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308
22 Surgical failures
22.1 Complications of Approach
An incorrect position of the patient on the operating table can make the entire procedure complicated
from the beginning. Either the target structures are
impossible to reach or the required stabilization
cannot be achieved. Improper positioning may also
result in either excessive venous bleeding due to
a dependent position of the surgical field or in air
embolism if the field is too high relative to the heart.
Neurosurgeons are particular about bloodless exposure of the spine. This aids in an easy identification
of anatomical structures and thus avoids injury to
the essential ones. Operating field covered in blood
can substantially decrease the visibility of important
structures and subject them to unnecessary risk. The
final goal of the approach is to clearly expose the
spine in an anatomical fashion. One must use all
preoperative imaging to their advantage and identify any potential anatomical variants (see Chaps.
1 and 6). One key structure to identify and avoid
during posterior approaches to the cervical spine is
the vertebral artery (VA). Wanibuchi et al. studied
injected cadaveric heads and defined a simple threestep approach to identification of the V3 segment of
the VA that was on average 19.1 mm lateral to the
C1 tubercle [7]. The artery could be injured during
a simple subperiostal exposure of C1 posterior arch
in the case of its ponticular covering. An exceptionally rare, persistent first intersegmental artery could
be injured during C2 isthmus exposure if not identified pre- or intra-operatively. Anomalous vessels are
more common in syndromic patients, e.g., Down’s
syndrome [8].
tissue and doing so at the end of a long tumor resection.
Such situation is a setup for a complication and the surgeon must be mentally ready to handle such challenges.
Whenever the dura is opened and the arachnoid
torn, CSF will escape the dural tube. This represents
another unintentional complication. In the majority of
cases, a watertight suture is not possible and dural substitutes with biological glue have to be applied. Many
cases require temporary CSF diversion (e.g., lumbar
drain) to avoid CSF fistulae. With CSF leak, the infection risk increases.
Surgical tools, when used inappropriately, will
result in complications. When performing bony decompression with high speed drills, we prefer to use diamond drill bits and operate at a high speed. Higher
speed and shaving movement without pressure directed
to dangerous tissue allows for better tactile feedback of
bone remnants on dura or vessels. More recently, various bone ultrasonic aspirators that target only osseous
structures without damage of soft tissues appear to be
a promising idea [3].
Finding and respecting the natural cleavage planes
with sparing of vessels not supplying the tumor is
another important point in tumor surgery. We feel
also that surgical microscope and electrophysiological monitoring have to be a part of the armamentarium
whenever working in the UCS and CVJ area as the
microscope aids in early identification of structures,
and thus avoiding their unnecessary injury, while electrophysiological monitoring helps in early diagnosis of
otherwise unforeseen events (e.g., during positioning).
22.3 Complications of Reduction
(Indirect Decompression)
22.2 Complications of Direct Decompression
Adequate decompression again requires an intimate
knowledge of anatomical variants identified on preoperative imaging but also the relationship of vital structures to
the compressive pathology. When addressing tumor
resections at the CVJ, it is not only the relationship to
neural structures that is important but also their vascular
supply. It is not unusual for the last part of decompression
to be the most delicate part requiring the utmost attention
to careful removal of tumor in direct contact with neural
In cases of indirect release of deformity by instrumented reduction, one has to be aware of the distance
of the spinal cord from the segment being reduced and
also the amount of safe free space. Other problems
that may arise when attempting to achieve a correct
alignment of the spine with good sagittal and coronal
balance are both an overcorrection (Fig. 16.2, Chap.
16) and hypocorrection (Fig. 22.1). In the majority of
cases, the realignment errors are minor without the
need for corrective procedures; however, if postoperative deficit or painful syndrome exists directly related
to the malalignment, a revision procedure should be
22.3 Complications of Reduction (Indirect Decompression)
abc
a
b
Fig. 22.1 Reducible odontoid pseudarthrosis fixed in suboptimal reduction by transarticular C1-2 screws. (a) Flexion showing AA
dislocation. (b) Complete reduction in extension. (c) Fixation according to Magerl in suboptimal position
309
undertaken. In ligamentous damage or injury, one has
to be aware of possible overdistraction.
