Management of acute 'pink pulseless' hand in pediatric supracondylar fractures of the humerus.

The management of a persistent pink pulseless hand after a satisfactory closed reduction in a pediatric supracondylar fracture of the humerus is controversial. Several recent publications have recommended vascular exploration in contrast to a more conservative approach accepted traditionally. We report the results of seven patients with a mean follow-up of 36.6 months with a persistent pulseless, but well-perfused hand postreduction. All patients were managed conservatively without vascular exploration. A palpable return of the radial pulse was seen in six patients at 3 weeks and at 6 weeks follow-up in the other patient with no long-term dysfunction. We believe that the management of a persistent pink pulseless hand remains a 'watchful expectancy'. Surgical exploration should be recommended only if there is either severe pain in the forearm persisting for more than 12 h after the injury or if there are signs of a deteriorating neurological function.

Novel technique of reduction of a chronic atlantoaxial rotatory fixation using a temporary transverse transatlantal rod.

BACKGROUND CONTEXT: Chronic atlantoaxial rotatory fixation (AARF) is uncommon as acute AARF is easily reduced either spontaneously or by conservative methods. Various anterior and posterior surgical approaches for a chronic AARF have been reported because of the difficulty encountered in obtaining reduction. PURPOSE: To describe a novel technique of reduction of a chronic AARF using a temporary transverse transatlantal rod. STUDY DESIGN: Technical report. METHODS: A 13-year-old girl presented with an 8-month-old chronic AARF with typical torticollis and "cock-robin" posture of the head with a normal neurology. As closed reduction with skull traction for 2 weeks failed to reduce the deformity, the patient underwent C1-C2 fusion. C1 lateral mass and C2 pedicle screws were inserted under computer navigation. A temporary transverse rod across the atlas and axis was placed to secure a three-column fixation to derotate the subluxed atlas into anatomical alignment. Rods were then connected between the C1 lateral masses and the C2 pedicle screws and fusion obtained with autologous iliac crest grafts. RESULT: Anatomic reduction of the atlantoaxial region was obtained without neural compromise, and satisfactory fusion was observed at 6-months follow-up. CONCLUSION: A temporary transatlantal rod provides a secure anchor point for easy maneuverability for reduction of a chronic AARF and has the advantage of being used even in the absence of the posterior arch of the atlas.

Acute spontaneous cervical epidural hematoma with neurological deficit after low-molecular-weight heparin therapy: role of conservative management.

BACKGROUND CONTEXT: Spontaneous spinal hematoma (SSH) after low-molecular-weight heparin (LMWH) therapy is a rare cause of compressive myelopathy with neurological deficit. Emergent surgical decompression is commonly advocated for optimal neurological recovery. Only three cases of spontaneous spinal subdural hematomas after LMWH therapy have been reported in the literature, and this is the first report of a spontaneous cervical epidural hematoma (EDH). PURPOSE: To highlight the importance of conservative management in an unusual case of cervical EDH with neurological deficit after LMWH therapy. STUDY DESIGN: Clinical case report. METHODS: A 65-year-old man presented with weakness of upper and lower limbs with bowel and bladder dysfunction after LMWH therapy for an acute coronary syndrome. Magnetic resonance imaging (MRI) revealed an anterior cervical EDH extending from C4 to T1 with significant cord compression. Associated comorbidities precluded emergent surgical intervention, and the patient was managed conservatively with cessation of LMWH therapy. RESULTS: The patient showed signs of early neurological recovery within 24 hours (ASIA C [American Spinal Injury Association] to ASIA D) of cessation of LMWH, and hence surgery was deferred. Complete motor and sensory recovery was observed at 1-month follow up with resolution of the cervical EDH without any cord compression evident on the MRI. CONCLUSIONS: LMWH therapy is an important cause of SSH leading to significant neurological deficits. Conservative management is a viable treatment option in patients who demonstrate early and sustained neurological recovery with the cessation of LMWH therapy.

Comparison of prognostic value of different MRI classifications of signal intensity change in cervical spondylotic myelopathy.

BACKGROUND CONTEXT: Signal intensity (SI) changes of the spinal cord on magnetic resonance imaging (MRI) in cervical spondylotic myelopathy (CSM) are thought to be a predictor of surgical outcome. However, the clinical significance of SI change remains controversial. Although several classifications exist for SI change, there are no previous studies comparing their prognostic significance. PURPOSE: To determine the MRI classification of SI changes in patients with CSM that is useful for prognostication of surgical outcome. STUDY DESIGN: Retrospective case study. PATIENT SAMPLE: Patients who underwent cervical laminectomy for CSM between the time period of January 2000 and December 2005. OUTCOME MEASURE: Clinical outcome was measured by the recovery rate (RR) and the postoperative Nurick grade. METHODS: We retrospectively studied 35 of the 77 CSM patients (mean age, 57.8 years; range, 30-69; preoperative symptom duration, 9.3 months) who underwent cervical laminectomy and who met the inclusion criteria. Postoperative MRIs were performed at a mean of 51.3 months postsurgery to assess for resolution of preoperative signal changes. The pattern of spinal cord SI was classified in three different ways: based on high SI on T2-weighted images (T2WI) (Grade 0-absent, Grade 1-obscure, and Grade 2-intense); based on the extent of SI change on T2WI into focal (confined to one disc level) and multisegmental (more than one disc level); and based on T1-weighted image (T1WI) and T2WI changes into Group A (MRI normal/normal), no intramedullary SI abnormality on T1WI or T2WI; Group B (MRI normal/high SI), no intramedullary SI abnormality on T1WI and high intramedullary SI on T2WI; Group C (MRI low/high SI changes), low-intensity intramedullary signal abnormality on T1WI and high-intensity intramedullary signal abnormality on T2WI. Preoperative clinical findings and MRI abnormalities were correlated with outcomes (Nurick scores, RR) after surgical intervention. RESULTS: Preoperative MRI studies demonstrated the following: Grade 0=1, Grade 1=13, Grade 2=13; focal=18, multisegmental=16; Group A=1; Group B=29; and Group C=5. Resolution of signal changes in T2WI was seen in most patients; however, four patients developed low SI in T1WI in the postoperative MRI. There was no significant difference in the RRs of patients with different grades in the T2WI or with focal or multisegmental SI changes (p=.47 and .28, respectively). In contrast, patients with low SI changes in T1WI were associated with a poor surgical outcome (p<.001). The linear regression model performed using low-intensity signal changes as a dependent variable and the RR as an independent variable confirmed the significance (p<.001) of low SI changes on T1WI as a predictor for surgical outcome. CONCLUSIONS: A classification system of MRI signal changes that accommodates both T1WI and T2WI is more predictive of surgical outcome than those that include T2W SI changes alone. Postoperative MRI is useful to identify late onset of low T1W intensity changes in patients with poor neurological recovery.

