C1-C2 sublaminar taping for displaced odontoid synchondrosis fracture in an infant: A case report and novel surgical technique.

Pediatric cervical spine injuries are rare, and the diagnosis and management can be challenging. Surgical intervention has been recommended in unstable odontoid synchondrosis injuries or those that have failed nonoperative measures. However, the literature remains sparse on the operative management of severe injuries due to the low incidence. An 18-month-old female sustained an unstable odontoid synchondrosis fracture from a motor vehicle accident. Due to ongoing instability after initial immobilization in a halo, the decision was made to proceed with surgical management. With the patient positioned prone and neural monitoring throughout, a posterior approach was utilized. Subperiosteal exposure of the C1 posterior arch was performed bilaterally. A spinal fixation band was passed under the right C1 posterior arch, around the C2 spinous process, under the left C1 posterior arch, and finally back under the C2 spinous process. The C1-C2 distraction was reduced using intraoperative imaging, and the sublaminar tape construct was secured and reinforced. The halo was then reattached. Postoperative recovery was complicated by a halo pin-site infection which was treated with oral antibiotics. The halo was removed after 3 months, following a computerized tomography that demonstrated union. X-rays at 6 months revealed anatomical alignment with the union. Surgery is recommended in pediatric odontoid synchondrosis fractures refractory to nonoperative management. Sublaminar taping of C1-C2 with a spinal fixation band has been demonstrated to be an effective surgical technique in the management of an unstable odontoid synchondrosis fracture.

Occult subaxial cervical disco-ligamentous injuries in computer tomography negative trauma patients.

PURPOSE: Due to lack of cervical clearance consensus in literature and the devastating consequences of missed cervical injuries, Magnetic resonance imaging (MRI) of the neurologically intact symptomatic patient with negative CT scan is frequently done to rule out disco-ligamentous injuries. This study retrospectively evaluates occult disco-ligamentous injuries detected by MRI in patients with no abnormalities detected by modern multi-detector CT scanning and postulates a new theory of ligamentous stability of cervical spine. METHODS: Cervical spine injury patients treated at a spinal trauma referral centre from 2010 to 2013 were retrospectively identified. Available clinical records and radiographic imaging were reviewed to find neurologically intact symptomatic patients with no identifiable acute cervical spine injury on CT scan but MRI evidence of isolated subaxial disco-ligamentous injuries. Patient demographics, injury profile, and treatment details were extracted. Subaxial Cervical Spine Injury Classification (SLIC) and Denis three-column spinal stability theory were adopted to assess stability of injuries. RESULT: 316/566 cervical spinal admissions had CT and MRI scans. 11 (3.5%) CT negative patients were found to have occult discoligamentous injuries on MRI. The average age (51.1 years) was not significantly different to all cervical trauma admissions (p = 0.09). Eight had flexion type and three had extension type injuries. The most common mechanisms were sports and fall on flat surface. The average SLIC score was 3.1. Four patients were classified as having unstable or potentially unstable injuries (two patients each) and three of these patients were surgically managed. Subtle CT changes to indicate discoligamentous injury could be retrospectively identified in all four of these patients. CONCLUSION: CT scans alone may be inadequate for clearing occult disco-ligamentous injuries of the subaxial cervical spine in trauma. Denis three-column stability theory may be beneficial in determining stability and guiding treatment along with the SLIC system for occult discoligamentous injuries of the subaxial cervical spine.