22.4 Complications of Hardware Insertion
The most dangerous complications can occur during
the reconstruction phase of the procedure. Sometimes,
it can be difficult to find an appropriate screw trajectory for sufficient and safe bone anchorage. Especially,
in brittle bone of osteoporotic patients or excessively
hard bone of degenerated spine, alternative solutions
may need to be found. In porotic spine, a bi- or quadri-cortical screw will minimize toggling and screw pull
out. When the bone is too hard and does not allow the
screw to pass easily through cancellous bone, direct
drilling and tapping may be necessary.
Such a situation may require a more complex reconstruction than was initially planned and alternative
solutions must be prepared for.
Complications related to low quality of implants are
much less frequent nowadays, particularly in Western
world. Nevertheless, we feel it is important to draw the
reader’s notice to this potential problem as it may be
encountered in many places due to economic reasons.
In the past, we have encountered screw breakage during surgery of UCS. For example, strong final tightening of odontoid screws can lead to their breakage,
especially if the tip is not drilled through and tapped
(Figs. 22.2 and 22.3). Odontoid screw fixation is often
a subject of surgical errors clearly related to a lack of
sufficient experience (Fig. 22.4). Although not very
frequent, an error during insertion of a transarticular
C1-2 screw can lead to a VA injury, especially when an
incorrect trajectory is selected (Fig. 22.5). Even when
all anatomical landmarks are identified correctly and
Fig. 22.2 Broken screws
during tightening in odontoid
type II fracture. Right one is
cannulated titanium screw
and left one 3.5 mm stainless
steel screw. (a) AP radiogram
showing healed fracture after
2 years. (b) Lateral film of
the same patient
310
ab
a
c
d
b
Fig. 22.3 First screw broken
during final tightening
requiring other two screw
introduction. (a) Peroperative
fluoroscopical image of
broken thread-shank
transitional area of 3.5 mm
stainless steel screw.
(b) Introduction of the other
two screws
22 Surgical failures
Fig. 22.4 Patient referred to our hospital from another institution
coming for regular check without any complaints. (a) Transoral
radiogram showing too long odontoid single screw used for fixation of type II fracture. (b) CT in sagittal reconstruction depicting
the enjambment of the screw over the odontoid process apex
(also pseudarthrosis was revealed). (c) Transoral picture obtained
odontoid pseudarthrosis after screw removal. (d) Posterior transarticular fixation according to Magerl
References
ab
cd
Fig. 22.5 Erroneous
trajectory of second
transarticular screw tapping
leading to VA injury in RA
patient with atlas settling. (a)
Correct purchase of the first
screw. (b) Incorrect too low
C2 trajectory of the tap for
second screw. (c) Point of VA
injury (pulsating arterial
blood came after tap
removal). (d) Plugging with a
short pars screw
311
an appropriate entry point is selected, attention has to
be paid to the trajectory of any screw and prompt an
early identification of vertebral foraminal breach.
Ignoring the radiographic signs of incorrect trajectory
results. We strongly believe that centralization of care
for patients with UCS and CVJ pathologies is the answer
to reduction of complication rate and guaranteed continued education of new generations of CVJ surgeons.
then results in tapping of the VA, a point of no return
in terms of avoiding the injury.
In conclusion, many potential complications exist
References
during reconstructions of the CVJ and UCS. Preparation
and planning of intended procedure as well as bailout
options are the best solution to complication avoidance. If a complication does occur, prompt identification is essential to avoid long-term sequelae. When
appropriate, all tools available should be used to protect the patient from inadvertent injuries in the operating room (monitoring, fluoroscopy, and microscope).
Complications do occur, even in the hands of an
experienced surgeon. This is not an excuse for difficult
procedures to be done by inexperienced centers.
Obviously, if one does not perform CVJ reconstructions,
they will never encounter a complication thereof.
