Treatment of severe double spinal cord injuries.

This is a case report describing an injury--sustained by a 25-year-old man during a car accident, and characterized by fracture dislocation of the spine at the level of C7 and T4 accompanied by pulmonary contusion. He had an incomplete spinal cord lesion at the level of C7 and a complete lesion at the level of T4 (T4 ASIA A). Imaging of the spine showed three column fractures with ventral spinal cord compression at both levels. Discussants of this case comment on the concept of acute treatment of severe double spinal cord injuries, and present their chosen way of management in this particular case.

Significance of endocrine studies in the general assessment and prediction of fatal outcome in head injury.

Serial basal blood glucose, serum insulin, cortisol, growth hormone, glucagon and catecholamine examinations were performed in 81 brain-injured patients. 32 patients with severe injuries of other parts of the body (chest, abdomen, limbs or polytrauma), and 17 patients with non-traumatic acute brain lesions served as double control. In the brain-injured patients there is a close relation between changes of the state of consciousness and those of basal blood glucose levels: the deeper coma the higher and wider is the pathological glucose-level range. Four types of blood-glucose changes could be identified in the background of which different alterations of each hormone level were observed. Fatal outcome could be predicted in a non-diabetic patient in the first days when seeing: 1) Fasting hyperglycaemia above 14 mmol/l; 2) Fluctuating basal blood glucose levels between 5 and 22 mmol/l; 3) Deeply depressed and unchanged basal insulin level; 4) Extremely high cortisol level; 5) Decreased plasma epinephrine level. These changes in the carbohydrate metabolism seen after acute brain lesions are not identical to diabetes mellitus.

The modern approach of hangman's fracture.

Upper cervical spine injuries associated with the characteristic alterations of the axis are termed by the international literature as hangman's fracture (HF). The specific changes of the clinical picture include fracture of the bilateral pedicles of the axis, dislocation of the arch, luxation and discopathy between the second and third (C2-C3) vertebrae, eventually other accessory fractures of vertebrae C2-C3 (Fig. 1). There are two kinds of it, i.e. (i) one of a hyperextensive-distractive mechanism with the very severe neurological lesion leading to the classical injury due to hanging and (ii) one of a hyperextensive-compressive mechanism without neurological lesion of current traffic injuries or with slight neurological symptoms. The latter more often occurring type of injury encompasses a relatively wide range, which can be classified into three types: The stable injuries can be managed by conservative treatment, the unstable ones by Halo treatment or ventral surgical therapy meeting the up-to-date requirements. Prognosis is good. The authors have been the first in Hungary to present a critical and detailed survey of the world literature and their 11-year experience, in the form of a clinical study.

[Rehabilitation problems in traumatic spinal cord injuries following spinal stabilization using Harrington's fixation device]. / Traumás gerincvelösérültek rehabilitációs problémái Harrington-eszközzel történt gerincstabilizáció után.

Authors describe their experiences in medical rehabilitation of 18 patients with traumatic injuries of the medulla after spinal stabilisation with Harrington instrument. The Harrington method is a classical method for spinal stabilization used in the whole world. Besides its doubtless advantages experiences are gathered on its numerous disadvantages: It is not suitable for direct reduction, its stability is insufficient against flexion and extension forces, its biomechanical characteristics are not the most favourable in respect of consolidation, it is too long and includes healthy sections of the spine in immobilization, finally external fixation is needed. For all this, the claims of modern rehabilitation cannot be fulfilled. In possession of newer, more modern methods (fixateur interne, groove plate) the use of it is not at all recommended.

[Current views on "hangman's fracture"]. / A "Hangman's Fracture" korszerü szemlélete.

The international literature calls "Hangman's fracture" (HF) the injury of the upper cervical spine with characteristic lesions of the epistropheus. The typical bone lesion in this injury is the bilateral fracture of the penduncles of the epistropheus, the dislocation of the arch, the luxation between CII and CIII and the injury of the disk, by chanche other additional fractures of the vertebrae CII and CIII too. Two forms are known: that of hyperextension distraction mechanism, leading to the classical death by hanging with very severe neurological lesion, and that with hyperextension compression mechanism, seen in modern traffic injury without neurological lesion or with relatively mild neurological symptoms. The later injury, seen more and more frequently in our days, appears with a rather broad spectrum and can be divided in three types. The stable injuries can be treated conservatively, the unstable injuries with Halo traction or with anterior operative methods, according to modern requirements. The prognosis is good. Authors describe their experiences, first in the Hungarian literature, gained from a critical review of the world literature and from a 11 years material.

