Upper Cervical Trauma.

Craniocervical injuries (CCJs) account for 10% to 30% of all cervical spine trauma. An increasing number of patients are surviving these injuries due to advancements in automobile technology, resuscitation techniques, and diagnostic modalities. The leading injury mechanisms are motor vehicle crashes, falls from height, and sports-related events. Current treatment with urgent rigid posterior fixation of the occiput to the cervical spine has resulted in a substantial reduction in management delays expedites treatment of CCJ injuries. Within CCJ injuries, there is a spectrum of instability, ranging from isolated nondisplaced occipital condyle fractures treated nonoperatively to highly unstable injuries with severely distracted craniocervical dissociation. Despite the evolution of understanding and improvement in the management of cases regarding catastrophic failure to diagnose, subsequent neurologic deterioration still occurs even in experienced trauma centers. The purpose of this article is to review the injuries that occur at the CCJ with the accompanying anatomy, presentation, imaging, classification, management, and outcomes.

Glass Fragment Injury to the Craniocervical Junction with Interatlantooccipital Penetration to the Subarachnoid Space: Not-To-Be-Missed Important Aspects of Craniocervical Trauma Even in the Middle of the COVID-19 Pandemic: Case Report and Review of Literature.

BACKGROUND: Nonmissile penetrating injuries to the craniocervical junction caused by a glass fragment are rare, and a standard management strategy has not been established. CASE DESCRIPTION: A 75-year-old Japanese man was brought into our emergency department after receiving a left retroauricular stab wound by broken glass fragments. After spinal immobilization, a computed tomography (CT) scan revealed glass fragments penetrating at the right craniocervical junction to the interatlantooccipital subarachnoid space. CT angiography showed that both vertebral arteries were not injured. Magnetic resonance imaging demonstrated that the glass fragments did not penetrate the cervical cord or medulla oblongata. These glass fragments were removed via a midline incision from the external occipital protuberance to the C7 and with laminectomy without suboccipital craniectomy. Five of the glass fragments were found and removed in total. The dural defect was patched with a free fascia autograft. His postoperative course was uneventful. Postoperative CT angiography showed that both vertebral arteries were intact and the glass fragments had been removed completely. CONCLUSIONS: CT graphical diagnosis is useful for the management of penetrating craniocervical junction trauma, and it should be considered in the evaluation of patients who have suffered craniocervical penetrating injury even in the absence of major wounds or bleeding. Spinal immobilization of patients with craniocervical penetrating injuries is crucial to avoid not only secondary neurologic damage but also secondary critical vascular damage. Incomplete or inadequate assessment of craniocervical stab wounds results in unexpected hazards that are preventable.

Isolated Nerve Grafting for a Young Patient with a Complete Common Peroneal Nerve Palsy Following a Traumatic Knee Dislocation: A case report.

BACKGROUND: Common peroneal nerve (CPN) injury following a knee dislocation is a serious problem, and an optimal treatment is yet to be established. We report a case of complete CPN palsy following a knee dislocation treated with sural nerve grafting. CASE: A 19-year-old man suffered a knee injury during a hurdle race. Diagnosis in a previous hospital revealed a complex ligament injury with CPN palsy. Ten weeks following injury, he was admitted to our institution because of a lack of neurological improvement. Considering the grade 0 results obtained in the manual muscle test (MMT) of tibialis anterior (TA) and extensor hallucis longus (EHL), the patient was diagnosed with complete neurotmesis of CPN, and surgery was performed. Operative findings revealed CPN discontinuity and an extended nerve defect length of 15 cm; therefore, sural nerve grafting was performed to repair the CPN injury. One year postoperatively, a grade 1 result from MMT of TA and EHL indicated a gradual neurological recovery. Three years postoperatively, MMT of TA and EHL showed significant improvement to grade 4+ and grade 4, respectively, and he could walk and jog without a knee brace. DISCUSSION: Nerve graft length of >6 cm has shown limited success, and their efficacy for the treatment of CPN palsy following knee dislocations is controversial. However, young patients with complete CPN lesion are more likely to recover regardless of the length of nerve injury. Therefore, in such cases, nerve grafting can be considered as one of the treatments for complete CPN lesion following knee dislocations.

Dextran-based tube-guides for the regeneration of the rat sciatic nerve after neurotmesis injury.