Subaxial injury classification scoring system treatment recommendations: external agreement study based on retrospective review of 185 patients.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To test validity of subaxial injury classification (SLIC) treatment recommendations. SUMMARY OF BACKGROUND DATA: Although SLIC has been tested for reliability, external studies that test the validity of its treatment recommendations are lacking. METHODS: The SLIC score was determined by reviewing imaging studies and clinical records in a consecutive series of 185 patients with subaxial cervical spine trauma presenting to a level 1 spinal injury referral center. Details including attending surgeon responsible for treatment decision, treatment received, and surgical approach were collected. RESULTS: Treatment received matched SLIC guidelines in 93.6% nonsurgically managed patients and 96.3% surgically managed patients. The mean SLIC score of the surgically treated group of patients was significantly higher than that of the nonsurgical group (7.14 vs. 2.22; P<0.001). Sixty-six patients had a SLIC score of 3 or less, and 94% of them were nonsurgically managed (P<0.001). One hundred two patients had a SLIC score of 5 or more, and 95% of them were surgically managed (P<0.001). Seventeen patients had a SLIC score of 4, and 65% were nonsurgically managed (P=0.032). Injury morphology scores were not predictive of surgical approach. Increasing SLIC scores correlated with increasing complexity of treatment (r=0.77; P<0.001). The distribution of patients with regard to severity of injuries and treatment delivered by the 7 spinal surgeons was comparable. The past practice of these 7 fellowship-trained spine surgeons was individually in agreement with SLIC treatment recommendations. CONCLUSION: Our past practice reflects SLIC treatment recommendations for nonsurgical treatment of patients with SLIC scores of 3 or less and surgical treatment of patients with SLIC scores of 5 or more. The use of SLIC as an ordinal severity scale is validated as increasing SLIC scores correlated with increasing complexity of treatment. The injury morphology score did not predict a surgical approach. Significantly higher numbers of patients with a SLIC score of 4 were treated nonsurgically. LEVEL OF EVIDENCE: 3.

Mobile garbage bins and hand injuries in older people.

OBJECTIVES: To conduct a database search, chart and literature review of open extensor tendon and proximal interphalangeal joint injuries incurred while handling mobile garbage bins. DESIGN, SETTING AND PARTICIPANTS: A review of medical records at a Sydney tertiary referral hospital and a NSW rural Level 2 trauma hospital from 1 January 2006 to 31 December 2010, identified through database searches of appropriate medical record codes and followed by a chart review. RESULTS: We identified 11 patients with finger injuries from handling mobile garbage bins that necessitated hospital-based treatments. Their average age was 75 years. Eight patients required surgery. Patients typically fell while maintaining their grip on mobile garbage bin handles, causing abrasive injury to the dorsal aspect of the proximal interphalangeal joint. CONCLUSIONS: Older patients are at risk of significant injuries to the dorsal side of their fingers when manoeuvring mobile garbage bins. This risk could be reduced by providing older members of the community with help to move their bins, or by modifying the design of bin handles. We propose a simple modification to the design of bin handles.

Migration of rod through skull, into brain following C1-C2 instrumental fusion for os odontoideum: a case report.

STUDY DESIGN: Case report and brief literature review. OBJECTIVE: To describe a unique complication following C1/2 fusion in a pediatric patient. SUMMARY OF BACKGROUND DATA: Os odontoideum, if symptomatic or unstable, should be treated by internal fixation. Posterior instrumented fusion of the cervical spine is not an uncommon surgical procedure. METHODS: Direct observation and management of the patient during representation with postoperative complication. RESULTS: This case report details the previously unrecorded and unusual migration of a fixation device through the skull into the brain and outlines its subsequent removal. CONCLUSION: Failure of bony fusion can result in micromotion and subsequent migration of fixation device components. This can occur even if the screw fixation is apparently sound. Extended routine radiographic follow-up would identify migration earlier.

Clinical case seminar: Fibroblast growth factor 23: a new clinical marker for oncogenic osteomalacia.

The phosphate-wasting condition, oncogenic osteomalacia, is problematic to diagnose and manage clinically due to difficulty in locating the causative tumor. Fibroblast growth factor 23 (FGF23) has recently been implicated in the pathogenesis of oncogenic osteomalacia. In this case the patient presented with clinical features typical of oncogenic osteomalacia. Removal of an angiolipoma from the thigh did not correct the clinical or biochemical abnormalities. Subsequent identification and removal of a benign giant cell tumor in the pubic ramus, however, did result in normalization of his symptoms and signs. Positive staining for FGF23 protein by immunohistochemistry was demonstrated in the giant cell tumor, but not in the angiolipoma. The serum concentration of FGF23 was elevated in preoperative serum, then normalized after removal of the giant cell tumor. Expression of both FGF23 mRNA and protein was demonstrated in the giant cell tumor tissue, and FGF23 mRNA expression and renal phosphate uptake inhibitory activity were also detected in cultured giant cell tumor cells. This case provides further evidence for the involvement of FGF23 in the pathogenesis of oncogenic osteomalacia and for the utility of serum FGF23 measurement and immunohistochemical detection of FGF23 in the diagnosis and clinical management of this condition.

