[Frequency of Ponticulus posticus and Ponticulus lateralis in patients admitted to hospital with traumatic brain injur]. / Vstrechaemost' (chastota) zadnikh i lateral'nykh mostikov anomalii Kimmerle u bol'nykh, postupivshikh v statsionar s cherepno-mozgovoi travmoi.

OBJECTIVE: To determine the frequency of Ponticulus posticus and Ponticulus lateralis among patients admitted to a24-hour emergency hospital. MATERIAL AND METHODS: The study included 2887 patients with a traumatic history who were admitted to the hospital for emergency reasons. This principle of sampling allowed us to exclude a high concentration of studies of patients with chronic neurological diseases, the cause of which could be symptomatic Kimmerle's anomaly (KA). During the period 01.01.20 to 31.12.20, primary CT was performed on an emergency basis in 7348 patients. Of these, CT scans of the brain and cervical spine were performed in 2965 patients. Some patients (78 people) were excluded from the study due to the presence of cervical vertebral fractures and metal artifacts in the craniovertebral region. RESULTS: The Ponticulus posticus was detected in 1162 (40.2%) patients, among them class 3 and 4 was detected in 27.7%, and class 2 ossification in 12.5%. This Ponticulus posticus was significantly more common (χ2 test, p=0.0005) in men. The Ponticulus lateralis was identified in 231 patients (8%), among them 94 patients (3.3%) had complete ponticulus on both sides, 29 patients (1%) - on one side, and 108 patients (3.7%) - two-sided incomplete ponticulus. In patients with class 2-3-4, Ponticulus lateralis were detected significantly more often (χ2 test, p<0.0001). CONCLUSION: The cumulative incidence of KA was 42%, 17% of patients are carriers of a complete KA bridge, which is significantly higher than in the European or Asian regions. The data suggest that KA is not the result of ossification of the posterior atlanto-occipital membrane, since different classes of KA occur equally often at different ages. Further studies of KA are needed, including its occurrence in patients of the neurological department and its correlation with individual neurological syndromes to determine the need for surgical treatment in the population.

[Endonasal repair of spontaneous CSF fistulas of the lateral recess of the sphenoid sinus]. / Endonazal'naya plastika spontannykh likvornykh fistul lateral'nogo karmana klinovidnoi pazukhi.

CSF fistulas of the lateral recess of the sphenoid sinus are a rare surgical pathology. Cerebrospinal fluid leak from lateral recess of the sphenoid sinus is observed with a frequency of 7.7% among all leakafe of the skull base. The article presents 3 clinical cases of patients with spontaneous cerebrospinal fluid leak from lateral recess of the sphenoid sinus and surgical treatments by transsphenoidal and transpterygoid (transpterygoid) endoscopic approaches with various postoperative results. The plastic surgery success of CSF fistulas from lateral recess of the sphenoid sinus doesn`t depend on the type of endonasal surgical approach, but on the plastic quality and the preoperative level of CSF pressure.

[Recovery of spinal cord functions after experimental complete crossection under the effect of chitosan polymeric compounds]. / Vozmozhnosti klinicheskogo vosstanovleniya funktsii spinnogo mozga pri ego polnom peresechenii v eksperimente pod vozdeistviem polimernykh soedinenii khitozana.

Currently, there is no effective method of treating complete spinal cord intersection. One of the promising experimental approaches is substances promoting repair and fusion of axonal membranes. OBJECTIVE: To study clinical and functional recovery in experimental animals with transected spinal cord after management with photo-cross-linked chitosan in a homogeneous mixture with polyethylene glycol. MATERIAL AND METHODS: We studied 20 rabbits with a model of complete spinal cord transection at the level of Th9. There were control and experimental groups (n=10; n=10). In the experimental group, we intraoperatively injected photo-cross-linked chitosan in a homogeneous mixture with polyethylene glycol. Neurological status was assessed using the modified Basso Beattie Bresnahan scale. Histological examination was performed after removing the animals from the experiment. RESULTS: In the experimental group, significant regression of neurological disorders was accompanied by partial recovery of movements, sensitivity and control of pelvic functions by the 30th day of the experiment. There was no mortality in the experimental group. Paraplegia and anesthesia persisted in the control group while mortality was 40% (n=4). Histological analysis in the main group revealed axonal «bridges¼ in the area of injury and spread of DiI dye through this area. CONCLUSION: These phenomena confirm the positive effect of chitosan and polyethylene glycol on functional recovery after experimental spinal cord injury. These data are consistent with histological findings.

