Category Archives: Spine

XVII Congreso Neuroraquis

El plazo para la presentación de comunicaciones y posters digitales en el XVII Congreso Neuroraquis, finaliza el 19 de febrero.  Puede enviar su comunicación pulsando en el botón correspondiente o a través del siguiente enlace:

Se otorgarán los siguientes  premios:

  • Mejor Comunicación Oral, con una dotación económica de 400 €
  • Premio al mejor Póster, con una dotación económica de 200 €

Un año más, se ha convocado el Premio José Barberá con una dotación económica de 1.000 €. La fecha límite de presentación de trabajos es el 19 de febrero de 2017. Puede consultar las bases en el siguiente enlace:


Tel. +34 902 190 848 / Fax +34 902 190 850 / e-mail:

Adult and Pediatric Spine Trauma, An Issue of Neurosurgery Clinics of North America, 1e

Adult and Pediatric Spine Trauma, An Issue of Neurosurgery Clinics of North America, 1e (The Clinics: Surgery)By Douglas L. Brockmeyer MD FAAP, Andrew T. Dailey MD

Adult and Pediatric Spine Trauma, An Issue of Neurosurgery Clinics of North America, 1e (The Clinics: Surgery)

List Price: $98.99


This issue will focus on both adult and pediatric spine trauma. Featured articles are as follows:

Pharmacologic Treatment of SCI; Classification of Adult Subaxial Cervical Trauma; Classification and Management of Pediatric Craniocervical Injuries; Classification and Management of Pediatric Subaxial Injuries; Classification of Adult Thoracolumbar Injuries; Management of Pediatric Thoracolumber Injuries; Treatment of Odontoid Fractures in the Aging Population; Treatment of Facet Fractures in the Cervical Spine; and many more!

Product Details

  • Published on: 2017-02-11
  • Original language: English
  • Dimensions: 8.27″ h x .87″ w x 5.91″ l,
  • Binding: Hardcover

New Book: Imaging in Spine Surgery, 1e (Hot Topics)

Imaging in Spine Surgery, 1e (Hot Topics)
By Jeffrey S. Ross MD, Bernard R. Bendock MD FAANS, Jamal McClendon Jr. MD

Imaging in Spine Surgery, 1e (Hot Topics)

lIST pRICE: $179.99


Imaging in Spine Surgery tailors the highly regarded Diagnostic Imaging series templates with radiology images and color graphics to the needs of neurosurgeons, orthopedic spine surgeons, pain management and rehab (PM&R) physicians, and anesthesiologists. It provides clinical information for diagnosis and appropriate care for the patient, resulting in the perfect comprehensive text for spine surgeons.

    • Combines chapters that include all entities that neurosurgeons, orthopedic spine surgeons, PM&R physicians, and anesthesiologists who do spine procedures are likely to encounter from the following Amirsys radiology titles:
    • Imaging Anatomy: Musculoskeletal by Manaster
    • Diagnostic Imaging: Spine by Ross
    • Specialty Imaging: Craniovertebral Junction by Ross
    • Specialty Imaging: Postoperative Spine by Ross
  • Specialty Imaging: Pain Management by LaBarge
  • Allows readers to understand the significance of a given radiologic finding and what should be done next for the appropriate care of that patient
  • Each chapter contains Key Facts and 4 images (a mix of radiology images and drawings) with captions and extensive annotations designed specifically for surgeons, important clinical information, and definitions and clarifications of unfamiliar radiology nomenclature
  • Selected prose intros and imaging anatomy chapters help nonradiology clinicians quickly master the key points of imaging relevant to spine surgery
  • Written at a level accessible to neurosurgery and orthopedic residents, but also contains “pearls” the most experienced surgeons will find useful
  • Expert Consult eBook version included, which allows you to search all of the text, figures, and references from the book on a variety of devices

Product Details

  • Published on: 2017-02-01
  • Original language: English
  • Binding: Hardcover
  • 536 pages

Spinal schwannoma


Incidence: 0,3-0,4/100.000/yr.

Schwannomas have an incidence of 3% of all spinal tumors.

Most occur sporadically and are solitary, but they may also be associated with Neurofibromatosis type 2, but can occur with Neurofibromatosis type 1.

Spinal schwannoma constitutes approximately 25% of the intradural spinal tumors 1) 2) 3) 4) 5) 6) 7). 8) 9) 10) 11) 12).


In a paraspinal location, they are the commonest cause of intradural extramedullary tumors but may also be extradural or extramedullary 13).

Most are entirely intradural, but 8-32 % may be completely extradural 14) 15). 1-19 % are a combination, 6-23 % are dumbbell spinal schwannomas, and 1 % are intramedullary schwannomas.

The most common location of spinal schwannomas are the lumbar spine (48%) 16).

