Delayed pulmonary perforation. A rare complication of tube thoracostomy.

Tube thoracostomy is a standard therapy for a number of pulmonary disorders. The procedure is associated with a certain incidence of morbidity related to the technique of insertion, the patient population selected, and the length of time the tube remains in place. Complications of tube placement previously described include empyema, residual pneumothorax, lung perforation, placement of the tube in the chest wall, diaphragmatic perforation, perforation of intraabdominal organs (such as spleen, liver and stomach), unilateral pulmonary edema, bronchopleural fistula, hemothorax, cardiogenic shock and Horner syndrome. A case of a delayed pulmonary perforation developing several days after placement of a chest tube is described with a discussion of the clinical and radiographic findings associated with this complication. A possible pathophysiologic mechanism by which this complication may have occurred is proposed.

Role of cyclooxygenase 2 in acute spinal cord injury.

Cyclooxygenase, or prostaglandin G/H synthase, is the rate-limiting step in the production of prostaglandins. A new isoform, cyclooxygenase-2 (COX-2), has been cloned that is induced during inflammation in leukocytes and by synaptic activity in neurons. The objectives of this study are to determine the nature of COX-2 expression in normal and traumatized rat spinal cord, and to determine the effects of selective COX-2 inhibition on functional recovery following spinal cord injury. Using a weight-drop model of spinal cord injury, COX-2 mRNA expression was studied with in situ hybridization. COX-2 protein expression was examined by immunohistochemistry and Western analysis. Finally, using the highly selective COX-2 inhibitor, 1-[(4-methylsufonyl)phenyl]-3-tri-fluro-methyl-5-[(4-flur o)phenyl]prazole (SC58125), the effect of COX-2 inhibition on functional outcome following a spinal cord injury was determined. COX-2 was expressed in the normal adult rat spinal cord. COX-2 mRNA and protein production were increased following injury with increases in COX-2 mRNA production detectable at 2 h following injury. Increased levels of COX-2 protein were detectable for at least 48 h following traumatic spinal cord injury. Selective inhibition of COX-2 activity with SC58125 resulted in improved mean Basso, Beattie, and Bresnahan scores in animals with 12.5- and 25-g/cm spinal cord injuries; however, the effect was significant only for the 12.5g/cm injury group (p=0.0001 vs. p=0.0643 in the 25-g/cm group). These data demonstrate that COX-2 mRNA and protein expression are induced by spinal cord injury, and that selective inhibition of COX-2 improves functional outcome following experimental spinal cord injury.

Lateral extracavitary approach for thoracic and thoracolumbar spine trauma: operative complications.

BACKGROUND: The lateral extracavitary approach (LECA) to the thoracic and thoracolumbar spine allows ventral decompression and dorsal fixation of the spine through the same incision during a single procedure. The approach, however, is technically demanding and time-consuming. We sought to determine the incidence of complications associated with the LECA in patients with acute thoracolumbar spine injuries. PATIENTS AND METHODS: A retrospective chart review of all patients with acute fractures or dislocations of the thoracic or thoracolumbar spine who underwent surgery via the LECA was conducted to assess the incidence and type of perioperative complications associated with the LECA. RESULTS: Thirty-three patients with thoracic or thoracolumbar spine injuries treated using the LECA between June 1990 and June 1996 were identified and had available medical records. Complications occurred in 18 of these patients. Pulmonary complications predominated. Eleven patients required tube thoracostomy for hemothorax or persistent pleural effusions, and seven patients developed postoperative pneumonia. There were no cases of neurological worsening. There was no mortality. CONCLUSION: Decompression and stabilization of acute thoracolumbar fractures with the LECA in the acute setting is associated with a 55% incidence of morbidity. Whereas some of this morbidity may be attributed to the effects of the injury, there is a certain intrinsic morbidity associated with the LECA. Although this morbidity may compare favorably with that of sequential ventral/dorsal approaches, the biomechanical advantages obtained with a combined ventral and dorsal construct must be balanced against the inherent morbidity of such approaches.

The effect of hypothermia on the incidence of delayed traumatic intracerebral hemorrhage.