[Early experience with the use of the Halo device in the treatment of damage to the cervical spine]. / Halo-készülékkel szerzett korai tapasztalataink nyaki gerinckórképek kezelése során.

Authors report on their experiences gained in 5 cases with the Halo device. The method of treatment is described. On the basis of a literary overview the field of indication, the advantages and the disadvantages of the method are described. In the assessment of the method it is stressed that according to their opinion this is the best conservative method of treatment, and the results compete with that of the operative treatment.

Ventral spondylodesis: basic method in the treatment of cervical spine injuries.

Ventral spondylodesis or ventrofixation is the most important surgical method for the treatment of severe cervical spine injuries accompanied by instability. Its wide indications include fracture-dislocations, compression fractures of the vertebral body, injuries to the disc, luxations, 'tear drop fractures' as well as "hangman's fractures". The essential parts of its technique: previous reduction by traction, anterior cervical approach, removal of the injured parts of vertebral body and disc(s), replacement by corticocancellous bone graft with subsequent plate-screw fixation. The authors performed in their Institute nearly 100 operations of this type, in a 10-year period of which; detailed account is given. Good results of surgery can be expected only by ensuring adequate technical conditions and professional knowledge, performing the operations in centres having sufficient experience.

Screw fixation of odontoid fractures: preliminary report.

In the period from 1981 to 1985, 32 odontoid fractures were treated in the National Institute of Traumatology. In four cases anterior stabilization was provided with compression screws inserted from the front. Two cases of odontoid fracture are shown, one accompanied by ventral, the other by dorsal dislocation. A brief review is provided of the results obtained with different methods of treatment drawing on the international literature.

Spectrum of operations on the cervical spine in a neurosurgical spinal centre with trauma profile.

A statistical review is given about the treatment in the Neurosurgical Department of our Institute of cervical spine injuries and non-traumatic spinal diseases during 11 years, as well as about the trends of development in spine surgery. The ratio of operative and conservative methods is described, analysing the indications and yearly numbers of different surgical procedures as compared to the data of non-traumatic spinal diseases. Altogether 786 patients were treated, 319 operations were performed on the cervical vertebral column. By the follow-up of different surgical techniques a radical change of attitude has been shown: ventral desis has got the leading role instead of dorsal spondylodesis which formerly used to be the method of choice. In addition, combined dorsal and ventral desis, lateral exposure, screw-fixation of the dens axis and the Halo-method are important techniques of the up-to-date treatment in special types of injuries.

Up-to-date method of treatment of most frequent axis-injuries: screw-fixation of the odontoid fractures.

In the period from 1981 to 1985, 32 odontoid fractures were treated in the National Institute of Traumatology. In 4 cases anterior stabilization was made with compression-screws from the ventral approach. Two cases of odontoid fractures are shown, one accompanied by ventral, the other by dorsal dislocation. A brief review of the results with different methods of treatment is given on the basis of the international literature.

Fixateur interne--new method for segmental stabilization of the thoracolumbar spine.

The Fixateur Interne (F.I.) is a new device developed by W. Dick and F. Magerl for the internal fixation of the thoracolumbar spine. This is a completely new system since it does not act as a four point bending system like long rod instrumentation but it is a two point fixation system and it is stable in flexion by itself. Segmental stabilization is attained in the best way by it. The device consists of two pairs of Schanz screws, short connecting threaded rods and hinges. Instrumentation is quite simple: from a posterior approach long Schanz screws are driven into the bodies in transpedicular way above and below the injured level. Reduction is made by manual action, rod-connection, reclination and distraction, stabilization by nut fixation. Its main advantages are excellent reposition-possibilities, good fixation, all kinds of decompression-procedures are possible beside it, simple technique, immobilization of only two segments, good for all kinds of injuries between Th 8 and S 1, postoperative external fixation is not necessary and early rehabilitation is possible. According to our early experiences and the data of literature it is worth while to turn to F. I. if proper supply can be assured.

First Hungarian neurosurgical experiences with "Fixateur Interne" in the treatment of thoraco-lumbar spine injuries. Technical note.

The Fixateur Interne (F.I.) is a new device for internal fixation of the thoraco-lumbar spine developed by Dick and Magerl. It is based on a new principle since it does not act as a four-point bending system like long rod instrumentations but it is a two-point fixation system and it is stable in flection by itself. Because the system seems not well known among neurosurgeons, its use and advantages are described and two cases reported.