A congenital teratoid tumor arising and protruding through the mouth is classified as epignathus or fetus in fetu. On review of literature, we found various reports of midline mandibular and lower lip cleft associated with flexion contracture of neck, midline cervical cord, but there is only one report of association with midline dermoid. We present an unusual case of midline cleft of mandible with an epignathus. A 2.3-kg male child, delivered transvaginally in the 38th gestational week, was referred to us for management of a large irregular growth hanging outside the mouth. On examination, he had a wide median cleft of the mandible with tongue adherent to the “V”-shaped defect in the area of lower lip. A midline irregular mass of size 12 × 8 × 5 cm with variegated consistency was arising in the midline from the floor of the mouth between the tongue and lower lip. X-ray and computed tomography scan showed a rounded soft tissue mass arising from the alveolus with multiple calcifications within it along with a large triangular calcification and absence of hyoid bone. The mass was excised by mobilizing the tip of tongue. Staged repair was planned for the defect in the mandible. Unfortunately, the baby succumbed postoperatively to complex congenital heart disease. Histopathology was suggestive of epignathus. We discuss hereby the embryology and current management strategies of the problem.
Epignathus; Fetus in Fetu; Midline cleft mandible
Intraspinal bronchogenic cysts are rare congenital cystic lesions. In all the reported cases, the cysts have been located in the cervical, upper thoracic or thoracolumbar segments. We report the case of an intraspinal bronchogenic cyst in the sacral location. We present the case of a 5-month-old female with a skin dimple in the midline over the sacral vertebra. Magnetic resonance image of the lumbar and sacral vertebra revealed a dermal sinus tract and an epidural cystic mass at the S2 level. The patient underwent the removal of the dermal sinus tract and the cyst. The cystic mass was shown to be connected to the subarachnoid space through a slender pedicle from the dura. The cyst was diagnosed to be a bronchogenic cyst based on the results of the histopathological examination. We conclude that intraspinal bronchogenic cysts may appear in the sacral location.
Bronchogenic Cyst; Endodermal Cyst
Congenital anterior midline clefts of the atlas are rare developmental anomalies with only a few reported cases in the literature. This normal variant of the atlas results when the anterior arch fails to fuse during the ossification process. Series of cadaveric dissections have demonstrated anterior midline atlas clefts in 0.1-0.2% of the general population. Histological examinations have revealed that the bony defect, which ranges from 1-5 millimetres in width, is bridged by fibrocartilagenous tissue, resulting in what is generally believed to be a stable atlas.
Radiographically, congenital anterior clefts mimic many types of atlantal fractures, including Jefferson burst fractures, and vertical fractures of the anterior arches. The distinct radiographic appearances of congenital clefts and acute fractures of the atlas help to distinguish them from each other.
In the majority of cases, anterior clefts of the atlas remain undetected and have no clinical ramifications. Detection usually occurs during emergency post-traumatic radiographic imaging of the upper cervical spine. Under these circumstances, the presence of this congenital anomaly can make it difficult to differentiate between an acute fracture and a congenital variant. Where there is suspicion of fracture, computed tomography (CT) must be considered, as it is the most useful means of differentiating between these two clinical entities.
Chiropractors considering spinal manipulative therapy should be concerned with stability of an atlas with an anterior cleft, particularly in patients with a recent history of injury to the cervical spine. Appropriate clinical and radiographic examinations must be used to rule out cervical spine instability, before treatment is commenced. A reasonable course of treatment may include the judicious use of spinal manipulation.
abnormalities; athletic injuries; atlas; cervical vertebrae; chiropractic; diagnosis; differential; radiography; sports medicine; manipulation
Congenital anomalies in arches of the atlas are rare, and are usually discovered incidentally. However, a very rare subgroup of patients with unique radiographic features is predisposed to transient quadriparesis after minor cervical or head trauma. A 46-year-old male presented with a 2-month history of tremor and hyperesthesia of the lower extremities after experiencing a minor head trauma. He said that he had been quadriplegic for about 2 weeks after that trauma. Radiographs of his cervical spine revealed bilateral bony defects of the lateral aspects of the posterior arch of C1 and a midline cleft within the anterior arch of the atlas. A magnetic resonance imaging revealed an increased cord signal at the C2 level on the T2-weighted sagittal image. A posterior, suboccipital midline approach for excision of the remnant posterior tubercle was performed. The patient showed significant improvement of his motor and sensory functions. Since major neurologic deficits can be produced by a minor trauma, it is crucial to recognize this anomaly.