Schwannomas are frequently located in the extramedullary region, and may present as dumbbell shaped in 10-15% of cases. They may also be located at the intramedullary region. Ten percent of the tumors were in the extradural location, and 1% in the intradural intramedullary regional location.

Up to 2.7% of schwannomas are located in the retroperitoneal region 17).

Most arise from the dorsal root of spinal nerve (sensory) rootlets (75%). Paraspinal schwannomas involve the dorsal nerve roots, affecting people in the fourth and fifth decades of life 18).



Antoni A and Antoni B tissue.

Clinical features

Patients typically present with local pain. Early symptoms are often radicular.

Neurological deficits develop late.

Tumor may cause radiculopathy, myelopathy, radiculomyelopathy or cauda equina syndrome.


The final diagnosis should be established by clinical findings and imaging methods and MRI is the best method for diagnosis and differential diagnosis.

The size and specific margins of the mass demonstrate the localization and invasion to the contiguous structures. The changes such as foramen enlargement and erosion in the pedicles detected in the direct graphs may be seen as masses with sharp margins and involve the peripheral contrast in the CT scans.

Paraspinal schwannomas are frequently asymptomatic and diagnosed incidentally on imaging of the spine 19).


Surgical resection is the treatment of choice 20) 21).

They need a tailored treatment, which in most cases works through one surgical approach. Usually it is possible to perform a complete resection with a good postoperative prognosis 22).

Unlike neurofibromas, schwannomas do not arise from the nerve fibers and so the tumor is easily separated from nerve fibers without neurologic compromise. In the rare case that this is impossible, the remnant tumor may be followed up radiographically if it is histologically benign. Malignant schwannomas are treated with adjuvant radiation therapy.

In the series of Asazuma et al., a posterior approach was used in 35 patients; 7 others underwent a combined anterior and posterior approach. A posterior approach was used for all type IIa and IIIa tumors, and for some type IIIb (upper cervical), IV, and VI tumors; a combined posterior and anterior approach was used for type IIb and the remainder of type IV and VI. Reconstruction was performed using spinal instrumentation in 4 patients (9.5%). Resection was subtotal in 6 patients (14.3%) and total in 36 (85.7%). 23).


Recurrence is rare after total excision (except in neurofibromatosis).

The risk for motor deficit is higher for schwannomas than for neurofibromas, for cervical vs. lumbar tumors, and for cervical tumors wiyh extradural extension.

Case series


The subjects were 48 patients (22 males and 26 females) with spinal schwannoma who were classified into three subgroups: iso/homo, high/rim, and hetero/hetero, based on T2WI/contrast T1WI. A retrospective analysis of tumor size and MIB-1 index was performed in the context of these MRI findings. Intraoperative findings and pre- and postoperative motor performance were also examined.

The average tumor size was 32.4 mm (range 10-130 mm) and the average MIB-1 index was 3.8% (range 1-12). In the three subgroups, there were no significant differences in sex, age, duration of disease, tumor lesion, and dumbbell type. In the hetero/hetero group, the tumor size was significantly greater and the MIB-1 index was significantly higher (both P < 0.05), than the other two groups. The tumor adherence rate was significantly higher for hetero tumors (P < 0.05) and preoperative paralysis was more common in cases with tumor adhesion. The rate of paralysis improvement at 1 month was significantly lower for hetero tumors, but all cases had improved at 6 months.

Contrast T1WI MRI was useful for prediction of the proliferative activity and growth of spinal schwannomas, which are associated with increased tumor size and adhesion. A heterogeneous pattern on contrast T1WI indicated an increase in size and adhesion of the tumor. This pattern reflected the preoperative motor status and postoperative motor recovery 24).

Thirty-two patients with giant spinal schwannomas underwent surgery between September 1998 and May 2013. Tumor size ranged from 2.5 cm to 14.6 cm with a median size of 5.8 cm. There were 9 females (28.1%) and 23 males (71.9%), and the median age was 47 years (range 23-83 years). The median follow-up duration was 36.0 months (range 12.2-132.4 months). Three patients (9.4%) experienced recurrence and required further treatment. All recurrences developed following subtotal resection (STR) of cellular or melanotic schwannoma. There were 3 melanotic (9.4%) and 6 cellular (18.8%) schwannomas included in this study. Among these histological variants, a 33.3% recurrence rate was noted. In 1 case of melanotic schwannoma, malignant transformation occurred. No recurrence occurred following gross-total resection (GTR) or when a fibrous capsule remained due to its adherence to functional nerve roots.

Resection is the treatment of choice for symptomatic or growing giant schwannomas, frequently requiring anterior or combined approaches, with the goals of symptom relief and prevention of recurrence. In this series, tumors that underwent GTR, or where only capsule remained, did not recur. Only melanotic and cellular schwannomas that underwent STR recurred 25).