However, surgical morbidity needs to be minimized with
experience, continued learning, and audit of one’s own
1. Cao, Z.L., Ying, Q.S., Liu, J.F., et al.: The reason and prevention of upper cervical reoperations. Zhonghua Wai Ke Za
Zhi 41, 567–569 (2003)
2. Finn, M.A., Apfelbaum, R.I.: Atlantoaxial transarticular
screw fixation: update on technique and outcomes in 269
patients. Neurosurgery 66, A184–A192 (2010)
3. Ito, K., Ishizaka, S., Sasaki, T., et al.: Safe and minimally
invasive laminoplastic laminotomy using an ultrasonic bone
curette for spinal surgery: technical note. Surg Neurol 72,
470–475 (2009). discussion 475
4. Rihn, J.A., Winegar, C.D., Donaldson 3rd, W.F., et al.:
Recurrent atlantoaxial instability due to fracture of the posterior C1 ring: a late finding following posterior C1-C2 fusion
using the Halifax clamp. J Surg Orthop Adv 18, 45–50 (2009)
5. Rudzki, J.R., Lenke, L.G., Blanke, K., et al.: Pseudarthrosis
of a thirty-nine-year-old dens fracture causing myelopathy. A
case report. J Bone Joint Surg Am 86-A, 2509–2513 (2004)
312
22 Surgical failures
6. Suchomel, P., Stulik, J., Klezl, Z., et al.: Transarticular fixation of C1-C2: a multicenter retrospective study. Acta Chir
Orthop Traumatol Cech 71, 6–12 (2004)
7. Wanibuchi, M., Fukushima, T., Zenga, F., et al.: Simple
identification of the third segment of the extracranial vertebral artery by extreme lateral inferior transcondylar-transtu-
bercular exposure (ELITE). Acta Neurochir (Wien) 151,
1499–1503 (2009)
8. Yamazaki, M., Okawa, A., Hashimoto, M., et al.: Abnormal
course of the vertebral artery at the craniovertebral junction
in patients with Down syndrome visualized by three-dimensional CT angiography. Neuroradiology 50, 485–490 (2008)
Index
A
AAD. See Atlantoaxial dislocation
AAOA. See Atlantoaxial osteoarthritis
AARF. See Atlantoaxial rotatory fixation
ALL. See Anterior longitudinal ligament
Aneurymal bone cysts (ABCs)
autologous bone grafts, 255
description, 253
diagnosis
“ballooning out”, bone cortex, 254
coronal plane and sagittal reconstruction, 256
spinal canal contents, 256
progression, prevention, 254–255
recurrence rate, 255
spinal canal contents, 256
treatment
en bloc resection, 254
radiation therapy, 254
Anterior longitudinal ligament (ALL)
atlanto-occipital membrane, 10
degenerative disc disease, 189
Anterior spinal artery (ASA), 13
Anterior structural reconstruction techniques
bridge fixation principle, 60
C0-C1-C2 segment, 60
CVJ, 59
rigid immobilization, 61
AOD. See Atlantooccipital dislocation
Atlantoaxial dislocation (AAD)
diagnosis, 216
distractive force, 217
etiology and epidemiology, 216
radiology, 216
treatment
dislocations, 217
neurological compromise, 216
translational injuries, 217
Atlantoaxial osteoarthritis (AAOA)
AA instability, 302
C1–C2 transarticular fixation, 303
description, 299, 305
marked osteophytosis, 300
primary conservative treatment, 303
principal symptom, 299–300
Atlantoaxial rotatory fixation (AARF)
defined, 30
dynamic imaging, 30
Atlantooccipital dislocation (AOD)
clinical symptoms, 139
CVJ craniometrics, 287
diagnosis, 142–143
etiology, 139
intubation and prone positioning, 142
morphological classification, 142
MRI, 143
radiology, 139–141
treatment strategy, 141
vision and fluoroscopic guidance, 142
Atlas
anchoring structure
anterior C1 lateral mass screw
anterior/posterior approach, 71–72
neurovascular structures, 72
posterior arch, 72–73
posterior lateral massa screw, 73
anterior arch, 5
C1–2 combination injuries, 157
classification, fractures
devoid muscular and soft tissue, 152
intra-articular, 153
posterior arch, 151
radiological literature, 152
sagittal split, 154
therapeutic consequences, 151–152
transoral radiogram, 152
transverse ligament disruptions, 153
types, 151–153
clinical symptoms, 154
decision process, 157
description, 151
diagnosis, fractures
atlantoaxial joint, 154
LTA, 154–155
TAL deficiency, 154–155
transoral radiographs, 154
etiology, fractures
