Contusion of the cervical spinal cord following dental treatment of a patient at risk to stroke: A case report.

OBJECTIVES: It is essential that especially elderly patients are correctly positioned in dental chairs, based on medical history and careful observation. METHOD: We report a case where reclination of the patient's head resulted in weakness of the limbs. RESULTS: Subsequent investigation determined traumatic contusion of the cervical spinal cord. CONCLUSIONS: This case highlights the need for accurate anamnesis, close observation and interdisciplinary communication to determine correct positioning. Exceptional circumstances necessitate speedy response to minimise adverse events in elderly patients.

Endoscopic treatment of vesicoureteral reflux with non-simultaneous involuntary detrusor contraction in chronic spinal cord injury patients with neurogenic detrusor overactivity.

OBJECTIVE: To analyze whether it is correct to use endoscopic treatment via bulking agents of vesicoureteral reflux (VUR) seen on video urodynamics with non-simultaneous involuntary detrusor contraction in chronic spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO). METHODS: A retrospective study was performed with a cohort of 76 patients (age 48.9 ± 14.4 years) (mean ± standard deviation) of both sexes with chronic SCI who underwent endoscopic treatment of VUR during the years 2008 to 2011. Patients were subjected to clinical examinations and video urodynamic studies preoperatively and 22 ± 11.4 months after the intervention. RESULTS: Resolution of VUR was achieved in 46 cases (61%). Cured patients had a statistically significant younger age and showed stress urinary incontinence more frequently. On the contrary, a greater grade of VUR, presence of bilateral reflux and presence of NDO were positively associated with treatment failure. The variables that independently influenced the cure of the reflux were NDO and reflux grade. CONCLUSIONS: The failure rate was high in patients with NDO, even though the reflux was not synchronous with involuntary detrusor contraction, and therefore these patients should have NDO eradicated before doing any anti-reflux procedures.

Current concepts in cervical spine trauma.

Much has been written about cervical spine trauma. Although occipitocervical dislocations result in high mortality rates at the scene of the injury, more patients are surviving this injury as a result of safety improvements. Injuries to this region of the spine are often undiagnosed, even by experienced spine surgeons and radiologists. Substantial controversy and debate remain surrounding cervical spinal clearance, spinal cord injury, odontoid fractures, traumatic spondylolisthesis of C2 on C3, and subaxial cervical spine facet subluxations and dislocations. Although debate regarding appropriate treatment algorithms for these injuries still exists, management recommendations based on the available evidence will be helpful to the treating surgeon.

Upper cervical injuries - a rational approach to guide surgical management.

CONTEXT: The complex anatomy and the importance of ligaments in providing stability at the upper cervical spine region (O-C1-C2) require the use of many imaging modalities to evaluate upper cervical injuries (UCI). While separate classifications have been developed for distinct injuries, a more practical treatment algorithm can be derived from the injury pattern in UCI. OBJECTIVE: To propose a practical treatment algorithm to guide treatment based on injuries characteristic of UCI. METHODS: A literature review was performed on the Pubmed database using the following keywords: (1) "occipital condyle injury"; (2) "craniocervical dislocation or atlanto-occipital dislocation or craniocervical dislocation"; (3) "atlas fractures"; and (4) "axis fractures". Just articles containing the diagnosis, classification, and treatment of specific UCI were included. The data obtained were analyzed by the authors, dividing the UCI into two groups: Group 1 - patients with clear ligamentous injury and Group 2 - patients with fractures without ligament disruption. RESULTS: Injuries with ligamentous disruption, suggesting surgical treatment, include: atlanto-occipital dislocation, mid-substance transverse ligament injury, and C1-2 and C2-3 ligamentous injuries. In contrast, condyle, atlas, and axis fractures without significant displacement/misalignment can be initially treated using external orthoses. Odontoid fractures with risk factors for non-union are an exception in Group 2 once they are better treated surgically. Patients with neurological deficits may have more unstable injuries. CONCLUSIONS: Ascertaining the status of relevant ligamentous structures, fracture patterns and alignment are important in determining surgical compared with non-surgical treatment for patients with UCI.

