Anterior odontoid screw fixation indications

Anterior odontoid screw fixation indications

Anterior odontoid screw fixation (AOSF) and posterior occipitocervical fusion are both well-accepted techniques for surgical treatment but with unique indications and contraindications as well as varied reported outcomes.

Joaquim et al. reviewed the literature about specific patients and fracture characteristics that may guide treatment toward one technique over the other. AOSF can preserve atlantoaxial motion, but requires a reduced odontoid, an intact transverse ligament, and a favorable fracture line to achieve adequate fracture compression. Additionally, older patients may have a higher rate of pseudarthrosis using this technique, as well as postoperative dysphagia. posterior occipitocervical fusion has a higher rate of fusion and is indicated in patients with severe atlantoaxial misalignment and with poor bone quality. posterior occipitocervical fusion allows direct open reduction of displaced fragments and can reduce any atlantoaxial instability. It is also used as a salvage procedure after failed AOSF. However, this technique results in loss of atlantoaxial motion, requires prone positioning, and demands a longer operative duration than AOSF, factors that can be a challenge in patients with severe medical conditions. Although both anterior and posterior approaches are acceptable, many clinical and radiological factors should be taken into account when choosing the best surgical approach. Surgeons must be prepared to perform both procedures to adequately treat these injuries 1)

Full-Endoscopic Anterior Odontoid Screw Fixation is a feasible and effective option for Odontoid fracture type II treatment. The procedure is less invasive than other techniques and provides clear direct visualization of the involved structures 2).

Direct anterior screw fixation is an effective and safe method for treating recent odontoid fractures (<6 months postinjury). It confers immediate stability, preserves C1-2 rotatory motion, and achieves a fusion rate that compares favorably with alternative treatment methods. In contradistinction, in patients with remote fractures (> or = 18 months postinjury), a significantly lower rate of fusion is found when using this technique, and these patients are believed to be poor candidates for this procedure 3).

Although anterior screw fixation is the ideal choice for type Ⅱ odontoid fractures with anterior superior to posterior inferior fracture line, it may not be the best choice for comminuted or fracture end hardened type Ⅱ odontoid fractures 4).


Joaquim AF, Patel AA. Surgical treatment of Type II odontoid fractures: anterior odontoid screw fixation or posterior cervical instrumented fusion? Neurosurg Focus. 2015 Apr;38(4):E11. doi: 10.3171/2015.1.FOCUS14781. PMID: 25828487.

Kotheeranurak V, Pholprajug P, Jitpakdee K, Pruttikul P, Chitragran R, Singhatanadgige W, Limthongkul W, Yingsakmongkol W, Kim JS. Full-Endoscopic Anterior Odontoid Screw Fixation: A Novel Surgical Technique. Orthop Surg. 2022 Apr 20. doi: 10.1111/os.13271. Epub ahead of print. PMID: 35445547.

Apfelbaum RI, Lonser RR, Veres R, Casey A. Direct anterior screw fixation for recent and remote odontoid fractures. J Neurosurg. 2000 Oct;93(2 Suppl):227-36. PubMed PMID: 11012053.

Yang S, Liu YJ, Jiang WM. Experience in surgery treatment of type Ⅱ odontoid fractures: A report of two cases and review of the literature. Chin J Traumatol. 2019 Nov 1. pii: S1008-1275(19)30333-5. doi: 10.1016/j.cjtee.2019.10.003. [Epub ahead of print] PubMed PMID: 31757743.

Vagus Nerve Stimulation Indications

Vagus Nerve Stimulation Indications

Vagus-nerve stimulation (VNS) is the most common neuromodulation technique and has been approved by the FDA for treating refractory epilepsy and refractory depression.

It is being investigated in heart failure, headache, gastric motility disorders and asthma.

Although it has been used (off label) for treatment-resistant depression and other psychiatric conditions, the FDA approved indication is for adjunctive therapy for patients > 12 years old with partial-onset seizures refractory to medical treatment.

VNS may be relatively safe and effective for the fetus and mother during pregnancy, and turning off VNS during pregnancy is unnecessary. However, owing to the small sample size and short follow-up time, further research is needed 1).

see Vagus nerve stimulation for drug-resistant epilepsy.

Results suggest that vagus nerve stimulation paired with tones could become an effective therapy for the treatment of tinnitus 2).

see Vagus nerve stimulation for depression.


Ding J, Wang L, Wang C, Gao C, Wang F, Sun T. Is vagal-nerve stimulation safe during pregnancy? A mini review. Epilepsy Res. 2021 May 14;174:106671. doi: 10.1016/j.eplepsyres.2021.106671. Epub ahead of print. PMID: 34022523.