Hypothermia has been shown to cause coagulation abnormalities, primarily related to platelet dysfunction. We reviewed coagulation function and the incidence of delayed traumatic intracerebral hemorrhage in a series of 36 patients with severe head injuries (Glasgow Coma Scale 3-7) enrolled in a prospective, randomized, clinical trial of therapeutic moderate hypothermia. Patients were randomized to a normothermic group (n = 16) or to a group cooled to 32 to 33 degrees C within 6 hours of injury (n = 20). Prothrombin times, partial thromboplastin times, and platelet counts were obtained in the emergency room and then again within 24 hours of randomization. Delayed traumatic intracerebral hemorrhage occurred in 6 of 20 (30%) hypothermic patients and 5 of 16 (31%) normothermic patients. In the hypothermic group, 9 of 17 patients had an increased prothrombin time during hypothermic therapy, as opposed to 11 of 16 in the normothermic group during the corresponding time period. The partial thromboplastin time was prolonged in 2 of 17 hypothermic patients and 2 of 16 normothermic patients. Three patients in the hypothermic group and one in the normothermic group developed thrombocytopenia (a platelet count of less than 100,000). There were no significant differences between the two groups in the incidence of delayed traumatic intracerebral hemorrhage, in measured coagulopathy, or in the mean values of measured coagulation parameters. Although the possibility of a hypothermia-induced coagulopathy has not yet been excluded, the short-term use of hypothermia does not appear to increase the risk for intracranial hemorrhagic complications in head injuries.

The significance of carotid canal involvement in basilar cranial fracture.

OBJECTIVE: Basilar cranial fractures have been associated with injury to the carotid artery. We sought to determine whether fracture through the carotid canal was a significant risk factor for carotid injury. METHODS: A retrospective chart review was performed, and 230 patients with basilar cranial fractures were identified. Fifty-five of the 230 patients had visible fractures that extended through one or both carotid canals (CC fx group). Evidence for vascular injury, based on medical records, angiography, magnetic resonance imaging, and other studies, was compiled. The anatomic characteristics of the fractures were also noted and recorded. RESULTS: Ten patients in the CC fx group suffered vascular complications; for six of them, the complications were directly related to the intracranial carotid artery. This compares to four patients in the non-CC fx group with vascular complications (P < 0.005), only one of which was carotid-specific (P < 0.005). The most common site of fracture through the canal was at the junction of the lacerum and cavernous portions of the canal (the spheno-occipital suture) (62% of all carotid canal fractures occurred at that site); however, vascular injury was seen most often in patients who sustained fractures through the petrous segment (67% of carotid canal-specific injuries occurred in that group, and 25% of patients with petrous canal fractures suffered carotid injury, [P = not significant]). The mean Glasgow Coma Scale score and the mean age were both lower (P < 0.05) in the CC fx group. CONCLUSION: Vascular complications are more frequently observed after basilar cranial fractures when there is involvement of the carotid canal. The lacerum-cavernous junction, which is partly formed by the spheno-occipital suture, is the most frequently fractured segment of the carotid canal. Fracture through the petrous segment of the carotid canal is associated with a relatively high incidence of carotid injury. Fracture through the carotid canal may serve as an index of injury severity, because patients with these fractures suffered more severe head injuries.

Microvascular decompression for pediatric onset trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia (TGN) is generally a disease of the elderly. Vascular compression, the causative agent in the majority of cases, is thought to result from atherosclerotic changes within the vessels of the posterior fossa. Rarely, the disease presents during childhood, before the onset of severe atherosclerotic changes. We therefore sought to explore the role of vascular compression in pediatric patients with medically refractory TGN. PATIENTS AND METHODS: Twenty-three patients were identified in whom the onset of typical TGN had occurred during childhood (age 18 yr or younger) and who underwent exploration of the cerebellopontine angle. Twenty-two of 23 underwent microvascular decompression (MVD) of the trigeminal nerve. Twenty-one of these patients were followed for more than 1 year. A retrospective chart review was conducted to determine the efficacy of MVD for the treatment of TGN in this select population. Operative findings were recorded and correlated with patient outcome. RESULTS: Twenty-two of 23 patients (96%) were found to have vascular compression of the trigeminal nerve at the time of exploration. One patient was found to have an epidermoid tumor. MVD resulted in complete pain relief at the time of discharge in 16 of 22 patients (73%), with an additional 4 patients (18%) having a greater than 75% diminution of pain. The 21 patients who were followed for at least 1 year were followed for a mean of 105 months. At the time of their last follow-up, 9 of these patients (43%) continued to have complete pain relief and 3 (14%) had a greater than 75% diminution of pain. The most common operative finding was a vein compressing the nerve, often in combination with a branch of the superior cerebellar artery. DISCUSSION: MVD has been demonstrated to be a safe and efficacious treatment for TGN in the adult population. Patients whose symptoms begin in childhood do not enjoy the same therapeutic response to MVD as do patients with TGN onset in adulthood. An increased incidence of venous compression was noted in this population, as was a longer duration of symptoms before MVD. These factors may be responsible for the decreased efficacy of MVD in this patient population.

