Short versus long-segment posterior fixation in the treatment of thoracolumbar junction fractures: a comparison of outcomes.

PURPOSE: To compare clinical and radiological outcomes between short (SSPF) and long-segment (LSPF) posterior fixation for thoracolumbar junction (TLJ) fractures. MATERIALS AND METHODS: Retrospective review of adult patients, with single-level, TLJ (T11-L2) fractures, treated with posterior fixation between 2007 and 2014 at a regional spinal centre. SSPF and LSPF were defined as transpedicular screw fixation at one and two levels above and below the fractured vertebra, respectively. Construct failure was defined as instrument breakage or screw pull-out requiring operative intervention. Two independent assessors measured the kyphotic Cobb angle at up to six months. RESULTS: A total of 28 patients were included with a median age of 38 years (range 20-76 years) and median follow-up period of 14 months (4-41 months). All patients sustained traumatic fractures and the male to female ratio was 19:9. AO fracture classes were: A (29%), B (50%) and C (21%). SSPF and LSPF were performed in 17 (61%) and 11 (39%) patients, respectively. There was no significant difference in age (Fisher's exact, p > 0.99), AO fracture class (chi-squared, p = 0.510), preop TLICS score (independent t-test, p = 0.668) and length of stay (independent t-test, p = 0.106) between the groups. Construct failure occurred in three SSPF cases (3-14 months postop) and was associated with an increased mean loss of correction. By six months, the Cobb angle had increased significantly in the SSPF group (paired t-test, p = 0.049), but not the LSPF group (paired t-test, p = 0.157). CONCLUSIONS: Our data identified a trend towards better clinical and radiological outcomes in the LSPF, compared to the SSPF group. Although supported by some studies, these findings should be evaluated in future clinical trials.

Conservative management of type II and III odontoid fractures in the elderly at a regional spine centre: A prospective and retrospective cohort study.

BACKGROUND: The optimal management of odontoid fractures in the elderly population is unclear and management of this group of patients is complicated by multiple co-morbidities. This study aimed to determine the outcomes after conservative management strategies were applied in this patient group. METHODS: We carried out retrospective and prospective analyses of all patients with axial cervical spine injuries, at a single centre. We included patients aged over 60 years with type II and III odontoid fractures. Information was gathered on demographics, ASA grading-associated injuries and complications. The outcome measures were rates and type of union, pain and neurological functions, specifically ambulation. RESULTS: Fifty-seven adult patients with a median age of 78 years (range 60-92 years) were included. There were 42 type II and 15 type III odontoid fractures. Three patients required surgical fixation due to displaced fractures, which could not be reduced with manual traction. Twenty-four (41%) patients were managed with a rigid pinned halo orthosis to obtain adequate reduction and immobilisation. The remaining 30 (53%) were managed in a hard cervical collar. Patients managed with a halo were significantly younger and had more associated injuries than patients managed in a collar (age: t-test=4.05, p<0.01, associated injuries: Chi-square=4.38, p<0.05). At a mean follow-up of 25 weeks, 87% of type II and 100% of type III fractures had achieved bony union or stable, fibrous non-union. There were no statistical differences in fracture type, follow-up or neurological outcomes between the halo and collar groups. However, overall more patients managed in a collar developed stable fibrous non-union than bony fusion (Fisher's exact test, p<0.05), although this was not significant when analysed by each fracture type individually. A regression model was constructed and identified fracture type as the only independent predictor of time to union, with type III fractures healing faster than type II. CONCLUSIONS: High rates of bony union and stable fibrous non-union with a good functional outcome can be achieved in the elderly population sustaining type II or III odontoid fractures, when managed non-surgically. Halo orthosis may not offer any clear advantage over hard collar in this group. Close follow-up is needed for late complications and there must be a willingness to perform surgery if conservative measures fail.

Spontaneous and recurrent subdural haematoma in a patient with May-Hegglin anomaly.

Both acute and chronic subdural haematomas typically occur following trauma. Non-traumatic causes are less common, but aetiologies include arteriovenous malformation, intracranial aneurysm rupture, tumour-associated haemorrhage and coagulopathies. May-Hegglin anomaly is an example of a coagulopathy, which is caused by a mutation in the gene encoding non-muscle myosin heavy chain 9 (MYH9) and therefore falls into a group of diseases referred to as MYH9-related diseases (MYH9-RD). The symptomology of MYH9-RD is often mild, and patients tend to experience epistaxis, gingival bleeding and bruising. Life-threatening haemorrhage rarely occurs. In this short report, we describe a patient with known May-Hegglin anomaly who presented with a potentially life-threatening, spontaneous subdural haematoma requiring surgery on two occasions. This is only the second such report in the literature, and the first of spontaneous and recurrent haemorrhage in association with May-Hegglin anomaly.

The long-term outcome of microvascular decompression for trigeminal neuralgia.