Congenital anomalies; Cervical atlas; Spinal cord injury; Head trauma
Congenital midline cervical cleft (CMCC) is a rare developmental anomaly of the anterior neck, mostly found in Caucasian females. Most authors consider it within the spectrum of branchial arch developmental abnormalities. There have been about 100 reported cases in the literature. However, there is no agreement on the age of surgery in this anomaly.
In this report we present our experience of managing this anomaly in the early neonatal period in two neonates. One of them had concomitantly congenital heart disease.
It is important to recognize this rare congenital anomaly in neonate. Although the exact time of surgery for CMCC is not mentioned, based on our results the earliest time of intervention is recommended since then the operating result will be excellent.
Congenital Anomaly; Branchial Arch; Midline Cervical Cleft
Congenital midline cervical cleft is a rare congenital anomaly. The cardinal diagnostic features are-(1). Fistula's opening are located caudally (2) Internuittent serous fluid discharge in the early neonatal period (3). Nipple like appearance of the cleft in the superior aspect (4). Widened scar and mininual neck contracture in later life. Two such cases are reported herewith with briefreview of literature and it's surgical management.
Midline cervical cleft; Associated anomaly; Management
Stickler syndrome is an autosomal dominant disorder with characteristic ophthalmological and orofacial features, deafness, and arthritis. Abnormalities of vitreous gel architecture are a pathognomonic feature, usually associated with high myopia which is congenital and non-progressive. There is a substantial risk of retinal detachment. Less common ophthalmological features include paravascular pigmented lattice degeneration and cataracts. Non-ocular features show great variation in expression. Children with Stickler syndrome typically have a flat midface with depressed nasal bridge, short nose, anteverted nares, and micrognathia. These features can become less pronounced with age. Midline clefting, if present, ranges in severity from a cleft of the soft palate to Pierre-Robin sequence. There is joint hypermobility which declines with age. Osteoarthritis develops typically in the third or fourth decade. Mild spondyloepiphyseal dysplasia is often apparent radiologically. Sensorineural deafness with high tone loss may be asymptomatic or mild. Occasional findings include slender extremities and long fingers. Stature and intellect are usually normal. Mitral valve prolapse was reported to be a common finding in one series but not in our experience. The majority of families with Stickler syndrome have mutations in the COL2A1 gene and show the characteristic type 1 vitreous phenotype. The remainder with the type 2 vitreous phenotype have mutations in COL11A1 or other loci yet to be identified. Mutations in COL11A2 can give rise to a syndrome with the systemic features of Stickler syndrome but no ophthalmological abnormality.
Keywords: Stickler syndrome; collagen; vitreous
Human tails and pseudotails are rare sacrococcygeal lesions that are associated with a wide variety of anomalies and syndromes. Anorectal malformations are also relatively uncommon congenital defects that often occur in conjunction with syndromes or other congenital abnormalities. The anomalies associated with both disorders determine the timing and approach to surgical correction. We present an unusual case of a patient with both imperforate anus and a pseudotail in the absence of a syndrome or other associated anomalies and we emphasize the necessity of a thorough preoperative evaluation.
A Caucasian girl was born at term after an uncomplicated pregnancy and was noted at birth to have a skin-covered posterior midline mass and imperforate anus with a fistula to the vaginal vestibule. Ultrasound and magnetic resonance imaging revealed a predominately fatty lesion without presacral extension and ruled out associated spinal and cord abnormalities. The patient underwent diversion with colostomy and a mucous fistula in the newborn period as a fistulogram demonstrated a long fistulous tract to normal rectum and it was anticipated that anoplasty and resection of the mass would require extensive posterior dissection. The sacrococcygeal mass was removed during posterior sagittal anorectoplasty at the age of six weeks which was determined to be a pseudotail because of the composition of brown fat and cartilage. The patient is now 14 months old with normal bowel function after a colostomy takedown.
A comprehensive preoperative assessment and thoughtful operative plan were necessary in this unusual case because of the extensive differential diagnosis for sacrococcygeal masses in the newborn and the frequency of anomalies and syndromes associated with tail variants and imperforate anus. The pediatricians and neonatologists who initially evaluate such patients and the surgeons who correct these disorders must be aware of the potential pitfalls in their management.
Congenital midline cervical cleft is a very uncommon malformation of the anterior neck, with less than 100 cases reported in medical literature. Herein we present a case of a female neonate with this anomaly. A detailed description of the macroscopic and microscopic characteristics is performed. As it is derived from the natural history of the lesion, prompt clinical diagnosis, and operative treatment during early infancy predispose to a better aesthetic and functional prognosis.