axial head compression, 153
“bursting” mechanism, 154
odontoid process, 154
transverse process fractures, 154
P. Suchomel and O. Choutka, Reconstruction of Upper Cervical Spine and Craniovertebral Junction,
DOI: 10.1007/978-3-642-13158-5, © Springer-Verlag Berlin Heidelberg 2011
313
314
Index
lateral masses, 5–6
lower articular surface, 6
posterior arch, 5
superior articular surface, 6
transverse foramen, 6–7
treatment, fractures
AA posterior fixation, 159–160
active surgical approach, 156
bony fusion, 158
direct compressive osteosynthesis, 159, 161
gradual traction release, 157
gun shot, 159–160
Harms fixator, 159, 161
healing, bony, 155
neural structures, 158–159
non sagittal fracture, 158
potential risks, 156
screw methods, 156
wedge-shaped lateral masses, 157
Axis, anchoring structure
C2 vertebra, 80
laminar C2 screws
anatomical background, 93
atlantoaxial stabilization techniques, 92
cortex and cancellous intralaminar bone, 94
drawback, 100
free-hand technique, 93
lag screw tightening, 99–100
monocortical isthmic screws, 93
surgical technique, 93–94
transisthmic screw technique, 94
Wright’s method, 93
long pars interarticularis screw
anatomical structures, 91
anterior tubercle, 86
atlantoaxial dislocation, 91
bailout technique, 89
bony canal, 90
C0–1 joint, 90
3D modeling, 90
drawbacks, 92
electrophysiological monitoring electrodes, 90
image-guided placement, 87
imaging techniques, 88–89
intra-articular bone fusion, 91
intraforaminal cortical breaches, 87
isthmic bone bridge, 86
joint capsule, atlantoaxial, 88
lateral fluoroscopy, 91
Magerl’s technique, 88
nomenclature, anatomical, 86
preclude screw placement, 85
preoperative CT planning, 87
space available, 89
spinal canal contents, 89
transverse foramen perforation, 86
VA-bone occupancy ratio, 88
venous bleeding, 92
odontoid process screw
anatomical background, 94–95
Apfelbaum retractor, 98
double odontoid screw purchase, 99
fractures, 94
lateral C2 view, 98
oblique surgical canal spreading, 98–99
preoperative fluoroscopical testing, 97
rectangular fluoroscopes, 96–97
surgical technique, 95–96
pedicle screw
axis ring fractures, 85
compressive osteosynthesis, 80
cortex penetration, 84–85
3D modeling, 81
entry and exit points, 84
free hand technique, 82
lateral radiogram, 82–83
neural anatomy and pathology, 83
placement algorithm, 81
standard technique, 81–82
structures, neural, 83–84
subaxial cervical spine, 80
virtual planning, 83
short C2 pars interarticularis screw
advantage, 92
rod connection, 92
use, 92
B
Basion-dental interval (BDI)
and BAI, 28
Dublin method, 28–29
radiology, 139–140
“Rule of Twelve”, 28
Basion-posterior axial line interval (BAI)
MRI, 141
normal values in adults and children, 28
parameters, 140
Benign primary bone tumors
ABCs (see Aneurymal bone cysts)
classification, grading and staging, 250
clinical symptoms, 251
fibrous dysplasia, 257
GCTs (see Giant cell tumors)
Gorham disease, 257
hemangiomas, 257
LCH, 257
lesions, 250
osteoid osteomas and osteoblastomas
C2 lamina, 252
difference, 251–252
intralesional excision, 252
male predominance, 251
radiation therapy, 253
radical resection, 253
symptomatic patient, 253
total spondylectomy, 254
vertebra involvement and structure, 252
“vertebra plana” appearance, 252
radiology, 251
treatment, 251
Index
315
WBB surgical staging
and Enneking status, 250–251
vertebral tumor, 250
Bergman’s ossicle. See Ossiculum terminale
Biomechanical remarks
atlantoaxial complex (C1–C2), 17
atlantoaxial joint
anterior horizontal displacement, 20
rotation-limiting ability, 20
transverse ligament, 20–21
atlantooccipital joints (C0–C1), 17–18
CVJ and UCS
axial load distribution
clinical and morphological instability, 20–21
occipitoatlantal joint
AO hypermobility, 20
basilar invagination, 20
BDI and BAI, 20
occipitoatlantoaxial complex (C0-C1-C2), 17
Burst fractures, axis body
comminution, 204
external immobilization, 203
surgical fixation and fusion, 203, 205
unconscious patient, 204
C
Cervicomedullary angle (CMA)