Consecutive 49 patients with intradural extramedullary (IDEM) schwannoma were surgically resected: 31 patients via MIS approach (MIS group), 6 patients via muscle-splitting using tubular retractor, and 25 patients via unilateral hemilaminectomy preserving the contralateral paraspinal muscle. Eighteen patients underwent total laminectomy (TL group). Medical record including perioperative data and radiologic data were reviewed.

On initial magnetic resonance image, mean maximal sagittal diameter of tumor was 23.9 mm and 26.9 mm, and mean maximal axial diameter was 16.1 mm and 22.8 mm in MIS and TL group, respectively (p=0.452 and p=0.011, respectively). The foraminal extension of tumor was identified in 8 in MIS and 9 in TL group (p=0.081). The tumor location involved was mostly observed in 20 lumbar spines in MIS group and 17 cervicothoracic spines in TL group (p=0.001). Intraoperatively, all tumors in MIS group could be totally resected with reduced operative time and blood loss. During the follow-up period of 38.2 months and 51.2 months in the MIS and TL group, the clinical improvement was not different between the surgical approaches (p=0.332).

Safe and complete resection of IDEM schwannoma was obtained through MIS approach. Regardless of sagittal extension of tumor, axial diameter within 16 mm-sized schwannoma located at the lumbar spine could be an effective indication for MIS approach even for foraminal extension 26).


Conti et al., present a series of 179 spinal neurinomas consecutively observed at the Department of Neurosurgery at the University of Florence for a period of 30 years (between 1967 and 1997). We decided to limit the retrospective study to obtain at least 5 years of follow-up. Therefore, 20 additional neurinomas treated between 1997 and 2002 were excluded.

All the cases are evaluated under statistical, clinical, neuroradiological, and surgically technical profiles based on data from clinical records and from periodic check-ups after surgery. In particular, the results are analyzed on the basis of an accurate pre- and postsurgical evaluation using Karnofsky’s scale and Kleklamp-Samii’s scoring system.

We treated 179 spinal neurinomas in 152 (93 male and 59 female) patients. The mean age was 44.3. In 33 cases the neurinoma was sited in the cervical tract, in 59 cases in the dorsal tract, and in 87 cases in the lumbo-sacral tract. Eleven patients harbored Recklinghausen’s neurofibromatosis (7 NF1 and 4 NF2 of which 1 was intramedullary). In 123 cases the neurinoma was intradural, in 11 cases it was extradural, in 2 intra/extradural, in 9 it had a dumbbell form, and in 2 cases it was intramedullary; the remaining cases had neurofibromatosis. The most common presurgical symptom was segmental pain. Total removal of the lesion was possible in the first operation for 174 neurinomas. We encountered 3 cases of malignant neurinoma of which 1 was in NF2. The result of surgery was recovery in 108 cases; 2 patients with NF2 died, and local recurrence occurred even after total exeresis (excision) and radiotherapy in the cases of malignant neurinoma.

Schwannomas represent the most frequent tumor lesions of the spine with prevalence for the cervical-inferior tract and the dorso-lumbar passage. Intramedullary neurinomas are rarely observed. The total surgical removal of neurinomas is often an attainable goal, and clinical improvement is the common outcome with exception to malignant forms and NF2 neurofibromatosis. We describe a series of 179 treated schwannomas 27).


Are spinal schwannomas as benign as we think? To what extent do patients recover? Are patients prone to develop late complications such as cystic myelopathy or symptomatic spinal deformity? Is their life expectancy compromised? In an effort to answer these questions, the authors analyzed the long-term outcome for 187 patients from one neurosurgical department with surgically treated spinal schwannoma. Median follow-up period was 12.9 years (2454 patient years). One-fifth of the patients considered themselves free of symptoms at follow-up examination. The most common late complaint was local pain (46%), followed by radiating pain (43%), paraparesis (31%), radicular deficit (28%), sensory deficit due to a spinal cord lesion (27%), and difficulty voiding (19%). Late complications occurred in 21% of the patient population, including cystic myelopathy (2%), spinal arachnoiditis (6%), spinal deformity (6%), and troublesome pain (7%). Life expectancy of the patients corresponded to that of the general population 28).