Evaluation of palpable neck masses may be a diagnostic problem in pediatric patients, with differential diagnosis including congenital, inflammatory, tumoral and traumatic lesions. Ultrasonography is usually a satisfactory method to make a correct pre-operative evaluation of neck masses, although diagnosis is often challenging for the surgeon and the radiologist and sometimes only possible after a histopathological examination of the resected lesion.
We report an 8-month-old patient with a cervical, anterior midline mass. Ultrasonographic images showed features suggesting a partly cystic lesion, with a preoperative suspect of thyroglossal duct cyst. Histological examination, performed after surgical removal of the mass, led to a diagnosis of lymph node angiomyomatous hamartoma (AH).
AH, a rarely occurring benign lymph node lesion, has been reported in the neck lateral region only twice. This case, presenting as a palpable neck midline mass, is the first reported case occurring in infancy. Although rare, AH should be included in the differential diagnosis of head and neck masses.
Angiomyomatous hamartoma; Pediatric neck mass; Ultrasonography; Lymph node
A 59-year-old patient had been treated by the general surgery department at her local hospital for a recurrent sebaceous cyst on the back of her neck. Cervical MRI showed a cystic structure, posterior to fused vertebral bodies, connected to the skin by a sinus passing through the middle of a split cord malformation. The lesion was excised via an anterior approach. Histology confirmed a benign neurenteric cyst. This rare developmental anomaly, mimicking a common acquired surgical condition, highlights the need for caution in the diagnosis of midline pathology.
Conventional laminectomy is the most popular technique for the complete removal of intradural spinal tumors. In particular, the central portion intramedullary tumor and large intradural extramedullary tumor often require a total laminectomy for the midline myelotomy, sufficient decompression, and adequate visualization. However, this technique has the disadvantages of a wide incision, extensive periosteal muscle dissection, and bony structural injury. Recently, split-spinous laminectomy and tubular retractor systems were found to decrease postoperative muscle injuries, skin incision size and discomfort. The combined technique of split-spinous laminectomy, using a quadrant tube retractor system allows for an excellent exposure of the tumor with minimal trauma of the surrounding tissue. We propose that this technique offers possible advantages over the traditional open tumor removal of the intradural spinal cord tumors, which covers one or two cervical levels and requires a total laminectomy.
Cervical cord tumor; Split-spinous laminectomy; Quadrant tube retractor
The transoral approaches have become commonplace in modern neurosurgical practice for treatment of ventral midline lesions of the clivus and upper cervical spine. Although the standard technique of transoral surgery is conceptually simple, anatomic relationships are not so readily appreciated. The present study was undertaken in an effort to define more clearly the midline anatomic relationships as they pertain to the standard transoral and transpalatine operations. The anatomic relationships involved in planning microsurgical transoral approaches were examined in 15 human cadavers. Landmarks approximating the midline of the skull base and the upper cervical spinal canal were defined to assist the surgeon's orientation. Measurements were made in axial, sagital, and parasagittal planes to various neurovascular structures in the posterior cranial fossa and upper cervical spinal canal. The study revealed that, for the standard transoral and transoral-transpalatine dissections, the carotid arteries, abducens nerves, interior petrosal sinuses, hypoglossal nerves, and vertebral arteries would be a greatest risk being 0.76, 1.06, 1.51, 1.34, and 1.52 cm from the midline at specified locations. The measurements and the computed tomography images provide a useful reference for the surgeon.
Objective: There is widespread belief among doctors that posterior midline tenderness is virtually a prerequisite for spinal fracture in alert, sober patients without any painful distracting injury or neurological deficit. This paper examines and challenges this belief.
Methods and results: We present three patients in whom significant thoracic and lumbar vertebral fractures were missed, or were thought to be "old", because of lack of posterior midline tenderness. We also present two further patients, one with a lumbar spine fracture and one with a cervical spine fracture, in whom posterior midline tenderness was absent but in whom the correct diagnosis was made. All these patients were sober and fully alert and none had a neurological deficit or a painful distracting injury.
Conclusion: The absence of posterior midline tenderness does not exclude significant spinal injury. We suggest that patients should satisfy both the Canadian and British guidelines before it is decided that imaging of the cervical spine is unnecessary.
