Dr. Smith
Anesthesia: Dr. Jones
Procedure:
The patient was brought to the OR in supine position, prepped and draped in the usual sterile fashion. A midline incision was made from the inion to C7. Subperiosteal dissection was performed down to the occiput and C7. Lateral fluoroscopy was used to identify the appropriate levels. A high-speed burr was used to perform a laminectomy from C1 through C6. Pedicle screws were placed bilaterally at C2, C3, C4, C5, C6 and C7 under fluoroscopic guidance. Occipital screws were placed bilaterally under the superior n
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
Full-endoscopic lumbar discectomy is an innovative, minimally invasive alternative to microdiscectomy for patients with symptomatic lumbar disc herniations. IELD and TELD offer two complementary surgical corridors to spinal pathology and allow for treatment of the vast majority of lumbar disc herniations. There is level one evidence suggesting that full-endoscopic spine surgery results in similar functional outcomes compared with microsurgical technique, and has a favorable rate of perioperative complications.
Applied surgical anatomy of the craniovertebral spineKshitij Chaudhary
This presentation was made at the Advanced Cervical Spine Course conducted by Dr. Sandeep Sonone and Dr. Kshitij Chaudhary for the Bombay Orthopaedic Society. http://bombayorth.org/academics/instructional-courses/
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
Full-endoscopic lumbar discectomy is an innovative, minimally invasive alternative to microdiscectomy for patients with symptomatic lumbar disc herniations. IELD and TELD offer two complementary surgical corridors to spinal pathology and allow for treatment of the vast majority of lumbar disc herniations. There is level one evidence suggesting that full-endoscopic spine surgery results in similar functional outcomes compared with microsurgical technique, and has a favorable rate of perioperative complications.
Applied surgical anatomy of the craniovertebral spineKshitij Chaudhary
This presentation was made at the Advanced Cervical Spine Course conducted by Dr. Sandeep Sonone and Dr. Kshitij Chaudhary for the Bombay Orthopaedic Society. http://bombayorth.org/academics/instructional-courses/
A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury.
Dr.MD.Monsur Rahman,PT
MPT-Musculoskeletal Disorders
Maharishi Markandeshwar Institute Of Physiotherapy And Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana - Ambala,133-207 (Haryana)
How to Make a Field invisible in Odoo 17Celine George
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Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
How to Create Map Views in the Odoo 17 ERPCeline George
The map views are useful for providing a geographical representation of data. They allow users to visualize and analyze the data in a more intuitive manner.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
2. 73 year old woman cc: neck pain R>L UE pain
HPI: presented April 2015; referred by neighbor.
Pain occiput to neck, radiates to trapezial area,
lateral arm not past elbow, numbness entire
hand R=L IF worse, ataxia, 4 falls in last month,
difficulty and weakness with hands opening
things, taking money out of wallet and slow with
buttons. 1st spinal consult did not recommend
surgery.
PMH: thoracic PSF 1971, c4c7 acdf 2001, L2L5
PSF 2010, T12L5 PSF 2012, B TKA, R hip ORIF
2014, DVT, gastric ulcer surgery, severe arthritis
SH: RHD divorced mother of 5 grown children.
