Unilateral facet joint dislocations of subaxial cervical spine are difficult to reduce, when complicated with posterior facet fractures or ligamentous injury. Surgical decision making can be based on severity scores and CT scans; however, for those irreducible dislocations, MR imaging is recommended to identify ventral and dorsal compressive lesions (disk herniation, hematoma, bone segments) as well as ligamentous or capsule rupture. The application of MR imaging is critically important for determination of surgical approach and beneficial for avoidance of clinical worsening. From posterior approach, cervical reduction can be improved safely by direct facet poking, and wire rope fixation of adjacent spinous process compensates for cervical stability because of disrupted ligaments dysfunction. From the anterior approach, early decompression can be achieved with direct observation of the anterior pathology. The anterior plate provides imme- diate stability of the construct, by acting like a buttress in flexion and a tension band during extension. Combined with the posterior interspinous wire, which restricts exces- sive flexion of the involved segments, anterior fixation and fusion proved to be sufficient for both segmental stability and final fusion. This surgical method has advantages of safety, ease of operation, and less iatrogenic damage.
Our study population was comprised of 61 patients all come from northeastern China and may not have been sufficiently large to be generalized to the greater popula- tion. Therefore, our study results may be applicable only to those northeastern Chinese population. Larger popu- lation coming from all parts of China even Asia enrolled in this kind of study may provide more persuasive and typical morphological results. And our center is cur- rently preparing for launching a plan of multicenter morphological study on subaxial cervical spine of the Asian population.
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This is the first study to provide CT scan-based mor- phometric evaluation of the subaxial cervical spine pedi- cles of Arab adults. Our results revealed that the morphometric parameters of the C3–C7 cervical spine pedicles were larger in males than in females. This find- ing is similar to results found among other ethnic groups [2, 9, 21, 22]. Spine surgeons should carefully take into account such gender differences before performing TPSF surgery. Moreover, the CT scan dimensions of the sub- axial pedicles of our subjects were found to be slightly different when compared to Asians, Europeans and Americans [2, 9]. Height and width were noted to be smaller in Arab people compared to Asians and European/ Americans, highlighting the importance of thorough pre- operative planning for Arab patients undergoing TPSF of the cervical spine.
Vaccaro et al formulated a subaxial cervical spine injury classification system ( SLIC) in which SLIC score 5 or > 5 needs operative management. The first recorded operative treatment for spinal injury was a laminectomy in the seventh century. Today, improved operative techniques have led to major advances in spinal stabilization. The development of dedicated spinal cord injury centers and improved postoperative rehabilitation have led to significant improvement in functional outcome. The treatment of cervical spine fractures and dislocations has several goals, including reduction of the deformity and stabilization, minimizing or decreasing neurologic injury, and early rehabilitation. The choice of treatment modality is based on the anatomy of the fracture and the experience of the surgeon.(9) .
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According to the angular parameters, we did not find the statistically significant difference among right and left cervical pedicles of each cervical level in both ped- icle transverse angle (PTA) and the pedicle sagittal angle (PSA) (Figure 2C and D). The variation in case of both PTA and PSA among the gender has not been demon- strated in this present study (Figure 3C and D). How- ever, we found that the PTA variation among C3 to C7 demonstrated the same pattern among the left and right pedicles as they had wide angle in the upper subaxial cervical spine, C3 to C5, and became slightly narrow in the lower cervical region at C6 and C7 (Figure 2C). Our results revealed the characteristic trend, which were comparable to the previous studies [17,23,26,27,30]. The PSA among the right and left pedicles also demonstrated the same results as they gradually changed from upward inclination at the upper subaxial cervical spine, C3 and C4, to neutral at the C5 and downward inclination at the lower cervical region, C6 and C7 (Figure 2D). This finding was also similar to the previous studies [17,26,27,30]. However, in our measurement, the C7 PSA showed a sig- nificantly larger angle when compared to the C6 PSA. This finding showed a deviation when compared to the pre- vious reports mentioned above in which it had demon- strated the similar PSA between C6 and C7 in most studies. We assume that this result may be caused by meas- urement error representing the variation in pedicular axis drawing due to the relatively large dimension of the C7 in- ternal pedicle height (IPH) and the variation among the shape of C7 vertebral endplate which may be distorted in a step of image reconstruction.
