Radiographic analysis of type II odontoid fractures in a geriatric patient population: description and pathomechanism of the "Geier"-deformity.

INTRODUCTION: Type II odontoid fractures are one among the most common cervical spine fractures in the elders. We reviewed a consecutive series of patients, aged 65 years and older, presenting to our institution with type II odontoid fractures. Our analysis focused on the radiographic outcome, union rate and the development of cervical spine postural deformity. PATIENTS/METHODS: Indications for surgical treatment (OP) included displaced or unstable injuries. Stable, non-displaced injuries or patients with significant co-morbidities were treated nonoperatively (non-op). RESULTS: Ninety patients (50 f, 40 m) with an average age of 83 years (65-101) were identified. 31 (34.4%) patients were received OP and 57 (63.3%) were received non-op treatments. The hospital length of stay was significantly longer after OP (mean 10 days vs. 6 days non-op) treatment (p = 0.007). At follow-up, higher union rates were noted in the OP (76.2%) than in the non-op group (58.3%). CONCLUSION: We observed a characteristic cervical spine deformity in geriatric patients with type II odontoid fractures, and have termed this the "Geier-deformity". Clinical findings of the deformity include sagittal imbalance and kyphosis of the lower cervical spine.

Referral indications and prevalence of sleep abnormalities in children with early onset scoliosis.

This study describes the utility of overnight sleep studies in children with early onset scoliosis (EOS). Children with EOS have diminished respiratory reserve which is associated with abnormal breathing and sleep quality in children. Currently, there are no criteria for referral of these children to evaluate breathing during sleep or data on the use of sleep treatments as part of their supportive care. A review of the 159 patients with EOS who were followed at a single institution from 2003 to 2016 identified 68 who underwent overnight polysomnograms (PSGs). Sixty-five of 68 (96%) had elevated apnea-hypopnea index (AHI) and a majority (56%) were prescribed nighttime respiratory support. A majority of young children (< 5 years) with PSG were referred for a history of snoring, apnea, or restless sleep; all 30 had abnormal PSGs. Twenty-seven (90%) had nighttime hypoxemia (nadir oxygen saturation values < 92%). Eighteen (60%) were referred to otolaryngology, of whom 11 (37%) subsequently underwent tonsil and/or adenoid removal. In older children (≥ 5 years), those referred for PSGs had more severe restrictive chest wall disease [lower forced vital capacity (FVC) values] than those who were not sent for PSG. Correlation between FVC and apnea-hypopnea index, however, was not significant. Pre-operative coronal curve magnitude did not strongly correlate with nadir SaO2 or AHI in either age group. These results suggest that sleep studies are underutilized in the management of children with EOS. Inadequate and poor-quality sleep adversely affects growth, behavior, and cognitive function in children. This study suggests that screening for sleep abnormalities should be incorporated into assessment and treatment of more patients with EOS.

Early stabilization and decompression for incomplete paraplegia due to a thoracic-level spinal cord injury.

All patients treated between 1985 and 1990 for acute incomplete spinal cord injury between T2 and T11 were retrospectively studied. This level was chosen for study because by excluding cervical cord, conus, and cauda equina injuries, neurologic improvement could be attributed to improvement of spinal cord function. Only 14 patients with incomplete thoracic level paraplegia were identified, representing 1.2% of all spinal injuries. All 14 patients were treated by early operative reduction, stabilization, or decompression. Twelve patients had surgery within 24 hours of neurologic injury, one at 36 hours, and one at 5 days. Twelve patients had initial posterior instrumentation and fusion, one of whom subsequently had an anterior decompression. Two patients had initial anterior decompression and fusion. Both later had posterior instrumentation and fusion to treat progressive deformity. Follow-up averaged 20 months (range, 9-65 months). Neural function before surgery and at follow-up was given a Frankel grade and lower extremity motor index score. Of 13 surviving patients, seven were initially Frankel B and six Frankel C. Of the seven patients initially Frankel B, four recovered to Frankel E, two improved to Frankel D, and one remained Frankel B. Of the six patients originally Frankel C, five recovered to Frankel E and one improved to Frankel D. Average neurologic improvement was 2.2 Frankel grades per patient, lower extremity motor index improved from an average of 7 to 44. Early surgical reduction, stabilization, and decompression is safe and improves neurologic recovery in comparison to historical controls treated by postural reduction or late surgical intervention.