[Outcomes of lumbar decompression microsurgery]. / Iskhody mikrokhirurgicheskoi dekompressii koreshkov spinnogo mozga na poyasnichnom urovne.

BACKGROUND: Microsurgical decompression of the spinal root in patients with herniated intervertebral discs is the most common spinal surgery. However, most national and foreign studies devoted to assessment of postoperative outcomes contain no consensus on the timing of radicular pain syndrome relief after decompression and predictors of unfavorable outcomes. OBJECTIVE: To determine the period of radicular pain syndrome relief after microsurgical decompression and to identify clinical and neuroimaging predictors of unfavorable postoperative outcomes. MATERIAL AND METHODS: The study included 58 patients aged 26-73 years with clinical manifestations of L5 radiculopathy following compression by L4-L5 herniated disc. We assessed neurological status, functional state (Oswestry Disability Index) and fatty infiltration of paravertebral muscles. Results. Isolated radicular pain was observed in 31% of patients, combination of pain syndrome and sensory disorders - 17%, pain syndrome and motor disorders - 24%, pain syndrome, sensory and motor disorders - 28% of patients. Duration of disease until surgery was significantly longer in women (p=0.030). Complete relief of radicular pain immediately after surgery was observed in 24 (48%) patients. Sixteen (32%) patients had persistent pain syndrome for up to 1 month. Relief of radicular pain on the first postoperative day was significantly more common in patients without motor disorders (p<0.014). The outcomes of microsurgical decompression did not depend on duration of disease (p=0.551), sex (p=0.794), age (p=0.491) and degree of fatty infiltration of paravertebral muscles (p=0.686). CONCLUSION: Radicular pain regresses within 4 weeks after microsurgical decompression. The predictor of unfavorable postoperative outcomes (long-standing pain syndrome and no functional improvement) is any preoperative motor impairment.

Evaluation of the Effectiveness of Systemic Therapy of Spinal Cord Injury of Moderate Severity with Human Umbilical Cord Placental Blood Mononuclear Cells Using Indicators of Dispersion of Articular Angles in the Swimming Test.

Female Sprague-Dawley rats were used as models of moderate contusion spinal cord injury to evaluate the efficiency of single systemic (intravenous) infusion of human mononuclear cord blood cells for restoration of the motor function of hind limbs. The dynamics of recovery of hind limb motor function was assessed using a specially designed method based on calculation of selective dispersion and amplitude-dependent dispersion of hind limbs joint angles measured in the swimming test. The obtained data suggest that systemic application of human mononuclear cord blood cells significantly (p<0.05) promoted recovery of hind limb motor function in the animal models of contusion spinal cord injury of moderate severity in comparison with control animals (without cell therapy).

[Expert errors in formulating a forensic diagnosis and conclusions in cases of diffuse axonal brain damage]. / Ekspertnye oshibki pri formulirovanii sudebno-meditsinskogo diagnoza i vyvodov v sluchayakh diffuznogo aksonal'nogo povrezhdeniya mozga.

The study objective is to review expert errors in the wording of a post-mortem diagnosis and expert conclusions in cases of traumatic brain injury with diffuse axonal brain damage. We reviewed 50 corpse examinations of those who died from a traumatic brain injury with diffuse axonal brain damage. A retrospective analysis of the results of expert examinations, the structure of the post-mortem forensic diagnosis, and the validity of expert conclusions showed that expert errors were made in 30% of cases. In 93% of cases, the errors were epistemological due to the lack of a scientifically based methodological approach to the expert opinion on a particular mechanism for the development of traumatic brain injury with diffuse axonal brain damage; and lack of professional expertise. A case is provided demonstrating the most common expert errors in the examination of this type of traumatic brain injury.