De Ridder D, Kilgard M, Engineer N, Vanneste S. Placebo-Controlled Vagus Nerve Stimulation Paired with Tones in a Patient with Refractory Tinnitus: A Case Report. Otol Neurotol. 2015 Feb 14. [Epub ahead of print] PubMed PMID: 25689839.

Intracranial Meningioma Surgery Indications in Elderly

Intracranial Meningioma Surgery Indications in Elderly

Since the number of elderly people with intracranial meningiomas (IM) continues to rise, surgical treatment has increasingly become a considerable treatment option, even in very old (≥ 80 years old) meningioma patients. Since little is known about whether intracranial meningioma surgery in this age group is safe and justified, Rautalin et al. conducted a systematic review to summarize the results of surgical outcomes in very old meningioma patients. They performed a systematic literature search in PubmedCochrane Library, and Scopus databases. Primarily, they extracted 1-month and 1-year survival rates, and 1-year morbidity rates, as well as information about preoperative morbidity, operative complications, meningioma size, location, histology, and peritumoral edemaQuality of the included studies was evaluated by Cochrane Handbook for Systematic Reviews of Interventions and Critical Appraisal Skills Program. From the 1039 reviewed articles, seven retrospective studies fulfilled the eligibility criteria. Motor deficits (27-65%) and mental changes (51-59%) were the most common indications for surgery. One-month and 1-year mortality rates varied between 0-23.5% and 9.4-27.3%, respectively. Most of the operated IM patients (41.2-86.5%) improved their performance during postoperative follow-up. Impaired preoperative performance and comorbidities were most commonly related to higher postoperative mortality. None of the studies fulfilled the criteria of high quality. Based on the evidence currently available, surgical treatment of very old IM patients seems to improve the performance of highly selected individuals. Given the rapid increase of the aging population, more detailed retrospective studies, as well as prospective studies, are needed to prove the outcome benefits of surgery in this patient group 1).

The Japanese population features the highest rate of elderly individuals worldwide. Moreover, Japan has the highest number of computed tomography/magnetic resonance imaging devices in the world, which has led to an increase in the incidental detection of meningioma in healthy elderly patients. Many previous papers have discussed the risks and indications for surgery in this patient population, but available information remains insufficient, and the definition of “elderly” has not been standardized. This review tried to clarify the published evidence and challenges associated with elderly meningioma based on a search of the PubMed database using the terms “meningioma,” “elderly,” and “surgery” for English-language clinical studies and collected related papers published from 2000 to 2016. Twenty-four papers were reviewed and classified by definition of elderly age: over 60, 65, 70, and 80 years old. Six of seven papers that defined the elderly cutoff as over 65 years old were published after 2010, which suggested the consensus definition. Four preoperative grading scoring systems were described and associated with mortality. The 1-year and 5-year mortality rates ranged from 0% to 16.7% and from 7% to 27%, which were comparable with unselected cohorts. Review of risk factor analysis emphasized the importance of considering the preoperative status, presence of comorbidities, and optimum surgical timing during patient selection. Careful choice of patients can also lead to better quality of life. A prospective randomized study considering patient frailty should address the causes and prevention of complications 2).

The results of a study suggested that age should not be a limitation in surgical indications in patients older than 70 years old with intracranial meningioma. No statistical differences were found in functional status compared with conservative management or in surgical complications between younger and elderly patients 3).

A grading system, called the Clinical-Radiological Grading System (CRGS), was developed to standardize surgical indications in elderly patients harboring intracranial meningiomas. Patients with a score lower than 10 had a bad prognosis regardless of surgical treatment, those with a score between 10 and 12 had a prognosis positively influenced by surgery, and those with a score higher than 12 had a good prognosis regardless of surgical treatment. The authors performed a prospective cross-sectional study to validate further the use of the CRGS as a clinical tool to orientate surgical decision making in elderly patients and to explore prognostic factors of survival.

From 1990 to 2000 the authors consecutively recruited and surgically treated 90 patients 70 years of age or older with neuroimaging findings of intracranial meningiomas and a preoperative evaluation based on the CRGS. The surgical mortality rate, which covers deaths within 3 months after surgical intervention, was 7.8%, and the 1-year mortality rate was 15.6%. Female sex and a higher CRGS score were associated with a higher probability of survival. Among the different subset items of the CRGS score, no peritumoral edema for surgical survival and no concomitant diseases for 1-year survival provide the strongest predictive contribution, even if not at a statistically significant level.

The CRGS score is a useful and practical tool for the selection of elderly patients affected by intracranial meningiomas as surgical candidates. A CRGS score higher than 10 and female sex are good prognostic factors of survival. whereas age is not a contraindication to surgery 4).