OBJECTIVE: Evaluation of the effectiveness of Microvascular Decompression (MVD) for Trigeminal Neuralgia (TGN), with emphasis on patient's perception of outcome, and satisfaction with the procedure. MATERIALS AND METHODS: A cohort of 372 MVD operations carried out between 1982 and 2005 were reviewed, contact could be attempted with 319 patients. Questionnaires assessing the patient's perception of outcome returned by 266 patients (71%). statistical analysis of the data was carried out using a cox proportional-hazard regression analysis. Anticipated outcome measures: Time to pain recurrence; predictive value of imaging, operative findings and complications; patients' satisfaction, and outcome of revision MVD. RESULTS: Complete pain relief (off medication) achieved in 71% of patients at 10 years. Overall 84% of responders to questionnaires expressed satisfaction with the operative outcome, the mean duration of TGN was 80 months and mean post-operative follow-up of 7 years. No mortality reported in this series. CONCLUSION: This is a large review of MVD, which confirms the long-term effectiveness of the procedure, and uniquely reflects patient's perception of the operation. Predictors of favourable outcome were shorter preoperative duration of TGN, older age at time of MVD, typical features, and vascular compression; moreover, complications, and previous neurodestructive procedures did not show significant effect on long-term pain relief. Satisfaction with MVD was exclusively related to long-term pain relief without medications.

Management Challenges of Metastatic Spinal Cord Compression in Pregnancy.

Primary and secondary spinal tumours with cord compression often represent a challenging condition for the patient and clinicians alike, even more so during pregnancy. The balance between safe delivery of a healthy baby and management of the mother's disease bears many clinical, psychological, and ethical dilemmas. Pregnancy sets a conflict between the optimal surgical and oncological managements of the mother's tumour and the well-being of her foetus. We followed the CARE guidelines from the EQUATOR Network to report an exemplificative case of a 39-year-old woman with a 10-year history of breast cancer, presenting in the second trimester of her first pregnancy with acute onset severe thoracic spinal instability, causing mechanical pain and weakness in lower limbs. Neuroradiological investigations revealed multilevel spinal deposits with a pathological T10 fracture responsible for spinal cord compression. The patient was adamant that she wanted a continuation of the pregnancy and her baby delivered. After discussion with her oncologist and obstetrician, we agreed to perform emergency spinal surgery-decompression and instrumented fixation. The literature search did not reveal a similar case of spinal metastatic breast cancer undergoing spinal instrumentation and delivery of a healthy baby a few months later. Following the delivery, the patient had further oncological treatment, including chemotherapy and radiotherapy. The paucity of such reports prompted us to present this case and highlight the relevance of a multidisciplinary approach involving obstetrician, oncologist, spinal surgeon, and radiologist to guide the optimal decision-making process.

Educational section: picture quiz. Cervical spine.

The picture quiz provides questions on the mechanism of cervical spine injuries and related radiological findings.

External Immobilization of Odontoid Fractures: A Systematic Review to Compare the Halo and Hard Collar.

BACKGROUND: The aim of this systematic review was to compare the halo and hard collar in the management of adult odontoid fractures. METHODS: Systematic and independent searches on MEDLINE (PubMed) and the Cochrane Database of Systematic Reviews. Inclusion criteria included studies 1) with clinical outcomes, 2) in adults (18 years of age or order), 3) with odontoid fractures, 4) with patients immobilized using a halo or hard collar, and 5) in multiple (more than 5) patients. Treatment failure rates were calculated as the proportion requiring operative intervention. RESULTS: There were 714 cases included, who were managed in a halo (60%) or collar (40%). The mean age was 66 years (range, 18-96 years). Type 2 odontoid fractures were the most common (83%). There was no significant difference in failure rates between the halo and collar in patients with type 2 odontoid fractures (P = 0.111). This was also true in elderly (older than 65 years of age) patients (P = 0.802). The collar had a higher failure rate in type 3 odontoid fractures, though numbers were small (P = 0.035). Fibrous malunion occurred in 56 patients, and only 7% failed. There was only 1 case of neurological deterioration. Although mortality rates were similar between the collar and halo (P = 0.173), the halo was associated with a significantly higher complication rate (P < 0.001). CONCLUSIONS: For the most common clinical scenario, the halo and collar have similar failure rates, such that the higher morbidity associated with the halo may not be justified, especially in elderly patients. Malunion usually represents a stable clinical outcome, and surgery is rarely required. Prospective randomized studies are needed to more definitively compare the devices.

External ventricular drains: is there a time limit in children?

BACKGROUND/PURPOSE: The time limit for the use of external ventricular drains (EVDs) has always been controversial. The purpose of this study is to find out if there is a time limit with regard to infection of EVDs and their duration of use in children. METHODS: The records of 28 patients who had a total of 46 EVDs over a 4-year period at the Regional Paediatric Neurosurgical Centre at the Royal Liverpool Children's Hospital, Alder Hey, Liverpool, UK, were retrieved. The cerebrospinal fluid (CSF) white cell counts, CSF Gram stains and the CSF culture results were analysed. CONCLUSION: There is no time limit for EVDs in children. They can be left as long as clinically indicated provided strict protocols are followed in the handling of the set.