AIM--To determine whether sampling the anterior and posterior cervical lips in hysterectomy specimens provides the best opportunity for detecting unsuspected cervical intraepithelial neoplasia (CIN). METHODS--The frequency with which CIN was identified at a range of positions on the anterior and posterior lips and left and right lateral aspects of the cervix was assessed in 100 cone biopsy specimens. RESULTS--CIN affected one or other cervical lip in all 100 cases studied and involved the midline positions (12 and 6 o'clock) in 94. The lateral edges of the cervical canal were also involved in 38 cases. CONCLUSION--CIN is more likely to be identified on the anterior and posterior lips than on the lateral aspect of the cervical os. The findings support the continuation of the established practice of taking blocks from the midline in these areas.
Background: Current recommendations for obtaining blood from neonates advise avoidance of the midline area of the heel and are based on postmortem studies.
Objective: Because of the potential pain and tissue damage from repeated heel pricking in the same area, to investigate using ultrasonography whether the distance from skin to calcaneus is less at the midline than at the borders.
Methods: One hundred consecutive healthy preterm and 105 consecutive healthy term neonates were studied 48–72 hours after delivery. The skin to perichondrium distance (SPD) was measured on two occasions by ultrasound at the external, midline, and internal areas of the heel.
Findings: Mean SPD was 0.2 mm less at the midline than at the other sites. The proportion of measurements <3 mm at any of the three sites was the same. Depth was <3 mm in less than 3% of the term and ∼20% of the preterm infants. The SPD correlated only with gestational age. Of children <33 weeks gestational age, 38% had an SPD <3 mm compared with 8% of older preterm infants. The proportions of preterm infants of ⩾33 weeks gestation and term infants with an SPD <3 mm were similar (8% v 3%).
Interpretation: With the use of automated lancets of 2.2 mm length or less, the whole heel plantar surface is safe for obtaining blood in term and preterm infants of ⩾33 weeks gestation. This means that soft tissue damage and pain from repeated pricking in the same area can be reduced.
Aims: To establish the validity of assuming that by examining midline blocks from the anterior and posterior lips of the cervix, a previously unsuspected cervical intraepithelial glandular neoplasia (CIGN) lesion would be identified.
Methods: The distribution of CIGN in 30 cone biopsy specimens of cervix was examined.
Results: Nine low grade and 21 high grade cases were identified involving one or other lip in 29 patients and one or both lateral edges in 20. The distribution of CIGN was unifocal in 20 patients, involved two distinct foci in nine, and three distinct foci in one. Only three patients had a circumferential distribution. Midline disease, either CIGN or squamous cervical intraepithelial neoplasia (CIN), or both, was present in 27 patients.
Conclusion: These findings suggest that examining the midline blocks from hysterectomy specimens will result in the identification of CIGN lesions in over 90% of patients, either because the CIGN lesion is present in the midline or because an associated squamous CIN lesion will be identified, which will result in the examination of the entire cervix, with the consequent identification of the CIGN lesion.
cervix; biopsy; tissue processing; adenocarcinoma in situ
The relationship of the esophagus to the cervical vertebral body (CVB), disc space and longus colli (LC) muscles, to our knowledge, has not been previously studied. The purpose of this study was to quantify the relationship of the esophagus to the CVB, disc space and LC. 30 patients were selected for a retrospective review of computed tomography (CT) scans. Measurements between the esophagus and the C5, C6, and C7 vertebral bodies as well as the C5/6 and C6/7 disc spaces were performed in the midline, 3 mm right and left of midline, and at the edge of the LC on both sides. The closest distance of the esophagus to the CVB and disc space occurs at the midline (range 1.02–1.31 mm at each level). The furthest distance occurred at the edge of the right LC (range 2.67–3.30 mm at each level). The mean distance from the edge of the right LC to the midline was significantly greater (P < 0.01) than mean distance from the edge of the left LC to the midline. No statistical significant differences were observed when comparing measurements at the individual vertebral bodies and disc spaces. The results of the study demonstrate that the esophagus lies in closest proximity to the CVB and disc space in the midline. A larger potential space exists between the esophagus and the CVB and disc space at the edge of the LC. These results may provide insight into a potential cause of post-operative dysphagia. Furthermore, it may help guide the future design of cervical plates to better utilize the potential space between the esophagus and the CVB and disc space at the edge of the LC.
Cervical spine; Esophagus; Anatomy; Cervical plate; Cervical disc replacement; Dysphagia
The aim of this study was to compare operative feasibility and surgical outcome of the modified Cherney incision and vertical midline incision in patients undergoing radical hysterectomy and pelvic lymphadenectomy.
