Cervical spinal cord compression and the Hoffmann sign.

Little information exists about the ability of the Hoffmann sign to predict cervical spinal cord compression. The objective of this study was to determine the correlation between the Hoffmann sign and cervical spinal cord compression in a consecutive series of patients seen by a single spine surgeon. All new patients with complaints related to their cervical spine were included. Hoffmann sign was elicited by flicking the nail of the middle finger. Any flexion of the ipsilateral thumb and/or index finger was considered positive. All imaging studies were reviewed for spinal cord compression. Cord compression was defined as flattening of the AP diameter of the spinal cord coexisting with obliteration of CSF around the cord compared to normal levels. Of 165 patients, 124 patients had imaging of their spinal canal. Review by the spine surgeon found sensitivity of the Hoffmann sign relative to cord compression was 58%, specificity 78%, positive predictive value 62%, negative predictive value 75%. 49 studies were also read by a "blinded" neuroradiologist, the sensitivity was 33%, specificity 59%, positive predictive value, 26%, negative predictive value 67%. Although attractive as a simple method of screening for cervical spinal cord compression, the Hoffmann sign, in the absence of other clinical findings, is not in our experience a reliable test.

Electrical muscle stimulation as an adjunct to exercise therapy in the treatment of nonacute low back pain: a randomized trial.

A prospective, randomized, double-blind, placebo-controlled clinical trial was performed to investigate the efficacy of electrical muscle stimulation when combined with a therapist-guided, standardized exercise therapy program in the treatment of nonacute low back pain. Eighty patients with low back pain of at least 6 weeks' duration were randomized into the following 2 groups: standardized exercise therapy with functional electrical muscle stimulation or standardized exercise therapy with placebo electrical stimulation. Subjects were evaluated at baseline, 2 months, and 6 months with a standardized back pain questionnaire and objective measurements of lumbar spine function. Exercise therapy was continued for 6 months, but electrical stimulation was discontinued at the 2-month interval. Of the 80 patients initially enrolled, 42 discontinued or withdrew before completing the entire study protocol. At the 2-month follow-up interval, subjects in the treatment group had statistically significantly improved lumbar spine function compared with the control subjects. This effect continued during the last 4 months of the study after electrical stimulation had been discontinued. This suggests that electrical muscle stimulation can be an effective adjunctive treatment modality for nonacute low back pain. The effects of this combined therapy seem to last beyond the duration of electrical stimulation treatment.

Cervical motion after adding a posterior pad to the halo vest.

Investigators have shown that significant segmental motion occurs in patients immobilized in halo vests. One cadaver study showed that this is decreased with a posterior pad added to the construct. To improve nonoperative care of patients with cervical trauma, segmental cervical motion was evaluated in normal volunteers immobilized in a halo vest with and without a posterior pad. Two commonly used methods to measure sagittal angulation were used. Thirty normal volunteers were placed in halo vests by using positioning pins on the cranium. A sphygmomanometer attached to the posterior uprights of the vest inflated to 40 mm Hg was used as a posterior pad at the greatest visible lordosis. Lateral radiographs of the cervical spine were taken with volunteers in the upright and supine positions with and without the posterior pad inflated. Radiographs were randomly sorted and were each read twice by 3 readers. Measurements of the posterior atlantodental interval, sagittal displacement, and sagittal rotation were recorded using 2 different methods: the Buetti-Bauml method, which uses lines drawn along the posterior vertebral bodies, and the method of White and colleagues, which uses lines drawn along the inferior vertebral bodies. Inflation status of the pad showed no statistically significant difference in any of the measured variables. This was true for both methods of measurement. Application of a posterior pad to the halo vest did not show any change in the segmental motion of the cervical spine in normal volunteers.

Distal short segment fixation of thoracolumbar and lumbar injuries.

Fifteen patients with thoracolumbar and lumbar spine injuries were treated between November, 1993, and April, 1996, using a posterior approach that involved short segment distal fixation at or one level below the level of injury. Medical records and radiographs were reviewed for complications, maintenance of correction, repeat surgeries and functional status. Indications for this technique included fractures and ligamentous injuries that did not require direct canal decompression and were without severe comminution. The level of injury was T12 in two patients, L1 in seven patients, L2 in two patients, L3 in three patients, and L4 in one patient. Average age at injury was 29.1 years (range 18-70). The average length of follow-up was 18 months (range 12-32). There were 11 males and four females. One patient presented with incomplete paraplegia; all others were intact to neurologic testing. Posterior instrumentation and fusion were performed in all patients with no attempt at direct decompression. Supplementary infralaminar hooks were used at the distal end in 12 of 15 patients. Mean sagittal plane correction of preoperative deformity was 7.0 degrees (range 1-24). Mean loss of correction on most recent follow-up was 4.4 degrees (range 0-11). There was one deep infection and two known cases of pseudoarthrosis. Four patients underwent hardware removal and one had loss of fixation at the superior end of the construct. No patients lost neurologic function. There were no mechanical complications at the distal end of the fixation. Three patients returned to relatively normal preinjury status, five suffered partial disability, six suffered full disability and one was lost to follow-up. From our review of this relatively small group of patients, short segment fixation distally for selected thoracolumbar and lumbar injuries appears to be a reasonable option.

