Anterior screw fixation of a dislocated type II odontoid fracture facilitated by transoral and posterior cervical manual reduction.

BACKGROUND: Early fixation of type II odontoid fractures has been shown to provide high rates of long-term stabilization and osteosynthesis. CASE: In this report, the authors present the case of a patient with a locked type II odontoid fracture treated by anterior screw fixation facilitated by closed transoral and posterior cervical manual reduction. CONCLUSION: While transoral intraoperative reduction of a partially displaced odontoid fracture has previously been described, the authors present the first case utilizing this technique in the treatment of a completely dislocated type II odontoid fracture.

Dynamic perfusion computerized tomography in cerebral vasospasm following aneurysmal subarachnoid hemorrhage: a comparison with technetium-99m-labeled ethyl cysteinate dimer-single-photon emission computerized tomography.

OBJECT: The aim of this study was to correlate cerebral blood flow (CBF) and mean transient time (MTT) measured on dynamic perfusion computerized tomography (CT) with CBF using (99m)Tc ethyl cysteinate dimer-single-photon emission computerized tomography (SPECT) in patients with cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH). METHODS: Thirty-five patients with vasospasm following aneurysmal SAH (12 men and 23 women with a mean age of 49.3 +/- 10.1 years) underwent imaging studies; thus, 35 perfusion CT scans and 35 SPECT images were available for comparison. The CBF and MTT values in 12 different brain regions were defined relative to the interhemispheric occipital cortex values using perfusion CT scans and were compared with qualitative relative (rel)CBF estimated on SPECT images. In brain regions with normal, mild (relCBF 71-85%), moderate (relCBF 50-70%), and severe (relCBF < 50%) hypoperfusion on SPECT, the mean relCBF values measured on perfusion CT were 1.01 +/- 0.08, 0.82 +/- 0.22, 0.6 +/- 0.15, and 0.32 +/- 0.08, respectively (p < 0.0001); the mean relMTT values were 1.04 +/- 0.14, 1.4 +/- 0.31, 2.16 +/- 0.46, and 3.3 +/- 0.54, respectively (p < 0.0001). All but one brain region (30 regions) with severe hypoperfusion on SPECT images demonstrated relCBF values less than 0.6 and relMTT values greater than 2.5 on perfusion CT scans. CONCLUSIONS: Relative CBF and MTT values on perfusion CT showed a high concordance rate with estimated relCBF on SPECT in patients with vasospasm following aneurysmal SAH. Given its logistical advantages, perfusion CT may be a valuable method of assessing perfusion abnormality in the acute setting of vasospasm and in patients with an unstable condition following aneurysmal SAH.

Minimal Access Posterior Approach for Extrapleural Thoracic Sympathectomy: A Cadaveric Study and Cases.

OBJECTIVE: Operatively, video-assisted thoracoscopic sympathectomy (VATS) involves pleural entry and poses risk in small children and patients with pulmonary disease. A conventional posterior sympathectomy is more invasive than VATS. We investigated a cadaveric feasibility study of a minimal access posterior approach for endoscopic extrapleural sympathectomy and discuss this minimal approach in children with cardiac sympathectomy. METHODS: A posterior endoscopic extrapleural approach for thoracic sympathectomy was performed using lightly embalmed cadavers; surgical corridor depth, width, and associated pleural violation were recorded. Two pediatric cases undergoing secondary prevention for breakthrough cardiac dysrhythmias using this approach are discussed: case 1, a 9-year-old girl with refractory long QT syndrome; and case 2, a 13-year-old boy with hypertrophic cardiomyopathy. RESULTS: The cadaveric study supported 100% identification of a craniocaudal-oriented sympathetic chain using an 18-mm tubular retractor, and a 10% pleural violation rate. There were no clinically significant pneumothoracies in either proof of concept cases. CONCLUSIONS: Minimal access posterior extrapleural sympathectomy is feasible to expose the sympathetic chain in the thoracic region with good visualization using either endoscopic or microscopic magnification. Single-position bilateral thoracic sympathectomy can be performed in pediatric patients with life-threatening ventricular arrhythmias. Based on the cadaveric study and the 2 preliminary cases, we believe that a posterior minimal access approach allows safe and effective access to the thoracic sympathetic chain for causes requiring sympathectomy using single positioning, with minimal risk of pneumothorax or Horner syndrome.

Transient rotational compression of the vertebral artery caused by herniated cervical disc. Case report.

Of the many causes of vertebrobasilar insufficiency (VBI), extrinsic compression of the vertebral artery (VA) is relatively uncommon. A syndrome of VBI caused by extrinsic compression of the VA secondary to head rotation has been termed positional vertebrobasilar ischemia. The authors present a case of transient VBI caused by herniation of a cervical disc. Transcranial Doppler ultrasonography was used preoperatively to confirm the diagnosis and intraoperatively to monitor cerebral perfusion and to confirm that adequate decompression of the VA had been achieved.