[Odontoid fracture after high impact trauma : Assess instability correctly]. / Densfraktur nach Hochrasanztrauma : Instabilität richtig einschätzen.

Odontoid process fractures are frequent injuries of the cervical spine and usually occur at an advanced age and often due to minor trauma. In younger patients they are mainly observed in the context of high impact trauma. Odontoid fractures are classified according to Anderson and D'Alonzo. In rare cases the fracture results in cervical myelopathy, which can be life-threatening.In this article, two cases of patients with odontoid fractures and traumatic myelopathy are presented. The first case concerns a type III fracture, the second a type II fracture. In both cases the instability present was incorrectly assessed on the basis of the anatomical position in the initial computed tomography (CT). In the further course both cases showed considerable instability, which led to fatal spinal cord injuries.The purpose of this case report is to draw attention to the possible presence of spinal cord injuries in supposedly trivial odontoid fractures when high speed trauma has occurred. In particular, spinal cord compression should be considered in patients requiring resuscitation without having an internal medical cause. If the patient with a bone injury on CT, e.g. cannot be adequately assessed clinically by intubation, the indications for magnetic resonance imaging must be generously considered. This is the only way to ensure early detection of a myelopathy and timely treatment.

Os odontoideum: presentation, diagnosis, and treatment in a series of 78 patients.

OBJECT: The most contentious issue in the management of os odontoideum surrounds the decision to attempt atlantoaxial fusion in patients with asymptomatic lesions. The authors examined the clinical presentation and outcome in patients with os odontoideum who underwent surgical stabilization, with an emphasis on 3 patients who initially received conservative treatment and suffered delayed neurological injury. METHODS: Seventy-eight patients (mean age 20.5 years; median 15 years) were identified in a 17-year retrospective review. The median follow-up period was 14 months (range 1-115 months). Neck pain was the most common symptom (64%), and 56% of patients presented after traumatic injury. Eighteen patients had neurological signs or symptoms at presentation, and an additional 15 had a history of intermittent or prior neurological symptoms. Fifteen patients had undergone > or = 1 attempt at atlantoaxial fusion elsewhere. RESULTS: Seventy-seven patients underwent posterior fusion and rigid screw fixation combined with a graft/wire construct: 75 had C1-2 fusion and 2 had occipitocervical fusion. One patient had an odontoid screw placed. Fusion was achieved in all patients at a median of 4.8 months (range 2-17 months). Approximately 90% of patients had resolution or improvement of their neck pain or neurological symptoms. CONCLUSIONS: The authors believe that patients with os odontoideum are at risk for future spinal cord compromise. Forty-four percent of our patients had myelopathic symptoms at referral, and 3 had significant neurological deterioration when a known os odontoideum was left untreated. This risk of late neurological deterioration should be considered when counseling patients. Stabilization using internal screw fixation techniques resulted in 100% fusion, whereas 15% of patients had previously undergone unsuccessful wire and external bracing attempts.

[Postnatal differential diagnosis of combined birth injury in newborn infants].

Constructional defects of skull base synchondroses related to a fatal birth injury result only from bottom-upwards pressure of the vertebral column and always combine with a crack or displaced fracture of the sapheno-occipital suture. A postnatal injury having the form of occipital synchondrosis fracture occurs in case of a local impact on the cervico-occipital region and is not associated with a shear strain of lateral synchondrosis and any damage to the sapheno-occipital suture. The spinal birth injury is due to the axial load on the vertebrae in combination with excessive bending and rotation. The postnatal spinal trauma results from neck compression and closure of the mouth and nose openings. It can be either flexural or extensive with a rotational component or without it; in any case, it shows no signs of axial load on the vertebrae. In case of a postnatal combined craniospinal injury in a newborn infant, unlike birth trauma, there are no constructive shear strains with the rupture of lateral synchondroses of the major portion of the occipital bone and synchondrosis between the main part of the occipital bone and the sphenoid bone.

