A splint designed for easy fixation and release during orthognathic surgery.

Orthognathic correction of jaw deformity may require a period of inter-maxillary fixation (IMF) at operation or during the post-operative period. A splint has been designed which may be used for both fixation and localisation of the jaws and which employs a quick release mechanism designed for use during surgery. It may be used also by the patient when intermittent fixation is required post-operatively and by non-medical staff in the event of an emergency such as airway obstruction.

Maxillofacial injuries in the multiply injured.

A survey of patients with maxillofacial injuries (MFI) was carried out in a triaged cohort of multiply injured patients (n = 802) evacuated from accident scenes by the helicopter emergency medical service (HEMS). Despite intubation at accident scenes, some patients required further airway protection on arrival at hospital. One hundred and ninety-six patients (24.5%) had MFI and 90 (11.2%) were classified as severe with ISS of facial region > 2 or more severe (ISS up to 16, median 4). The latter group were commonly found to be associated with other severe injuries (median ISS of 36) leading to death in 41 patients (5.1% of the total). Out of the 196 multiply injured patients with MFI, 57 (29%) had diagnostic peritoneal lavage for suspected haemorrhage, 27 (14%) subsequently underwent laparotomy. Six (3%) had thoracotomies and 29 (15%) had chest drains inserted. Seventeen (9%) had emergency craniotomies and 14 (7%) required intracranial pressure monitoring. Orthopaedic injuries were most commonly associated with MFI and 91 patients (46%) underwent surgical interventions. The purpose of the present study was primarily to establish a database for MFI patients with multiple injuries. The longer term objective being to gain evidence for early definitive management of these complicated cases rather than the more traditional expectant policies. In our view delayed management of MFI can rarely correct all the consequent facial deformities.

The ISG viewing wand: an application to atlanto-axial cervical surgery using the Le Fort I maxillary osteotomy.

Surgical access to the clivus and upper cervical spine may be facilitated by a number of approaches. The Le Fort I maxillary osteotomy has been described to give improved access to the skull base for removal of tumours and treating vertebrobasilar aneurysms. We describe a case in which the combination of a particularly high translocation of the body of C2 and poor mouth opening had precluded a standard transoral approach by restricting access to the operative field. Anterior decompression of the body of C2 was therefore performed via a maxillary down-fracture with the aid of an interactive image guidance system, the ISG Viewing Wand. The ISG Viewing Wand is a new intra-operative 3 dimensional (3D) image guidance system which has now been used in over three hundred neurosurgical cases at Frenchay Hospital, Bristol. We briefly discuss the principles of the viewing wand and describe its unique application providing anatomical navigation in upper cervical spine surgery.

Recurrent compound naevus of gingiva.

A case is described of a compound naevus of the gingiva. It was unusual in that it showed a number of recurrences and these appeared to be related to the hormonal status of the patient.

A simple technique to improve access to the adult palate.

A simple method to facilitate good access to the palate of the adult patient using the Dingman gag is described.

Is peroperative smear cytology necessary for CT-guided stereotaxic biopsy?

Neuropathology is a relatively scarce resource with uneven geographical distribution, and some surgeons rely on macroscopic appearances of tissue and await later paraffin section histology for the final diagnosis. The effect of the introduction of a peroperative cytology service has been assessed in a 5-year series of CT-directed stereotaxic biopsies of intracranial mass lesions using a low cost adapted pre-CT stereotaxic frame. The technique has been mastered by 28 different surgeons with varying degrees of neurosurgical expertise and 259 procedures have been performed in 245 patients. Benign lesions were detected in 24 (9.8%) patients, confirming the importance of making a histological diagnosis prior to initiating treatment. Permanent morbidity was 6.5% and mortality 3.3% and morbidity was balanced by an improvement in 19.6% of the patients following the procedure. For the first 142 patients no peroperative histological diagnosis was available and a diagnostic rate of 86.6% was achieved. For the last 103 patients the availability of peroperative smears improved the diagnostic rate to 94.2% and reduced the number of second biopsies needed for diagnosis from seven to zero. Our series demonstrates the need for peroperative cytology in CT stereotaxic biopsies, and confirms that a complete neuropathology service is a prerequisite for neurosurgical patient care.

An upper cervical spine injury producing paraesthesia in the distribution of the mandibular division of the trigeminal nerve.

A case is reported of a 37-year-old man who developed paraesthesia in the distribution of the mandibular division of the trigeminal nerve following an injury to the upper cervical spine during a game of rugby. The central pathways of the trigeminal nerve are discussed and it is proposed that mandibular fibres descended beyond their expected level in the spinal trigeminal nucleus, and that it was these fibres which were compressed in the unstable dislocation at the atlanto-axial joint producing the paraesthesia described. Other remote anatomical explanations for the paraesthesia are considered.