Variation in surgical opinion regarding management of selected cervical spine injuries. A preliminary study.

STUDY DESIGN: The opinions of orthopedic surgeons and neurosurgeons were compared regarding appropriate management of selected cervical injuries and the timing of stabilization. OBJECTIVE: To determine whether there is consistency of opinion regarding the management of cervical trauma. SUMMARY OF BACKGROUND DATA: Numerous forms of management for cervical trauma exist, but there are few consistent recommendations. No previous study has been done to determine uniformity of preferences of the surgeons who manage these injuries. METHODS: Thirty-one orthopedic surgeons and neurosurgeons were given a brief clinical situation and pertinent radiographic studies of five selected cervical injuries. Management options included halo and nonhalo orthoses, traction, and various forms of anterior and/or posterior procedures. The surgeons rated, in whole numbers from 1 to 10, their opinions on the appropriateness of each technique. Each surgeon was given a case of a "generic" cervical injury, in which stabilization was required and for which preoperative alignment was adequate in traction. They gave opinions on the timing of stabilization, with a choice of four time frames. Four neurologic situations were rated, ranging from intact to complete cord injury. RESULTS: Of 46 possible responses to the five test cases regarding appropriateness, 18 ranged from 1 to 10, the largest possible variation. Only 2 had a range of 5 or less, implying better consensus among tested surgeons. Mean values ranged from 1.9 to 9.5. Agreementamong respondents regarding appropriateness was slight with a range of kappa statistics from 0.09 to 0.14. Of 16 possible responses regarding timing, 14 were within a range of 8 or higher. Within 24 to 72 hours was the generally preferred time frame, with all possible responses showing a range of 3 or 4. Results of a multiple analysis of variance showed no significant differences among respondents. CONCLUSION: There is a large variety of opinion regarding appropriateness of specific operative and nonoperative management procedures and surgical timing among the surgeons polled who manage cervical trauma. This implies that there is no widely accepted standard management procedure for many of these injuries.

Continuous intrathecal meperidine via an implantable infusion pump for chronic, nonmalignant pain.

OBJECTIVE: To report a continuous infusion of intrathecal meperidine via an implanted infusion pump for nonmalignant, chronic pain. CASE SUMMARY: A 69-year-old white woman had chronic, nonmalignant low-back pain and bilateral leg pain. Multiple drug therapies and other interventional techniques had failed. The patient achieved significant pain relief by a continuous infusion of intrathecal meperidine via an implanted infusion pump. DISCUSSION: To our knowledge, this is the first report of meperidine administered intrathecally by continuous infusion. Continuous infusion of intrathecal and epidural opiates by implanted infusion pumps is becoming more widely recognized as an alternative treatment for patients with chronic, benign pain. Epidural and intrathecal meperidine is an effective analgesic for short-term surgical procedures. Data reporting effective relief and safety with continuous intrathecal meperidine remain limited. CONCLUSIONS: Continuous intrathecal meperidine via an implantable infusion pump may be an effective alternative in the treatment of chronic pain.

Retropharyngeal pseudomeningocele after atlanto-occipital dislocation: report of two cases.

OBJECTIVE AND IMPORTANCE: We report two cases of retropharyngeal pseudomeningocele after atlanto-occipital dislocation. This is rare, with only one other reported case in the literature. CLINICAL PRESENTATION: We report two patients who presented after blunt cervical and head trauma. Plain films revealed that each patient had atlanto-occipital dislocation. Subsequent magnetic resonance imaging revealed the delayed development of retropharyngeal pseudomeningocele. Concomitant hydrocephalus was noted in both patients. INTERVENTION: The surviving patient showed marked neurological improvement and resolution of his pseudomeningocele after ventriculoperitoneal shunting. CONCLUSION: For patients with closed head injuries who develop posttraumatic pseudomeningocele, we recommend cranial computed tomography to assess for the presence of hydrocephalus. In patients with atlanto-occipital dislocation, delayed neurological deterioration warrants magnetic resonance imaging of the craniocervical junction to rule out posttraumatic pseudomeningocele.

Determination of Kupffer cell Fc receptor function in vivo following injury.

