to occlude the laryngopharynx, and oral preparation is performed with 10% povidoneiodine and hydrogen peroxide. It consists of a frame with coiled springs for fastening stay sutures for retraction of tissue, tongue depressors of varying sizes, two cheek retractors movable in any direction, and two movable upper dental hooks. This retractor provides Odontoidectomy After dissection of soft tissue from the anterior arch of C1 centered over the tubercle of C1. The odontoid process is cored out, leaving an eggshell-thin layer of outer cortical bone. The remaining eggshell-thin odontoid process is removed with the drill, curettes, or rongeurs. In cases with congenital and abnormal bony anatomy such as with proatlas segmentation abnormalities or os odontoideum, these abnormal bony protuberances are resected. The inferior portion of the clivus is removed when indicated using a diamond bur and fine Kerrison rongeurs. However, in this case, given the previous fusion, the C1 arch was slightly rotated. During the operation, cervical traction is maintained for inherent, potential, or iatrogenic instability. The completion of decompression and resection is evident by the visualization of the transverse ligament, tectorial membrane, and the dura as well as the cruciate ligament inferiorly. Illustrative Case A 5-year-old girl with Down syndrome presented with a dystopic os odontoideum and dorsal displacement of the hypoplas- tic dens with instability between the craniocervical region and C2. At an outside institution, she underwent two previous posterior approaches including posterior decompression with instrumentation and fusion. She was unable to stand or walk or use her arms after her second operative procedure due to severe cervicomedullary compression. Therefore, a ventral transoral-transpalatopharyngeal approach and decompression with removal of the anterior arch of C1, os odontoideum, and odontoid process was indicated. Pulsations of the tectorial membrane and ligaments should be visualized demonstrating cervicomedullary decompression. Postoperative imaging after transoral-transpalatopharyngeal resection of the anterior arch of C1, dystopic os odontoideum, and odontoid process closure. Abnormalities of the cranio-vertebral junction with cervico-medullary compression. Application of neuromuscular blockade and intraoperative 3D imaging in the reduction of basilar invagination. One-step fixation of atlantoaxial rotatory subluxation: technical note and report of three cases. Direct posterior reduction and fixation for the treatment of basilar invagination with atlantoaxial dislocation. Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach. Combined transoral and median labiomandibular glossotomy approach to the upper cervical spine. The transoral approaches are categorized as standard and extended, and each variation provides a different degree of exposure. The location of the hard palate relative to the craniovertebral junction limits superior exposure, whereas the mandible and base of the tongue limit the inferior exposure. In most cases, exposure can be obtained from the inferior third of the clivus to the C2­3 interspace. In some children, however, young age or small size precludes adequate exposure with a soft palatal split alone. Therefore, additional exposure can be gained with the median labiomandibular glossotomy approach. Surgical Technique the patient, either child or adult, is brought to the operating room with a cervical collar in place as a precaution during intubation, maneuvers, and positioning. All adults and children 10 to 18 years of age undergo awake fiberoptic oral endotracheal intubation. In children younger than 10 years of age or in an older child who cannot tolerate the procedure, general anesthesia is utilized and fiberoptic intubation is performed through the mask. Depending on the pathology, a crown halo may be applied for traction and the patient placed in traction at the beginning of the procedure. Then a tracheotomy is performed, using a modified oral Ring­Adair­Elwyn endotracheal tube trimmed just beyond the curvature of the tube to provide adequate intubation of the trachea when the tube is sutured flush to the chest wall. At the conclusion of the procedure, the tube is replaced with an ageappropriate tracheostomy tube. If a costal cartilage graft is to be harvested, this portion of the procedure is performed using a separate operative field and separate instruments. The skin incision is made full thickness in the midline at the lip and sublabial crease, utilizing a notch to aid relocation at the vermillion border, and the incision is carried around the mental protuberance, in a line of relaxed skin tension, and over the lower border of the mandible and back to the midline; it extends inferiorly to the level of the hyoid. To expose the mandible, the labial sulcal incision must deviate from the midline toward the osteotomy site; the incision continues in the midline on the lingual surface at the alveolar ridge. After the stair-step osteotomy is marked, rigid fixation plates are molded to the midline mandible inferiorly and superiorly and secured in place. Following the mandibular osteotomy, the soft tissue dissection within the floor of the mouth is continued in the midline between the submandibular ducts and carried into the intrinsic tongue musculature. Dissection of the midline tongue is then carried posteriorly along the median raphe to expose the lingual surface of the epiglottis to the level of the hyoid. If further rostral Median Labiomandibular Approach with or without Glossotomy Indications A combined transoral-transpalatopharyngeal approach with a median mandibulotomy (median labiomandibular approach) provides increased caudal exposure to the C3­4 interspace and maintains the superior exposure to the inferior third of the clivus. Indications to use the median labiomandibular approach to augment exposure of the craniocervical junction and the upper cervical vertebrae include an inter-incisor opening distance of less than 2. In children as well as adults, adequate access to the 48 7 exposure of the clivus is required, a midline split of the soft palate to one side of uvula can be performed. Additionally, removal of a portion of the posterior hard palate can be removed as well for even greater rostral exposure of the clivus. The mucosa is incised, and dissection with monopolar cautery proceeds through the midline raphe between the pharyngeal muscles and the anterior longitudinal ligament to bone. The longus colli and longus capitis muscles are detached from their medial origin on the ventral surface of the cervical vertebrae and mobilized laterally in a subperiosteal fashion using bipolar electrocautery and blunt dissection. The midline is marked by the tubercle of the anterior arch of C1 and should be identified for orientation. A costal cartilage graft can be placed after bony decompression if needed for anterior vertebral body reconstruction. Meticulous closure is performed using the longus colli muscles, pharyngeal musculature, and mucosa. Layered closures of the tongue and soft palate are followed by mandibular reconstruction using the prefashioned rigid fixation plate and tension band. When closing the floor of mouth, care must be taken to cover the osteotomy site intraorally. Layered closure of the anterior neck soft tissue and skin is performed with careful reapproximation of the vermilion­cutaneous junction.

Additional information:

• Piroxicam
• Amoxicillin
• Valacyclovir

References

• Hamblin TJ, Davis Z, Gardiner A, et al. Unmutated Ig V(H) genes are associated with a more aggressive form of chronic lymphocytic leukemia. Blood 1999;94(6):1848-1854.
• Kunz R, et al. Meta-analysis: effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease. Ann Intern Med 2008;148:30-48.
• Lordick F, Ott K, Krause BJ, et al. PET to assess early metabolic response and to guide treatment of adenocarcinoma of the oesophagogastric junction: the MUNICON phase II trial. Lancet Oncol 2007;8(9):797-805.
• Armstrong JG, Steele RH. Localised pulmonary arteritis in rheumatoid disease. Thorax 1982;37(4):313-4.
• Miyasaka Y, Tsujimoto S, Maeba H, et al. Left atrial volume by real-time three-dimensional echocardiography: validation by 64-slice multidetector computed tomography.] Am Soc Echocardiogr 20 11;24:680-686.