Traumatic Atlantoaxial Lateral Subluxation With Chronic Type II Odontoid Fracture: A Case Report.

BACKGROUND: We report a case of an elderly patient who was diagnosed with lateral atlantoaxial subluxation with type II odontoid fracture, an extremely uncommon upper cervical spine injury that has not been previously reported in the literature to the knowledge of the authors. METHODS: An 87-year-old male reported to the emergency room following a syncopal episode after sustaining a fall. He complained of dizziness, fatigue, disruption of vision and audition, and worsening neck pain. Computed tomographic scans were positive of partial dislocation of the C1 relative to C2 and chronic fracture of dens classified as type II according to the Anderson and D'Alonzo classification system. Magnetic resonance imaging further revealed large fracture pannus tissue at the level of the dens, reducing the space in the spinal cord. There was no evidence of spinal cord injury. Atlas-axis fusion with instrumentation was performed to manage the injury. A review of the classification, occurrence, and management of upper cervical spine surgeries was performed. RESULTS: An acute injury to a previously unrecognized type II odontoid fracture with partial C1-C2 dislocation was identified as a rare upper cervical spine injury and classified based on the Anderson and D'Alonzo and Fielding and Hawkins classification systems. The decision was made to perform instrumented spinal fusion by inserting mass screws into C1, pars screws into C2, and locking rods to realign the vertebral bodies and address the atlantoaxial instability. Follow-up scans indicated good postsurgical reduction and fixation, including resolution of the pannus overgrowth without direct intervention. CONCLUSIONS: Lateral atlantoaxial subluxation with chronic type II fracture of the dens constitutes a rare injury of the upper cervical vertebrae. Posterior instrumented spinal fusion was used to effectively manage the injury, leading to reabsorption of retro-odontoid pannus tissue.

Prevalence of Protective Shielding Utilization for Radiation Dose Reduction in Adult Patients Undergoing Body Scanning Using Computed Tomography.

PURPOSE: Ionizing radiation is implicated in nearly 2% of malignancies in the United States; radiation shields prevent unnecessary radiation exposure during medical imaging. Contemporary radiation shield utilization for adult patients in the United States is poorly defined. Therefore, we evaluated the prevalence of protective shielding utilization in adult patients undergoing CT scans in United States' hospitals. MATERIALS AND METHODS: An online survey was sent to established radiology departments randomly selected from the 2015 American Hospital Association Guide. Radiology departments conducting adult CT imaging were eligible; among 370 eligible departments, 215 departments accepted the study participation request. Questions focused on shielding practices during CT imaging of the eyes, thyroid, breasts, and gonads. Prevalence data were stratified per hospital location, size, and type. Main outcomes included overall protective shielding utilization, respondents' belief and knowledge regarding radiation safety, and organ-specific shielding prevalence. RESULTS: Sixty-seven of 215 (31%) hospitals completed the survey; 66 (99%) reported familiarity with the ALARA (as low as reasonably achievable) principle and 56 (84%) affirmed their belief that shielding is beneficial. Only 60% of hospitals employed shielding during CT imaging; among these institutions, shielding varied based on CT study: abdominopelvic CT (13, 33%), head CT (33, 83%), or chest CT (30, 75%). CONCLUSIONS: Among surveyed hospitals, 40% do not utilize CT shielding despite the majority acknowledging the ALARA principle and agreeing that shielding is a beneficial practice. Failure to address the low prevalence of protective shielding may lead to poor community health due to increased risk of radiation-related cancers.

Comparative analysis of techniques to prevent laparoscopic fogging.

PURPOSE: To evaluate the efficiency and efficacy of two common and commercially available methods to resolve lens fogging: a Fluid Warming System (O.R. Solutions, Chantilly, VA) and the Clearify Visualization System (Covidien, Mansfield, MA). MATERIAL AND METHODS: We prospectively evaluated 40 patients undergoing laparoscopic renal procedures with the Fluid Warming System (first 20 cases) and then the Clearify Visualization System (second 20 cases). We utilized the standard Fluid Warming System per a 30-second modified protocol established in our laboratory. We used the Clearify according to manufacturer instructions. For each procedure we documented the etiology of each episode of visual obstruction, procedure type and surgery duration. We performed a cost analysis. For all cases we used the same insufflator, insufflation trocar location and trocar configuration. RESULTS: All 40 patients completed the study protocol without incident. The mean fogging events per hour for the Fluid Warming System and Clearify Visualization System were 0.7 (0-2.52) and 1.4 (0-5.02), respectively (P = 0.045). Surgery duration and cost per procedure were similar for both systems. CONCLUSION: The Fluid Warming System with modified technique was found to have less fogging events than the Clearify Visualization System, with no difference in operative time or cost.

Evaluation of Ignition and Burn Risk Associated with Contemporary Fiberoptic and Distal Sensor Endoscopic Technology.

PURPOSE: To evaluate the ignition and burn risk associated with contemporary fiberoptic and distal sensor endoscopic technologies. MATERIALS AND METHODS: We used new and used SCB Xenon 300 light sources to illuminate a 4.8 mm fiberoptic cable, 10 mm laparoscope, 5 mm laparoscope, rigid cystoscope, semirigid ureteroscope, flexible cystoscope, flexible fiberoptic ureteroscope, distal sensor cystoscope, and a distal sensor ureteroscope (Karl Storz, Inc., Tuttlingen, Germany). We measured peak temperatures at the distal end of each device. We then evaluated each device on a flat and folded surgical drape to establish ignition risk. Finally, we evaluated the effects of all devices on human cadaver skin covered by surgical drape. RESULTS: Peak temperatures recorded for each device ranged from 26.9°C (flexible fiberoptic ureteroscope) to 194.5°C (fiberoptic cable). Drape ignition was noted when the fiberoptic cable was placed against a fold of drape. Contact with the fiberoptic cable, 10 mm laparoscope, 5 mm laparoscope, and distal sensor cystoscope resulted in cadaver skin damage. Cadaver skin damage occurred despite little or no visible change to the surgical drape. Rigid and flexible fiberoptic cystoscopes and flexible fiberoptic ureteroscopes had no effect on surgical drapes or cadaver skin. CONCLUSIONS: Fiberoptic light cables and some endoscopic devices have the potential to cause thermal injury and drape ignition. Thermal injury may occur without visible damage to drapes. Surgeons should remain vigilant regarding the risks associated with these devices and take necessary safety precautions to prevent patient injury.