This study was carried out to determine whether Kupffer cell Fc receptor function is depressed after injury. Three approaches to the determination of Fc receptor function were evaluated: IgG-coated erythrocytes (EIgG) were used as the receptor probe with a perfused liver system, EIgG were used as the receptor probe in vivo, and small aggregates of IgG (AIgG) were used as the receptor probe in vivo. Nearly half of the injected dose of EIgG was taken up by the perfused liver (nonrecirculating, serum-free system). In contrast, only 2.6% of erythrocytes not coated with IgG were taken up, and only 5.6% of erythrocytes coated with IgM were taken up by the perfused liver. Thus, there was little nonspecific or complement-dependent uptake of EIgG by the liver. The uptake of EIgG by the perfused liver was depressed following thermal injury, endotoxemia, and the phagocytosis of EIgG. These results were interpreted as indicating that Kupffer cell Fc receptor function was depressed under these conditions. The results obtained with the hepatic uptake of EIgG in vivo were very similar to those with EIgG in the perfused liver. However, since it was found that complement receptors as well as Fc receptors were probably involved in the in vivo clearance of EIgG, these results could be due to a depression of one or both of these receptors. The hepatic uptake of AIgG was not depressed by complement depletion, but was decreased by the injection of large aggregates of IgG. However, the hepatic uptake of AIgG was not depressed following thermal injury, endotoxemia, or the phagocytosis of EIgG. Thus, AIgG was not sensitive to the effects of injury on Kupffer cell function, whereas the uptake of EIgG by the perfused liver may provide an indication of Kupffer cell Fc receptor function. The depression of Kupffer cell Fc receptor function following injury may contribute to the impairment of host defense caused by injury.

Hepatic macrophage complement receptor clearance function following injury.

Previous work has demonstrated that in vivo hepatic macrophage complement receptor clearance function is depressed following thermal injury. The present study was carried out to determine if complement receptor function depression is associated with other states of depressed host defense. Hepatic complement receptor clearance function was determined from the hepatic uptake of rat erythrocytes coated with antierythrocyte IgM (EIgM) in rats. Receptor function was determined following cannulation of a carotid artery, laparotomy plus enterotomy, hemorrhagic shock, trauma, thermal injury, acute bacteremia, acute endotoxemia, and injection of erythrocyte stroma, gelatinized lipid emulsion, or colloidal carbon. Hepatic uptake of EIgM was depressed following each of these experimental interventions except arterial cannulation. This effect was shown not to be due to a decrease in hepatic blood flow or depletion of complement and was therefore due to a depression in hepatic macrophage complement receptor clearance function. Thus, impairment of hepatic macrophage complement receptor function is associated with several states of depressed host defense.

Depression of in vivo clearance function of hepatic macrophage complement receptors following thermal injury.

Previous studies have implicated a role for impaired hepatic macrophage blood clearance function in the increased susceptibility to infection caused by experimental thermal injury. The present study evaluated in vivo hepatic macrophage complement receptor clearance function as a possible factor contributing to impaired hepatic clearance after thermal injury. Rat erythrocytes treated with anti-erythrocyte serum (EA) were used as the test particle in rats. EA were rapidly removed from the circulation primarily by the liver and hepatic uptake of EA was greatly depressed in animals rendered C3 deficient by treatment with cobra venom factor. Thermal injury caused a large depression in the hepatic uptake of EA. It was shown that the depression in the binding of EA to hepatic macrophages was not due to decreased hepatic blood flow, decreased serum complement levels, or increased fluid phase C3b. Also, the depression of the hepatic uptake of EA incubated with serum prior to injection (EAC) was not different from that of EA after thermal injury. On this basis it was concluded that the impairment in binding of EA to the macrophages was at the cellular level and represented a depression in complement receptor clearance function. Additional studies showed that the injection of erythrocyte stroma, as a model of intravascular hemolysis, also depressed in vivo hepatic macrophage complement receptor clearance function. This latter finding suggests that the intravascular hemolysis caused by thermal injury may contribute to the depression of macrophage receptor function. The depression of hepatic macrophage complement receptor clearance function may contribute to the impaired bacterial clearance and increased susceptibility to infection following experimental thermal injury.