Patient-reported outcome following nonsurgical management of type II odontoid process fractures in adults.

BACKGROUND: Transverse (type II) odontoid process fracture is among the most commonly encountered cervical spine fractures. Nonsurgical management through external immobilization is occasionally preferred to surgical management but is criticized for its higher rates of failure and lower patient satisfaction. Our aim is to analyze patient-reported outcomes in patients who underwent nonsurgical treatment for type II odontoid fractures. METHODS: We identified patients >18-year-old who underwent external immobilization as a treatment for isolated type II odontoid fracture between 2007 and 2012. We collected demographic parameters, clinical presentation, mode of injury, imaging studies and modality and duration of treatment (soft collar, halo-vest, or both). Patients were contacted by telephone to participate in a 15-min survey addressing their recovery including their subjective rate of return to preinjury level of functioning. RESULTS: Fifteen patients met the inclusion/exclusion criteria and participated in our survey. Patients were followed up for an average of 19 months after injury. Overall mean age was 61 years. Injury followed a mechanical fall or a road traffic accident in 11 and 4 cases, respectively. External immobilization was achieved by halo vest only in nine patients, soft collar only in two patients (13%), and through a sequential combination in the remaining 4 (27%). This was deployed for a mean of 7.8 months. Radiological studies at the last follow-up showed bony healing (27%), fibrous nonunion (60%), and persistent instability (13%). Patients reported gradual recovery of function throughout the 1st year after injury with levels above 70% of preinjury functioning achieved by 13% of patients at 6 months, 33% at 9 months, and 47% at 12 months. Overall satisfaction with nonsurgical management was 68%. CONCLUSION: In selected patients with type II odontoid fractures, external immobilization represents a good option with acceptable course of recovery.

Trigeminofacial reflex: a means of detecting proximity to ophthalmic and maxillary divisions of the trigeminal nerve during surgery.

OBJECT: The aim in this paper was to localize and detect incipient damage to the ophthalmic and maxillary branches of the trigeminal nerve during tumor surgery. METHODS: This was an observational study of patients with skull base, retroorbital, or cavernous sinus tumors warranting dissection toward the cavernous sinus at a university hospital. Stimuli were applied as normal during approach to the cavernous sinus to localize cranial nerves (CNs) III, IV, and VI. Recordings were also obtained from the facial muscles to localize CN VII. The trigeminofacial reflex was sought simply by observing a longer time base routinely. RESULTS: Clear facial electromyography responses were reproduced when stimuli were applied to the region of V1, V2, and V3. Response latency was increased compared with direct CN VII stimuli seen in some cases. Responses gave early warning of approach to these sensory trigeminal branches. CONCLUSIONS: The authors submit this as a new technique, which may improve the chances of preserving trigeminal sensory branches during surgery in this region.

Microvascular decompression for superior oblique myokymia: case report.

BACKGROUND: Superior oblique myokymia (SOM) is a rare disorder in which the patient suffers episodic uniocular torsional eye movement associated with diplopia and oscillopsia . Although the pathophysiology has been narrowed down to erratic discharge of the trochlear nerve, yet the exact etiology remains unclear; a handful of cases have been described in association with an identifiable space occupying lesions or dural AV fistulae. Neurovascular compression theory has been postulated in the early 1980s and to our knowledge, very few reports exist in the literature accrediting this hypothesis in the pathogenesis of superior oblique myokymia. CASE REPORT: We report a case of successful resolution of severe medication refractory SOM following microvascular decompression of the trochlear nerve. The clinical response has been sustained for a follow-up period of 18 months to date. CONCLUSION: Microvascular decompression may be considered as a definitive and least destructive surgical option for the treatment of medication refractory superior oblique myokymia.

C1-C2 transarticular screw fixation for atlantoaxial instability due to rheumatoid arthritis: a seven-year analysis of outcome.

STUDY DESIGN.: Observational study. Retrospective analysis of prospectively collected data. OBJECTIVE.: The purpose of this article was to report long-term (minimum 7 years) clinical and radiologic outcome of our series of patients with Rheumatoid Arthritis who underwent transarticular screw fixation to treat atlantoaxial subluxation. SUMMARY OF BACKGROUND DATA.: The indications for intervention in patients with atlantoaxial instability are pain, myelopathy, and progressive neurologic deficit. The various treatment options available for these patients are isolated C1-C2 fusion, occipitocervical fusion with or without transoral surgery. Review of current literature suggests that C1-C2 transarticular screw fixation has significant functional benefits, although there is discrepancy in this literature regarding improvement in function following surgery. METHODS.: Myelopathy was assessed using Ranawat myelopathy score and Myelopathy Disability Index. Pain scores were assessed using Visual Analogue Scale. The radiologic imaging was assessed and the following data were extracted; atlanto-dens interval, space available for cord, presence of signal change on T2 weighted image, and fusion rates. RESULTS.: Thirty-seven patients, median age 56, were included in the study. Average duration of neck symptoms was 15.8 months. Average duration of rheumatoid arthritis before surgery was 20.6 years. Preoperative symptoms: suboccipital pain in 26 patients; neck pain, 32; myelopathy, 22; and 5 were asymptomatic. After surgery: suboccipital pain, 2; neck pain, 3; and myelopathy, 10. Ninety percent patients with neck and suboccipital pain improved after surgery in their Visual Analogue pain scores, with all of them having >50% improvement in VAS scores (6.94-2.12 [P < 0.05]).Preoperative Ranawat grade was as follows: grade 1 in 15 patients, grade 2 in 7, and grade 3a in 14, grade 3b in 1.After surgery: grade 1 in 27 patients, grade 2 in 7, grade 3a in 1, and grade 3b in 2. The mean myelopathy score improved after surgery (59.62-32.75, P < 0.05).The space available for the cord was improved in 63%, unchanged in 33%, and worse in 4%.Twenty-seven percent had T2 signal change and 18% had cervicomedullary compression; 97% had bony fusion. BILATERAL SCREWS WERE USED IN 33 PATIENTS AND UNILATERAL SCREWS IN 4 PATIENTS (ABERRANT VERTEBRAL ARTERY).: Computer image guidance was used in 73%. CONCLUSION.: C1-C2 transarticular screw fixation is a safe technique for atlantoaxial subluxation for patients with rheumatoid arthritis. This study clearly demonstrates improvement in Visual Analogue Scale, Ranawat grading and the Myelopathy Disability Index even at long-term follow up.

