The effects of early or direct admission to a specialised spinal injury unit on outcomes after acute traumatic spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: For acute traumatic spinal cord injury (ATSCI), this study aimed to determine differences in outcomes between patient groups stratified by admission time (⩽24 vs >24 h) to the Spinal Injury Unit (SIU) and by the nature of the admission (direct admission to the SIU vs indirect admission via another hospital). We also aimed to measure the effect on time to admission of a 'non-refusal' policy that triggered immediate acceptance of ATSCI cases to the SIU. SETTING: New South Wales, Australia. METHODS: Study population was all adult SCI patients admitted to the Prince of Wales SIU from 1 January 2001 to 31 December 2012. Patients admitted with chronic-stage SCI or with incomplete data for the duration of their stay were excluded. Comparison of outcomes was made between groups according to the setting of admission. Time to admission before and after initiation (2009) of the 'non-refusal' policy was compared. The prevalence of complications, lengths of stay (LOSs) and time to admission were compared by Mann-Whitney non-parametric methods. Count modelling was used to control for confounders of age and gender. RESULTS: A total of 460 cases were identified and 76 were excluded. The early group had fewer pressure areas (41.8% vs 63.2%; P<0.001) and shorter LOS (136 vs 172 days; P<0.001) than the late group. The direct group had fewer pressure areas (35.2% vs 54.9%, P<0.001), deep vein thrombosis (9.9% vs 24.6%, P=0.003) and shorter LOS (124 vs 158 days, P=0.007) than those admitted indirectly. Time to admission was reduced after introduction of the 'non-refusal' policy (1.53 vs 0.63 days; P=0.001). CONCLUSIONS: Early and direct admission to SIU reduced complication rates and LOS. A non-refusal policy reduced time to admission.

A unique approach to fixed occipito-cervico-thoracic deformity.

We discuss a unique approach to a patient who presented with severe kyphosis and laterolisthesis of the cranio-cervico-thoracic spine, following a history of neck trauma 24months prior to presentation. The patient had organized voluntary euthanasia if no treatment could be performed. Our approach included a three-part procedure over a 3-week time interval, including: initial traction, division of anterior neck muscles, multilevel anterior fusion and, finally, posterior occipito-cervico-thoracic fusion. Follow-up at 6months revealed a patient in neutral sagittal and coronal balance of the neck.

Successful cranio-cervical fusion in a patient with Down syndrome.

We present a patient with Down syndrome with neck pain and severe cervical myelopathy. Imaging revealed occipito-atlantal and atlanto-axial instability with severe spinal cord compression. There are no standardized radiological or clinical guidelines to aid in managing this unique subset of patients. We demonstrate a successful occiput-C3 internal fixation and fusion without complication. Due to the largely unknown natural history and ongoing management difficulties in this population, we demonstrate a case that may aid future decision making for this specialized field. We also discuss an approach to reduce this deformity, which, to our knowledge, has not been published before.

The historical evolution of the management of spinal cord injury.

The history of spinal cord injury (SCI) is long and fascinating. From Ancient Egypt to the current day, SCI has gradually shifted from being seen as an inevitably fatal condition, to one most amenable to treatment, albeit not yet cure. Several controversies have paved the path of this condition's history, from the question of whether to treat, to the optimal timing of surgical intervention, to the potential of recent novel therapies. This article traces the major developments in the management of SCI, in addition to many broader historical developments relating to SCI.

Unrecognized ligamentous instability due to high-energy, low-velocity mechanism of injury.

We report a unique mechanism of injury and illustrate the difficulties of diagnosing purely ligamentous injuries to the cervical spine. To our knowledge, there have been no previous reports of this type of high-energy, low-velocity mechanism of injury. The pattern of injury is also unusual, consisting of anterolisthesis of L4 on L5 with bilateral perched facet joints, atlantoaxial instability and bilateral lower limb fractures. We present a 49-year-old man who experienced a high-energy, low-velocity crush injury that led to extreme hyperflexion of his spine. Standard trauma protocols were carried out, yet atlantoaxial instability was not diagnosed until 3 days post-operatively, when the patient went into respiratory failure due to high spinal cord compression. We fused the C1/2 vertebral bodies using Harm's technique; the patient exhibited no long-term spinal cord dysfunction. Although uncommon, if left undiagnosed or not considered, purely ligamentous injuries to the cervical spine can result in catastrophic complications. Such injuries are an important subgroup to be considered at the time of initial assessment. Furthermore, when managing the multi-trauma patient, clinicians must remember not to overlook the atlantoaxial joint, as high-energy, low-velocity injury to the cervical spine may lead to silent, life-threatening instability that may not be apparent on routine imaging.