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using a newly-acquired Optotrak® Certus tracking system and First Principles™ software (NDI, Waterloo, ON, Canada) (Figure 2.2A). The rigid body trackers used were Optotrak® Smart Markers, which consist of three infrared markers (Figure 2.2B). Trackers were connected to the vertebrae either along Kirschner (K) wires for the exposed C3 and C4 vertebrae or to the cranial and caudal potting fixtures for the C2 and C5 vertebrae. The original tracker backing and pin (“Orthopaedic Research Pin” style) was found cumbersome and ineffective for the cervical spine. As such, they were modified to custom plastic backings connected to long, threaded Kirschner (K) wires. Due to the limited size and surrounding ligaments of the cervical vertebrae, insertion of the K wire was challenging to achieve adequate fixation to the bone and limit soft tissue disruption. Two successful trajectories were found that maintained marker visibility and accommodated the required 90° orientation change for shifting from flexion-extension to lateral bending: 1) an anterior-posterior direction through the vertebral body, lateral to the anterior longitudinal ligament, and 2) laterally through the vertebral body, just anterior to the posterior longitudinal ligament. Furthermore, the locations of specific anatomic landmarks were digitized relative to the tracker location in order to create a local anatomic coordinate system on each vertebra. Using a custom digitizing wand, the anatomic landmarks recorded were: the superior and inferior points of the anterior midline of the vertebral body and the most lateral points of the left and right transverse processes. Coordinate systems constructed from the points had positive axes directed anterior (X axis), left lateral (Y axis) and superior (Z axis), and an origin at the inferior point of the midline of the vertebral body (Wilke et al., 1998).
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Ahmed et al in 2012, in his study used minimally invasive technique for percutaneous placement of TAFS with help of the cortical screws used for orthopaedic indications. He also stated that rods and plates needed in lateral mass technique can be avoided by using TAFS. 38 With recent inventions such as navigation and image guidance, it is very easy to place the trans facet screw in the sub axial cervical spine.
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At the long-term follow-up, 6 % of our patients com- plained of self-reported hoarseness. Voice-related disor- ders are well-known complications due to the anterior cervical approach, particularly in the early postoperative weeks . Subjective hoarseness present at long-term after cervical spine surgery may be related to both direct injury to the recurrent laryngeal nerve and other multi- factorial causes (e.g., intubation, multisegment fusion, SCI, predisposing factors). The majority of articles ad- dressing subjective voice problems after cervical spine surgery have examined patients undergoing an elective anterior approach for a degenerative disease. Several studies have reported no sustained voice disorders at the long-term follow-up, whereas other studies have re- ported a frequency of 9–19 % [27–29]. The incidence of persistent voice disorders is higher for multilevel fusion and surgery above the C4 level [28, 29]. In our patient group, this complaint was equally frequent in patients who were operated with posterior as with anterior ap- proaches, indicating multifactorial etiologies.
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In a cadaveric model, Onan and c o-workers demons trated that the subaxial c ervic al fac ets w ere highly mobile, and when the facets were is olated by disc onnecting them from the s urrounding lamina and vertebral body, the facet capsules by thems elves did little to restric t joint motion due to their laxity. In fact, capsular s train w as not obs erved in flexion until the joint had almost dis loc ated anteriorly. This s ugges ts that the facet capsules act as a pos terior restraint to flexion only at the extremes of fac et motion and are thus less frequently injured. Panjabi and colleagues supported this notion in s imulations of frontal impact, during whic h the c ervic al spine rapidly flexes forw ard w hen the “tors o” decelerates. They found that the caps ules (and PLL) rarely experienced s ignific ant strain during this injury model and thus are not prone to disruption during acc idents involving frontal impact. Although these data may sugges t that the capsules contribute little to the stability of the subaxial c ervic al spine, one should be careful not to dis rupt the capsules at the nonfus ed levels when performing pos terior approaches to the cervic al spine, as this may lead to subluxation at the level above or below.
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The most detailed and convincing work on kinematics of cervical spine was done by White & Punjabi. The spine is a mechanical structure. The vertebrae articulate with each other in a controlled manner through a complex of levers (vertebrae), pivots (facets & discs), passive restraints (ligaments) and activators (muscles). The major portion of mechanical stability of spine is due to highly developed, dynamic neuromuscular control system.