Brown-Sequard syndrome caused by hyperextension in a patient with atlantoaxial subluxation due to an os odontoideum.

Brown-Sequard syndrome is an uncommon complication of atlantoaxial arthrodesis. A 50-year-old female visited our emergency department after falling from a ladder. Radiologic evaluations revealed chronic C1-2 instability with acute spinal cord injury. The day after atlantoaxial fusion was performed, she developed left-sided motor weakness and the loss of right-sided pain and temperature sensation. Based on physical examination and radiologic findings, we diagnosed her as having Brown-Sequard syndrome. Spine surgeons performing this procedure should therefore consider Brown-Sequard syndrome if a patient displays signs of postoperative hemiplegia.

On-field issues of the C-spine-injured helmeted athlete.

Football is a violent collision sport and can lead to various serious injuries. Cervical spine injuries are numerous, ranging from bony fractures and dislocations to spinal cord disruption. These injuries can be a devastating and debilitating. Although most injuries that occur are self-limiting there is a significant proportion that can cause permanent disability. Due to the equipment used in football, unique on-field care is implemented in evaluating athletes with possible cervical spine injury. Early preseason preparation and proper on-field intervention can help improve outcomes for these athletes.

Limitations in transplantation of astroglia-biomatrix bridges to stimulate corticospinal axon regrowth across large spinal lesion gaps.

Regrowth of injured axons across rather small spinal cord lesion gaps and subsequent functional recovery has been obtained after many interventions. Long-distance regeneration of injured axons across clinically relevant large spinal lesion gaps is relatively unexplored. Here, we aimed at stimulating long-distance regrowth of the injured corticospinal (CS) tract. During development, an oriented framework of immature astrocytes is important for correct CS axon outgrowth. Furthermore, a continuous growth promoting substrate may be needed to maintain a CS axon regrowth response across relatively large spinal lesion gaps. Hence, we acutely transplanted poly(D,L)-lactide matrices, which after seeded with immature astrocytes render aligned astrocyte-biomatrix complexes (R. Deumens, et al. Alignment of glial cells stimulates directional neurite growth of CNS neurons in vitro. Neuroscience 125 (3) (2004) 591-604), into 2-mm long dorsal hemisection lesion gaps. In order to create a growth promoting continuum, astrocyte suspensions were also injected rostral and caudal to the lesion gap. During 2 months, locomotion was continuously monitored. Histological analysis showed that astrocytes injected into host spinal tissue survived, but did not migrate. None of the astrocytes on the biomatrices survived within the lesion gap. BDA-labeled CS axons did not penetrate the graft. However, directly rostral to the lesion gap, 120.9+/-38.5% of the BDA-labeled CS axons were present in contrast to 12.8+/-3.9% in untreated control animals. The observed anatomical changes were not accompanied by locomotor improvements as analyzed with the BBB and CatWalk. We conclude that although multifactorial strategies may be needed to stimulate long-distance CS axon regrowth, future studies should focus on enhancing the viability of cell/biomatrix complexes within large spinal lesion gaps.

Acute disposition of neck injuries.

Neck injuries can be some of the most serious and anxiety-producing injuries that occur during sporting events. It is important for the team physician to be prepared for the care of these injuries and be able to identify some of the more serious injuries. Proper care of these injuries can be life saving and prevent further injury and permanent disability. This article reviews the principles of management and latest evidence for acute neck injuries.

Freeze-dried poly(D,L-lactic acid) macroporous guidance scaffolds impregnated with brain-derived neurotrophic factor in the transected adult rat thoracic spinal cord.