Between March 2005 and December 2007, retrospective data of 78 patients (n=17; modified Cherney incision, n=61; vertical midline incision) with early stage cervical cancer who received radical hysterectomy and pelvic lymphadenectomy were reviewed.
Baseline characteristics of patients who underwent modified Cherney incision and vertical midline incision were similar except for age (mean±SD: 32.3±3.4 yr vs. 52.5±8.4 yr, p<0.001). Patients who received modified Cherney incision had earlier initiation of soft diet (mean±SD: 46.5±19.5 hr vs. 56.4±25.4 hr, p<0.016) and shorter hospital stay compared to those who received vertical midline incision (mean±SD: 18.0±4.8 days vs. 21.7±3.7 days, p<0.042). There was no difference in the number of dissected pelvic lymph nodes, hemoglobin change, postoperative pain, postoperative ileus, Foley indwelling duration, and perioperative complications.
Excluding the selection bias for age, there was no significant difference of the clinical outcome between the modified Cherney incision group and the vertical midline incision group. Modified Cherney incision can be cosmetically performed in young age women obtaining equal number of lymph nodes without increased operative morbidity compared to vertical midline incision.
Cervical cancer; Radical hysterectomy; Cherney incision
Pure ventral midline giant schwannoma is an extremely rare entity. Spinal intradural extramedullary schwannomas commonly occur posterolateral or anterolateral to the spinal cord. A case of a pure midline ventrally situated giant pan cervical extramedullary schwannoma in an 18-year-old male patient with compressive myelopathy and sphincter involvement is presented. Spinal MR imaging showed a midline ventrally situated extramedullary tumor with severe spinal cord compression extending from clivus to C7 vertebra. It was resected through a posterolateral approach. Histology was consistent with a schwannoma. Post operative MR imaging showed no evidence of the tumor. The radiological features, pathogenesis and surgical strategies in management of these difficult tumors are discussed and the relevant literature is briefly reviewed.
Extramedullary; Intradural; Giant schwannoma; Spine; Ventral location
Objective: Surgery is a cornerstone of treatment for a wide variety of neoplastic, congenital, traumatic, and inflammatory lesions involving the midline anterior skull base and may result in a significant anterior skull base defect requiring reconstruction. This study is a retrospective analysis of the reconstruction techniques and complications seen in a series of 58 consecutive patients with midline anterior skull base pathology treated with craniotomy or a craniofacial approach. The complication rates in this series are compared with other retrospective series and specific techniques that may reduce complications are then discussed. Design: This is a retrospective analysis of 58 consecutive patients who had surgery for a midline anterior skull base lesion between January 1994 and July 2003. Data were collected regarding pathology, surgical approach, reconstruction technique, and complications. Results: Twenty-nine patients underwent surgery for a meningioma (50%). The remainder had frontoethmoidal cancer, mucoceles/invasive nasal polyps, encephalocele, esthesioneuroblastoma, anterior falx dermoid cyst with a nasal sinus tract, or invasive pituitary adenoma. In most patients, a low and narrow two-piece biorbitofrontal craniotomy was used. When possible, the dura was repaired before entering the nasal cavity. Thirteen patients experienced a complication (22%). There was one case of postoperative cerebrospinal fluid (CSF) leak (2%), one case of meningitis (2%), two cases of bone flap infection (3%), and two cases of symptomatic pneumocephalus (3%). There were no deaths, no reoperations for CSF leak, and no patient had a new permanent neurologic deficit other than anosmia. Conclusions: Transcranial approaches for midline anterior skull base lesions can be performed safely with a low incidence of postoperative CSF leak, meningitis, bone flap infection, and symptomatic pneumocephalus. Our results, particularly with regard to CSF leakage, compare favorably with other retrospective series.
