Percutaneous suction aspiration for osteomyelitis. Report of two cases.

The nucleotome, a recently developed instrument for percutaneous disc excision, was used for suction aspiration in two cases of osteomyelitis of the spine. The technique obtained significant amounts of pus, serosanguinous material, and tissue, which provided adequate samples for histologic examination and culture. Both patients obtained immediate relief of pain after a significant amount of pus and infected material was removed. Appropriate antibiotics were used for subsequent control of the infections. The risk and morbidity of this technique are no greater than with conventional needle biopsy.

Closed reduction of dislocations of the lower cervical spine.

Dislocation of the lower cervical spine (C3-T1) is associated with a high incidence of neurologic injury. Attempted closed reduction by skeletal traction with weights ranging up to 50 lb (23 kg) is considered standard care in North America, although these attempts are often unsuccessful. This retrospective review, over a 6-year span, of 39 patients with dislocations and facet locks of the lower cervical spine treated with closed reduction showed that 35 (90%) were successful. Recommended weight was exceeded in 22 patients (63%) with no deteriorations in neurologic status. If patients are monitored radiologically and neurologically throughout traction, up to 70% of body weight can be used safely. An algorithm for treatment is provided.

Management of the fractured odontoid with halo-thoracic bracing.

This study of 65 cases of fractured odontoid indicates that halo-thoracic bracing is an effective method for treatment of the Types II and III fractures. There were 28 Type II, and 19 Type III fractures treated with halo-thoracic braces. Of these 47 patients, only 4 went on to nonunion after an average of 8 weeks in the brace, a rate of bony union of 91.5%. Seven of the remaining 18 patients underwent primary fusion at C1-2, two were treated in Guilford braces, and six received no treatment. Surgery was performed if the fracture was unstable, if the patient could not be relied upon to leave the halo in place, or if the patient chose it as primary treatment. All seven of these patients went on to bony fusion. All of the six patients who refused treatment went on to nonunion of the fracture. Three patients were lost to follow-up.

Repeat chymopapain injections. Results and complications.

In this review of 35 patients who received repeat chymopapain injections, 41% had an excellent result, 37% had some improvement, and 22% showed no improvement. Of the 21 patients followed who had the same disc injected twice, 43% had an excellent result and 24% had no improvement. Of the three patients followed who had a different disc injected on the second occasion, one had an excellent result, and none showed no improvement. There was no significant difference between the two groups. Six patients (17%) had an anaphylactic reaction to the second injection. Five had a major reaction. Repeat chymopapain injection may be a valid treatment for a protruded disc but should not be performed until a definitive test for sensitivity is developed.

Posttraumatic syringomyelia: the British Columbia experience.

Posttraumatic syringomyelia is an uncommon late complication of spinal cord injury. This study identified nine patients with posttraumatic syringomyelia and examined initial presentation, neurologic status, ability to perform functional activities, and results of treatment. Pain and numbness were the most common presenting symptoms. Motor impairment occurred later but was more disabling. Functional abilities depended mainly on the level of the original spinal cord injury. Three patients were managed conservatively and have had no significant progression of their neurologic deficit. Six patients were managed with syringoperitoneal or syringosubarachnoid shunts. Pain improved most consistently after surgery. Motor power improved less and sensation least. Ability to perform activities of daily living did not significantly change after surgery. Posttraumatic syringomyelia remains a difficult therapeutic problem in the spinal cord-injured population.

Cervical spine injuries in rugby players.

Nine patients with serious cervical spine injuries that occurred while they were playing rugby were seen in a British Columbia acute spinal cord injury unit during the period 1975-82. All the injuries had occurred during the "scrum" or the "tackle". Two of the patients were rendered permanently quadriplegic, and one patient died. There is a need for a central registry that would record all cervical spine injuries in rugby players as well as for changes in the rules of the game.

Halo-thoracic brace immobilization in 188 patients with acute cervical spine injuries.

The authors report 188 patients with acute cervical spine injury with fracture who underwent Halo-thoracic brace immobilization. The majority of the fractures were considered unstable. Early neurological assessment revealed 24 patients without neurological deficit. There were 164 patients with associated cervical cord injury; 84 patients with incomplete, and 80 patients with complete tetraplegia. Management consisted of skull traction and application of the Halo-thoracic brace about 1.3 weeks after admission. The average radiological union time was 11.5 weeks following a mean of 10.2 weeks of immobilization in a Halo apparatus. Satisfactory restoration of bone and ligament stability, with no significant posttreatment neck pain, was obtained in 168 cases (89%). This is comparable to the fusion rate achieved for cervical fractures in the literature. The follow-up periods range from 1 month to 6 years, with a mean of 10.8 months. The management and results in 73 patients with unilaterally and bilaterally locked facets with or without fractures are discussed. Complete tetraplegia is not considered a contraindication to Halo apparatus immobilization. The multiple factors responsible for overcoming the barrier of anesthetic skin are elucidated. Use of the Halo apparatus offers early mobilization and rehabilitation without neurological deterioration. Complications are few and insignificant.