[The frequency of vertebral artery sulcus ossification, grades III and IV, in patients with Kimmerle's anomaly: A systematic review and meta-analysis]. / Opredelenie chastoty vstrechaemosti III i IV stepenei ossifikatsii borozdy pozvonochnoi arterii u patsientov s anomaliei Kimmerle: sistematizirovannyi obzor i metaanaliz.

OBJECTIVE: To conduct a systematic review and meta-analysis to determine the frequency of Kimmerle's anomaly (KA) in patients with grades III and IV vertebral artery (VA) sulcus ossification. MATERIAL AND METHODS: We searched the PubMed and eLIBRARY.RU databases, identified 68 articles in English, and obtained data of 29.770 patients. To date, no study in Russia has reported KA. The incidence of KA was determined using single-group meta-analysis. We used odds ratios (OR) to investigate the association between sex and the frequency of KA. Publication bias was assessed using the Egger test. RESULTS: The pooled prevalence of complete KA was 8.6% (95%, confidence interval (CI) 7.8-9.5%); however, the Egger test confirmed publication bias (t=2.102, p=0.022), which was eliminated by dividing the patient sample by geographic macroregions. The incidence of KA in Europe and Asia was 10.1% and 6.5%, respectively. The pooled prevalence of KA associated with grade III ossification was 7.2% (95% CI 4.9-10.4%). The OR of KA in men vs. women was 1.23 (95% CI 1.098-1.389). CONCLUSION: The incidence of KA was significantly associated with the macroregion. Nearly 15.8% of the population may show grades III and IV VA sulcus ossification, and surgical treatment is required in some patients. KA formation is more typical for males. A population study is warranted to clarify the frequency of KA in the Russian population.

[Electrodiagnostic evaluation in differential diagnosis and neurosurgical treatment of radiculopathies caused by spine disorders. Diagnostic value and methodology]. / Elektromiograficheskie metody v differentsial'noi diagnostike i obosnovanii neirokhirurgicheskogo lecheniya radikulopatii, vyzvannykh zabolevaniyami pozvonochnika. Informativnost' i metodologiya.

One of the most common causes of radiculopathy requiring neurosurgical treatment is a herniated disc. Magnetic resonance imaging (MRI) is still the main diagnostic approach for this lesion. However, MRI does not allow assessing the functional state of the root. Neurophysiological examination assesses the function of peripheral nervous system. These methods are used for differential diagnosis of causes of neurological symptoms and determine the level of the nerve root injury. OBJECTIVE: To assess the role of electromyography including paraspinal muscle mapping in diagnosis of radiculopathies following spine diseases. MATERIAL AND METHODS: We have analyzed literature data in the Scopus, Pubmed, and RSCI databases and selected 93 references for primary reviewing. Final analysis enrolled the manuscripts with a detailed description of neurophysiological examinations and data on sensitivity/specificity of these methods. RESULTS: Needle electromyography (EMG) is the most informative neurophysiological method for diagnosis of radicular damage. Sensitivity of EMG is up to 90% for lumbosacral radiculopathy. Electromyography of the paraspinal muscles can be used in case of of cervical, thoracic and lumbar radiculopathy in addition to EMG of limb muscles. Therefore sensitivity increases to 100%. Diagnostic value of nerve conduction study (NCS) is low, and performing NCS without EMG is not useful. CONCLUSION: In neurosurgical practice electrodiagnostic (EDX) should be performed for differential diagnosis of radiculopathy and peripheral nervous system lesions, to determine the level of radicular compression, and when physical examination does not correspond with neuroimaging or MRI is not possible to perform.

A Method of Assessment of the Motor Function of Hind Limbs by Swim Test in Spinal Cord Injury Models.