1) Engelhard HH, Villano JL, Porter KR, et al. Clinical presentation, histology, and treatment in 430 patients with primary tumors of the spinal cord, spinal meninges, or cauda equina. J Neurosurg Spine. 2010;13:67–77.
2) Safavi-Abbasi S, Senoglu M, Theodore N, et al. Microsurgical management of spinal schwannomas: evaluation of 128 cases. J Neurosurg Spine. 2008;9:40–47.
3) Holland K, Kaye AH. Spinal tumors in neurofibromatosis-2: management considerations – a review. J Clin Neurosci. 2009;16:169–177.
4) Klekamp J, Samii M. Surgery of spinal nerve sheath tumors with special reference to neurofibromatosis. Neurosurgery. 1998;42:279–289.
5) Celli P, Trillò G, Ferrante L. Spinal extradural schwannoma. J Neurosurg Spine. 2005;2:447–456.
6) Jankowski R, Szmeja J, Nowak S, Sokół B, Blok T. Giant schwannoma of the lumbar spine: a case report. Neurol Neurochir Pol. 2010;44:91–95.
7) , 15) , 16) Conti P, Pansini G, Mouchaty H, Capuano C, Conti R. Spinal neurinomas: retrospective analysis and long-term outcome of 179 consecutively operated cases and review of the literature. Surg Neurol 2004; 61: 34-43.
8) , 14) , 28) Seppälä MT, Haltia MJ, Sankila RJ, Jääskeläinen JE, Heiskanen O. Long-term outcome after removal of spinal schwannoma: a clinicopathological study of 187 cases. J Neurosurg. 1995 Oct;83(4):621-6. PubMed PMID: 7674010.
9) De Verdelhan O, Haegelen C, Carsin-Nicol B, et al. MR imaging features of spinal schwannomas and meningiomas. J Neuroradiol. 2005;32:42–49.
10) Ahn DK, Park HS, Choi DJ, Kim KS, Kim TW, Park SY. The surgical treatment for spinal intradural extramedullary tumors. Clin Orthop Surg. 2009;1:165–172.
11) Sim JE, Noh SJ, Song YJ, Kim HD. Removal of intradural-extramedullary spinal cord tumors with unilateral limited laminectomy. J Korean Neurosurg Soc. 2008;43:232–236.
12) McCormick PC, Post KD, Stein BM. Intradural extramedullary tumors in adults. Neurosurg Clin N Am. 1990;1:591–608.
13) , 20) Wein S, Gaillard F. Intradural spinal tumours and their mimics: A review of radiographic features. Postgrad Med J. 2013;89(1054):457–69.
17) Cury J, Coelho RF, Srougi M. Retroperitoneal schwannoma: Case series and literature review. Clin São Paulo Braz. 2007;62(3):359–62.
18) , 19) , 21) Chamberlain MC, Tredway TL. Adult primary intradural spinal cord tumors: A review. Curr Neurol Neurosci Rep. 2011;11(3):320–8.
22) Krätzig T, Dreimann M, Klingenhöfer M, Floeth FW, Krajewski K, Eicker SO. Treatment of large thoracic and lumbar paraspinal schwannoma. Acta Neurochir (Wien). 2015 Jan 11. [Epub ahead of print] PubMed PMID: 25577451.
23) Asazuma T, Toyama Y, Maruiwa H, Fujimura Y, Hirabayashi K. Surgical strategy for cervical dumbbell tumors based on a three-dimensional classification. Spine (Phila Pa 1976). 2004 Jan 1;29(1):E10-4. PubMed PMID: 14699292.
24) Kobayashi K, Imagama S, Ando K, Hida T, Ito K, Tsushima M, Ishikawa Y, Matsumoto A, Morozumi M, Tanaka S, Ishiguro N. Contrast MRI Findings for Spinal Schwannoma as Predictors of Tumor Proliferation and Motor Status. Spine (Phila Pa 1976). 2017 Feb;42(3):E150-E155. doi: 10.1097/BRS.0000000000001732. PubMed PMID: 27306258.
25) Sowash M, Barzilai O, Kahn S, McLaughlin L, Boland P, Bilsky MH, Laufer I. Clinical outcomes following resection of giant spinal schwannomas: a case series of 32 patients. J Neurosurg Spine. 2017 Jan 13:1-7. doi: 10.3171/2016.9.SPINE16778. [Epub ahead of print] PubMed PMID: 28084933.
26) Lee SE, Jahng TA, Kim HJ. Different Surgical Approaches for the Spinal Schwannoma: A Single Surgeon’s Experience with 49 Consecutive Cases. World Neurosurg. 2015 Aug 29. pii: S1878-8750(15)01043-8. doi: 10.1016/j.wneu.2015.08.027. [Epub ahead of print] PubMed PMID: 26325210.
27) Conti P, Pansini G, Mouchaty H, Capuano C, Conti R. Spinal neurinomas: retrospective analysis and long-term outcome of 179 consecutively operated cases and review of the literature. Surg Neurol. 2004 Jan;61(1):34-43; discussion 44. Review. PubMed PMID: 14706374.

NOVOCART® Disk plus

Chondrocytes are the only cells found in healthy cartilage. They produce and maintain the cartilaginous matrix, which consists mainly of collagen and proteoglycans. Although the word chondroblast is commonly used to describe an immature chondrocyte, the term is imprecise, since the progenitor of chondrocytes (which are mesenchymal stem cells) can differentiate into various cell types, including osteoblasts.

