Management of cervical spinal cord trauma.

Trauma victims with cervical spinal cord injuries should be managed by proper immobilization and immediate reduction of spinal cord fractures to anatomical alignment. Patients must be stabilized medically, and a thorough neurologic and radiographic evaluation must precede any surgical intervention. Treatment must be individualized and depends on the level and severity of injury. New pharmacotherapies under intensive investigation offer some hope of recovery of function to patients with spinal cord injuries. Recent clinical trials with methylprednisolone indicate that the sensory and motor outcome of patients subject to trauma with spinal cord injuries improved when they received high doses within 8 hr of injury. Clinical trials are being proposed with tirilizad, a member of a new family of drugs, the 21-aminosteroids. This agent, which may be even more effective than methylprednisolone, has none of the side effects associated with other steroids.

Synovial cysts of the lumbosacral spine: diagnosis by MR imaging.

Intraspinal synovial or ganglion cysts are uncommon lesions associated with degenerative lumbosacral spine disease. CT usually reveals cystic lesions adjacent to a facet joint, and they may show calcification. MR imaging of four surgically confirmed cases of intraspinal synovial cysts revealed subtle signal changes compared with CSF. Short TR/TE images showed the lesions to be slightly hyperintense in three cases and isointense in one case. Long TR/TE sequences revealed a hyperintense appearance in two cases and a hypointense appearance in the others. A peripheral rim of decreased signal on long TR/TE images probably reflects fine calcification or hemorrhage in the margins of the cysts. The multiplanar and contrast characteristics of MR make this technique well suited to the diagnosis of herniated disk, degenerative facet disease, and synovial cyst.

Management of bilateral locked facets of the cervical spine.

The management of 15 cases of bilateral locked facets of the cervical spine is reviewed. The C-6, C-7 interspace was the most common interspace involved. There were 4 females and 11 males who were 16 to 63 years old (average, 26 years). Thirteen patients had a complete spinal cord lesion with loss of function below the level of the locked facets. Two had intact dorsal column function. One patient had an ascending spinal cord deficit, which did not change after open reduction. The remainder had no change in spinal cord function after reduction. However, after reduction, 1 patient had a transient root deficit and 2 patients improved in the function of the involved roots. Closed reduction was accomplished by (a) skeletal traction and weight application, (b) manual reduction under sedatives, or (c) manual reduction under general anesthesia. Five patients required open reduction. The failure of closed reduction was attributed to accompanying fractures of one of the facets in 2 cases, increasing neurological deficits during traction in 2 cases, and associated higher cervical fractures in 1 case. Internal stabilization with wire and bone or external stabilization with a halo vest or a brace was used. Twelve patients were followed for 1 1/2 to 7 years (average, 2.7 years). Stabilization after reduction was successful irrespective of the methods used. The various methods of reduction and stabilization are reviewed and discussed.

Delayed cerebral vasospasm after uncomplicated operation on an unruptured aneurysm: case report.

We present the case of a patient who developed significant vasospasm on the 9th postoperative day after the uneventful clipping of an unruptured asymptomatic berry aneurysm. We discuss the literature and potential mechanisms for vasospasm in the absence of subarachnoid hemorrhage.

Posterior C1-C2 transarticular screw fixation for atlantoaxial arthrodesis.

OBJECTIVE: To assess the outcomes associated with C1-C2 transarticular screw fixation. METHODS: The clinical outcomes of 121 patients treated with posterior C1-C2 transarticular screws and wired posterior C1-C2 autologous bone struts were evaluated prospectively. Atlantoaxial instability was caused by rheumatoid arthritis in 48 patients, C1 or C2 fractures in 45, transverse ligament disruption in 11, os odontoideum in 9, tumors in 6, and infection in 2. RESULTS: Altogether, 226 screws were placed under lateral fluoroscopic guidance. Bilateral C1-C2 screws were placed in 105 patients; each of 16 patients had only one screw placed because of an anomalous vertebral artery (n = 13) or other pathological abnormality. Postoperatively, each patient underwent radiography and computed tomography to assess the position of the screw and healing. Most screws (221 screws, 98%) were positioned satisfactorily. Five screws were malpositioned (2%), but none were associated with clinical sequelae. Four malpositioned screws were reoperated on (one was repositioned, and three were removed). No patients had neurological complications, strokes, or transient ischemic attacks. Long-term follow-up (mean, 22 mo) of 114 patients demonstrated a 98% fusion rate. Two nonunions (2%) required occipitocervical fixation. In comparison, our C1-C2 fixations with wires and autograft (n = 74) had an 86% union rate. CONCLUSION: Rigidly fixating C1-C2 instability with transarticular screws was associated with a significantly higher fusion rate than that achieved using wired grafts alone. The risk of screw malpositioning and catastrophic vascular or neural injury is small and can be minimized by assessing the position of the foramen transversaria on preoperative computed tomographic scans and by using intraoperative fluoroscopy and frameless stereotaxy to guide the screw trajectory.