Microvascular decompression for glossopharyngeal neuralgia.

Glossopharyngeal neuralgia is an uncommon cause of facial pain with a relative frequency of 0.2 to 1.3% when compared with trigeminal neuralgia. It is characterized by intermittent, lancinating pain involving the posterior tongue and pharynx, often with radiation to deep ear structures. Since its first description in 1910 by Weisenburg, a variety of destructive procedures have been performed to provide relief in patients whose pain was refractory to medical treatment. These procedures all necessitated the sacrifice of the glossopharyngeal nerve and, in most cases, also involved the destruction of at least part of the vagus nerve as well. In 1977, Laha and Jannetta reported good results in four patients who underwent microvascular decompression of the glossopharyngeal and vagus nerves for glossopharyngeal neuralgia. Since 1971, 40 patients have undergone microvascular decompression of the glossopharyngeal and vagus nerves for treatment of typical glossopharyngeal neuralgia. This procedure provided excellent immediate results (complete or > 95% relief of pain) in 79%, with an additional 10% having a substantial (> 50%) reduction in pain. Long-term follow-up (mean, 48 mo; range, 6-170 mo) reveals excellent results (complete or > 95% reduction in pain without any medication) in 76% of the patients and substantial improvement in an additional 16%. There were two deaths at surgery (5%) both occurring early in the series as the result of hemodynamic lability causing intracranial hemorrhage. Three patients (8%) suffered permanent 9th nerve palsy. (ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of blood velocity as measured by transcranial doppler ultrasonography to cerebral blood flow as determined by stable xenon computed tomographic studies after aneurysmal subarachnoid hemorrhage.

Transcranial doppler (TCD) ultrasonography is often used to guide the management of patients with subarachnoid hemorrhage (SAH). However, the correlation between increased blood velocity as measured by TCD ultrasonography and angiographic vasospasm was established before the routine use of hypervolemia/hemodilution and administration of nimodipine and did not address blood flow. The relationship of blood velocity as measured by TCD ultrasonography and local cerebral blood flow (LCBF) in SAH managed with these modalities is unknown. Patients presenting with aneurysmal SAH between January 1992 and September 1993 who underwent TCD ultrasonography and xenon computed tomographic (Xe/CT) LCBF studies within 12 hours were retrospectively studied. Fifty patients underwent a total of 94 paired studies, encompassing 709 vascular territories. All were treated with nimodipine and hypervolemia/hemodilution. Hematocrit, blood pressure, and partial carbon dioxide pressure were similar at the time of TCD ultrasonography and Xe/CT measurement of LCBF. When LCBF in the middle cerebral artery (MCA) was < or = 31 ml/100 g/min, the corresponding peak systolic velocity measured by TCD ultrasonography was 119 cm/s, whereas those > 31 ml/100 g/min had a velocity of 169 cm/s (P = 0.006). High LCBF was associated with high velocity in all vascular territories, reaching significance in all but the internal carotid artery. At the time of each study, 41 neurological examinations were focal and 53 were nonfocal. The Xe/CT measurement of LCBF in the MCA contralateral to a deficit was significantly less than in territories without corresponding clinical deficits (P = 0.01), whereas peak systolic velocities in the MCA were not significantly different (P = 0.71). Territories with increases in blood velocity in the MCA of > 50 cm/s/24 h did not have statistically different LCBF (P = 0.183). Our results suggest that increased blood velocity revealed by TCD ultrasonography correlates with increased LCBF and not with ischemia. No difference in LCBF was found in territories with and without rapid increases in blood velocity in the MCA. Furthermore, although focal neurological deficits corresponded with decreased contralateral LCBF in the MCA, increased velocity did not correlate with neurological findings. Therapeutic decisions based solely on blood velocity revealed by TCD ultrasonography might be inappropriate and potentially harmful. Xe/CT studies of LCBF are useful in guiding the management of SAH.