Dislocations of the lower cervical spine.

In 34 cases of cervical spine facet dislocation treated between 1975 and 1979, the dislocations were reduced by closed methods and immobilized in the halo thoracic brace. If closed reduction was unsuccessful, open reduction and fusion were performed. There is a high incidence of failure of closed reduction and halo thoracic immobilization in patients with minimal or no neurologic deficit. Bilateral facet dislocation was more frequently associated with severe neurologic injury than was unilateral facet dislocation, Use of closed reduction is time consuming, often unsuccessful, and may result in neurologic deterioration. Patients with facet dislocations and minimal neurologic injury are at risk of late instability following halo thoracic brace immobilization, and therefore open reduction and posterior cervical fusion may be advisable for them. However, surgical fusion carries a high incidence of long-term neck pain and stiffness, and is indicated only in patients at risk of developing late instability.

Management of fractures of the thoracolumbar and lumbar spite.

Eleven cases of fracture or fracture/dislocation of the thoracolumbar or lumbar spine were studied to determine the effectiveness of three methods of management of the injuries. Ten of the patients had a neurological deficit as well as a spinal injury. All cases were studied by computed tomographic (CT) scanning of the injury site before and after treatment. CT scanning was found to be superior to linear tomography in determining the degree of canal compromise by bone at the injury site. Eight patients underwent operation, with the aims of achieving spinal stability in unstable injuries and of decompressing neural structures. These 8 patients had received Harrington distraction instrumentation (HDI) as an initial procedure. In those patients with fracture/dislocations from flexion-rotation injuries and canal compromise resulting from bony malalignment, reduction of the fracture/dislocation by HDI resulted in stabilization of the spine and increase of the open canal area at the injury site. However, in those patients with canal compromise resulting from bursting fractures with retropulsed bone fragments, HDI did not reduce in bone fragments. Removal of the anterior vertebral body and the bone fragments, however, did result in significant improvement of the canal dimensions. A poor correlation was found between the degree of canal compromise as measured by the CT scanner and the resulting neurological deficit. Reasons for this are presented. Six of the 10 neurologically compromised patients, including 2 patients with stable bursting injuries and retropulsed bone fragments treated conservatively, had improved one grade on Frankel's classification by 3 months after injury. The rate and degree of recovery were not related to the degree of canal decompression achieved at operation.

Osteocartilagenous lesions of the talar dome.

Persistent ankle pain, swelling, and crepitus should suggest the possibility of osteocartilagenous lesions of the talar dome in some patients with ankle pain. Tomograms may be required to demonstrate their presence. Excision or excision and curettage of these lesions have been shown to provide a good result in 63%, and a fair result in 30% of the 31 cases that failed to respond to nonoperative treatment. Osteocartilagenous lesions of the talar dome appear to have a traumatic etiology. In the talar dome, what has been called osteochondritis dissecans, is, in most cases, a transchondral fracture.

Halo-thoracic brace management of odontoid fractures.

Thirteen patients with fracture of the odontoid were treated with halo-thoracic brace. Major trauma was responsible for the fracture in only 5. Neither the degree nor the direction of displacement prevented union, which occurred in all 13. All patients were treated for least 60 days; 11 were treated longer. No complications occurred. The method is recommended based on the results.

The fractured cervical spine rendered unstable by anterior cervical fusion.

Anterior interbody grafts are prone to displacement if there is posterior instability or gross deformity of the vertebral body. Twenty-one patients treated with anterior interbody fusion for cervical vertebral fractures and dislocations were studied. Twelve of the fractures were considered unstable preoperatively, and 50% of this group treated with anterior stabilization had graft migration postoperatively. If anterior fusion is used in unstable cervical fractures then posterior stabilization or complete bed rest with effective external stabilization (i.e., tongs or Halo-thoracic brace) for 4 weeks is mandatory. The other alternative is posterior stabilization before anterior decompression. In the presence of posterior instability, anterior interbody fusion alone cannot be recommended as the treatment of choice for cervical fractures.

A study of ankle instability utilizing ankle arthrography.

A preclinical and clinical study of ankle arthrography for chronic ankle instability was performed. In the first study, ankle arthrograms were done on 50 cadaver ankles to demonstrate the limits of the normal ankle joint, and it was demonstrated that contrast in tendon sheaths is not a sign of a torn ankle ligament. The second study consisted of investigating ten cases of chronic ankle instability utilizing ankle arthrography. It was concluded that ankle arthrography is helpful in diagnosing torn ankle ligaments if all remaining investigative procedures are negative. A positive ankle arthrogram is proof that a torn capsule and ligament has occurred. However, in this small series a negative a negative arthrogram and a normal talar tilt was still associated with a torn ligament of the ankle.