Type II odontoid fractures represent the most common cervical spine injury in the elderly. The decision for surgical treatment is still controversial, particularly with regard to the elevated peri-operative risk attributed to frequent comorbidities and poor bone quality. The purpose of this study was to assess both short-term mortality and mid-term clinical and radiological outcome in the elderly. Between January 2007 and December 2015, 35 patients with type II odontoid process fractures who underwent posterior atlanto-axial instrumentation using a modified Goel-Harms technique were retrospectively analyzed and prospectively examined clinically and radiologically. Comorbidities, mortality, and length of intensive care unit (ICU) and hospital stay were determined, as were medical and surgical complications. Quality of life was measured using the EuroQol five dimensions (EQ-5D) and Short Form-36 (SF-36) questionnaires at final follow-up. Average age was 86.5 years. All patients had severe comorbidities pre-operatively. No in-hospital mortality was observed. Average length of hospital stay was 13.8 days and 2.0 days for the ICU. Three patients developed cardiopulmonary complications; one wound infection developed post-operatively. Mean follow-up was 22 months (range, 6–72 months). The quality of life measured by EQ-5D showed a good outcome (0.7 ± 0.1). All SF-36 domains were reduced in comparison to a representative group. Solid bony fusion could be achieved in all patients. Atlanto-axial fusion by using intra-operative spinal navigation is a safe and effective procedure in the elderly, with few complications and preservation of favorable post-operative quality of life. The overall major complication rate was 11%. Surgery in the very old should be considered as first-choice treatment.

The diploic veins serve as an important connection between the extracranial and intracranial venous systems. They change in size during growth from adolescence to adulthood. The diploic space has been identified as an additional site of reabsorption of cerebrospinal fluid (CSF). Herein, the anatomy and physiology of the diploic veins are reviewed.

Study Design.: . Retrospective study. Objective.: . To determine incidence, risk factors, complications, and early postoperative outcome in patients with intraoperative ischemic stroke during elective spine surgery. Summary of Background Data.: . Overall, stroke is the fifth leading cause of death in the United States and the second leading cause of death worldwide. It can be a catastrophic event and the main cause of neurological disability in adults. Methods.: . A retrospective review of the electronic medical records of patients who underwent elective spine surgery between January 2016 and November 2018 at a larger tertiary referral center was conducted. Patients with infection and neoplastic disease were excluded. Patient demographics, pre- and postoperative neurological status, surgical treatment, surgical time, blood loss, intraoperative abnormalities, risk factors, history of stroke, medical treatment, diagnostics, hospital stay, complications, and mortality were collected. Results.: . Out of 5029 surgically treated patients receiving elective spine surgery, a total of seven patients (0.15%) were identified who developed an ischemic stroke during the surgical procedure. Patients were predominantly females (n = 6). Ischemic pontine stroke occurred in two patients. Further distributions of ischemic stroke were: left caudate nucleus, left posterior inferior cerebellar artery, left external capsule, left middle cerebral artery, and acute ischemic supratentorial spots. The main risk factors identified for intraoperative ischemic stroke include hypertension, diabetes, smoking, dyslipidemia, and possibly major intraoperative CSF leak. Three patients (43%) had neurological deficits which did not improve during hospital stay. Two patients recovered fully and two patients died. Therefore, in-hospital mortality rate of this subset of patients was 29%. Conclusion.: . With the increase of spinal procedures, it is important to identify patients at risk for having an ischemic stroke and to optimize their comorbidities preoperatively. Patients with intraoperative ischemic stroke carry a higher risk for morbidity and mortality during the index hospitalization. Level of Evidence: 4