In this work, dextran-based nerve tube-guides were prepared, characterized and used in a standardized animal model of neurotmesis injury. Non-porous and porous transparent tube-guides were obtained by photocrosslinking of two co-macromonomers based on dextran and poly(ε-caprolactone) (PCL). Swelling capacity of the tube-guides ranged from 40-60% with no visible constriction of their inner diameter. In vitro hydrolytic degradation tests showed that the tube-guides maintained their structural integrity up to 6 months. The in vivo performance of the tube-guides was evaluated by entubulation of the rat sciatic nerve after a neurotmesis injury, with a 10 mm-gap between the nerve stumps. The results showed that the tube-guides were able to promote the regeneration of the nerve in a similar manner to what was observed with conventional techniques (nerve graft and end-to-end suture). Stereological analysis proved that nerve regeneration occurred, and both tube-guides presented fibre diameter and g-ratio closer to healthy sciatic nerves. The histomorphometric analysis of Tibialis anterior (TA) skeletal muscle showed decreased neurogenic atrophy in the porous tube-guides treated group, presenting measurements that are similar to the uninjured control.

A Proposed Intention-to-Treat Anatomical Classification of Spinal Dural Tears.

To clarify outcomes and develop a novel classification according to CSF fistula in a selective cohort with intraoperative spinal dural tear, we examined 72 consecutive patients who underwent spinal dural repair after microdiscectomy (n=42) or lumbar spinal decompression (n=30). Group 1 consisted of 25 patients with Type I (mild) dural tear who were treated with either tissue-glue-coated collagen sponge or fibrin glue. Group 2 consisted of 26 patients with Type II (moderate) dural tear who were treated with both tissue-glue-coated collagen sponge and fibrin glue. Group 3 consisted of 21 patients with Type III (severe) dural tear who were treated with polypropylene suture along with tissue-glue-coated collagen sponge and/or fibrin glue. Evident postoperative internal or external CSF leak was used to determine the patient's postoperative result. Postoperative internal or external CSF leak was not evident during a minimum 1-year follow-up in Group 1. In contrast, internal CSF leak was evident in both Groups 2 (n=3) and 3 (n=3) during the same follow-up. No external CSF leak was noted in any of the patients. Three patients underwent re-do spinal surgery for CSF leak repair. Patients in all groups satisfactorily avoided CSF leak. According to the intraoperative findings of a distinct dural tear, patients can be treated adequately with a specific surgical technique.

Toward Functional Restoration of the Central Nervous System: A Review of Translational Neuroscience Principles.

Injury to the central nervous system (CNS) can leave patients with devastating neurological deficits that may permanently impair independence and diminish quality of life. Recent insights into how the CNS responds to injury and reacts to critically timed interventions are being translated into clinical applications that have the capacity to drastically improve outcomes for patients suffering from permanent neurological deficits due to spinal cord injury, stroke, or other CNS disorders. The translation of such knowledge into practical and impactful treatments involves the strategic collaboration between neurosurgeons, clinicians, therapists, scientists, and industry. Therefore, a common understanding of key neuroscientific principles is crucial. Conceptually, current approaches to CNS revitalization can be divided by scale into macroscopic (systems-circuitry) and microscopic (cellular-molecular). Here we review both emerging and well-established tenets that are being utilized to enhance CNS recovery on both levels, and we explore the role of neurosurgeons in developing therapies moving forward. Key principles include plasticity-driven functional recovery, cellular signaling mechanisms in axonal sprouting, critical timing for recovery after injury, and mechanisms of action underlying cellular replacement strategies. We then discuss integrative approaches aimed at synergizing interventions across scales, and we make recommendations for the basis of future clinical trial design. Ultimately, we argue that strategic modulation of microscopic cellular behavior within a macroscopic framework of functional circuitry re-establishment should provide the foundation for most neural restoration strategies, and the early involvement of neurosurgeons in the process will be crucial to successful clinical translation.

Rigid Internal Fixation for Traumatic Cranio-Cervical Dissociation in Infants and Young Children.