Intracerebral Ewing's sarcoma: case report.

A case of intracerebral Ewing's sarcoma is reported. Neurosurgical intervention was required for treatment. The increasing incidence of central nervous system involvement by Ewing's sarcoma is discussed.

Axis fractures: a comprehensive review of management and treatment in 107 cases.

The combination of movement, location, and anatomy of the axis predisposes it to multiple and varied fracture/dislocations distinct from other vertebrae. We examine all forms of axis fractures and address the appropriate treatment for each specific fracture type. In a retrospective review of 625 cervical spine fractures during an 8-year period, we found 107 axis fractures. There were 25 hangman's fractures (23%), 59 odontoid fractures (55%), and 23 miscellaneous fractures (22%). Each case was characterized by age, sex, the presence of associated injuries, presenting symptoms and findings, initial treatment, and results of that treatment. Excluding 6 early deaths, 90 of 101 patients were located for a median follow-up of 3.2 years. We found that 17% of cervical fractures involve the axis. Axis fractures have a high association with head and other cervical spine injuries, 40% and 18%, respectively. Few neurological deficits result from a fracture of the 2nd cervical vertebra. Hangman's fractures are effectively treated with external stabilization, preferably with a halo vest. We noted a shorter period of treatment using the halo vest as compared to the SOMI brace. Nonunion occurred in 26% of odontoid Type II fractures, but occurred in 67% of those with dens displacement of 6 mm or greater, regardless of age or direction of dislocation. We recommend early surgical therapy for this subgroup. There is no correlation between age and the rate of nonunion. In patients with odontoid Type II fractures with dens displacement of 0 to 5 mm, fusion occurs with external stabilization alone. Odontoid Type III fractures are one-half as common as Type II fractures, and all heal well with external stabilization. Twenty-two per cent of acute axis fractures are not hangman's or odontoid fractures. Miscellaneous fractures of the axis generally do well with external stabilization and immobilization.

Outcome analysis in 654 surgically treated lumbar disc herniations.

This article reports the outcomes of 654 consecutive patients treated during a 4.5-year period. Patients had a microdiscectomy, a laminectomy plus microdiscectomy, or a decompressive laminectomy with a microdiscectomy. The causes of ruptured discs were lifting (31.4%), falls (10.2%), and sports (10.0%). Almost all patients had complained of leg pain (99%), and 79% had radicular pain in a dermatomal distribution. Thirty-three percent of the patients had been involved in industrial accidents, and 6% had legal claims pending during the surgical period. Almost 11% of the patients had complications, and there was one death caused by abdominal arterial bleeding. Patients were also rated according to the Prolo Functional-Economic Outcome Rating Scale to improve the ability to compare series in the future. Almost 80% of the patients had good outcomes as defined by scores on this scale of 8 (16.2%), 9 (33.2%), and 10 (26.9%). Several conclusions can be drawn from the results of this series: 1) most patients had good outcomes; 2) patients with nonindustrial injuries had better outcomes than did patients with industrial injuries; 3) professionals with legal concerns and laborers with industrial insurance had good outcomes; and 4) the Functional-Economic Outcome Rating Scale appears to be a useful tool for comparing different procedures more objectively and for comparing the outcomes across series.

Amyloidoma of the cervical spine: a case report.

This is the first published report of an amyloidoma localized to the cervical spine. Primary amyloidosis of bone is rare. Only 5 cases involving the spine have been described. We present a 74-year-old man with cervical and occipital radicular pain as the manifestations of an amyloidoma involving the 2nd cervical vertebra. The signs and symptoms of this disease, when localized to the vertebrae, are nonspecific and result from bony destruction and compression of neural structures. Diagnosis requires a high index of suspicion and, ultimately, adequate tissue biopsy for histopathological studies. Curative resection is possible for well-localized lesions. Additionally, external immobilization with a halo vest and bony grafting for fusion may be indicated when the cervical spine is involved.