The effects of poly(D,L-lactic acid) macroporous guidance scaffolds (foams) with or without brain-derived neurotrophic factor (BDNF) on tissue sparing, neuronal survival, axonal regeneration, and behavioral improvements of the hindlimbs following implantation in the transected adult rat thoracic spinal cord were studied. The foams were embedded in fibrin glue containing acidic-fibroblast growth factor. One group of animals received fibrin glue with acidic-fibroblast growth factor only. The foams were prepared by a thermally induced polymer-solvent phase separation process and contained longitudinally oriented macropores connected to each other by a network of micropores. Both foams and fibrin only resulted in a similar gliotic and inflammatory response in the cord-implant interfaces. With BDNF foam, up to 20% more NeuN-positive cells in the spinal nervous tissue close to the rostral but not caudal spinal cord-implant interface survived than with control foam or fibrin only at 4 and 8 weeks after implantation. Semithin plastic sections and electron microcopy revealed that cells and axons more rapidly invaded BDNF foam than control foam. Also, BDNF foam contained almost twice as many blood vessels than control foam at 8 weeks after implantation. Tissue sparing was similar in all three implantation paradigms; approximately 42% of tissue was spared in the rostral cord and approximately 37% in the caudal cord at 8 weeks post grafting. The number of myelinated and unmyelinated axons was low and not different between the two types of foams. Many more axons were found in the fibrin only graft. Serotonergic axons were not found in any of the implants and none of the axons regenerated into the caudal spinal cord. The behavioral improvements in the hindlimbs were similar in all groups. These findings indicated that foam is well tolerated within the injured spinal cord and that the addition of BDNF promotes cell survival and angiogenesis. However, the overall axonal regeneration response is low. Future research should explore the use of poly(D,L-lactic acid) foams, with or without axonal growth-promoting factors, seeded with Schwann cells to enhance the axonal regeneration and myelination response.

Use of titanium wire in cervical spine fixation as a means to reduce MR artifacts.

MR imaging of the cervical spine is valuable for assessing traumatic injuries to the spinal cord and bony ligamentous structures. MR is also useful for detecting such long-term complications of spinal cord injury as syrinx, arachnoid cyst, cord adhesion, and persistent mechanical impingement on the spinal cord or spinal nerve roots. Treatment of cervical spine injuries that are mechanically unstable entails fixation and fusion. However, previous attempts at our institution to obtain clinically useful MR images of the cervical region after posterior wire fixation have failed because of image artifacts arising from ferromagnetic stainless steel wires. Use of biocompatible titanium wire for fixation allowed undistorted imaging of the spinal cord and spinal canal adjacent to the surgical fixation in a cadaver and in eight patients.

Management of pediatric cervical spine and spinal cord injuries.

STANDARDS: There is insufficient evidence to support diagnostic standards. GUIDELINES: In children who have experienced trauma and are alert, conversant, have no neurological deficit, no midline cervical tenderness, and no painful distracting injury, and are not intoxicated, cervical spine x-rays are not necessary to exclude cervical spine injury and are not recommended. In children who have experienced trauma and who are either not alert, nonconversant, or have neurological deficit, midline cervical tenderness, or painful distracting injury, or are intoxicated, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. OPTIONS: In children younger than age 9 years who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. In children age 9 years or older who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior, lateral, and open-mouth cervical spine x-rays be obtained. Computed tomographic scanning with attention to the suspected level of neurological injury to exclude occult fractures or to evaluate regions not seen adequately on plain x-rays is recommended. Flexion/extension cervical x-rays or fluoroscopy may be considered to exclude gross ligamentous instability when there remains a suspicion of cervical spine instability after static x-rays are obtained. Magnetic resonance imaging of the cervical spine may be considered to exclude cord or nerve root compression, evaluate ligamentous integrity, or provide information regarding neurological prognosis. STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines. OPTIONS: Thoracic elevation or an occipital recess to prevent flexion of the head and neck when restrained supine on an otherwise flat backboard may allow for better neutral alignment and immobilization of the cervical spine in children younger than 8 years because of the relatively large head in these younger children and is recommended. Closed reduction and halo immobilization for injuries of the C2 synchondrosis between the body and odontoid is recommended in children younger than 7 years. Consideration of primary operative therapy is recommended for isolated ligamentous injuries of the cervical spine with associated deformity.