Variation in surgical opinion regarding management of selected cervical spine injuries. A preliminary study.

STUDY DESIGN: The opinions of orthopedic surgeons and neurosurgeons were compared regarding appropriate management of selected cervical injuries and the timing of stabilization. OBJECTIVE: To determine whether there is consistency of opinion regarding the management of cervical trauma. SUMMARY OF BACKGROUND DATA: Numerous forms of management for cervical trauma exist, but there are few consistent recommendations. No previous study has been done to determine uniformity of preferences of the surgeons who manage these injuries. METHODS: Thirty-one orthopedic surgeons and neurosurgeons were given a brief clinical situation and pertinent radiographic studies of five selected cervical injuries. Management options included halo and nonhalo orthoses, traction, and various forms of anterior and/or posterior procedures. The surgeons rated, in whole numbers from 1 to 10, their opinions on the appropriateness of each technique. Each surgeon was given a case of a "generic" cervical injury, in which stabilization was required and for which preoperative alignment was adequate in traction. They gave opinions on the timing of stabilization, with a choice of four time frames. Four neurologic situations were rated, ranging from intact to complete cord injury. RESULTS: Of 46 possible responses to the five test cases regarding appropriateness, 18 ranged from 1 to 10, the largest possible variation. Only 2 had a range of 5 or less, implying better consensus among tested surgeons. Mean values ranged from 1.9 to 9.5. Agreementamong respondents regarding appropriateness was slight with a range of kappa statistics from 0.09 to 0.14. Of 16 possible responses regarding timing, 14 were within a range of 8 or higher. Within 24 to 72 hours was the generally preferred time frame, with all possible responses showing a range of 3 or 4. Results of a multiple analysis of variance showed no significant differences among respondents. CONCLUSION: There is a large variety of opinion regarding appropriateness of specific operative and nonoperative management procedures and surgical timing among the surgeons polled who manage cervical trauma. This implies that there is no widely accepted standard management procedure for many of these injuries.

Lumbar facet joint infection associated with epidural and paraspinal abscess.

A case of lumbar facet joint infection associated with abscesses of the paraspinal muscles and the epidural space is presented. The infection did not respond to intravenous antibiotic therapy and resolved only after incision and drainage of the epidural space, involved facet joint, and paraspinal musculature. Magnetic resonance imaging, which showed a widened facet joint, epidural abscess, and paraspinal involvement, aided in diagnosis and preoperative planning. This condition is rare, and this report outlines some clinical characteristics of the infection and the usefulness of magnetic resonance imaging in visualizing the extent of the infection.

Complications associated with the halo-vest. A review of 245 cases.

The cases of all patients treated with halo-vests for cervical trauma at the University of Virginia since 1977 were analyzed retrospectively. A standardized chart and radiographic review protocol were used to identify complications associated with the use of the orthosis. Two hundred and forty-five patients satisfied the criteria for inclusion in the study. No patient developed or suffered progression of a neurological deficit while immobilized. Complications included: pneumonia causing death (one patient); loss of reduction or progression of the spinal deformity (23 patients); spinal instability following orthotic immobilization for 3 months (24 patients); pin-track infection (13 patients); migration of anteriorly placed iliac-strut grafts (two patients); cerebrospinal fluid leakage from a halo pinhole (one patient); and miscellaneous (seven patients). The findings indicate several conclusions. The halo-vest protects patients with cervical instability from neurological injury. It does not absolutely immobilize the cervical spine nor does it prevent progressive deformity of malpositioned strut grafts. Even after a 3-month orthotic treatment period, surgery may be required on ligamentous and osseous injuries to provide spinal stability. Elderly kyphotic patients may require custom-made vests. A small subset of patients exists for whom the confining nature of the halo-vest is intolerable for 3 months.

Failure of immobilization of the cervical spine by the halo vest. A report of five cases.

The halo vest is considered by us, as well as by the majority of orthopaedic surgeons, to be the best commercially available orthosis for control of the cervical spine. However, we have seen five patients with posterior ligament injury of the neck who sustained a recurrence of facet dislocation or subluxation while in a halo vest.