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Similar to tumors of the subaxial cervical spine, atlantoaxial metastases generally involve the anterior elements (WBB, section 4–9). The anterior approach for resection of upper cervical tumors in this location is essential in most cases but was infrequently used in atlantoaxial metastases before [4–8, 11, 26]. Maxil- lotomy, transmandibular, and transoral approach were seldom used in atlantoaxial metastases since compli- cations such as large trauma, infections, and delayed union are the most common problems [27, 28]. The high anterior cervical approach avoids the infection risk of the transmandibular and transoral approach, and also allows for enough exposure to tumors of lat- eral mass, anterior arch, odontoid process, and C2 vertebra. In this study, we employed the high anterior cervical approach for all the anterior resection. Our practice and other studies [4, 25, 29] have demon- strated that the high anterior cervical approach is effective to perform tumor resection and reconstruc- tion in this region.
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Each image was manually marked and analyzed in a custom-designed Matlab-based program. Calculations of joint rotation were according to a previous validated method [7, 9, 30, 31]. The cervical joint motion was de- termined from the vertebral midplanes [3, 7]. Change in cervical joint motions were recorded as reposition errors in degrees. The analysis returned individual joint angles in degrees. The midplanes were resolved with respect to the horizontal plane, and change in the midplanes of C0 and C7 demonstrated a change in head position and the thoracic spine below C7, respectively. Anatomical struc- tures were marked on all vertebrae except for C0, which were marked with 4 external markers (Fig. 2).
overall mortality rates for CSI in chil- dren to be as high as 27%, with 66% of surviving children having persistent neurologic de ﬁ cit. Neurologic de ﬁ cits (21%) and death (7%) were less com- mon in our study and varied by age group, with younger children being the most severely affected. Poor outcomes were associated with age, injury to the axial region, associated cervical cord abnormalities on MRI, and comorbid injuries. These ﬁ ndings are supported by a pediatric autopsy study, which showed that the pediatric cervical spine could withstand signi ﬁ cant forces before fracture and instability occurs. As a result, young children ei- ther die of catastrophic axial CSI or survive the initial injury with minor fractures. 23 In contrast, older children
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Approval from the Colorado Multiple Institutional Review Board was obtained prior to initiation of this study (COMIRB #04-1118). The Trauma Registry at Den- ver Health Medical Center, an academic regional Level I Trauma Center, was queried to identify all those patients who presented to our institution between April 1, 2002 thru March 31, 2005 with a history trauma, who had a Glasgow Coma Score of 12 or less, or who were intubated prior to or shortly after arrival to DHMC. These criteria were selected so as to find the highest yield of patients having undergone ULCR as part of their workup to iden- tify cervical instability. Patients with a diagnosis of pene- trating trauma were excluded, as were patients under the age of 18. The records were further reviewed to determine
The study performed suggests that there is deviation of the cervical spine posture in female school teachers. This review has identified different possible risk and protective factors for MSD. As such there is need to develop and implement effective intervention strategies that are aimed at curbing the development of MSD among teachers. These intervention strategies may include ergonomically designed workplaces, proper equipment and training and reasonable job demands and exercise.
the clinical presentation will become more pronounced. However, our clinical investigation has implicated that the incidence of cervical spondylosis decreases with aging in the elderly population, especially after 60 years, although it increases with aging before age 50 years. Further assays subsequently proved that there is no relationship between the incidence of cervical spondylosis in the elderly and the age-related risk factors. Thus, we addressed the pathogen- esis of cervical spondylosis and showed that the volume and inflammation of the nucleus gets lesser since chronic degeneration contributes to atrophy of the nucleus with the aging process. 34–36 The pressure from the nucleus will
The position and amount of intervertebral space changes are mainly affected by traction force and traction angle. Previous studies   have examined how these two factors could affect the efficacy of the therapy. In general, large trac- tion force can achieve greater separation. Traction angle, on the other hand, helps to control the location of the separation to target the injured area. Howev- er, it is worth noting that traction position can also play a role in controlling in- tervertebral space changes. Traction position varies in mechanical traction de- vices and many researchers have examined their mechanisms to try to determine how they can affect the efficacy of cervical traction therapy. For instance, Chung et al.  compared the intervertebral disc space between axial and anterior lean traction and demonstrated that anterior lean traction in sitting position pro- vided more disc space anteriorly and posteriorly. Fater et al.  compared the supine and sitting position using home traction units and concluded that supine cervical traction may be more effective for increasing posterior vertebral separa- tion. Using a dynamic simulation model, Wong et al.  also examined the in- tervertebral separation of inclined and sitting positions and demonstrated that inclined position was able to create greater posterior separation in their model.