Simultaneous noncontiguous cervical spine injuries in a pediatric patient: case report.

OBJECTIVE AND IMPORTANCE: Noncontiguous traumatic injuries of the cervical spine in children are rare. We present the case of a child who simultaneously sustained a separation of the odontoid synchondrosis and a C6-C7 dislocation with a complete spinal cord injury. The management of simultaneous cervical spine injuries is discussed. CLINICAL PRESENTATION: A boy aged 4 years and 2 months was a restrained back-seat passenger involved in a head-on motor vehicle accident. The patient lacked neurological function below C7. Imaging studies revealed a separation of the odontoid synchondrosis as well as a traumatic dislocation of the spine at C6-C7. INTERVENTION: The patient was placed in a halo vest shortly after admission. Four days after his injury, he underwent a posterior wiring and fusion of C6 to C7. As the C6-C7 dislocation was reduced by posterior element wiring, intraoperative x-rays showed a gradual increase in the subluxation of C1 on C2. This increase in C1-C2 subluxation required intraoperative repositioning of the halo crown on the ventral halo vest posts to maintain acceptable C1-C2 alignment. Postoperatively, ideal alignment of the odontoid peg on the body of C2 could not be achieved by halo adjustments alone. The patient required a custom-made posterior neck cushion attached to the halo vest to maintain cervical lordosis and good alignment of the odontoid peg on the body of C2. CONCLUSION: Simultaneous traumatic cervical spine injuries in pediatric patients are rare. The intraoperative reduction of one spine injury can affect the alignment at the location of the second injury. In this case, a custom adjustment of the halo vest improved the alignment of the odontoid peg on the body of C2.

Intravertebral vacuum phenomenon in osteoporotic compression fracture: report of 67 cases with quantitative evaluation of intravertebral instability.

OBJECT: The objectives of this study were to: 1) describe the incidence and clinical features of intravertebral vacuum phenomenon (IVVP) in a relatively large number of cases; 2) quantitatively evaluate intravertebral instability and determine the factors affecting instability; and 3) evaluate the efficacy of percutaneous vertebroplasty in the treatment of this phenomenon. METHODS: A retrospective review was conducted of the records of 67 patients with IVVP among 652 consecutive cases of osteoporotic compression fracture. Comparisons between the IVVP group and a control group, a stable group, and an unstable group were conducted. Percutaneous vertebroplasty was performed in all patients. There were 67 patients (10.3%) in whom there were 70 vacuum phenomena of the intravertebral space. Intravertebral vacuum phenomena occurred predominantly in the thoracolumbar junction (81%) and in patients with a longer duration of symptoms (10.6 +/- 9.8 months) compared with the control group. Of 59 vertebrae for which flexion-extension radiographs were available, 26 vertebrae were categorized as stable and 33 as unstable. Twenty-one vertebrae (64%) had undergone compression fracture in the unstable group compared with nine (35%) compression fractures in the stable group. There were 28 (85%) fractures of the wedged vertebrae in the unstable group compared with 16 (61%) fractures in wedged vertebrae in the stable group. Percutaneous vertebroplasty was performed with successful clinical outcome. CONCLUSIONS: Intravertebral vacuum phenomenon is more common than has been previously appreciated. The results of this study indicate that biomechanics, not ischemic or avascular theory, may play an important role in pathogenesis of this phenomenon. Percutaneous vertebroplasty was found to be a minimally invasive and effective procedure for the treatment of IVVP.

Selective paralysis of the upper extremities after odontoid fracture: acute central cord syndrome or cruciate paralysis?