Retired deli manager 1998. Smoke 0.5 pack/day
11 years, 1-2 glass wine at night, 15
grandchildren and 4 great grandchildren
MEDS: Effexor, HCTZ, Lopressor, Norvasc,
Protonix, ASA, Calcium, Cyanocobalamin, MVI,
Senekot,
Exam: 4’11” 93 pounds, no neck extension,
minimal flexion, 10 degrees rotation, R>L
weakness, 4/5 right, 5/5 left, neg hoffmans no
clonus
9. Problem list:
1. 73 year old woman
occipito cervical
instability with clinical
myelopathy of falls,
upper and lower
dysfunction
2. cephalomedulary
angle 126 degrees
3. C4C7 ACDF
4. smoker
5. cachectic
6. dens erosion
7. rheumatoid
osteoporotic bone
8. pain
10. Cervical spine is the most common
site of disease in RA after the
hands and feet
11. Epidemiology of RA
• 1% of adults have RA, of those 10% have cervical spine
manifestations
• 3x more women and men
• RA affects cervical spine
• Ankylosing spondylitis affects SI joints and ALL
• RA manifestations in the cervical spine
• Atlantoaxial subluxation (19-79%)
• Subaxial subluxation (7-88%)
• Cranial settling (basilar impression or invagination, atlantoaxial
impaction, superior migration of the odontoid)
• 25-88% prevalence of cervical spine involvement in RA patients
• 7-34% will have neurologic symptoms that require surgical
consultation
• Lumbar spine rarely involved
12. Atlantoaxial Instability (C1-C2)
• Anterior, posterior, and rotatory subluxations
• Anterior: most common
• C1 anterior to C2
• Destruction of the transverse, apical and alar ligaments (most common)
• Atraumatic dens fracture
• Dens erosion
• RA pannus around the synovial joint between the dens and anterior arch
of C1 can result in additional compromise of SAC (space available for cord)
• Erosive pannus formation at the C1-C2 joints, bone
destruction --> laxity of the transverse atlantal ligament
• Normal anterior atlantodens interval <3mm (Adult)
• Atlantoaxial instability --> increase anterior atlantodens interval AND
decrease in space available for cord--> compression of spinal cord
13. Pannus?
theories on the pathogenesis of rheumatoid arthritis suggest that the synovial cells of these patients chronically express an antigen that triggers
oduction of rheumatoid factor (RF), an immunoglobulin molecule directed against other autologous immunoglobulins. An inflammatory response is
ed, involving immune complex formation, activation of the complement cascade, and infiltration of polymorphonuclear leukocytes. The proliferating
asts and inflammatory cells produce granulation tissue, known as rheumatoid pannus, within the synovium. The pannus produces proteolytic
es capable of destroying adjacent cartilage, ligaments, tendons, and bone. The destructive synovitis results in ligamentous laxity and bony erosion
esultant cervical instability and subluxation
14. Subaxial Subluxation
• Autoimmune destruction of the
facet joints
• Results in listhesis, kyphosis or
staircase deformity
• Subluxation defined:
• >3.5mm translation OR
• >20% vertebral body slip OR
• 11 deg of angular instability
• May have multiple levels involved,
leading to a staircase deformity
15. Cranial Migration
• Erosion of O-C1 and C1-C2 joints such that the
odontoid go into the foramen magnum.
• Occurs when there is a high degree of destruction
of
• Occipitoatlantal condyles
• Atlantoaxial facet joint
• C1 lateral mass destruction (most common)
• The head settles caudally --> compression of the
ventral brain stem around the dens death
16. Clinical Presentation
• 33-50% of all RA patients with cervical instability are ASYMPTOMATIC
• Neck pain, decreased ROM, neurological symptoms, altered mental
status
• Occipital headaches
• Secondary impingement of the greater or less occipital nerves (medial divisions
of the dorsal rami of C2 and C3 nerve roots
• C2 nerve claudication may cause pain in the face, ear, mastoid
• C1-C2 instability
• Vertigo, syncope, nystagmus, dysarthria, sleep apnea, swallowing difficulty,
facial parathesias
• Cervical myelopathy
• Muscle weakness, atrophy, numbness, tingling, paraesthesias, bowel/bladder
incontinence, hyperreflexia, loss of proprioception, gait instability
• Occurs in 10% of patients with RA who have cervical involvement
17. Laboratory Findings