Mapping dermatomes during selective dorsal rhizotomy: case report and review of the literature.

BACKGROUND: Studies suggest that the pattern of dermatomal segmental innervation in any given patient, may differ from the classic dermatomal maps first described in the 1890s. Such variability may limit the effectiveness of selective dorsal rhizotomy for treatment of neurogenic pain. CASE DESCRIPTION: A 46-year-old male presented with a 27-year history of intractable pain in his left arm after being shot during the Vietnam War; multiple surgical and medical therapeutic modalities failed to produce durable pain relief. The patient underwent selective dorsal rhizotomy, with intraoperative dermatomal and mixed somatosensory evoked potential recordings. Pre- and postrhizotomy recordings were compared, effectively mapping this patient's dermatomal pattern. At 4 years' follow-up, the patient remains pain free. CONCLUSION: Intraoperative monitoring of somatosensory evoked potentials during dorsal rhizotomy for neurogenic pain can be used to establish the degree to which an individual's pattern of segmental innervation conforms to the traditionally described dermatomes.

Timing of cranioplasty after decompressive craniectomy for trauma.

BACKGROUND: The optimal timing of cranioplasty after decompressive craniectomy for trauma is unknown. The aim of this study was to determine if early cranioplasty after decompressive craniectomy for trauma reduces complications. METHODS: Consecutive cases of patients who underwent autologous cranioplasty after decompressive craniectomy for trauma at a single Level I Trauma Center were studied in a retrospective 10 year data review. Associations of categorical variables were compared using Chi-square test or Fisher's exact test. RESULTS: A total of 157 patients were divided into early (<12 weeks; 78 patients) and late (≥12 weeks; 79 patients) cranioplasty cohorts. Baseline characteristics were similar between the two cohorts. Cranioplasty operative time was significantly shorter in the early (102 minutes) than the late (125 minutes) cranioplasty cohort (P = 0.0482). Overall complication rate in both cohorts was 35%. Infection rates were lower in the early (7.7%) than the late (14%) cranioplasty cohort as was bone graft resorption (15% early, 19% late), hydrocephalus rate (7.7% early, 1.3% late), and postoperative hematoma incidence (3.9% early, 1.3% late). However, these differences were not statistically significant. Patients <18 years of age were at higher risk of bone graft resorption than patients ≥18 years of age (OR 3.32, 95% CI 1.25-8.81; P = 0.0162). CONCLUSIONS: After decompressive craniectomy for trauma, early (<12 weeks) cranioplasty does not alter the incidence of complication rates. In patients <18 years of age, early (<12 weeks) cranioplasty increases the risk of bone resorption. Delaying cranioplasty (≥12 weeks) results in longer operative times and may increase costs.

Postoperative prevertebral soft tissue swelling does not affect the development of chronic dysphagia following anterior cervical spine surgery.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To characterize the relation between postoperative soft tissue swelling and the development of chronic dysphagia after anterior cervical spine surgery. Chronic dysphagia was defined as dysphagia that persists more than 1 year. SUMMARY OF BACKGROUND DATA: Dysphagia is commonly reported in the early postoperative period after anterior cervical spine surgery. Although prevertebral soft tissue swelling (STS) has been hypothesized as a potential risk factor for development of dysphagia, no studies have assessed STS' relation to dysphagia that persists more than 1 year. METHODS: Sixty-seven patients who underwent elective anterior cervical spine surgery from 2008 to 2011 and completed a dysphagia questionnaire were included in the study. Prevertebral STS was measured at the caudal endplates of C2 and C6 on plain lateral cervical radiographs preoperatively, immediately after, and 6 and 12 weeks postoperatively. The presence and severity of chronic dysphagia was assessed using the Bazaz-Yoo Dysphagia Score. The prevalence of dysphagia in relation to STS was evaluated using the Wilcoxon rank-sum test. RESULTS: By 6 weeks after surgery, 89% of STS at C2 and 97% of STS at C6 had resolved, as compared with preoperative values. The overall dysphagia prevalence in our cohort was 73%, with 48% reporting no or mild symptoms. Moderate symptoms were present in 39% and severe symptoms were present in 13% of the patients. There was no relation between STS measured at all time points compared with the development of chronic dysphagia. Dysphagia did trend toward significance with higher cervical fusions (C4 and above) and as the number of levels fused increased, but STS did not seem to influence this. CONCLUSION: Postoperative STS is a self-limiting process. The magnitude of STS during the postoperative period does not seem to influence the development of chronic dysphagia.