A patient presented with selective paralysis of the arms after having sustained a fall. X-ray of the cervical spine showed a type II odontoid fracture with posterior atlantoaxial dislocation. The diagnosis in the emergency room was cruciate paralysis, which is frequently associated with fractures of axis and/or atlas. However, magnetic resonance imaging (MRI) of the cervical spine revealed a lesion consistent with the acute central cord syndrome (CCS) at the C2-C6 level. The patient underwent posterior atlantoaxial arthrodesis to correct instability and was discharged, without much neurological improvement. Cruciate paralysis has been reported to be associated with fractures of axis and/or atlas, and acute CCS has rarely been associated with the fractures. However, this case illustrates that the lesion responsible for selective paralysis of the upper extremities is not as specific as it had been thought to be, and that it is difficult to accurately identify the level of the cervical cord injury by neurological diagnosis and X-rays alone. Supplementary diagnostic modalities, particularly MRI, are required to make a correct diagnosis and develop a therapeutic strategy.

Brain and cervical spine injuries occurring during organized sports activities in children and adolescents.

Eighty per cent of severe sports-related central nervous system trauma occurs as a result of collision sports, chiefly American football and rugby union football, followed by wrestling and gymnastics. Although serious head injury is uncommon, episodes of concussion are frequent; repeated concussion should be grounds for suggesting that the athlete give up collision sport. American and rugby union football are the sports mainly responsible for cervical spine injury with resultant quadriplegia.

Acute sports-related spinal cord injury: contemporary management principles.

Improvements in helmet and equipment design have led to significant decreases in overall injury incidence, but no available helmet can prevent catastrophic injury to the neck and cervical spine. The most effective strategy for preventing this type of injury appears to be careful instruction, training, and regulations designed to eliminate head-first contact. The incidence of football-related quadriplegia has decreased from a peak of 13 cases per one million players between 1976 and 1980 to 3 per million from 1991 to 1993, mostly as a result of systematic research and an organized effort to eliminate high-risk behavior. An episode of transient quadriparesis does not appear to be a risk factor for catastrophic spinal cord injury. Torg reported that 0 of 117 quadriplegics in the National Football Head and Neck Injuries Registry recalled a prior episode of transient quadriparesis, and 0 of the 45 patients originally studied in his transient quadriparesis cohort have subsequently suffered quadriplegia. The significance of developmental spinal stenosis is unclear. Plain radiographic identification of a narrow spinal canal in a player sustaining cervical cord neurapraxia warrants further evaluation by MRI to rule out functional stenosis. The presence of actual cord deformation or compression on MRI should preclude participation in high-risk contact or collision sports.

Trauma sites and clinical features associated with acute hyperextension spinal cord injury without bone damage--relationship between trauma site and severity.

To elucidate whether a relationship exists between the site of trauma and severity of acute hyperextension spinal cord injury without bone damage, we examined the clinical features of 25 male and 10 female patients aged 13 to 88 years. None of the patients had vertebral damage such as fracture and dislocation. The site of impact was classified as the buccal, forehead, or mandibular region. The neurological findings were assessed according to Frankel's classification at admission and at follow up after 3 months or more to assess outcome. Eleven patients suffered trauma in the buccal region, one patient in Frankel's grade B, three in grade C, and seven in grade D at admission. All 11 of these patients showed an improvement of one grade or more to an outcome of C in one patient, D in one, and E in nine. Trauma occurred at the forehead region in 18 patients, four in grade B, 10 in grade C, and four in grade D. Improvement was seen at follow up by one grade or more to C in one patient, D in 10, and E in seven. Trauma occurred at the mandibular region in six patients, four in grade B and two in grade C. Four of these patients showed improvement of one grade or more to grade B in one, grade C in four, and grade E in one. Overall, seven patients had poor outcomes, five of whom suffered trauma to the mandibular region, indicating that impact to the mandibular region tends to have an unfavorable clinical outcome. Our findings indicate that the site of trauma greatly influences the severity of hyperextension spinal cord injury.