In most studies, various load tests are used to assess the recovery of functions after spinal cord injury in animals. However, the existing methods of assessing the movement in animals are not sufficiently accurate and objective. We developed a new method for assessing motor activity of laboratory animals that allows objective and highly accurate evaluation of movements in animals with serious neurological disorders caused by spinal cord injury. The swimming test was used as the main load test. Motor activity of swimming animals was assessed by measuring angles relative to the axis of motion, and the degree of angle spread for each joint and limb was estimated using the dispersion parameters depending on the values of the angles of the joints and the dispersion depending on the amplitudes of the angles. In Sprague-Dawley rats, contusion of the spinal cord at the Th9 level was modeled. In the swimming test, healthy control animals showed stability of both variance indicators over 6 weeks. In rats with spinal cord injury, motor activity of the hind limbs tended to increase from the first to the third weeks and remained at this level from the third to sixth weeks. The results suggest that the proposed method can become a good analogue of modern methods for assessing motor activity.

[Spinal motor segment labeling with a mixture of n-butyl-2-cyanoacrylate and iohexol in determining the level of thoracic spine surgery]. / Opyt markirovaniya pozvonochno-dvigatel'nogo segmenta smes'yu kleya na osnove n-butil-2-tsianoakrilata s iogeksolom pri opredelenii urovnya operativnogo vmeshatel'stva na grudnom otdele pozvonochnika.

Erroneous determining the level of spine surgery is an urgent problem in modern vertebrology. Incidence of this complication is up to 1 per 3110 patients, among patients undergoing thoracic spine surgery - 1 per 25 patients. Despite widespread use of spine surgery, there is still no standard rational method for prevention of erroneous determining the level of intervention. OBJECTIVE: To develop a safe minimally invasive low-traumatic and cost-effective method for preoperative marking the level of thoracic spine surgery. MATERIAL AND METHODS: A mixture of biodegradable adhesive based on cyanoacrylate and water-soluble iodine-containing X-ray contrast agent was used for preoperative marking in 8 patients scheduled for thoracic spine and spinal cord surgery. This mixture was injected into paravertebral tissues at the level of further intervention. RESULTS: Preoperative marking ensured a fixed and clearly visible landmark during intraoperative fluoroscopy in 7 patients. In 1 patient, mixture spread in paravertebral soft tissues that did not allow us to obtain appropriate landmark during intraoperative radiography. CONCLUSION: The described method makes it possible to create an immobile X-ray-positive «mark¼ in paravertebral soft tissues, which can be used to control the level of intervention at all surgical stages.

[Role of the RUANS recommendation protocol for decision-making in patients with acute traumatic cervical spine injuries]. / Rol' rekomendatel'nogo protokola Assotsiatsii neirokhirurgov RF pri vybore optimal'noi taktiki lecheniya patsientov s ostrymi travmaticheskimi povrezhdeniyami sheinogo otdela pozvonochnika.

Since 2013, neurosurgeons have been guided by the RUANS recommendation protocol for surgical management of patients with acute cervical spine fractures in Russia. However, there are no studies devoted to interobserver agreement between specialists with different experience. OBJECTIVE: To evaluate the role of the RUANS recommendation protocol for decision-making in patients with acute traumatic cervical spine injuries. MATERIAL AND METHODS: Twenty-one neurosurgeons from 5 hospitals estimated data of 64 patients with cervical spine fractures. The study implied choosing an option for patient treatment (conservative therapy; anterior, posterior and circular fusion surgery). Two evaluations of CT and MR scans with an interval of 1.5 months were conducted. In the main group (9/21), neurosurgeons strictly followed the RUANS recommendation protocol during re-evaluation. In the control group (12/21), neurosurgeons analysed data considering their own knowledge and experience. Interobserver agreement was evaluated using a Fleiss' or Cohen's Kappa (K). RESULTS: Among the junior neurosurgeons (up to 5 years of experience), change in consent level during re-evaluation was greater in the main group (∆K=0.25) compared to the control group (∆K= -0.17). Among neurosurgeons with medium level of experience (5-10 years), ∆K was 0.19 in the main group and -0.15 in the control group. Among experienced neurosurgeons (over 10 years of experience), the main group showed an increase in Kappa (∆K=0.24), while level of consent remained almost the same in the control group (∆K=0.05). CONCLUSION: The RUANS recommendation protocol can significantly improve interobserver agreement between specialists with various levels of experience regarding management of acute cervical spine injury.