Peripheral nerve stimulation for the treatment of chronic pain.

The aim of this retrospective study is to evaluate the role of the implanted peripheral nerve stimulator in patients with pain in a peripheral nerve distribution. The current study is the largest in the literature that examines the role of the implantable peripheral nerve stimulator in the chronic pain patient. Our patient sample included 38 patients (with 41 nerve stimulators), consisting of 19 males and 19 females with a mean age of 44 years (SD=11 years). Four groups of etiologic factors were identified; blunt or sharp nerve trauma (14/38), iatrogenic injuries from surgery (9/38), inadvertent injection of a nerve (9/38) and post surgery for entrapment or tumour (8/38). Stimulation was attempted in 45 patients, but an initial trial failed in 4. Mean follow-up time from implantation of the stimulator was 31 months (SD=19 months). Compensation benefit was an issue in 29 cases (76%). Outcome following implantation was assessed based on pain criteria, narcotic usage and return to normal function/ work. Relief from preoperative pain was judged as good (>50% relief) by 23/38 patients (61%). A total of 15 patients reported fair or poor results (39%). Six patients required removal of their stimulators (15%) due to infection or reduction of pain control after an initial good result. A statistically significant decrease in reported pain level was found postoperatively (p<0.05). Workers' compensation patients have equivalent outcomes to non-compensable patients (p>0.05). Eighteen of 38 (47%) patients reported a significant improvement in their activity levels following stimulator implant. In conclusion, over 60% of patients had a significant improvement in their pain and lifestyle following implantation of peripheral nerve stimulators. We therefore conclude that peripheral nerve stimulation can be useful in decreasing pain in well selected patients with severe pain in the distribution of a peripheral nerve.

Endoscopic-assisted sciatic nerve exploration.

A sciatic nerve lesion is uncommon. We report the utility of the endoscope in an 18-year-old female with multiple lesions of her sciatic nerve. Somatosensory evoked potentials and MRI were indicative of a sciatic nerve lesion. We describe a simple technique of endoscopic exploration of the sciatic nerve to assist intraoperative decision making.

Treatment of painful peripheral neuroma by vein implantation.

Painful neuromas form on cutaneous nerves as a result of trauma, pressure, stretch or entrapment. Since the earliest descriptions of neuromas, proposed treatments have been met with poor results and controversy. The myriad of treatments described include: simple division of an affected nerve, implantation into muscle or bone, silicon sleeves and caps, repeated injection of steroids, end-to-side neurorrhaphy, medication and vein caps to name a few. Due to encouraging recent reports of treatment of painful neuromas by vein implantation, the authors describe a simple technique to achieve this surgical goal. As veins are readily accessible due to their proximity in the neurovascular bundle, they serve as a ready source for grafting. The advantages include minimisation of trauma to bone and muscle as compared with previous treatment techniques and the relative ease of the method.

Posterior femoral cutaneous nerve entrapment neuropathy: operative exposure and technique.

An isolated posterior femoral cutaneous nerve lesion is rare. There have been seven reported cases to date. We report a 51-year-old male with pain in the posterolateral thigh, atypical from the classic anatomical description. Somatosensory evoked potentials were suggestive of a posterior femoral cutaneous nerve lesion. We describe our operative exposure and technique for decompression of the posterior femoral cutaneous nerve and include a comparative anatomical explanation for the unusual area of our patient's pain.

Outcome following anterior cervical discectomy in compensation patients.

This is a retrospective study aimed to analyse the clinical outcomes of patients following anterior cervical decompression and fusion for radiculopathy in worker's compensation, third party and non-compensable group. The outcome of 224 cases operated between 1991 to 1998 were analysed. Only patients with radiculopathy due to a cervical disc protrusion and spondylosis were included. There were 140 non-compensable patients, 58 worker's compensation and 26 third party. There was no statistical difference in radiological fusion between the three groups (P=0.46). The worker's compensation and third party claimant groups, had an 'excellent' outcome at 65% and 69% respectively, compared to the non-compensation group at 79% (P=0.042). Rates of poor outcome were high in the worker's compensation group (9%) compared with third party (4%) and the non-compensable group (5%). Financial incentives seem to significantly influence the outcome of cervical disc surgery in our patient population.