Transcript - Catalyst

Orthopaedic Surgeons Should
Expose Themselves
(courtesy of Dr. Gow)
Dan Holtzman, MD
R1, Dept. of Orthopaedics &
Sports Medicine
Patient BWN, H3096539
HPI:
13 yo M, o/w healthy wrestler was “body slammed”
to mat and landed head first. Felt immediate
neck pain and had difficulty walking. Reported
UE parasthesias upon initial presentation.
OSH PE noted to have lateralized UE/LE
weakness.
Started on methylprednisolone and transferred to
HMC for management.
Patient BWN, H3096539
PE:
Neuro:
GCS 15
CN II-XII intact
Motor: BL UE weakness 3-4+/5 in muscle groups
tested. BL LE ext 5/5.
Sensory: 2/2 in all dermatomal dist.
Reflexes: 2+, no Hoffman’s sign present
Patient BWN, H3096539
On HD #2, UE weakness & parasthesias had
resolved.
Pt discharged home w/ Miami-J collar for 6 weeks.
Upon RTC, pt continued to be asymptomatic.
However, on flexion-extension films:
Patient BWN, H3096539
To OR:
Pt underwent C2-3 anterior cervical interbody
fusion with diskectomy and interbody spacer.
(Submandibular/Retropharyngeal approach to
C2-3 interspace performed by the
Otolaryngology service)
Cervical Spine Injuries In Children
Brown et al. 2002, Cincinnati Children’s
• Retrospective case series, 103
cases over 9 years
• Mean age: 10.3 +/- 5.2, male
predominance
• Overall mortality: 18%
• MVCs
• Younger children (mean: 5)
• Higher lesions (50% mortality
C1 dislocation)
• Associated w/ CHI
• 68% C1-C4, 25% C5-C7, 7% both
• 52% MVCs, 27% sports (29%
football)
• 38% SCIWORA
• Complete cord lesions associated
w/ lower (C4-C7) injuries
• C-spine injury and SCIWORA
should always be included as part of
evaluation in child abuse.
Cervical Spine Injuries:
Considerations in the Pediatric Population
• Increased risk of upper (Occ-C3) cervical spine injuries:
1.
2.
3.
4.
5.
Fulcrum of movement at C2-C3
Relatively large head and weak neck muscles
Ligamentous and joint capsule laxity
Horizontal facet joint orientation
Increased cartilage to bone ratio with relative anterior wedging
of the vertebrae
6. Incomplete ossification of the odontoid process
Evaluation of Cervical Spine Injury
• Ehrlich et. al 2009
• Cohort A – 125 pts
• Examined NEXUS & CCR criteria for
• Criteria applied for NEXUS 58%,
imaging in patients 10 years or
CCR 76%
younger
• NEXUS missed 3, CCR missed 1
• Retrospective, case-matched
• Cohort A: Imaging; Cohort B: No
• Cohort B – 250 pts
Imaging; Only 3% pts w/ C-spine injury
• NEXUS identified 8, CCR 13
(~88 % of pts could be classified)
• Overall Results
• Significantly different predictions
(p = .002)
• CCR sens: 86%, spec: 94%
• NEXUS sens: 43%, spec: 96%
Indications For (Anterior) Cervical Spine
Instrumentation
1. Trauma
•
•
•
•
Fracture
Spinal Cord Injury
Disc Herniation
Instability
2. Infectious
3. Degenerative
4. Neoplastic
5. Deformity
• Kyphosis
• Scoliosis
Anterior Retropharyngeal Approach to the
Cervical Spine
1) Transverse incision in submandibular
region
•
Extend inferiorly for multilevel exposure
2) Carry incision through platysma &
superficial fascia of the neck
Danger #1: Identify marginal mandibular
branch of the facial nerve
3)
Mobilize the anterior border of the SCM
•
Divide superficial & deep cervical
fascia
McAfee et. al 1987
Anterior Retropharyngeal Approach to the
Cervical Spine
4) Reflect the SCM to protect contents
of carotid sheath
5) Resect the submandibular gland
(optional)
6) Divide the digastric muscle
•
Protects facial nerve & allows
medialization of hyoid to prevent
exposure of esophagus,
hypopharynx.
Danger #2: Identify hypoglossal
nerve and reflect superiorally
McAfee et. al 1987
Anterior Retropharyngeal Approach to the
Cervical Spine
7) Ligate branches of ECA & IJV to
increase exposure
•
Superior Thyroid Artery
Danger #3: Identify and mobilize
superior laryngeal nerve
8)
Finally, divide alar & prevertebral
fascia & remove longus colli
muscles from anterior aspect of
vertebral bodies
McAfee et. al 1987
Where do our danger zones lie?
• Cadaver study, 10 heads &
necks (20 sides)
• Noted positions of:
• marginal mandibular
branch of the facial nerve
• hypoglossal nerve
• superficial laryngeal
nerve
relative to mandibular bone
(& hyoid bone for CN XII).
Russo et. al 2009
Is it safe for Orthopaedic Surgeons to
perform deep anterior spinal dissections?
• Holt et. al 2003
• Retrospective, examined incidence & types of perioperative complications.
• Included thoracotomies, thoracolumbar retroperitoneal, and lumbosacral
approaches
• 450 patients over 12 years
• Results: decreased incidence of complications, less blood loss, and shorter
operative time
• Jarrett et. al 2009
• Retrospective review of 265 patients over 3 years in anterior lumbar surgery
• Spine surgeon vs. Vascular surgeon
• Similar rates of complications in both groups, including vascular injury
References
•
•
•
•
•
•
•
•
•
Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of 103 patients
treated consecutively at a level 1 pediatric trauma center. 2001. Jour of Ped Surg. 36: 1107-14.
Browner BD, et al. Skeletal Trauma, 4th ed. 2008.
Canale ST & Beaty JH. Campbell's Operative Orthopaedics, 11th ed. 2007.
Ehrlich PF et al. Canadian C-spine Rule and the National Emergency X-Radiography Utilization
Low-Risk Criteria for C-spine radiography in young trauma patients. 2009. Jour of Ped Surg. 44:
987-91.
Green NE & Swiontkowski MF. Skeletal Trauma in Children, 4th ed. 2008.
Holt RT et al. The efficacy of anterior spine exposure by an orthopedic surgeon. J Spinal Disord
Tech. 2003. 16: 477-86.
Jarrett CD, Heller JG, Tsai L. Anterior exposure of the lumbar spine with and without an "access
surgeon": morbidity analysis of 265 consecutive cases. J Spinal Disord Tech. 2009. 22: 559-64.
McAfee PF. The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone
Joint Surg Am. 1987. 69:1371-83.
Russo A et al. Submandibular approach to the C2-3 disc level: microsurgical anatomy with clinical
application. J Neurosurg Spine. 2009. 10:380-9.
Go Giants!!!