[Lateral retropleural and retrodiaphragmatic approach in patients with spine trauma and diseases: a systematic review and meta-analysis]. / Primenenie lateral'nogo retroplevral'nogo i retrodiafragmal'nogo dostupa u patsientov s travmoi i zabolevaniyami pozvonochnika: sistematicheskii obzor i metaanaliz.

BACKGROUND: Retropleural and/or retrodiaphragmatic approach is one of the options for anterolateral access to the thoracic spine and thoracolumbar region. This technique has no disadvantages associated with thoracotomy or extensive tissue dissection following posterolateral approaches. OBJECTIVE: Systematic analysis of foreign and national researches devoted to the possibility, safety and effectiveness of lateral retropleural approach to the thoracic spine and meta-analysis of the most common complications associated with this approach. MATERIAL AND METHODS: Initial searching revealed 133 abstracts for further study. Inclusion criteria: 1) available full-text version of the manuscript in English or Russian; 2) age of patients over 18 years; 3) description of lateral retropleural or retrodiaphragmatic approach complicated or not complicated by access-associated complications. According to these criteria, we enrolled 10 manuscripts. RESULTS: Meta-analysis showed high (10.6%) probability of pleural injury associated with surgical approach. Compared to endoscopic transthoracic interventions, the above-mentioned access is characterized by similar or slightly greater blood loss (401.2 ml vs. 100-775 ml) and slightly longer surgery time (200.5 vs. 97.5-186 min) that may be due to small number of interventions and relatively little experience of such operations. The number of patients with approach-related complications is comparable to that for endoscopic transthoracic access (5% vs. 3.7-13.3%). Compared to transthoracic minithoracotomy, this approach is characterized by similar blood loss (401.2 vs. 391 ml), longer surgery time (200.5 vs. 168 min) and similar or lower morbidity (5% vs. 5-13.5%). CONCLUSION: Minimally invasive anterolateral retropleural and/or retrodiaphragmatic approach to the thoracic spine and thoracolumbar junction for corpectomy and discectomy ensures effective spinal canal decompression and less incidence of complications following open or thoracoscopic thoracic spine surgery. Dissection of parietal pleura should be of special attention because injury of this structure occurs in 10.6% of cases. Skin incision 7.1 cm and rib resection for at least 5 cm may be valuable to prevent plural damage.

[Rigid transpedicular fusion surgery in the treatment of degenerative lumbar stenosis]. / Rigidnaya transpedikulyarnaya fiksatsiya v lechenii patsientov s degenerativnym poyasnichnym stenozom.

OBJECTIVE: To compare an effectiveness of different methods of rigid transpedicular fixation and decompression in patients with degenerative lumbar stenosis. MATERIAL AND METHODS: A prospective study included 160 patients with degenerative lumbar spine stenosis. In the first group (n=37), patients underwent laminectomy and transpedicular fixation, in the second group (n=60) - laminectomy, transpedicular fixation and implantation of interbody fusion cage. In the third group (n=30), interlaminar decompression and transpedicular fixation were carried oud, in the fourth group (n=33) - interlaminar decompression, transpedicular fixation and implantation of interbody fusion cage. Surgeries were performed in three clinics in Moscow. Outcomes were assessed using a visual analogue scale (VAS) and Oswestry questionnaire in 1 and 2 years after surgery. Between-group comparison of the outcomes was performed. In patients with unfavorable outcome, we analyzed the cause of unsatisfactory result and risk factors. RESULTS: Satisfactory result was noted in 103 patients (64%) in 2 years after surgery. Outcomes were comparable in all groups. More significant regression of back pain was noted in group II (laminectomy, transpedicular fixation, interbody cage) compared to other groups. Preoperative risk factors of adverse outcome were resting leg pain VAS score > 4 and age over 71 years. Incidence of pseudoarthrosis and back pain was higher among patients without interbody cage. Incidence of adjacent level lesion was higher among patients with interbody cages. CONCLUSION: Decompression type and implantation of interbody cage do not significantly change postoperative outcomes in most patients with degenerative lumbar stenosis undergoing transpedicular fixation. However, interbody cage implantation during transpedicular fixation is advisable in patients with severe back pain (VAS score > 5-6).