Spinal and spinal cord injuries in horse riding: the New South Wales experience 1976-1996.

OBJECTIVES: The objective of the present study was to determine the incidence of acute spinal cord injuries (ASCI) in all forms of horse riding in New South Wales (NSW) for the period 1976-1996. Other aims of the present study were to compare and contrast ASCI with vertebral column injuries (VCI) without neurological damage and to define appropriate safety measures in relation to spinal injury in horse-riding. DESIGN: A retrospective review was done of all ASCI cases (n = 32) admitted to the two acute spinal cord injury units in NSW for the cited period. A comparable review of VCI cases (n = 30) admitted to these centres for the period 1987-1995 was also undertaken. RESULTS: A fall in flight was the commonest mode of injury in both groups. Occupational and leisure riding accounted for 88% of ASCI and VCI. The incidence of ASCI is very low in those riding under the aegis of the Equestrian Federation of Australia - two cases in 21 years; and there were no cases in the Pony Club Riders or in Riding for the Disabled. The difference in the spinal damage caused by ASCI and VCI is in degree rather than kind. Associated appendicular/visceral injuries were common. CONCLUSIONS: No measures were defined to improve spinal safety in any form of horse riding. The possible role of body protectors warrants formal evaluation. Continued safety education for all horse riders is strongly recommended.

Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients.

BACKGROUND: The treatment of open fractures of the tibial shaft is often complicated by delayed union and nonunion. The objective of this study was to evaluate the safety and efficacy of the use of recombinant human bone morphogenetic protein-2 (rhBMP-2; dibotermin alfa) to accelerate healing of open tibial shaft fractures and to reduce the need for secondary intervention. METHODS: In a prospective, randomized, controlled, single-blind study, 450 patients with an open tibial fracture were randomized to receive either the standard of care (intramedullary nail fixation and routine soft-tissue management [the control group]), the standard of care and an implant containing 0.75 mg/mL of rhBMP-2 (total dose of 6 mg), or the standard of care and an implant containing 1.50 mg/mL of rhBMP-2 (total dose of 12 mg). The rhBMP-2 implant (rhBMP-2 applied to an absorbable collagen sponge) was placed over the fracture at the time of definitive wound closure. Randomization was stratified by the severity of the open wound. The primary outcome measure was the proportion of patients requiring secondary intervention because of delayed union or nonunion within twelve months postoperatively. RESULTS: Four hundred and twenty-one (94%) of the patients were available for the twelve-month follow-up. The 1.50-mg/mL rhBMP-2 group had a 44% reduction in the risk of failure (i.e., secondary intervention because of delayed union; relative risk = 0.56; 95% confidence interval = 0.40 to 0.78; pairwise p = 0.0005), significantly fewer invasive interventions (e.g., bone-grafting and nail exchange; p = 0.0264), and significantly faster fracture-healing (p = 0.0022) than did the control patients. Significantly more patients treated with 1.50 mg/mL of rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months (p = 0.0008). Compared with the control patients, those treated with 1.50 mg/mL of rhBMP-2 also had significantly fewer hardware failures (p = 0.0174), fewer infections (in association with Gustilo-Anderson type-III injuries; p = 0.0219), and faster wound-healing (83% compared with 65% had wound-healing at six weeks; p =0.0010). CONCLUSIONS: The rhBMP-2 implant was safe and, when 1.50 mg/mL was used, significantly superior to the standard of care in reducing the frequency of secondary interventions and the overall invasiveness of the procedures, accelerating fracture and wound-healing, and reducing the infection rate in patients with an open fracture of the tibia.