STUDY DESIGN: Retrospective review. OBJECTIVE: Evaluate radiographic and clinical outcomes for infants and children, who underwent rigid occipito-cervical fixation for traumatic craniocervical dissociation (tCCD). SUMMARY OF BACKGROUND DATA: Traumatic craniocervical dissociation is devastating. Children are at high risk but make up a large number of survivors. Non-rigid fixation has traditionally been favored over screw and rod constructs due to inherent challenges involved with instrumenting the pediatric craniocervical junction. Therefore, outcomes for rigid occipito-cervical instrumentation in infants and young children with tCCD remain uncertain. METHODS: Retrospective review of children who survived tCCD between 2006 and 2016 and underwent rigid occipito-cervical fixation. RESULTS: Fifteen children, from 8 months to 8 years old (mean, 3.8 yr), were either a passenger (n = 11) or a pedestrian (n = 4) in a motor vehicle accident. Seven patients had weakness: five with quadriplegia, one with hemiparesis, and one with bilateral upper extremity paresis. Ten patients had concurrent C1-2 instability. At last follow-up, four patients had improved motor function: one with bilateral upper extremity paresis and one with hemiparesis regained full strength, one with quadriplegia regained function on one side while another regained function in bilateral upper extremities. All underwent rigid posterior occipito-cervical fixation, with two patients requiring additional anterior and posterior fixation at non-contiguous levels. Fourteen patients were stable on flexion-extension x-rays at a mean follow-up of 31 months (9-1 yr or longer, 7-2 yr or longer). There were no cases of deformity, growth disturbance, or subaxial instability. CONCLUSION: Children who survive tCCD may regain function after stabilization. Rigid internal rod and screw fixation in infants and young children safely provided long-term stability. We advocate using C2 translaminar screws to exploit the favorable anatomy of pediatric lamina to minimize the risks of occipitocervical (OC) instrumentation. LEVEL OF EVIDENCE: 4.

Peripheral nerve injuries in the pediatric population: a review of the literature. Part I: traumatic nerve injuries.

OBJECTIVE: This article reviews the clinical results that can be obtained after repair of a traumatic peripheral nerve injury in the pediatric population. METHODS: A systematic review of the published literature has been made. RESULTS: Functional outcome after major nerve injuries is sometimes disappointing in adults. However, children have been reported to experience much better functional results after nerve repair than adults. Moreover, recovery generally is faster in children. The superior capacity of children's central nervous system to adapt to external or internal environmental changes (neural plasticity) and the shorter recovery distance from the axon repair site to the target muscle are claimed to be crucial determinants of their favorable outcomes. Moreover, even in the pediatric population, it has been demonstrated that functional results are better the younger the patient is, including better clinical results in those injured in early childhood (< 6 years old) than in those injured in adolescence. Other favorable prognostic factors include the type of nerve injury (with complete transections doing less well than crush injuries) and the timing of surgery (with better outcomes after early repairs). CONCLUSIONS: All efforts should be done to repair in a timely and adequate fashion traumatic peripheral nerve injuries in children, as the results are good.

Predictive value of a diagnostic block in focal nerve injury with neuropathic pain when surgery is considered.

OBJECT: In patients with focal nerve injury and neuropathic pain cutting the nerve to obtain permanent pain reduction can be considered. Surgery is indicated only if a diagnostic nerve block provides temporary pain relief. We evaluated the predictive value of a block on the outcome of surgery. METHODS: In total, three blocks were performed at two week intervals. Patients were blinded to injections containing lidocaine 1% and a placebo was included. Surgery was offered regardless of the effect of the blocks. Twenty-four patients received 72 blocks. Sixteen patients opted for surgery, 5 patients refrained from surgery, and in 3 the blocks provided permanent pain relief. The predictive ability of the block on the outcome of surgery was assessed by calculating the area under a Receiver Operating Characteristic curve (AUC). RESULTS: The AUC of the first lidocaine block was 0.35 with a 95% confidence interval from 0.077 to 0.62. At 95% confidence (two-sided), the AUC is less than 0.62, and hence the predictive ability of the block was poor. The outcome of the second lidocaine block and saline block did not change the conclusion of the first block. CONCLUSIONS: We conclude that the use of blocks to select patients for surgery should be critically appraised. PERSPECTIVE: A pain relieving response to one open block is currently considered mandatory before patients with focal nerve injury and neuropathic pain are offered surgery. Blinded blocks including a placebo show that responses for selection should be carefully interpreted because they may not be as predictive as generally presumed.

Long-Term Outcomes of Glenohumeral Arthrodesis.

