Morbidity and mortality in cervical spine injuries in the elderly.

BACKGROUND: The aim of our study was to identify the demographics and complications in elderly cervical spine injuries and predictive factors for surgery, complications and mortality. We hypothesized younger healthier patients were more likely to undergo surgical intervention. METHODS: A retrospective review of 225 consecutive patients aged 65 years and over with cervical spine injuries was carried out over a 3-year period. RESULTS: There were 113 males and 112 females with an average of 79.7 years (range 65-98). The most common fracture was C2 peg type (21.8%). Five patients had complete spinal cord injury (2.2%), 25 had incomplete spinal cord injury (11.1%) and 84% were neurologically intact. Fifty-four patients were managed operatively (24%), while 171 patients were managed non-operatively (76%). The operative group had higher rates of pneumonia (odds ratio (OR) 5.3, 95% confidence interval (CI) 2.6-10.7, P < 0.01), cardiac arrhythmia (OR 4.1, 95% CI 1.5-11.2, P < 0.01) and respiratory failure (OR 2.6, 95% CI 1.2-5.5, P < 0.05). There was no difference in mortality between the operative and non-operative group (18.5% and 12.9%, P = 0.3). Patients with complete spinal cord injury had 100% mortality. Significant predictive factors for complications and death were neurological deficits, comorbidities and the presence of other injuries (P < 0.05). Surgery was not predictive for death and the operative group was younger than the non-operative group (P < 0.05). CONCLUSIONS: In the setting of a high complication rate, consideration should be given to palliation in elderly patients with complete spinal cord injury and there must be good rational for surgery.

Endoscopic transsphenoidal pituitary surgery: a single surgeon experience and the learning curve.

Endoscopic transsphenoidal surgery for pituitary adenomas has been introduced as an alternative to transsphenoidal microsurgery. This is the first Australian study to evaluate a single surgeon's experience by comparing our results with other series and attempting to identify a learning curve. Retrospective analysis was carried out on 79 consecutively treated patients by fully endoscopic transsphenoidal surgery by a single neurosurgeon over a period spanning from July 1998 to September 2010 at St George Public and Private hospitals. The mean age at time of surgery was 56.7 years (SD ± 16.3, range 26-85) and the mean follow-up period was 38.2 months (SD ± 33, range 1-136). Gross total resection (GTR) was noted in 63% of patients, endocrinological cure was achieved in 53% and visual field improvements were noted in 86% of patients. Intra-operative CSF leaks occurred in 19% of procedures, while the rates of post-operative CSF rhinorrhea was 3% and post-operative diabetes insipidus was 13%. There was one post-operative death (1%). Compared to microsurgery, intra-operative CSF leaks and meningitis seem less frequent with an endoscopic approach. With increasing experience, we found a non-statistically significant trend towards higher rates of GTR, and improved visual fields. Endocrinological cure rates were clearly better with experience (p < 0.01). There may be a learning curve that can be overcome in 30-40 cases. Endoscopic transsphenoidal surgery provides similar tumour and patient outcomes when compared to transsphenoidal microsurgery. In this single surgeon's experience, there was a trend to indicate improved performance with more case experience.

The role of nitric oxide in tendon healing.

Nitric oxide (NO) is a small free radical that is generated by a family of enzymes called the nitric oxide synthases (NOS). There are 3 isoforms of NOS: endothelial NOS (eNOS), brain or neuronal NOS (bNOS), and inducible NOS (iNOS). In experiments performed during the last 20 years, we have shown that NO is induced by all 3 isoforms of NOS after tendon injury and that NOS activity is upregulated in tendinopathy. In normal uninjured tendons, there is very little NOS activity. In injured rat and human tendons, NOS activity was found in healing fibroblasts in a temporal fashion. In animal models, competitive inhibition of NOS resulted in reduced tendon healing, whereas the addition of NO resulted in enhanced tendon healing. In cultured human cells, the addition of NO via chemical means and adenovirus transfection resulted in enhanced collagen synthesis. We performed 3 randomized, double-blinded clinical trials that demonstrated a significant positive beneficial effect of NO treatment on clinical symptoms and function in patients with Achilles tendinopathy, tennis elbow, and supraspinatus tendonitis. NO was delivered via glyceryl trinitrate (GTN) patches. We also conducted a 3-year prospective follow-up that demonstrated significant long-term efficacy of GTN patches in treating noninsertional Achilles tendinopathy. In a 5-year prospective comparison treating lateral epicondylitis, we found no additional benefits of GTN vs placebo at 5 years. The use of a new GTN patch, OrthoDerm, demonstrated no evidence for efficacy in treating chronic lateral epicondylitis.