• RF= 80% of patients
• Low specificity
• Antinuclear antibodies: 30% of patients
• ESR/CRP/serum globulin levels
• CRP shown to predict the risk of joint deterioration
• Anti-CCP, anti-MCV
• High sensitivity and specificity
• Predictive and prognostic in RA
• Anti-MCV:
• Good for +RF and +anti-CCP-2
• Patients who are seronegative for RF but positive for anti-
CCP have increased radiographic progression and poorer
functional outcomes than other patients with RA
18. Radiographic Findings
• Standard AP, PA, lateral flex-extension, open mouth
view
• CT better than open mouth view
• Atlantodens interval (ADI)
• Men <3.0mm
• Women<2.5mm
• Instability: ADI>5mm
• ADI>10mm --> complete loss of the structural integrity of the
transverse, apical and alar ligaments
• Space Available for Cord
• More reliable indicator for neurological compromise
• <13-14mm indication for surgery
19. Natural History
• Without treatment of RA, the spine can be
associated with progressive disability resulting from
atlantoaxial dislocation along with the risk of
sudden death caused by cord or brain stem
compression
• 7 year survival is low in patients with myelopathy
2/2 to atlantoaxial subluxation who refuse surgical
tx
20. Nonsurgical Management
• Physical Therapy
• Soft collar for comfort
• Hard collar for known spinal instability
• No evidence that they reduce neurological progression or prevent
further subluxation
• External immobilization does not control instability
• Poorly tolerated due to involvement of temporomandibular joint
• DMARDS
• Methotrexate, hydroxychloroquine, leflunomide, sulfasalazine
• TNF inhibitor
• Adalimumab, certolizumab, pegol, etanercept, golimumab,
infliximab_
• Biologic
• Abatacept, rituximab, tocilizumab
21.
22. Surgical Management
• Atlantoaxial instability
• C1-C2 Posterior Fusion
• Superior Migration
• Early: C1-C2 fusion
• Late: Suboccipital craniotomy and C1 laminectomy
• Persistent compression: Transoral dens resection
• Subaxial
• Laminectomy and PSF
23.
24. Synovial bursa between the transverse atlantal
ligament and the odontoid process; Occiput C1
C2 have no discs (not affected by rheumatoid
disease)
41. ALERT TEST QUESTION: ADI>10mm complete
loss of transverse as well as checkrein (apical
and alar) ligaments
42.
43.
44.
45.
46.
47.
48.
49.
50. - Ranawat's line:
- center of C2 pedicle to a line
connecting the anterior and posterior C1
arches;
- normal measurement in men is 17
mm, whereas in women it is 15 mm;
- distance of < 13 mm is consistent with
impaction;
- less than 7 mm is associated with
medullary compression on MR image
- McRae's line:
- defines the opening of the foramen
magnum;
- the tip of the dens may protrude
slightly above this line, but if the dens is
below this line then impaction is not present;
- McGregor's line:
- line drawn from the posterior edge of
the hard palate to the caudal posterior
occipit curve;
- cranial settling is present when the tip
of dens is more than 4.5 mm above this line;
- this measurement can be difficult
when there is dens errosion;
- problem w/ this measurement is that
the hard palate position may vary w/ mid
facial anomalies;
- Chamberlain's line:
- line from dorsal margin of hard palate
to the posterior edge of the foramen
magnum;
- this line is often hard to visualize on
standard radiographs;
- if dens is > 6 mm above this line,
consistent w/ impaction
51.
52.
53.
54. 88 year old man with cc:
headaches R neck pain
HPI: Frontal headaches with
R posterior neck pain.
Supine position helps relieve
pain, dizzy spells last 6
months, need for a walker
the last 2-3 years
PMH: HTN, A fib, Pacemaker
2011, B THA, BPH,
SH: widower,
PE: 5 feet 9 inches 165 lb,
wide based slow cadence,
bent forward posture
76. Problem list:
1. occipito cervical
instability with clinical
myelopathy of falls,
upper and lower
dysfunction
2. cephalomedulary
angle 126 degrees
3. C4C7 ACDF
4. smoker
5. cachectic
6. dens erosion
7. rheumatoid
osteoporotic bone
8. pain
treatment?
77. DOS 4/23/15
Occiput C7 PSF, posterior
laminectomy C1 through C6, L
PICBG,
IVF: 4.5 liters
EBL: 1.2 liters
Operative time 5 hours
UO: 500cc
C1C2 ligamentum flavum adherent
to dura but peeled off without
incident