Combined effects of compression and hypotension on nerve root function. A clinical case.

Previous animal experiments suggest that mild compression may increase susceptibility of nerve roots to the effects of hypotension. The authors report the case of a patient with an unstable L2 burst fracture whose motor skills and senses were intact. During fracture reduction and spinal distraction, sensory-evoked potentials were recorded from the epidural space after right and left femoral and tibial nerve stimulation. Induced hypotension was used during the surgery. All responses were normal at the outset of the surgery. With hypotension, a marked drop in the amplitude of the right femoral evoked potential amplitude occurred; left femoral and both tibial responses remained unchanged. Evoked potential changes were reversible with reversal of hypotension. Postoperatively, the patient was neurologically intact. Further analysis revealed a significant correlation between the right femoral evoked potential amplitude and systolic blood pressure (r = 0.63, P < 0.005), whereas amplitudes of the other responses were not significantly correlated with systolic blood pressure. This report provides clinical evidence to support the hypothesis that hypotension and local compression exert additive adverse effects on nerve root function.

Comparison of same-day sequential anterior and posterior spinal fusion with delayed two-stage anterior and posterior spinal fusion.

STUDY DESIGN: This was a retrospective review. Short-term outcomes were compared based on two different surgical techniques. OBJECTIVES: To determine the safety, efficacy, and cost effectiveness of two different surgical techniques of anterior and posterior spinal fusion for pediatric patients with spinal deformity. SUMMARY OF BACKGROUND DATA: Brown et al, Floman et al, and Bradford et al have reported on combined anterior and posterior spine fusions with a 1-2-week recovery period between stages. However, advances in surgical and anesthetic techniques combined with the prohibitive cost of prolonged hospitalization and theoretical advantages in pulmonary function and nutrition have led to increasing use of combined anterior and posterior spinal fusion under one anesthetic. METHODS: The authors reviewed records and radiographs of patients with pediatric spinal deformities who underwent anterior spine fusion/posterior spine fusion and instrumentation performed by the senior author (HAK) at one institution. RESULTS: Same-day sequential anterior spine fusion/posterior spine fusion resulted in less blood loss (575 +/- 275 ml; P < or = 0.0045), shorter hospital stay (8.00 +/- 2.68 days; P < or = 0.0001), and reduced hospital costs ($18,762 +/- $4,925; P < or = 0.0001). Operative time and complication rate were not affected. CONCLUSIONS: In selected patients with pediatric spinal deformity, experienced spinal surgeons can reduce blood loss, hospital stay, and costs by performing anterior and posterior spinal fusions sequentially under one anesthetic.

Tibial rotational osteotomy for idiopathic torsion. A comparison of the proximal and distal osteotomy levels.

A retrospective analysis was done of 52 rotational tibial osteotomies (RTOs) performed on 35 patients with severe idiopathic tibial torsion. Thirty-nine osteotomies were performed at the proximal or midtibial level. Thirteen were performed at the distal tibial level with a technique previously described by one of the authors. Serious complications occurred in five (13%) of the proximal and in none of the distal RTOs. For severe and persisting idiopathic tibial torsion, the authors recommend correction by RTO at the distal level. Proximal level osteotomy is indicated only when a varus or valgus deformity required concurrent correction.

Early versus delayed surgery for acute cervical spinal cord injury.

The optimal timing of surgical intervention in cervical spinal cord injuries has not been defined. The goals of the study were to investigate changes in neurologic status, length of hospitalization, and acute complications associated with surgery within 3 days of injury versus surgery more than 3 days after the injury. All patients undergoing surgical treatment for an acute cervical spinal injury with neurologic deficit at two institutions between March 1989 and May 1991 were reviewed retrospectively. Forty-three patients initially were evaluated. At one institution, patients with neurologic spinal injuries had surgical intervention within 72 hours of injury. At the other institution, patients underwent immediate closed reduction with subsequent observation of neurologic status for 10 to 14 days before undergoing surgical stabilization. This study indicates that patients who sustain acute traumatic injuries of the cervical spine with associated neurologic deficit may benefit from surgical decompression and stabilization within 72 hours of injury. Surgery within 72 hours of injury in patients sustaining acute cervical spinal injuries with neurologic involvement is not associated with a higher complication rate. Early surgery may improve neurologic recovery and decrease hospitalization time in patients with cervical spinal cord injuries.