From least- to terminally-differentiated, the chondrocytic lineage is:

Colony-forming unit-fibroblast (CFU-F)

Mesenchymal stem cell / marrow stromal cell (MSC)


Hypertrophic chondrocyte

When referring to bone, or in this case cartilage, the originally undifferentiated mesenchymal stem cells lose their pluripotency, proliferate and crowd together in a dense aggregate of chondrogenic cells (cartilage) at the location of chondrification. These chondrogenic cells differentiate into so-called chondroblasts, which then synthesize the cartilage extra cellular matrix (ECM), consisting of a ground substance (proteoglycans, glycosaminoglycans for low osmotic potential) and fibers. The chondroblast is now a mature chondrocyte that is usually inactive but can still secrete and degrade the matrix, depending on conditions.

BMP4 and FGF2 have been experimentally shown to increase chondrocyte differentiation.

Chondrocytes undergo terminal differentiation when they become hypertrophic, which happens during endochondral ossification. This last stage is characterized by major phenotypic changes in the cell.

Autologous chondrocyte implantation (ACI, ATC code M09AX02 (WHO)) is a biomedical treatment that repairs damages in articular cartilage. ACI provides pain relief while at the same time slowing down the progression or considerably delaying partial or total joint replacement (knee replacement) surgery. The goal of ACI is to allow people suffering from articular cartilage damage to return to their old lifestyle; regaining mobility, going back to work and even practicing sports again.

ACI procedures aim to provide complete hyaline repair tissues for articular cartilage repair. Over the last 20 years, the procedure has become more widespread and it is currently probably the most developed articular cartilage repair technique.

The surgical technique was first performed in Sweden in 1987; the results of the 9 year follow up are available in Lars Peterson et al. 2000. Brittberg published the first description of the technique on humans in 1994. He reported good and promising results with 23 patients for defects on the femoral condyles .The technique also seems promising with regard to long-term results.

NOVOCART® Disk plus, an autologous cell compound for autologous disk chondrocyte transplantation, was developed to reduce the degenerative sequel after lumbar discectomy or to prophylactically avoid adjacent segment disease, if present.

The NDisc trial is an ongoing multi-center, randomized study with a sequential phase I study within the combined phase I/II trial with close monitoring of tolerability and safety. Twenty-four adult patients were randomized and treated with the investigational medicinal product NDisc plus or the carrier material only. Rates of adverse events in Phase I of this trial were comparable with those expected in the early time course after elective disk surgery. There was one reherniation 7 months after transplantation, which corresponds to an expected reherniation rate. Immunological markers like C reactive protein and IL6 were not significantly elevated and there were no imaging abnormalities. No indications of harmful material extrusion or immunological consequences due to the investigational medicinal product NDplus were observed. Therefore, the study appears to be safe and feasible. Safety analyses of Phase I of this trial indicate a relatively low risk considering the benefits that patients with debilitating degenerative disk disease may gain 1).

1) Tschugg A, Diepers M, Simone S, Michnacs F, Quirbach S, Strowitzki M, Meisel HJ, Thomé C. A prospective randomized multicenter phase I/II clinical trial to evaluate safety and efficacy of NOVOCART disk plus autologous disk chondrocyte transplantation in the treatment of nucleotomized and degenerative lumbar disks to avoid secondary disease: safety results of Phase I-a short report. Neurosurg Rev. 2017 Jan;40(1):155-162. doi: 10.1007/s10143-016-0781-0. Erratum in: Neurosurg Rev. 2017 Jan;40(1):177. PubMed PMID: 27567635.

Update: Spinal cord injury stem cell therapy

Unflammation and toxins released by damaged cells at the site of a spinal injury often cause further harm to surrounding cells. Researchers are developing treatments that reduce inflammation and soak up toxins and free radicals to minimise additional damage.

Spinal cord injuries often damage neurons and the supporting cells that wrap & insulate neurons. Damaging the supporting cells can cause otherwise functional neurons to die. Researchers are studying how stem cells might be used to replace neurons and their supporting cells to greatly improve a patient’s chances for recovering function.

As a potentially unlimited autologous cell source, patient induced pluripotent stem cells (iPSCs) provide great capability for tissue regeneration, particularly in spinal cord injury (SCI). However, despite significant progress made in translation of iPSC-derived neural stem cells to clinical settings, a few hurdles remain. Among them, non-invasive approach to obtain source cells in a timely manner, safer integration-free delivery of reprogramming factors, and purification of NSCs before transplantation are top priorities to overcome.

Liu et al., developed a safe and cost-effective pipeline to generate clinically relevant NSCs. They first isolated cells from patients’ urine and reprogrammed them into iPSCs by non-integrating Sendai virus vectors, and carried out experiments on neural differentiation. NSCs were purified by A2B5, an antibody specifically recognizing a glycoganglioside on the cell surface of neural lineage cells, via fluorescence activated cell sorting. Upon further in vitro induction, NSCs were able to give rise to neurons, oligodendrocytes and astrocytes. To test the functionality of the A2B5+ NSCs, they grafted them into the contused mouse thoracic spinal cord. Eight weeks after transplantation, the grafted cells survived, integrated into the injured spinal cord, and differentiated into neurons and glia.