[Neurophysiological methods for predicting outcome in cases of spine and spinal cord injury]. / Neirofiziologicheskie metody prognozirovaniya iskhoda pozvonochno-spinnomozgovoi travmy.

The purpose of the review was to determine the capabilities of neurophysiological examination for predicting the outcome of spinal injury. We have analyzed the methods of neurophysiological examination of spinal cord function and the role of these data in prediction of functional recovery in patients with complicated vertebral-spinal injury. Application of functional diagnostic methods for spinal shock was also considered.

[The effect of various multimodal analgesia regimens during surgical treatment of patients with spinal stenosis on the rate of failed back surgery syndrome]. / Vliianie razlichnykh mul'timodal'nykh skhem analgezii pri khirurgicheskom lechenii patsientov so stenozom pozvonochnogo kanala na chastotu sindroma neudachnoi operatsii na pozvonochnike.

OBJECTIVE: To determine the effect of various methods of perioperative analgesia on the rate of failed back surgery syndrome in patients operated on for spinal stenosis. MATERIAL AND METHODS: A total of 122 patients were operated on for spinal stenosis in 2010-2016. The patients were assigned to groups according to the type of received analgesia: Group K (n=19) underwent analgesia on-demand. Patients in the PMA group (n=21) received preventive multimodal analgesia (PMA) with ketoprofen, paracetamol and morphine. Patients in the PMA+PG (n=20) and PMA+N (n=20) groups additionally received pregabalin and nefopam, respectively. Patients in the PMA+E group (n=22) received continuous epidural analgesia with a combination of ropivacaine and morphine. In patients in the PMA+I group (n=20), the wound was infiltrated with ropivacaine and ketorolac. RESULTS AND CONCLUSION: In Group K, analgesia was not adequate during five postoperative days. Analgesia with PMA resulted in significant pain reduction during three postoperative days compared to Group K. Wound infiltration in addition to PMA was followed by more significant pain relief during six postoperative hours (compared to the PMA group). Administration of pregabalin or nefopam, as well as epidural analgesia, did not improve quality of postoperative analgesia. Five to seven months after the surgery, 66% (57; 75%) of patients had low back and/or leg pain; 41% (32; 50%) of patients had leg pain. Among patients suffering from pain, 32-41% patients had the severe chronic pain syndrome that resulted in sleep disorder, disability and significant deterioration of quality of life. The rate of failed back surgery syndrome did not depend on the perioperative analgesia regimen.

[Prognostic models of the severity of acute dynamic pain on the first postoperative day and the likelihood of chronic postoperative pain in spine surgery]. / Prognosticheskie modeli vyrazhennosti ostroi dinamicheskoi boli v pervye sutki posle operatsii i veroiatnosti vozniknoveniia khronicheskoi posleoperatsionnoi boli v khirurgii pozvonochnika.

The risk factors for acute pain as well as chronic pain syndrome (CPS) in spine surgery have not been defined to date. PURPOSE: To define the prognostic parameters of acute pain severity and the risk of CPS in patients operated on for spinal diseases and injuries. MATERIAL AND METHODS: The study included 291 patients operated on for degenerative diseases and injuries of the spine at the Sklifosovsky Research Institute of Emergency Medicine in 2010-2016. Sociodemographic and clinical data and the psychological status of patients were evaluated. A mechanical algometer was used to measure the pain threshold (PT) and pain tolerance. The movement pain intensity was assessed by using a visual analog scale (VAS) on the day of surgery. Pain was considered minor at a median score of 0-4 cm and severe at a median score of 5-10 cm. The presence of CPS was assessed during a telephone survey 5-7 months after surgery. RESULTS: The gender, PT, dynamic pain intensity before surgery, and expectation of postoperative pain are risk factors for severe acute postoperative pain. A multinomial logit regression model (Hosmer-Lemeshow test - 4.322; p=0.827) predicts minor dynamic pain on the 1st postoperative day with an accuracy of 70% (95% CI 63-76). The age and dynamic pain intensity on the 1st postoperative are the risk factors for CPS; the multinomial logit regression model (Hosmer-Lemeshow test - 3.1; p=0.928) predicts CPS with an accuracy of 65% (95% CI 59-71) 5-7 months after surgery. CONCLUSION: The developed software in the form of MS Excel calculators provides a particular patient with preoperative assessment of the risk for minor acute dynamic pain on the 1st postoperative day and CPS 5-7 months after surgery.

