In-hospital neurologic deterioration following fractures of the ankylosed spine: a single-institution experience.

OBJECTIVE: To determine the rate and severity of in-hospital neurologic deterioration following vertebral fractures of spinal hyperostosis. METHODS: A retrospective review of 92 fractures in 81 patients with diffuse idiopathic skeletal hyperostosis (42%) or ankylosing spondylitis (58%) was performed. Data on demographics, comorbidities, and fracture and treatment characteristics were recorded. Neurologic presentation and outcomes were categorized using American Spinal Injury Association grades and the modified Rankin Scale. Univariate and multivariate analyses were used to identify risk factors for neurologic deterioration or poor outcome (modified Rankin Scale 4-6). RESULTS: Most fractures (66%) occurred after falls of standing height or less. Presentation was delayed in 41% of patients (median 7 days), and diagnosis was delayed in 21% (median 8 days). Most fractures were extension (60%) or distraction (78%) injuries involving all 3 spinal columns. Median Subaxial Cervical Spine Injury Classification and Thoracolumbar Injury Severity Scale scores were 6 (interquartile range 5-7) and 7 (interquartile range 6-8), respectively. Of patients, 62% underwent open operative fusion either as initial therapy or after failed conservative treatment, 20% had percutaneous instrumentation, and 27% were treated in an external orthosis (52% required open fusion). Neurologic deterioration after presentation occurred in 7 patients (8.6%); 5 of these patients deteriorated after surgical treatment, constituting a 7.6% surgical risk. The presenting American Spinal Injury Association grade and patient age predicted poor outcome at 1-year outcome (P < 0.001). Death occurred in 17 patients within 1 year of injury (23%). CONCLUSIONS: Neurologic deterioration during the initial hospitalization after spinal fractures in the setting of diffuse idiopathic skeletal hyperostosis or ankylosing spondylitis is common, and 1-year mortality is high.

A survey of joint and muscle aches, pain, and stiffness comparing women with and without breast cancer.

CONTEXT: Joint and muscle aches, pain, and stiffness have been reported to be a problem for some women after adjuvant breast cancer treatment; however, the extent and impact of this problem are unknown. OBJECTIVES: The purpose of this study was to determine the prevalence of this problem in comparison with women of a similar age without breast cancer. METHODS: Two hundred forty-seven women attending breast cancer follow-up clinics were invited to complete pain and quality-of-life measures. A comparison group of 274 women of similar age was drawn from women attending breast screening and benign breast clinics. Prevalence and severity of pain were compared between the two groups. RESULTS: The mean age of all women in the study was 59 years (range 30-86 years). The median time since diagnosis of cancer was 28 months (range 2-184 months). Adjuvant treatments included radiotherapy (79%), chemotherapy (45%), and hormone therapy (81%). Sixty-two percent of women with breast cancer reported pain "today" compared with 53% of women without breast cancer (P = 0.023). Significant predictors of pain in both patient groups were cancer, age, and arthritis. For the cancer cases, significant predictors of pain were age, arthritis, taxane chemotherapy, aromatase inhibitors, and tamoxifen. Quality of life (measured by the Short Form-36) was significantly worse for women with breast cancer compared with controls and was significantly worse in the breast cancer cases with pain. CONCLUSION: Treatment with tamoxifen, taxane chemotherapy, and aromatase inhibitors for breast cancer is predictive of joint pain, which may have an impact on women's lives for some years after breast cancer.

Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure.

In surgical treatment of head and neck cancer, when local tumor recurrence or failure of the previous reconstruction method occurs, reoperation for reconstruction of complicated soft-tissue defects can become a challenge for the plastic surgeon. This article describes the authors' experience with the extended vertical trapezius myocutaneous flap for head and neck complicated soft-tissue defects in nine patients ranging in age from 17 to 72 years. The causes of the defects were squamous cell carcinoma of the external ear (n = 2), lip (n = 2), larynx (n = 1), and oral cavity floor (n = 1); congenital hemifacial atrophy-temporomandibular joint ankylosis (n = 1); synovial sarcoma at the mandibular ramus (n = 1); and malignant fibrous histiocytoma at the posterior cranial fossa (n = 1). Eight of the nine patients had previously been operated on using other flap procedures, including free flaps and/or distant pedicled flaps (pectoralis major and deltopectoral flaps). One patient had been operated on using a graft procedure. After failure of the previous flap procedures in four patients and tumor recurrence in five patients, the extended vertical trapezius myocutaneous pedicled flap was used as a salvage procedure. The mean flap size was 7 x 34 cm. The flap was based solely on the transverse cervical artery. Superior muscle fibers of the trapezius were preserved and the caudal end of the flap was extended from 10 to 13 cm beyond the caudal end of the trapezius muscle. Three weeks postoperatively, the pedicle was separated. No flap failure occurred. The donor sites were closed primarily. There were no disabilities with regard to shoulder motion. Tumor recurrence was observed in two patients. In conclusion, for complicated soft-tissue defects of the head and neck, the extended vertical trapezius flap can be preferred as a salvage procedure because it is a simple, reliable, large flap that is located far enough from the damaged area.

Cervical ankylosis with acute spinal cord injury.

Twenty-three cases of acute spinal cord injury in persons with cervical ankylosis are presented. Certain characteristics of major sub-groups are described: ankylosing spondylitis (N = 8), degenerative spondylosis (N = 9) and congenital fusion (congenital non-segmentation) (N = 6). The ankylosing spondylitic group presented a grim prognosis for survival (death rate 50 per cent within 60 days) and for loss of neurological function. Five out of eight cases had permanent neurological loss subsequent to their injuries. Both the ankylosing spondylitic and degenerative spondylotic groups presented problems in diagnosis and medical management. The basic principle is immobilisation of the fracture and mobilisation of the patient. The halo is the technique of choice for fracture immobilisation. An integrated intensive respiratory management programme is essential. Patients with ankylosed spines, particularly those with ankylosing spondylitis, should be educated in simple measures to prevent fracture of their spines.