Torticollis with Atlantoaxial Rotatory Subluxation in Children: A Clinical Review.

A small proportion of children with a sudden onset torticollis ("wry neck") presents with an atlantoaxial rotatory subluxation, usually after mild trauma or recent head or neck infection. Torticollis is a clinical diagnosis and imaging is usually not indicated, though often performed in clinical practice. Atlantoaxial rotatory subluxation on imaging is often a physiological phenomenon in torticollis, and concomitant neurological symptoms are therefore rare. Treatment is primarily conservative, with analgesics, a rigid neck collar, and if needed benzodiazepines to counteract muscle spasms and anxiety. In case of treatment failure or chronic subluxation, cervical repositioning and fixation under general anesthesia may be considered. Surgical treatment is only indicated in a small percentage of patients with chronic refractory subluxation, concomitant cervical fractures, or congenital anomalies. Early diagnosis and treatment are important, since this is associated with a more successful conservative outcome than a prolonged approach.

Complete Traumatic Spinal Cord Injury: Current Insights Regarding Timing of Surgery and Level of Injury.

STUDY DESIGN: A narrative literature review. OBJECTIVES: To review the neurological recovery patterns in traumatic spinal cord injury (tSCI) patients with a complete lack of motor and sensory function below the level of injury (ie, ASIA A [American Spinal Injury Association scale]), as well as the impact of level of injury and timing of surgical intervention. RESULTS: Spontaneous neurological recovery in patients with complete tSCI differs per level of injury: patients with cervical and thoracolumbar tSCI recover ≥1 ASIA grade in 17.3% to 34.0% 1 year after injury, compared with 10.7% to 18.6% in thoracic tSCI. Surgical decompression within 24 hours has a beneficial effect on neurological recovery in patients with complete cervical tSCI, whereas this effect is less clear for thoracic and thoracolumbar tSCI. A 1- or 2-grade improvement in the ASIA scale does not necessarily result in functional recovery. CONCLUSION: In complete tSCI, the level of injury as well as surgical timing affect neurological recovery. There appears to be a beneficial effect of early surgical decompression in patients with complete cervical tSCI, more so than for thoracic and thoracolumbar tSCI. Frequently, the effect of surgical intervention is evaluated by an improvement in ASIA grade, but it is unclear whether this scale is sensitive enough to evaluate meaningful effectiveness of the intervention and desired outcome for patients with tSCI.

Impact of Early (<24 h) Surgical Decompression on Neurological Recovery in Thoracic Spinal Cord Injury: A Meta-Analysis.

The impact of surgical timing in neurological recovery in thoracic and thoracolumbar traumatic spinal cord injury (tSCI) is still a subject of discussion. While in cervical tSCI one may expect a beneficial effect of early intervention within 24 h, especially in complete cases, this has not yet been demonstrated clearly for thoracic tSCI. This study addresses neurological improvement after early and late surgery for thoracic and thoracolumbar tSCI. A systematic search retrieved 14 publications of observational studies reporting outcome measurements after surgery in 1075 patients with thoracic and thoracolumbar tSCI from PubMed and Embase databases. Surgery was considered early within 24 h and late thereafter. An improvement of at least one and two grades on the American Spinal Injury Association Impairment Scale (ASIA) was evaluated. The Meta-Analyses and Systematic Reviews of Observational Studies guidelines were followed. Improvement rates were summarized using individual patient data in a Bayesian random effects model and compared for those with early and late surgery. In the qualitative analysis, six of seven studies, which investigated the effect of surgical timing, observed a significant effect of early surgery on at least one ASIA grade improvement. Quantitative analysis in 948 patients with thoracic and thoracolumbar tSCI data, however, did not reveal a significant increase in odds of ≥1 ASIA grade recovery in early surgery (66.8% [95% confidence interval (CI): 45.0-87.8%] compared with late surgery (48.9% [95% CI: 25.1-70.7%; odds ratio (OR) 2.2 (95% CI: 0.6-14.0]). This study did not observe a significant beneficial effect of surgical decompression within 24 h in patients with thoracic and thoracolumbar tSCI.

Severe kyphosis with spinal cord compression after resection of a superior sulcus tumor.

Vertebral involvement is no longer a contraindication for resection of superior sulcus tumors. We describe a patient who developed a kyphoscoliosis with spinal cord compression after resection of a superior sulcus tumor that invaded the vertebral column. Risk factors for spinal instability and indications for stabilization are discussed.

In situ treatment of an infected intrathecal baclofen pump implant with gentamicin-impregnated collagen fleece.

Intrathecal delivery of baclofen using a subcutaneous pump is an effective long-term treatment for spasticity. Infections of the pocket, however, are often hard to eliminate with intravenous antibiotics. If a 2-stage procedure involving removal of the pump and baclofen withdrawal will create serious problems for the patient, infections can be treated with repetitive local application of gentamicin-impregnated collagen fleece.

A basic model for practice of intracranial microsurgery.

BACKGROUND: Intracranial microsurgical procedures often take place in a deep location, with a limited access space, necessitating the use of long knee-bend instruments and limiting the degree of movement. We devised an easily accessible model that allows the neurosurgical trainee to gain familiarity with intracranial microsurgical techniques. METHODS: The model consists of a pedestal, on which 2 movable vices are placed. The object to be practiced on can be placed on a working area, or the vices may hold the object. The pedestal can be covered by a box with a centered hole. When using this box, the vices can move together in the vertical plane over a trajectory of 5.5 cm to simulate superficial or deep microsurgical procedures. To simulate several sizes of hypothetical craniotomies, 3 rings can be used to decrease the diameter of centered hole in the box. RESULTS: Using the model, these techniques were judged to be technically more challenging and difficult to execute through the centered hole. CONCLUSIONS: Our model can be a useful method to train for basic intracranial microsurgery.