Anatomical study of the superficial temporal artery.

Fifty consecutive human autopsy specimens were studied to determine the suitability of the superficial temporal artery (STA) for use in microvascular anastomoses. Ten variations of the STA were found. The STA at the zygoma averaged 2.2 mm in outside diameter. The STA averaged 31.7 mm from the zygoma to its bifurcation, where the average outside diameter was 1.9 mm. Eight per cent of the specimens had no bifurcation, and 92% had at least one branch in a frontal or parietal distribution that was greater than or equal to 1 mm. A suitable frontal branch (i.e., greater than or equal to 1 mm in diameter and greater than or equal to 70 mm in length) was found in 90% of the specimens, and a suitable parietal branch was found in 71%. Six specimens (12%) had an additional branch, all of which were of suitable length and diameter. Eight per cent of the specimens lacked a vessel suitable for microvascular anastomosis.

The infant whiplash-shake injury syndrome: a clinical and pathological study.

The cases of 13 infants (median age, 3 months) who sustained nonaccidental trauma were reviewed. All presented with profound neurological impairment, seizures, retinal hemorrhages, and intracranial subarachnoid and/or subdural hemorrhages. Of 8 infants who died, autopsy was performed on 6. No patient had a skull fracture, and only one had an extracalvarial contusion. Five of the 6 patients on whom autopsy was performed had injuries at the cervicomedullary junction consisting of sub- or epidural hematomas of the cervical spinal cord with proximal spinal cord contusions. The authors conclude that direct cranial trauma is not an essential element of the injury mechanism in young patients who sustain severe whiplash-shake injuries. In addition to the classic injuries reported to occur with the shaken-baby syndrome, hemorrhages and contusions of the high cervical spinal cord may contribute to morbidity and mortality.

Bilateral upper extremity paralysis (Bell's cruciate paralysis) from a gunshot wound to the cervicomedullary junction.

Cruciate paralysis is characterized by midline involvement of the rostral portion of the pyramidal decussation, resulting in paralysis of the upper extremity without lower extremity involvement. The neuroanatomical basis is the more rostral and medial decussation of the upper extremity motor fibers in the medulla compared with the more caudal and lateral decussating fibers of the lower extremity at the lower boundary of the cervicomedullary junction. We believe this to be the first reported case of Bell's cruciate paralysis caused by a gunshot wound to this region. The neuroanatomical basis and the mechanisms that produce this unique clinical entity are discussed.

Caspar plate fixation for the treatment of complex hangman's fractures.

This report details our recent experience with the surgical treatment of complex hangman's fractures after failure of closed reduction and immobilization in external orthosis. We have successfully treated hangman's fractures in 5 patients with anterior Caspar plate stabilization and C2-C3 interbody fusion. The specific anatomical features of these fractures were complex, rendering the spines of the patients highly unstable. The patients were considered surgical candidates when reduction could not be achieved or maintained with axial traction or halo immobilization. Each patient underwent anterior C2-C3 interbody bone fusion and Caspar plating from C2 to C3. All patients achieved adequate intraoperative reduction and were immobilized postoperatively with a halo vest. The follow-up period ranged from 3 to 28 months and provided a 100% fusion rate with no complications related to plating or nonunion. Our initial experience indicates that anterior C2-C3 interbody bone fusion and Caspar plate fixation is a suitable treatment option for patients with complex hangman's fractures who are not successfully managed nonoperatively.

Neurosurgery at the Barrow Neurological Institute.

Neurosurgery at the Barrow Neurological Institute exists within the unique context of this nonuniversity-based center. The institute, a relative newcomer to academic medicine, opened in Phoenix in 1961 under the leadership of John Raymond Green, M.D., who remained its medical director until his retirement at the end of 1985. Since then, the institute has experienced a dynamic growth phase in its clinical and academic arenas. This article describes how the development of the institute has shaped the program in neurosurgery and vice versa.

Injuries involving the transverse atlantal ligament: classification and treatment guidelines based upon experience with 39 injuries.