The specific focus on cell source, reprogramming, differentiation and purification method purposely addresses timing and safety issues of transplantation to SCI models. It is Liu et al., belief that this work takes one step closer on using human iPSC derivatives to SCI clinical settings 19).

1) Syková E, Homola A, Mazanec R, Lachmann H, Konrádová SL, Kobylka P, et al. Autologous bone marrow transplantation in patients with subacute and chronic spinal cord injury. Cell Transplant 2006;15:675–87.
2) Yoon SH, Shim YS, Park YH, Chung JK, Nam JH, Kim MO, et al. Complete spinal cord injury treatment using autologous bone marrow cell transplantation and bone marrow stimulation with granulocyte macrophage-colony stimulating factor: phase I/II clinical trial. Stem Cells 2007;25:2066–73.
3) Deda H, Inci MC, Kürekçi AE, Kayihan K, Ozgün E, Ustünsoy GE, et al. Treatment of chronic spinal cord injured patients with autologous bone marrow-derived hematopoietic stem cell transplantation: 1-year follow-up. Cytotherapy 2008;10:565–74.
4) Saito F, Nakatani T, Iwase M, Maeda Y, Hirakawa A, Murao Y, et al. Spinal cord injury treatment with intrathecal autologous bone marrow stromal cell transplantation: the first clinical trial case report. J Trauma 2008;64:53–9.
5) Pal R, Venkataramana NK, Bansai A, Balaraju S, Jan M, Chandra R, et al. Ex vivo-expanded autologous bone marrowderived mesenchymal stromal cells in human spinal cord injury/paraplegia: a pilot clinical study. Cytotherapy 2009;11:897–911.
6) Park JH, Kim DY, Sung I, Choi GH, Jeon MH, Kim KK, et al. Long-term results of spinal cord injury therapy using mesenchymal stem cells derived from bone marrow in humans. Neurosurgery 2012;70:1238–47.
7) Saito F, Nakatani T, Iwase M, Maeda Y, Murao Y, Suzuki Y, et al. Administration of cultured autologous bone marrow stromal cells into cerebrospinal fluid in spinal injury patients: a pilot study. Restor Neurol Neurosci 2012;30:127–36.
8) Jiang PC, Xiong WP, Wang G, Ma C, Yao WQ, Kendell SF, et al. A clinical trial report of autologous bone marrow-derived mesenchymal stem cell transplantation in patients with spinal cord injury. Exp Ther Med 2013;6:140–6.
9) Mendonça MVP, Larocca TF, Souza BS, de Freitas Souza BS, Villarreal CF, Silva LF, et al. Safety and neurological assessments after autologous transplantation of bone marrow mesenchymal stem cells in subjects with chronic spinal cord injury. Stem Cell Res Ther 2014;5:126
10) Zurita M, Vaquero J. Functional recovery in chronic paraplegia after bone marrow stromal cells transplantation. Neuroreport 2004;15:1105–8.
11) Zurita M, Vaquero J. Bone marrow stromal cells can achieve cure of chronic paraplegic rats: functional and morphological outcome one year after transplantation. Neurosci Lett 2006;402:51–6.
12) Vaquero J, Zurita M, Oya S, Santos M. Cell therapy using bone marrow stromal cells in chronic paraplegic rats: systemic or local administration? Neurosci Lett 2006;398:129–34.
13) Zurita M, Vaquero J, Bonilla C, Santos M, De Haro J, Oya S, et al. Functional recovery of chronic paraplegic pigs after autologous transplantation of bone marrow stromal cells. Transplantation 2008;86:845–53.
14) Vaquero J, Zurita M. Bone marrow stromal cells for spinal cord repair: a challenge for contemporary neurobiology. Histol Histopathol 2009;24:107–16.
15) Bonilla C, Zurita M, Otero L, Aguayo C, Vaquero J. Delayed intralesional transplantation of bone marrow stromal cells increases endogenous neurogenesis and promotes functional improvement after severe traumatic brain injury. Brain Inj 2009;23:760–9.
16) Vaquero J, Zurita M. Functional recovery after severe CNS trauma: current perspectives for cell therapy with bone marrow stromal cells. Prog Neurobiol 2011;93:341–9.
17) Otero L, Zurita M, Bonilla C, Aguayo C, Vela A, Rico MA, et al. Late transplantation of allogeneic bone marrow stromal cells improves neurological deficits subsequent to intracerebral hemorrhage. Cytotherapy 2011;13:562–71.
18) Otero L, Zurita M, Bonilla C, Aguayo C, Rico MA, Rodriguez A, et al. Allogeneic bone marrow stromal cell transplantation after cerebral hemorrhage achieves cell transdifferentiation and modulates endogenous neurogenesis. Cytotherapy 2012;14: 34–44.
19) Liu Y, Zheng Y, Li S, Xue H, Schmitt K, Hergenroeder GW, Wu J, Zhang Y, Kim DH, Cao Q. Human neural progenitors derived from integration-free iPSCs for SCI therapy. Stem Cell Res. 2017 Jan 5;19:55-64. doi: 10.1016/j.scr.2017.01.004. [Epub ahead of print] PubMed PMID: 28073086.