Isolated fractures of the atlas in adults.

STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: Treatment options in the management of isolated fractures of the atlas are based on the specific atlas fracture type. It is recommended that isolated fractures of the atlas with an intact transverse atlantal ligament be treated with cervical immobilization alone. It is recommended that isolated fractures of the atlas with disruption of the transverse atlantal ligament be treated with either cervical immobilization alone or surgical fixation and fusion.

Isolated fractures of the axis in adults.

UNLABELLED: FRACTURES OF THE ODONTOID: STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: Type II odontoid fractures in patients 50 years and older should be considered for surgical stabilization and fusion. OPTIONS: Type I, Type II, and Type III fractures may be managed initially with external cervical immobilization. Type II and Type III odontoid fractures should be considered for surgical fixation in cases of dens displacement of 5 mm or more, comminution of the odontoid fracture (Type IIA), and/or inability to achieve or maintain fracture alignment with external immobilization. TRAUMATIC SPONDYLOLISTHESIS OF THE AXIS (HANGMAN'S FRACTURE): STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: Traumatic spondylolisthesis of the axis may be managed initially with external immobilization in most cases. Surgical stabilization should be considered in cases of severe angulation of C2 on C3 (Francis Grade II and IV, Effendi Type II), disruption of the C2--C3 disc space (Francis Grade V, Effendi Type III), or inability to establish or maintain alignment with external immobilization. FRACTURES OF THE AXIS BODY (MISCELLANEOUS FRACTURES): STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: External immobilization is recommended for treatment of isolated fractures of the axis body.

Management of combination fractures of the atlas and axis in adults.

STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: Treatment of atlas-axis combination fractures based primarily on the specific characteristics of the axis fracture is recommended. External immobilization of most C1--C2 combination fractures is recommended. C1--Type II odontoid combination fractures with an atlantodens interval of 5 mm or more and C1--hangman's combination fractures with C2--C3 angulation of 11 degrees or more should be considered for surgical stabilization and fusion. In some cases, the surgical technique must be modified as a result of loss of the integrity of the ring of the atlas.

Os odontoideum.

STANDARDS: There is insufficient evidence to support diagnostic standards. GUIDELINES: There is insufficient evidence to support diagnostic guidelines. OPTIONS: Plain x-rays of the cervical spine (anteroposterior, open-mouth odontoid, and lateral) and plain dynamic lateral x-rays performed in flexion and extension are recommended. Tomography (computed or plain) and/or magnetic resonance imaging of the craniocervical junction may be considered. STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: Patients with os odontoideum, either with or without C1--C2 instability, who have neither symptoms nor neurological signs may be managed with clinical and radiographic surveillance. Patients with os odontoideum, particularly with neurological symptoms and/or signs, and C1--C2 instability may be managed with posterior C1--C2 internal fixation and fusion. Postoperative halo immobilization as an adjunct to posterior internal fixation and fusion is recommended unless successful C1--C2 transarticular screw fixation and fusion can be accomplished. Occipitocervical fusion with or without C1 laminectomy may be considered in patients with os odontoideum who have irreducible cervicomedullary compression and/or evidence of associated occipitoatlantal instability. Transoral decompression may be considered in patients with os odontoideum who have irreducible ventral cervicomedullary compression.

Treatment of subaxial cervical spinal injuries.