For Buhl et al. age, in general, was not a contraindication for operation. In cases of incidental findings of small meningiomas, we recommend observation and MRI follow-up. Symptomatic meningiomas should be removed whenever there is an acceptable risk from an internal or anesthesiological point of view 5).

Few authors have reported on patients who have undergone surgery for intracranial meningiomas in their 9th decade of life, without providing indications regarding the surgical criteria and the prognostic factors. We report on a series of 17 patients who have received surgery for intracranial meningiomas in their 9th decade of life, with the goal of determining some surgical criteria for general physicians and neurosurgeons. Patients with severe systemic disease and definite functional limitations (American Society of Anesthesiology Class III) had major postoperative morbidity (P = 0.020) and mortality (P = 0.005), especially if they scored low (< 70) on the preoperative Karnofsky Rating Scale (P = 0.010). The risk of postoperative morbidity was higher when the maximum diameter of the tumor was > 5 cm (P = 0.031) 6).

Arienta et al. studied 46 cases of intracranial meningioma in patients over 70 years of age, 34 patients were operated on while 12 patients were not, although both groups were subjected to long term follow-up. The operative mortality rate was 12%, a rate which increased to 20% at 3 months follow-up. Various unfavourable prognostic factors were taken into consideration, the most significant of which were: poor overall clinical condition, peritumoral oedema, the presence of diabetes mellitus and the duration of surgery. A scored grading system was created to standardize surgical indications in elderly patients with cerebral meningioma. An analysis of the grading system, when applied to patients submitted to surgery, showed that the decreased patients within 3 months of surgery had a score which varied from 7 to 12, with a mean score of 10. The surviving patients had a score averaging from 10 to 16 with a mean of 13. The patients with the lowest scores (7-9) had a 100% mortality rate while those in the upper ranges (13-16) demonstrated a mortality rate of 0%. Among the conservatively treated patients the worst outcome was seen in patients with a grading equal to or less than 12 7).

Papo in 1983 stated that after 65, postoperative complications and mortality increased steeply: of the patients over 65 in whom the growth was excised 55% died. The radical surgery of intracranial meningiomas in geriatric patients over 65 still remains a tremendous challenge despite all the advances in operative technique, neuro anesthesia, and intensive care. On these grounds, in such patients surgical indications should be carefully evaluated 8).



Rautalin I, Niemelä M, Korja M. Is surgery justified for 80-year-old or older intracranial meningioma patients? A systematic review. Neurosurg Rev. 2020 Apr 4. doi: 10.1007/s10143-020-01282-7. [Epub ahead of print] PubMed PMID: 32248508.

Ikawa F, Kinoshita Y, Takeda M, Saito T, Yamaguchi S, Yamasaki F, Iida K, Sugiyama K, Arita K, Kurisu K. Review of Current Evidence Regarding Surgery in Elderly Patients with Meningioma. Neurol Med Chir (Tokyo). 2017 Oct 15;57(10):521-533. doi: 10.2176/nmc.ra.2017-0011. Epub 2017 Aug 15. Review. PubMed PMID: 28819091; PubMed Central PMCID: PMC5638779.

Troya Castilla M, Chocrón Gonzalez Y, Márquez Rivas FJ. [Complications and outcomes in the elderly with intracranial meningioma]. Rev Esp Geriatr Gerontol. 2016 Mar-Apr;51(2):82-7. doi: 10.1016/j.regg.2015.06.004. Epub 2015 Jul 17. Spanish. PubMed PMID: 26195279.

Caroli M, Locatelli M, Prada F, Beretta F, Martinelli-Boneschi F, Campanella R, Arienta C. Surgery for intracranial meningiomas in the elderly: a clinical-radiological grading system as a predictor of outcome. J Neurosurg. 2005 Feb;102(2):290-4. PubMed PMID: 15739557.

Buhl R, Hasan A, Behnke A, Mehdorn HM. Results in the operative treatment of elderly patients with intracranial meningioma. Neurosurg Rev. 2000 Mar;23(1):25-9. PubMed PMID: 10809483.

Mastronardi L, Ferrante L, Qasho R, Ferrari V, Tatarelli R, Fortuna A. Intracranial meningiomas in the 9th decade of life: a retrospective study of 17 surgical cases. Neurosurgery. 1995 Feb;36(2):270-4. PubMed PMID: 7731506.

Arienta C, Caroli M, Crotti F, Villani R. Treatment of intracranial meningiomas in patients over 70 years old. Acta Neurochir (Wien). 1990;107(1-2):47-55. PubMed PMID: 2096608.

Papo I. Intracranial meningiomas in the elderly in the CT scan era. Acta Neurochir (Wien). 1983;67(3-4):195-204. PubMed PMID: 6846076.
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