[Ventral decompression techniques in patients with traumatic and non-traumatic atlanto-axial dislocations]. / Metody ventral'noi dekompressii u patsientov s atlanto-aksial'nymi dislokatsiiami travmaticheskogo i netravmaticheskogo geneza.

Compression of the caudal medulla oblongata and ventral portions of the spinal cord is the most dangerous complication of atlanto-axial dislocation (AAD). AIM: The study objective was to improve surgical management of patients with ventral compression of the spinal cord in the setting of AAD of various genesis. MATERIAL AND METHODS: We analyzed treatment outcomes in 250 patients with C1 and C2 injuries and diseases for the period between 2002 and 2016. Persistent ventral compression of the neural structures in the setting of AAD was detected in 34 (13.6%) patients. Anterior or posterior dislocation was in 21 patients, vertical dislocation occurred in 7 patients, and mixed (anterior and vertical) occurred in 6 cases. The causes of AAD included odontoid fractures (21 patients, 61.8%), Jefferson fractures (6 patients, 17.6%), atlas transverse ligament rupture (1 patient, 2.9%), rheumatoid arthritis (4 patients, 11.8%), and nonspecific spondylitis (2 patients, 5.9%). RESULTS: All dislocations were divided into Halo-tractable and Halo-intractable ones. In 24 cases, ventral decompression was achieved due to Halo reposition. Additional resection of a compressing substrate was performed through the submandibular approach in 4 patients, through the transoral approach in 5 patients, and through the transnasal approach in 1 case. In the postoperative period, complications in the form of pharyngeal edema developed in 1 patient after transoral decompression. In the other cases, there were no postoperative complications. All patients had improvement in their condition in the form of regression of a neurological deficit. CONCLUSION: Halo reposition is a technique eliminating, completely or partially, ventral compression in certain traumatic and non-traumatic dislocations. The choice of a surgical corridor should be performed after preliminary Halo correction. If the nasopalatine line runs in the odontoid neck projection, the submandibular approach may be used in the case of a Halo-tractable dislocation, and the endonasal approach may be used in the case of a Halo-intractable dislocation.

[THE CHOICE OF PERIOPERATIVE MULTIMODAL ANALGESIA IN PATIENTS WITH LUMBAR HERNIATED DISC: THE PRELIMINARY RESULTS.]

DESIGN: 129 patients scheduled for elective lumbar discectomy in 2010-2013 were enrolled in prospective study. Group K (n=20) underwent general anaesthesia and postoperative analgesia on-demand. Group PMA+SA (n=23) got subarachnoid block and preventive multimodal analgesia (PMA) including ketoprofen, paracetamol and nalbuphine. At PMA group (n=21) general anaesthesia and PMA were used; at PMA+I (n=21) also bupivacaine wound infiltration was administrated; at PlvL4+S (n=20) - depo-corticosteroid was applied locally on affected spinal nerve root; at PMA+IS (n=24) wound infiltration and local corticosteroids were combined. Patients could use i.v. nalbuphine on-demand by PCA device in addition to PMA post-operatively. 7 days post-operatively, the pain scores using 10 cm VAS at rest and during movement were also recorded. RESULTS: Group K patients had not adequate pain relief during 4 postoperative days. At PMA group the postoperative analgesia was adequate during the whole assessment time, PMA group patients had significant less pain scores than at K group during 4 postoperative days. Patients at PM +SA had better than PMA group pain relief only during 2 hours postoperatively. Groups PMA+I and PMA+IS did not demand nalbuphine at al. Their pain scores were signifcant less than at PMA group during 2 postoperative days. CONCLUSIONS: Postoperative analgesia on-demand is not adequate but the PMA is. Subarachnoid block results in decreasing severity of pain only during first hours postoperatively. The additional bupivacaine wound infiltration in pa- tients with lumbar herniated disc follows avoiding of opioids and significant pain relief during 2 postoperative days.