Non-syndromic trigonocephaly: surgical decision making and long-term cosmetic results.

BACKGROUND: Surgical correction is often required for cosmetic correction of trigonocephaly. The purpose of this paper was to report the long-term aesthetic outcome as appreciated by the parents/patients themselves. The self-evaluation of cosmetic outcome after trigonocephaly correction has not previously been reported. The management and different surgical techniques utilized over a 16-year period are discussed. MATERIALS AND METHODS: An observational study was undertaken of the clinical outcome, operative data, complications and cosmetic satisfaction of these trigonocephaly patients. The parents/child were asked to rate their satisfaction with the cosmetic outcome both in terms of head shape and scar appearance, on a five-point scale (excellent-5, very good-4, good-3, fair-2 and poor-1). RESULTS: Sixty-three patients presented with non-syndromic trigonocephaly over the 16 years. Nineteen of 63 had a mild form of trigonocephaly and were managed conservatively. The remainder underwent surgical correction. Forty-two of 44 (95%) underwent fronto-orbital advancement with either barrel staving (26/44) or frontal bone rotation/re-modelling (16/44), with 2 of 44 having burring of the metopic ridge. Head shape rating was regarded as excellent in 25 of 63 (40%), very good in 18 of 63 (28%), good in 18 of 63 (28%) and fair in 2 of 63 (4%). Of those that underwent surgery, the scar was zigzag in 32 of 44 and straight in 12 of 44. Scar was rated as being excellent in 21 of 44 (48%), very good in 12 of 44 (28%) good in 11 of 44 (24%). CONCLUSIONS: Metopic synostosis can result in varying degrees of severity. Milder forms can be treated conservatively, with more severe forms requiring both frontal bone re-modelling and fronto-orbital advancement. Surgical correction results in a high level of patient/parent satisfaction.

Compression of the rostral ventrolateral medulla by a vagal schwannoma of the cerebellomedullary cistern presenting with refractory neurogenic hypertension: case report.

OBJECTIVE: The rostral ventrolateral medulla is thought to serve as a final common pathway for the integration of central cardiovascular information and to be important for the mediation of central pressor responses. An association between essential hypertension and neurovascular compression of the rostral ventrolateral medulla has been reported. This may be mediated by an increase in sympathetic tone. CLINICAL PRESENTATION: Schwannomas arising from the lower cranial nerves (Cranial Nerves IX-XI) are rare, constituting only 3% of all intracranial schwannomas unassociated with neurofibromatosis. The majority of these tumors present as jugular foramen lesions and, less commonly, they occur along the extracranial course of these nerves. An intracisternal location is extremely rare. Fewer than 15 cases of pathologically proven intracisternal vagal schwannomas in the absence of neurofibromatosis have been reported. INTERVENTION: We report a case of vagal schwannoma in the cerebellomedullary cistern causing distortion of the vagal root entry zone and presenting with refractory neurogenic hypertension. Total microsurgical excision of this tumor, arising from one of the rootlets of the vagus nerve, was achieved. Immediately postoperatively, blood pressure decreased markedly, and despite our effort to maintain the blood pressure with fluids, the patient developed a cerebral infarction in the watershed zone. CONCLUSION: We discuss the proposed mechanism of hypertension, and the perioperative management, stressing blood pressure control. A review of the literature regarding vagal schwannomas is also presented. To the best of our knowledge, this is the first case report of a cerebellomedullary cistern vagal schwannoma presenting with neurogenic hypertension.

Behavioral, developmental, and educational problems in children with nonsyndromic trigonocephaly.

OBJECT: The neurobehavioral morbidity of nonsyndromic trigonocephaly is incompletely understood. The purpose of this study was twofold: first, to assess the degree of developmental, educational, and behavioral problems in patients with nonsyndromic trigonocephaly and second, to establish whether patients with mild degrees of trigonocephaly had a lower frequency of such problems. METHODS: The authors performed an observational study of the frequency of developmental, educational, and behavioral problems in 63 children with trigonocephaly at the National Craniofacial Centre in the Republic of Ireland between 1989 and 2004. The parents of the children completed a follow-up questionnaire. Thirty percent of patients had a mild form of trigonocephaly and were treated conservatively. The remainder underwent surgical correction. Speech and/or language delay was reported in 34% of the children. Thirty-three percent of the children needed to be assessed by a school psychologist, and 47% were receiving remedial or resource hours within the school system. Twenty percent of children required a special needs classroom assistant because of behavioral issues, and 37% of parents expressed concerns about their child's behavior. There were no statistically significant differences between children treated with surgery and those who had a mild deformity and were treated conservatively. CONCLUSIONS: Nonsyndromic trigonocephaly is associated with a high frequency of developmental, educational, and behavioral problems. The frequency of these problems is not related to the severity of the trigonocephaly.