BACKGROUND: Glenohumeral arthrodesis is associated with a high rate of complications. Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. The purpose of this study was to examine the clinical outcomes of glenohumeral arthrodesis. METHODS: Twenty-nine patients with 29 affected shoulders underwent primary glenohumeral arthrodesis between 1992 and 2009. Surgical indications included rotator cuff arthropathy and pseudoparalysis (n = 7), neurologic injuries (n = 12), chronic infection (n = 3), recurrent dislocations (n = 3), and proximal humeral or shoulder girdle tumors (n = 4). Surgical fixation techniques included plates and screws in 18 patients and screws only in 11 patients. RESULTS: All patients were examined, with a mean follow-up of 12 years (range, 2 to 22 years). Twelve patients (41%) had postoperative complications, including 6 periprosthetic fractures, 7 nonunions, and 3 infections. Eleven patients (38%) required additional surgical procedures after arthrodesis, including revision internal fixation to achieve glenohumeral fusion after nonunions (n = 7), irrigation and debridement with antibiotic treatment for deep infections (n = 2), open reduction and internal fixation to treat fracture (n = 2), and implant removal to treat symptomatic patients (n = 3). Patients experienced reasonable overall pain relief. The mean postoperative scores were 35 points for the Subjective Shoulder Value, 58 points for the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 54 points for the Short Form-36. Eighty-seven percent of patients reported postoperative limitations. Patients with neurologic injuries had worse functional outcomes, and an arthrodesis position of ≥25° yielded better functional outcomes. CONCLUSIONS: Glenohumeral arthrodesis is associated with a high rate of patients with complications (41%). Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Immediate Enhancement of Nerve Function Using a Novel Axonal Fusion Device After Neurotmesis.

BACKGROUND: The management of peripheral nerve injuries remains a large challenge for plastic surgeons. With the inability to fuse axonal endings, results after microsurgical nerve repair have been inconsistent. Our current nerve repair strategies rely upon the slow and lengthy process of axonal regeneration (~1 mm/d). Polyethylene glycol (PEG) has been investigated as a potential axonal fusion agent; however, the percentage of axonal fusion has been inconsistent. The purpose of this study was to identify a PEG delivery device to standardize outcomes after attempted axonal fusion with PEG. MATERIALS AND METHODS: We used a rat sciatic nerve injury model in which we completely transected and repaired the left sciatic nerve to evaluate the efficacy of PEG fusion over a span of 12 weeks. In addition, we evaluated the effectiveness of a delivery device's ability to optimize results after PEG fusion. RESULTS: We found that PEG rapidly (within minutes) restores axonal continuity as assessed by electrophysiology, fluorescent retrograde tracer, and diffusion tensor imaging. Immunohistochemical analysis shows that motor axon counts are significantly increased at 1 week, 4 weeks, and 12 weeks postoperatively in PEG-treated animals. Furthermore, PEG restored behavioral functions up to 50% compared with animals that received the criterion standard epineurial repair (control animals). CONCLUSIONS: The ability of PEG to rapidly restore nerve function after neurotmesis could have vast implications on the clinical management of traumatic injuries to peripheral nerves.

[Myositis Ossificans Traumatica in the Craniocervical Junction: A Case Report and Review of Literature]. / Myositis ossificans traumatica im kraniozervikalen Übergang ­ Fallbericht und Literaturübersicht.

Background Myosits ossificans (MO) is a rare but important differential diagnosis for a heterotrophic bony tumor in the muscles. It is often misdiagnosed as a malignant tumor. With a previous trauma the diagnosis is myositis ossificans traumatic (MOT). In most cases, it is benign and predominantly seen in the big muscles. But there can be malignant etiologies too. Case Description We report a rare case of MO in the muscle of the craniocervical junction. This 37-year-old woman had a riding accident years ago. Because of persisting pain and cervical dysfunction, we did a total resection. Clinical Implications MOT is a benign tumor that can be treated conservative in most cases. In case of persistent pain or neurological deficits, and especially for securing diagnosis, surgical resection is recommended.

Management of a Complex Basilar Invagination Case with Multiple Revision Surgeries ­ Case Report

We describe a Basilar Invagination (BI) case with craniocervical instability and many previous failure surgeries and poor wound coverage. The patient had been submitted to a large posterior fossa craniectomy (which greatly limited the availability of an adequate area for bone fixation) and showed a poor quality of the surgical wound in the posterior craniocervical region. We performed an occipito-cervical fixation, using the bone overlying the torculla as a point of cranial fixation. Craniocervical realignment was achieved by the use of distractive maneuvers with occipital rods, followed by coverage of the hardware via a pedicled longitudinal trapeze myocutaneous flap. We used local ribs removed from the region where the myocutaneous flap was harvested as autologous bone grafts for craniocervical fusion. Post-operatively, the patient was placed in a halo-vest for three months. The patient improved substantially after the procedure, recovered some muscular strength and experienced total relief of her pain. We hereby discuss the surgical strategy used for treating this complex case in details, with illustrative pictures.