UNLABELLED: SUBAXIAL CERVICAL FACET DISLOCATION INJURIES: STANDARDS: There is insufficient evidence to recommend treatment standards. GUIDELINES: There is insufficient evidence to recommend treatment guidelines. OPTIONS: Closed or open reduction of subaxial cervical facet dislocation injuries is recommended. Treatment of subaxial cervical facet dislocation injuries with rigid external immobilization, anterior arthrodesis with plate fixation, or posterior arthrodesis with plate or rod or interlaminar clamp fixation is recommended. Treatment of subaxial cervical facet dislocation injuries with prolonged bedrest in traction is recommended if more contemporary treatment options are not available. SUBAXIAL CERVICAL INJURIES EXCLUDING FACET DISLOCATION INJURIES: STANDARDS: There is insufficient evidence to recommend treatment standards. GUIDELINES: There is insufficient evidence to recommend treatment guidelines. OPTIONS: Closed or open reduction of subluxations or displaced subaxial cervical spinal fractures is recommended. Treatment of subaxial cervical spinal injuries with external immobilization, anterior arthrodesis with plate fixation, or posterior arthrodesis with plate or rod fixation is recommended.

Management of acute central cervical spinal cord injuries.

STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: Intensive care unit (or other monitored setting) management of patients with acute central cervical spinal cord injuries, particularly patients with severe neurological deficits, is recommended. Medical management, including cardiac, hemodynamic, and respiratory monitoring, and maintenance of mean arterial blood pressure at 85 to 90 mmHg for the first week after injury to improve spinal cord perfusion is recommended. Early reduction of fracture-dislocation injuries is recommended. Surgical decompression of the compressed spinal cord, particularly if the compression is focal and anterior, is recommended.

Management of vertebral artery injuries after nonpenetrating cervical trauma.

STANDARDS: There is insufficient evidence to support diagnostic standards. GUIDELINES: There is insufficient evidence to support diagnostic guidelines. OPTIONS: Conventional angiography or magnetic resonance angiography is recommended for the diagnosis of vertebral artery injury after nonpenetrating cervical trauma in patients who have complete cervical spinal cord injuries, fracture through the foramen transversarium, facet dislocation, and/or vertebral subluxation. STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: Anticoagulation with intravenous heparin is recommended for patients with vertebral artery injury who have evidence of posterior circulation stroke. Either observation or treatment with anticoagulation in patients with vertebral artery injuries and evidence of posterior circulation ischemia is recommended. Observation in patients with vertebral artery injuries and no evidence of posterior circulation ischemia is recommended.

Cervical spine immobilization before admission to the hospital.

STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: All trauma patients with a cervical spinal column injury or with a mechanism of injury having the potential to cause cervical spine injury should be immobilized at the scene and during transport by using one of several available methods. A combination of a rigid cervical collar and supportive blocks on a backboard with straps is effective in limiting motion of the cervical spine and is recommended. The long-standing practice of attempted cervical spine immobilization using sandbags and tape alone is not recommended.

Transportation of patients with acute traumatic cervical spine injuries.

STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: Expeditious and careful transport of patients with acute cervical spine or spinal cord injuries is recommended, from the site of injury by the most appropriate mode of transportation available to the nearest capable definitive care medical facility.

Clinical assessment after acute cervical spinal cord injury.

UNLABELLED: NEUROLOGICAL EXAMINATION: STANDARDS: There is insufficient evidence to support neurological examination standards. GUIDELINES: There is insufficient evidence to support neurological examination guidelines. OPTIONS: The American Spinal Injury Association international standards for neurological and functional classification of spinal cord injury are recommended as the preferred neurological examination tool for clinicians involved in the assessment and care of patients with acute spinal cord injuries. FUNCTIONAL OUTCOME ASSESSMENT: STANDARDS: There is insufficient evidence to support functional outcome assessment standards. GUIDELINES: The Functional Independence Measure is recommended as the functional outcome assessment tool for clinicians involved in the assessment and care of patients with acute spinal cord injuries. OPTIONS: The modified Barthel index is recommended as a functional outcome assessment tool for clinicians involved in the assessment and care of patients with acute spinal cord injuries.

Radiographic assessment of the cervical spine in asymptomatic trauma patients.

STANDARDS: Radiographic assessment of the cervical spine is not recommended in trauma patients who are awake, alert, and not intoxicated, who are without neck pain or tenderness, and who do not have significant associated injuries that detract from their general evaluation.