brainstem and spinal cord compression, 27
description, 287
Chondrosarcoma
description and diagnosis, 267
treatment, 267–268
Chordoma
anterior reconstruction, 265
description, 259
diagnosis
anterior and intraspinal, 260
axial CT scan, 259
plain films, 259
follow-up, 260, 267
middle column reconstruction and occipitocervical fusion,
260, 266
navigation system, 261
treatment
chemotherapy, 259–260
long-term cure, 259
surgical radical resection, 260
wide-margin resection, 260
Clivus
basilar portion, 71
canal angle, 286
growth and correct formation, 5
sphenoid bone, 71
wedge-shaped, 71
CMA. See Cervicomedullary angle
Combined atlas-axis fractures
external bracing, 211
hangman’s with odontoid, 210
hard collar, 212
miscellaneous C2 and AA instability, 213
neurological deficit, 210
odontoid type III, hangman and Jefferson, 212
rotatory atlanto-axial subluxation, 213
Computer tomographic angiograms (CTA), 74
Condylar hypoplasia, 287
Condylus tertius, 287
Congenital and developmental abnormalities
atlantooccipital assimilation
partial atlas, 289
simultaneous synostosis, 288
atlas anomalies
arch defects, 289
split atlas, 289
axis anomalies, 289
basilar impression, invagination
acquired deformity, 292
groups, 293
IAAD, 294
posterior and anterior decompression, 293
reconstruction, 293
basioccipital hypoplasia
bulging, 288
clivus shortening, 287
fused odontoid process, 288
clinical appearance, 286
condylar hypoplasia
atlas assimilation, 287
condylus tertius, 287
“cranial settling”, 294
etiology
distorted CVJ development, 285
unfinished bone growth, postnatal, 285
extended anterior decompression, 295
occiput anomalies, 287
odontoid hypoplasia and aplasia, 290
Os odontoideum
anterior and posterior instability, 290–291
definition, 290
deterioration, 291
dystopic type, 290, 292
Magerl and Goel-Harms technique, 292
orthotopic type, 290, 291
surgery, 291
ossiculum terminale, persistent, 289
radiology
cervicomedullary angle (CMA), 287
“the basal line”, 286
Wackenheim’s clivus line, 286–287
transoromaxillar approach, anterior, 294, 295
Coronal axis body fractures
anterior graft and plate fusion, 201
partial involvement, posterior wall, 200
stable, 199, 200
transverse, 199, 200
vertical, 200
Craniovertebral junction (CVJ)
anterior
column reconstruction, 60
muscles, 11
atypical axial load distribution, 19
316
Index
biomechanical properties, 55
clinical and morphological instability, 19–20
complex bony abnormalities, 23
components, 28
computer guidance, 130
craniometric parameters, 24
deformities, RA, 242
distorted development, 285
dorsal approaches, 3
dynamic imaging, 30
Halo ring, 141
ICA, 13
instrumentation, 134
intradural tumors (see Intradural tumors)
iso-C navigational techniques, 129
ligaments, 9, 142–143
MRI evaluation, 142
osteoarthritis, 299
posterior techniques, 59–61
primary abnormalities (see Congenital and developmental
abnormalities)
radiographic evaluation, 33
reconstructions, 307, 311
soft tissue and bony dynamics, 24
structures, 30
transoral decompression, 304
trauma evaluation, 142
tumor resections, 308
unique morphology, 55
VA, 12
vascular evaluation, 31
vertebral artery compression, 32
visualization, 24
vital structures, 130
CVJ. See Craniovertebral junction
D
Degenerative disorders
clinical symptoms
degenerative pannus, 300
pain, 299–300
synovial cyst, 300–301
etiology, 299
Goel-Harms method, 304
history
cervical arthritis, 299
transarticular fusion, 299
occipital headache, 304
radiology
coronal/parasagittal reconstructions, 301, 302
degenerative intradental cyst, 303
“geodes”, 303
obliteration, AA joint, 301
vertebromedullary relationship, 302
treatment
conservative, 303
surgical, 303–304
Dynamic reference array (DRA)
anterior approaches, 130
C2 surface registration, 127
dorsal spine bony anatomic landmarks, 127
navigational system, 47–48
E
Enneking staging
malignant spine tumors, primary, 258
primary benign spine tumors, 250
EOP. See External occipital protuberance
Eosinophilic granulomas. See Langerhans cell