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Blastomyces dermatitidis is endemic to the southern and southeastern states bordering the Mississippi and Ohio River valleys as well as Midwestern states and Canadian provinces that border the Great Lakes . B. dermatiti- dis is endemic in wooded/forested areas around Chicago and the Great Lakes area. The patient lived in an urban environment and denied any recent exposure to wooded/forested areas. Lacking this type of exposure, we suspect that the moist soil exposed during the course of the basement construction, could possibly have been the source of the patient’s exposure. Osseous involvement is the third most common location for Blastomyces derma- titidis after lungs and skin, with ribs, long bones, skull, and vertebrae being the most common bones involved . While vertebral osteomyelitis most commonly af- fects the lower thoracic and lumbar areas of the spine, a few reports of cervical, upper-thoracic, and sacral in- volvement have been previously reported . We suspect that in our patient, undiagnosed pulmonary blastomycosis seeded the C6 vertebral body when the patient fell and in- jured her neck.
usual care or usual care alone. Paritcipants in the manual therapy group received up to six sessions over 12 weeks of manipulation and mobilization to the cervical spine, upper thoracic spine, and adjacent ribs by a physiotherapist. Usual care was provided as outlined by the Dutch College of General Practitioners and could involve information, advice, medication, corticosteroid injections, and physio- therapy. Participants in the manual therapy group were more likely to report ‘ completely recovered’ or ‘much im- proved’ immediately following the 12 weeks intervention [RR 2.0 (95 % CI 1.2, 3.4)] and at the 52 weeks follow-up [RR 1.5 (95 % 1.0, 2.2)] but not at the 26 weeks follow-up (Table 4). Furthermore, the manual therapy group was more likely to report their symptoms to be improved to the point where they were no longer inconvenient at the 52 weeks follow-up [RR 1.4 (95 % CI 1.0, 1.9)]. There were statistically significant but not clinically important differ- ences favouring the manual therapy group for pain (NRS) at the 12, 26, and 52 weeks follow-ups. Moreover, there were statistically significant differences favouring the man- ual therapy group for disability (SDQ) at the 26 weeks follow-up but not immediately following the 12 weeks intervention or at the 52 weeks follow-up (Table 4). The clinical importance of this finding is not known. There were no important differences between groups in health- related quality of life. Treatment preference may have biased the outcome in favour of the manual therapy group, because 12 % more participants in the usual care group prefered manual therapy at baseline.
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trauma center between March and November 2011, following blunt trauma, who underwent screening CT of the cervical spine as part of their evaluation were eligible for the study. According to the Trauma Practice Guidelines of our institution, CT is the rec- ommended technique to assess cervical spine injury when imag- ing is clinically indicated. For each eligible patient, clinicians were instructed to complete a survey (Fig 1) documenting the follow- ing: mechanism of injury, indication for ordering the study, and clinical suspicion for cervical spine injury. Among the survey in- dications were the 5 NEXUS criteria, as well as an “abbreviated” set of CCR criteria, including age 65 years or older, dangerous mechanism, paresthesias in the extremities, and inability of the patient to actively rotate his or her neck. Due to the nature of the survey, we thought that, with the exception of midline C-spine tenderness, the 5 low-risk criteria (simple rear-end motor vehicle crash, sitting position in the emergency department, ambulatory at any time, delayed onset of neck pain, absence of midline C- spine tenderness) could not be accurately documented. In addi- tion to the NEXUS and CCR criteria, clinicians could select from a number of other potential indications or could document their own indications. Triage acuity levels, which categorize patients according to their need for emergent medical intervention, were obtained for each enrolled patient.