Management of Type II odontoid process fracture in octogenarians

As odontoid process fractures become increasingly common in the aging population, a technical understanding of treatment approaches is critical.

Establishing a clear treatment paradigm for octogenarians with odontoid fracture type II in hampered by a literature replete with level III articles.

Surgical treatment

Anterior approach

Anterior odontoid screw fixation was first reported by Nakanishi 1) and Bohler 2). This procedure provides immediate spinal stability, preserves the normal rotation between C1-2, allows the best anatomical and functional outcome for type II odontoid fracture, and is associated with rapid patient mobilization, minimal postoperative pain and a short hospital stay. Acute odontoid fractures treated by anterior screw fixation have a fusion rate of approximately 90 percent 3).

Posterior approach

Posterior approach for stabilization of odontoid fracture is indicated in the cases of odontoid fracture that are not amenable to anterior screw fixation. Commonly used procedures involve wedging a bone graft between posterior arch of C1 and the C2 lamina with sublaminar wiring. The well-described different methods for this C1- 2 posterior fusion procedure are the Gallie, Brooks, Sonntag techniques. These procedures have a satisfactory fusion rate of about 74 percent. The demerit of this procedure is that it causes elimination of the normal C1-2 rotatory motion ( which accounts for more than 50% of all cervical spine rotatory movements) and reduced cervical spine flexion– extension by 10 percent.

Another excellent alternative technique for odontoid fracture is the posterior C1-2 transarticular screw fixation (Magerl’s procedure) using unilateral or bilateral screws. This provides an excellent spinal rotational spinal stability. This is an indirect method of stabilizing the fracture (in which the normal anatomical configuration is disrupted). Preoperative CT evaluation is mandatory to avoid vertebral artery injury in this procedure. This technique can be supplemented with metal plate for occipito-cervical stabilization. Alternatively, Jain’s technique of occipitocervical fusion, Goel’s plate and screw lateral mass fixation, or a Ransford’s contoured rod technique31 may be utilized.

Case series


In the study by Graffeo et al., the authors evaluated 111 patients over the age of 79 (average age: 87) with type II odontoid fractures undergoing nonoperative (94 patients) vs. operative intervention (17 total; 15 posterior and 2 anterior). They studied multiple variables and utilized several scales [abbreviated injury scale (AIS), injury severity score (ISS), and the Glasgow coma scale (GCS)] to determine the outcomes of nonoperative vs. operative management.

Graffeo et al. concluded that there were no significant differences between nonoperative and operative management for type II odontoid fractures in octogenarians. They found similar frequencies of additional cervical fractures, mechanisms of injury, GCS of 8 or under, AIS/ISS scores, and disposition to “nonhome” facilities. Furthermore, both appeared to have increased mortality rates at 1-year post injury; 13% during hospitalization, 26% within the first post-injury month, and 41% at 1 year.

In the editorial by Falavigna, his major criticism of Graffeo’s article was the marked disparity in the number of patients in the operative (17 patients) vs. the nonoperative group (94 patients), making it difficult to accept any conclusions as “significant”. He further noted that few prior studies provided level I evidence, and that most, like this one, were level III analyses that did not “significantly” advance our knowledge as to whether to treat octogenarians with type II odontoid fractures operatively vs. nonoperatively 4).

Pisapia et al., present in a stepwise fashion the technique of odontoid screw placement using the Medtronic O arm navigation system and describe their initial institutional experience with this surgical approach.

The authors retrospectively reviewed all cases of anterior odontoid screw fixation for Type II fractures at an academic medical center between 2006 and 2015. Patients were identified from a prospectively collected institutional database of patients who had suffered spine trauma. A standardized protocol for navigated odontoid screw placement was generated from the collective experience at the authors’ institution. Secondarily, the authors compared collected variables, including presenting symptoms, injury mechanism, surgical complications, blood loss, operative time, radiographically demonstrated nonunion rate, and clinical outcome at most recent follow-up, between navigated and nonnavigated cases.

Ten patients (three female; mean age 61) underwent odontoid screw placement. Most patients presented with neck pain without a neurological deficit after a fall. O-arm navigation was used in 8 patients. An acute neck hematoma and screw retraction, each requiring surgery, occurred in 2 patients in whom navigation was used. Partial vocal cord paralysis occurred after surgery in one patient in whom no navigation was used. There was no difference in blood loss or operative time with or without navigation. One patient from each group had radiographic nonunion. No patient reported a worsening of symptoms at follow-up (mean duration 9 months).