Descrevemos caso de paciente com diagnóstico de invaginação basilar e instabilidade crânio cervical com múltiplas cirurgias prévias e deiscência de ferida operatória. Devido a falha de osso na escama occipital, assim como da cobertura cutânea adequada, realizamos realinhamento craniocervical, com descompressão indireta anterior, fixação occipitocervical na região da tórcula e cobertura da pele com flap miocutâneo longitudinal pediculado de trapézio. As costelas removidas da região do retalho miocutâneo foram transferidas para serem usadas como enxerto autólogo de osso para fusão craniocervical. No pós-operatório, a paciente utilizou um halo-vest por 3 meses. No presente artigo, apresentamos nuances ilustrados de manobras para realinhamento craniocervical por via posterior na invaginação basilar, bem como estratégias para otimizar a artrodese e o fechamento cutâneo.

Classification and Management of Pediatric Craniocervical Injuries.

This article addresses the key features, clinical presentation, patterns of injury, indicated workup, and radiographic findings associated with craniocervical injuries in the pediatric population. It discusses nonsurgical and surgical management of pediatric cervical spine trauma, addressing when each is indicated, and the various techniques available to the pediatric neurosurgeon.

Retrospective analysis of a case series of patients with traumatic injuries to the craniocervical junction / Análise retrospectiva de série de casos com lesões traumáticas da junção craniocervical

ABSTRACT Objective To evaluate the correlation between the treatment, the characteristics of the lesions and the clinical outcome of patients with traumatic injuries to the craniocervical junction. Methods This was a retrospective study of patients treated conservatively or surgically between 2010 and 2013 with complete data sets. Results We analyzed 37 patients, 73% were men with mean age of 41.7 years. Of these, 32% were submitted to initial surgical treatment and 68% received conservative treatment. Seven (29%) underwent surgery subsequently. In the surgical group, there were seven cases of odontoid type II fractures, two cases of fracture of posterior elements of the axis, one case of C1-C2 dislocation with associated fractured C2, one case of occipitocervical dislocation, and one case of combined C1 and C2 fractures, and facet dislocation. Only one patient had neurological déficit that improved after treatment. Two surgical complications were seen: a liquoric fistula and one surgical wound infection (reaproached). In the group treated conservatively, odontoid fractures (eight cases) and fractures of the posterior elements of C2 (five cases) were more frequent. In two cases, in addition to the injuries of the craniocervical junction, there were fractures in other segments of the spine. None of the patients who underwent conservative treatment presented neurological deterioration. Conclusion Although injuries of craniocervical junction are relatively rare, they usually involve fractures of the odontoid and the posterior elements of the axis. Our results recommend early surgical treatment for type II odontoid fractures and ligament injuries, the conservative treatment for other injuries.

RESUMO Objetivo Avaliar a correlação entre o tratamento, as características das lesões e o resultado clínico em pacientes com lesões traumáticas na junção craniocervical. Métodos Estudo retrospectivo de pacientes maiores de 18 anos tratados de forma conservadora ou cirúrgica, entre 2010 e 2013. Resultados Foram analisados 37 pacientes, 73% eram do sexo masculino e a média de idade foi de 41,7 anos. Inicialmente 32% dos pacientes foram submetidos a tratamento cirúrgico, e 68% foram submetidos a tratamento conservador. Sete pacientes (29%) do grupo conservador foram submetidos posteriormente à cirurgia. No grupo cirúrgico, houve sete casos de fratura de odontóide tipo II, dois casos de fratura de elementos posteriores do áxis, um caso de luxação C1-C2, um caso de deslocamento occipito-cervical e um caso de fraturas de C1 e C2 e luxação facetária. Um paciente apresentava déficit neurológico, melhorando após o tratamento. Houve duas complicações pós-cirúrgicas, uma fístula liquórica e uma infecção de ferida operatória (reabordada). No grupo conservador, predominaram as fraturas do odontóide (oito) e dos elementos posteriores de C2 (cinco). Em dois casos, havia também fraturas em outros segmentos da coluna. Nenhum dos pacientes deste grupo apresentou deterioração neurológica. Conclusão As lesões da junção craniocervical são raras, sendo mais frequentes as fraturas do odontóide e dos elementos posteriores do áxis. Nossos resultados recomendam o tratamento cirúrgico precoce para os pacientes com fraturas do odontóide tipo II e lesões ligamentares, e tratamento conservador para os demais pacientes.

Neurotrauma in China.

China is a densely populated country faced with more than 1 million cases of traumatic brain injury annually. Since the late 1930s, there has been a great improvement in the field of neurosurgery in the treatment of neurotrauma. The objective of this article is to delve into the genesis of neurotrauma and its present situation to fellow neurosurgeons to enhance academic exchange and interaction between China and other parts of the world. We present a historical vignette of the development of neurotrauma in China over almost 80 years. It is valuable to have this documentation of the growth of neurosurgery in China by authors who are familiar with the subject matter.