Anterior skull base; cerebrospinal fluid leak; complications; craniofacial approach; meningioma; skull base surgery
Solitary median maxillary central incisor syndrome (SMMCI) is a complex disorder consisting of multiple, mainly midline defects of development resulting from unknown factor(s) operating in utero about the 35th–38th day(s) from conception. It is estimated to occur in 1:50,000 live births. Aetiology is uncertain. Missense mutation in the SHH gene (I111F) at 7q36 may be associated with SMMCI. The SMMCI tooth differs from the normal central incisor, in that the crown form is symmetric; it develops and erupts precisely in the midline of the maxillary dental arch in both primary and permanent dentitions. Congenital nasal malformation (choanal atresia, midnasal stenosis or congenital pyriform aperture stenosis) is positively associated with SMMCI. The presence of an SMMCI tooth can predict associated anomalies and in particular the serious anomaly holoprosencephaly. Common congenital anomalies associated with SMMCI are: severe to mild intellectual disability, congenital heart disease, cleft lip and/or palate and less frequently, microcephaly, hypopituitarism, hypotelorism, convergent strabismus, oesophageal and duodenal atresia, cervical hemivertebrae, cervical dermoid, hypothyroidism, scoliosis, absent kidney, micropenis and ambiguous genitalia. Short stature is present in half the children. Diagnosis should be made by eight months of age, but can be made at birth and even prenatally at 18–22 weeks from the routine mid-trimester ultrasound scan. Management depends upon the individual anomalies present. Choanal stenosis requires emergency surgical treatment. Short stature may require growth hormone therapy. SMMCI tooth itself is mainly an aesthetic problem, which is ideally managed by combined orthodontic, prosthodontic and oral surgical treatment; alternatively, it can be left untreated.
The differential diagnosis of midline nasal masses includes inflammatory lesions, post-traumatic deformities, benign neoplasms, malignant neoplasms, congenital and vascular masses. Midline congenital lesions of the nose are rare congenital anomalies. Their incidence is estimated at 1 per 20,000 to 40,000 births consisting of gliomas, encephaloceles, and nasal dermoid sinus cysts. Nasal dermoid sinus cysts account for 1–3% of dermoid cysts overall and 11–12% of head and neck dermoids. Most lesions are diagnosed within the first three years of life but in some cases the diagnosis can be prolonged. We present an 18-year old and a two and a half-year old male patients who are concerned about drainage from the tip of the nose with recurrent infection and operated with a diagnosis of nasal dermoid sinus cyst.
congenital; dermoid cyst; adult; nasal mass.
The purpose of this study was to investigate the cutaneous nerves at risk during the posterior midline approach to the elbow and proximal ulna. Ten fresh frozen cadaver upper extremities were used for this study. A posterior midline skin incision extending from 10 cm proximal to 15 cm distal to the olecranon tip was created. All superficial nerves were identified and preserved. Nerve diameters were measured, their distance from the olecranon tip assessed, and they were dissected proximally to confirm their nerve of origin. Point of nerve arborization to skin from the midline incision was quantified. An average of one confirmed nerve proximal and five distal to the olecranon tip were identified with an average diameter of 0.9 mm proximal and 1.3 mm distal to the olecranon. The largest nerves were typically located 2 cm proximal (range 7–46 mm) and 45 mm distal (range 9–135 mm) to the olecranon. The branches arborized into the skin an average of 5.2 mm lateral to the incision. All nerves joined the posterior medial antebrachial cutaneous nerve. The branches of the medial antebrachial cutaneous nerve are at risk with a straight posterior midline elbow incision, though the clinical significance of injury to these nerves at this location is unknown.
Nerves; Midline incision; Elbow
The author presents a retrospective clinical study addressing the outcome after posterior stabilisation of the occipital-cervical spine using a new cranio-spinal implant. The range of surgical methods for operative treatment of occipito-cervical instability remains wide, and it is still a demanding technique that frequently requires improvisation by the surgeon. No previous studies have been published of occipito-cervical reconstructions using two contoured asymmetrical occipital plates interdigitating in the midline at the occiput and allowing various methods of cervical fixation, by means of different hooks, a claw device or screws. Nine patients with severe occipito-cervical instability and/or subaxial malalignment underwent reconstructive surgery with the new implants between 1998 and 2001. Seven patients suffered from rheumatoid arthritis (RA) including cranial settling. Two patients had widespread cervical metastases. All patients suffering RA were treated by preoperative cervical traction for up to 28 days, and intraoperative traction, to try to restore the malalignment. Traction was also used, to diminish pain and to improve neurological symptoms. The lowest vertebra fused was T3. All patients were immobilised with an external orthosis or brace for 6 weeks or 3 months. A solid fusion was achieved in all patients. None of the patients deteriorated postoperatively. No serious complications occurred. One occipital screw broke and one hook loosened, needing a re-fixation. The simplicity of applying these cranio-cervical implants makes them practical for every orthopaedic or neurosurgeon with a special interest in cervical spine surgery.
Cranio-cervical instability; Atlanto-axial instability; Occipito-cervical fusion; Laminar hooks; Lateral mass screws