Comprehensive anatomic and clinical analyses of 39 patients with injuries involving the transverse atlantal ligament or its osseous insertions were performed to assess the morphology of the injured ligaments and the patients' capacity to heal. Injuries of the upper cervical spine were screened with plain radiographs, thin-section computed tomography, and magnetic resonance imaging studies. The injuries were classified as disruptions of the substance of the ligament (Type I injuries, n = 16) or as fractures and avulsions involving the tubercle for insertion of the transverse ligament on the C1 lateral mass (Type II injuries, n = 23). These two types of injuries had distinctly different clinical characteristics that were useful for determining treatment. Type I injuries were incapable of healing satisfactorily without internal fixation; they should be treated with early surgery. Type II injuries, which rendered the transverse ligament physiologically incompetent even though the ligament substance was not torn, should be treated initially with a rigid cervical orthosis, because they had a 74% success rate nonoperatively. Surgery should be reserved for patients with Type II injuries that have nonunion with persistent instability after 3 to 4 months of immobilization. Type II injuries had a 26% rate of failure of immobilization; therefore, close monitoring is needed to detect patients who will require delayed operative intervention.

Planum sphenoidale meningioma mimicking pituitary apoplexy: a case report.

A patient with a planum sphenoidale meningioma mimicking a classic case of pituitary apoplexy is presented. A review of the apoplectiform onset of meningiomas is included.

Traumatic atlantooccipital dislocation with survival.

Survival after traumatic atlantooccipital dislocation is rare. Only long-term survivors have been reported in the literature; however, improved prehospital care is likely responsible for the increase in the number of these patients seen at neurotrauma centers over the last decade. Associated severe and persistent neurological deficits are common in the few survivors. We report the case of a 10-year-old boy with traumatic atlantooccipital dislocation and a severe neurological injury. Low-field magnetic resonance imaging provided the additional diagnosis of an associated cervicomedullary epidural hematoma. The patient underwent emergency operative evacuation of the hematoma and an occipital-cervical fusion with internal fixation. He had a remarkable recovery in neurological function and achieved stable bony fusion 3 months postoperatively. With early recognition of this entity, improved neuroradiological imaging techniques, and aggressive treatment, patients may survive with significant neurological recovery.

Acute traumatic atlas fractures: management and long term outcome.

Fractures of the 1st cervical vertebra (C1) represent 7% of all acute cervical spine fractures. Isolated atlas fractures are most commonly bilateral or multiple fractures through the ring of C1. Frequently (44% of cases), the atlas will be fractured in combination with the axis. Treatment of isolated C1 fractures should be governed by the rules of Spence. The treatment of combination C1-C2 fractures is dictated by the type and severity of the C2 fracture. Experience with 57 cases of acute atlas fractures is reviewed. Nonoperative external immobilization was used in 53 patients (with 1 failure), and early surgical wiring and fusion were performed in 4 patients. The long term outcome from an atlas fracture is good (median follow-up, 40 months).

Comparative transoral dural closure techniques: a canine model.

A watertight dural closure is difficult to achieve after transoral-transclival operation for ventral intradural lesions at the craniocervical junction. These procedures have a high morbidity and mortality from cerebrospinal fluid (CSF) fistula, meningitis, and abscess. We used a canine model to test three different techniques of dural closure after transoral intradural operation: primary suture closure, laser patch weld, and fibrin glue patch closures. The primary suture closure technique was inadequate. All eight leaked CSF at the time of operation, and five had radiographic leaks and were incompetent at autopsy. All seven of the laser closures leaked CSF at operation, yet only one was incompetent at autopsy. The fibrin glue technique was superior and provided a solid seal at operation, even with repeated Valsalva maneuvers to 40 mm Hg. The immediate and persistent seal at operation is clinically significant because it may prevent CSF leak, meningitis, and abscess formation in human patients after transoral surgery. Fibrin glue is excellent for repairing complex dural defects and merits evaluation in clinical trials.

New subtype of acute odontoid fractures (type IIA).

A new subtype of axis fracture, thought to be a variant of the Type II odontoid fracture, is described. High resolution, thin section computed tomography can assist in the identification of comminuted fractures at the base of the dens with associated free fracture fragments. Because these injuries are markedly unstable and cannot be suitably realigned and reduced by external means, early surgical therapy should be considered.