Isolated extraosseous epidural myeloma presenting with thoracic compressive myelopathy.

BACKGROUND CONTEXT: Multiple myeloma is the commonest primary malignancy of the spine, but it rarely presents as an extraosseous epidural tumor with only five cases reported in literature so far. PURPOSE: The purpose of this study was to heighten awareness and treatment options of a rare case of extraosseous epidural myeloma. STUDY DESIGN: The study design comprises a case report and literature review. METHODS: We present a 60-year-old lady with progressive paraplegia (American Spinal Injury Association grade C) with sensory blunting below T8 level of 2 months' duration. Magnetic resonance imaging showed an extradural tumor in the dorsal epidural space from T6 to T7 without local bony involvement. She underwent a T6 and T7 laminectomy, T5-T8 pedicle screw instrumentation, and gross total resection of tumor. Histopathological diagnosis was consistent with myeloma. After surgery, the patient underwent local irradiation and adjuvant chemotherapy. RESULTS: Neurological improvement of one grade (American Spinal Injury Association grade C to D) was observed at 3 weeks postoperatively. CONCLUSIONS: Isolated extraosseous epidural myeloma without destruction or collapse of vertebral bodies should be included in the differential diagnosis of epidural mass lesions causing spinal cord compression. The overall prognosis in terms of survival is poor, but early decompression can prevent neurological deterioration and improve quality of life.

Isolated tuberculosis of the lumbar apophyseal joint.

BACKGROUND CONTEXT: Posterior element tuberculosis is rare accounting for only 3% to 5% of all spinal tuberculosis. To our knowledge, no case of isolated facet joint tuberculosis with coronal decompensation has been reported in literature so far. PURPOSE: The purpose of this study was to describe a case of tuberculous arthritis of the lumbar facet joint and its effect on coronal balance of the spine. STUDY DESIGN: The study design was a case report. METHODS: A 14-year-old boy presented with a 3-month history of back pain without radiation and with normal neurological findings. Computed tomography and magnetic resonance imaging showed destruction of the right L4-L5 facet joint with L5-S1 spondylolytic listhesis. Despite 2 months of antitubercular medication after a core biopsy confirmation of L4-L5 facet tuberculosis, there was progression of coronal decompensation of the spine with severe pain. Instrumentation with intertransverse fusion was done as a secondary procedure. RESULTS: The patient was completely relieved of symptoms after instrumented fusion along with antitubercular medication. CONCLUSION: Isolated lumbar facet joint tuberculosis is a rare entity with a potential for coronal decompensation of the spine, which makes early instrumented fusion with antitubercular medication a viable treatment modality.

Diffusion tensor imaging in horizontal gaze palsy with progressive scoliosis.

Horizontal gaze palsy with progressive scoliosis (HGPPS) is a rare disorder characterized by absence of conjugate horizontal eye movements, preservation of vertical gaze and convergence, progressive scoliosis developing in childhood and adolescence. It is caused by mutations in the ROBO3 gene which are critical for the crossing of long ascending medial lemniscal and descending corticospinal tracts in the medulla. Diffusion tensor imaging on a 14-year-old boy with HGPPS revealed ipsilateral ascending and descending connectivity in the brainstem without any crossing over of the major tracts although normal interhemispheric connections in the corpus callosum was demonstrable. Absent decussation of smaller sized superior cerebellar peduncles but with normal crossing over of the middle cerebellar peduncle was also observed. Tractography is a valuable investigative modality to assess neuronal connections in the brain and is a useful adjunct to the structural magnetic resonance imaging in confirming the diagnosis of HGPPS.

Pediatric transverse sacral fracture with cauda equina syndrome.

BACKGROUND CONTEXT: Transverse sacral fracture in pediatric patients is extremely uncommon with only nine cases reported in literature so far. PURPOSE: The purpose of this study was to heighten awareness and treatment options of a rare injury of traumatic pediatric transverse sacral fracture with cauda equina syndrome. STUDY DESIGN: This is a clinical case report and literature review. METHODS: We report a case of a 13-year-old girl with a Type III Roy-Camille, Zone III Denis sacral fracture whose only neurological deficit was a cauda equina syndrome with bowel and bladder involvement. She underwent emergent sacral laminectomy and surgical stabilization to decompress the cauda equina. RESULTS: The patient regained bowel and bladder function at 6-month follow-up. CONCLUSIONS: This case is presented to highlight the rarity of a pediatric transverse sacral fracture, which requires a high index of suspicion as early decompression helps in reversing the neurological deficit.