The authors provide a detailed step-by-step guide to the navigated placement of an odontoid screw. Their surgical experience suggests that O-arm-assisted odontoid screw fixation is a viable approach. Future studies will be needed to rigorously compare the accuracy and efficiency of navigated versus nonnavigated odontoid screw placement 5).


Twenty-one of 22 patients who underwent posterior C1-C2 temporary fixation of an odontoid fracture achieved fracture healing and regained motion of the atlantoaxial joint. The functional outcomes of these 21 patients were compared with that of a control group, which consisted of 21 randomly enrolled cases with posterior C1-C2 fixation and fusion. The differences between the 2 groups in the visual analog scale score for neck pain, neck stiffness, Neck Disability Index, 36-Item Short Form Health Survey, and time to fracture healing were analyzed.

Significantly better outcomes were observed in the temporary-fixation group for visual analog scale score for neck pain, Neck Disability Index, and neck stiffness. The outcomes in the temporary-fixation group was superior to those in the fusion group in all dimensions of the 36-Item Short Form Health Survey. There were no significant differences in fracture healing rate and time to fracture healing between the 2 techniques.

Functional outcomes were significantly better after posterior C1-C2 temporary fixation than after fusion. Temporary fixation can be used as a salvage treatment for an odontoid fracture with an intact transverse ligament in cases of failure of, or contraindication to, anterior screw fixation 6).


Data of twenty patients who underwent posterior temporary-fixation due to Anderson-D’Alonzo type II odontoid fractures with intact transverse ligament were retrospectively reviewed. Another twenty patients undergoing anterior screw fixation were randomly selected as the control group. The range of motion (ROM) in rotation of C1-C2 measured on functional computed tomography (CT) scan and outcomes evaluated by the visual analog scale (VAS) for neck pain, neck stiffness, patient satisfaction, and neck disability index (NDI) were compared between two groups at the final follow-up.

At the final follow-up, 19 cases in each groups achieved facture healing. Total C1-C2 ROM in rotation on both sides in the posterior temporary-fixation group was 32.4 ± 12.5°, smaller than 40.0 ± 13.0 in the anterior fixation group. However, there was no statistical difference between two groups. And there was no significant difference between two groups in functional outcomes evaluated by VAS for neck pain, neck stiffness, patient satisfaction and NDI.

Posterior temporary-fixation can spare the motion of C1-C2 and achieve same good clinical outcomes as anterior screw fixation in the treatment of Anderson-D’Alonzo type II odontoid fractures. It was an ideal alternative strategy to anterior screw fixation 7).

The treatment of type II odontoid fractures in elderly patients is controversial.

Anterior screw fixation is a well-recognized technique that is used to stabilize Type IIB fractures of the odontoid process in the elderly. However, advanced age and osteoporosis are 2 risk factors for pseudarthrosis. Kyphoplasty has been described in the treatment of lytic lesions in C-2. Terraux et al. decided to combine these 2 techniques in the treatment of unstable fractures of the odontoid.

Two approximately 90-year-old patients were treated for this type of fracture. Instability was demonstrated on dynamic radiography in one patient, and the fracture was seen on static radiography in the other.

Clinical parameters, pain, range of motion, 36-Item Short Form Health Survey (SF-36) score (for the first patient), and radiological examinations (CT scans and dynamic radiographs) were studied both before and after surgery. After inflating the balloon both above and below the fracture line, the authors applied a high-viscosity polymethylmethacrylate cement. Some minor leakage of cement was noted in both cases but proved to be harmless. The screws were correctly positioned. The clinical result was excellent, both in terms of pain relief and in the fact that there was no reduction in the SF-36 score. The range of motion remained the same. A follow-up CT scan obtained 1 year later in one of the patients showed no evidence of change in the materials used, and the dynamic radiographs showed no instability. This combination of kyphoplasty and anterior screw fixation of the odontoid seems to be an interesting technique in osteoporotic Type IIB fractures of the odontoid process in the elderly, with good results both clinically and radiologically 8).

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6) Guo Q, Deng Y, Wang J, Wang L, Lu X, Guo X, Ni B. Comparison of Clinical Outcomes of Posterior C1-C2 Temporary Fixation Without Fusion and C1-C2 Fusion for Fresh Odontoid Fractures. Neurosurgery. 2016 Jan;78(1):77-83. doi: 10.1227/NEU.0000000000001006. PubMed PMID: 26348006.
7) Guo Q, Zhang M, Wang L, Lu X, Guo X, Ni B. Comparison of Atlantoaxial Rotation and Functional Outcomes of two Non-Fusion Techniques in the Treatment of Anderson-D’Alonzo type II Odontoid Fractures. Spine (Phila Pa 1976). 2015 Dec 10. [Epub ahead of print] PubMed PMID: 26656043.
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