histiocytosis
Ewing sarcoma (ES), 268
Extended transoral approaches
anterior arch, 49
Crockard’s mouth distractor, 47–48
electrophysiology, 47
fluoroscopical visibility, 47
infiltrated mucosa, 48
maxillotomy, 50
microsurgical transoral odontoidectomy, 48
odontoid pseudoarthrosis, 49
preoperative fluoroscopical testing, 47
radical extirpation, 50
stabilization procedure, 47
transmandibular, 46–47
transmaxillar, 46
uvula, 48
External occipital protuberance (EOP)
bone thickness, 4, 66
screw placement, 67
subperiostal dissection, 67
Extradural UCS tumors
primary bone
benign, 250–257
chondrosarcoma, 267–268
chordoma, 259–267
ES, 268
malignant, 257–259
OS, 268
solitary plasmocytoma, 268–269
radiological remarks
gadolinium, 248
narrowed vertebral artery, 249
oropharynx displacement, 249
plain radiographs, 247
stabilization procedures, 247, 248
secondary bone
classification, grading and scoring, 272
diagnosis, 269–272
therapeutics, 272–273
spine, 275
surgical oncologic terms
margin, 249
resection, 248, 250
therapeutics, 248
treatment teams, 247
F
Foramen magnum (FM)
clivus, 285
narrowing, 285
Index
317
neural compromise, 235
odontoid distance, 287
palate and posterior, 286
Fractures, ring of axis. See Hangman type fractures
G
“Geodes”, 303
Giant cell tumors (GCTs), 256–257
Goel-Harms technique
bone graft, 108
C1–2 posterior fixation, RA, 241
fusion rate, 108
joint distraction and placement, 108
vs. Magerl’s technique, 109
occipitocervical fusion, 108
Os odontoideum, 292
Gorham disease, 257
H
Hangman type fractures
borderline instability, 192
classification
Effendi, 181–182
Francis, 182
Levine and Edwards, 182
Roy-Camille, 182
definition, 183
direct osteosynthesis, 189, 191
dislocation, extension, 189
etiology and epidemiology, 182
extension and flexion, 193
fracture line visibility, 189, 191
hanging punishments, 179
isolated, 189
Levine type, 180–181
“long drop”, 179–180
MRI, 188
non-displaced, C2 abruption, 190
radiology
C2 ring to verberal body, 183, 184
distant fracture, arch, 183, 184
dynamic MRI, 186
Levine type II, 185–186
line invasion, 184
“slipping”, 185
superior facet joint involvement, 184–185
symmetric transisthmic pattern, 184
symptoms and signs, 182–183
terminological alternatives, 179
treatment
anterior surgery, 187–188
anterolateral approach, 188
direct pars fixation, 188
halo immobilization, 186–187
halo-vest, 187
posterior and combined approach, 188
traction and bracing, 186
verbal shortcuts, evaluation, 181
High anterolateral approach
oblique visibility, 43
submandibular gland, 42
surgical technique, 42
I
IAAD. See Irreducible atlantoaxial dislocations
Internal carotid artery (ICA)
lumen, 13, 73
risk, 73
standard angiography, 83
UCS and CVJ, 13
Intradural tumors
ependymoma and astrocytoma, 277–278
intramedullary cavernous hemangioma, 279
meningiomas, 276
removal, 277
statodynamic system, 275–276
UCS region, 275
Intraoperative electrophysiological monitoring (IOM)
electrodes, 39
fiberoptic guidance, 45
UCS surgery, 47
Irreducible atlantoaxial dislocations (IAAD), 294
L
Langerhans cell histiocytosis (LCH), 257
Lateral approaches
C1-C2 transarticular fixation, 41–42
posterolateral, 40–41
Ligamental tubercle avulsion (LTA), 154–155
Ligaments and joints
atlantoaxial lateral, 10
atlantodental joint, 10
atlanto-occipital, 10
UCS and CVJ ligamentous connections, 9–10
M
Magerl’s technique
atlantoaxial transarticular screws, 105
biomechanical stability, 104
Goel-Harms procedure, 106
graft-related problems, 106–107
Olerud modification, 107
pediatric population, 105
wire fusion, 104–105
Malignant primary bone tumors
classification, grading and staging, 258
diagnosis
clinical complaints, 257
mild osteolysis, 258
needle/incisional biopsy, 258
osteolytic lesion, 257, 258
treatment
decision-making, 258–259
radical surgery, 259
Minimally invasive approaches
endoscopic techniques, 50
image-guided techniques, 51
odontoid fixation, 51
transcervical route, 51
Miscellaneous C2 fractures