Cases reported "Joint Instability"

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1/38. Transoral fusion with internal fixation in a displaced hangman's fracture.

    STUDY DESIGN: A case is reported in which late displacement of a "hangman's fracture" was managed by transoral C2-C3 fusion by using bicortical iliac crest graft and a titanium cervical locking plate. OBJECTIVES: To review the management of unstable fractures of the axis and to study other reports of transoral instrumentation of the cervical spine. SUMMARY OF BACKGROUND DATA: Undisplaced fractures of the axis are considered to be stable injuries. Although late displacement is unusual, it can lead to fracture nonunion with persisting instability and spinal cord dysfunction. In this situation, an anterior fusion of the second and third cervical vertebrae is preferred to a posterior fusion from the atlas to the third cervical vertebra, which would abolish lateral rotation between C1 and C2. methods: The literature on hangman's fractures was reviewed. Clinical and radiographic details of a case of C2 instability were recorded, and the particular problems posed by late displacement were considered. RESULTS: There are no other reports of transoral instrumentation of the cervical spine. A sound fusion of C2-C3 was obtained without infection or other complications. Good neck movement returned by 6 months after surgery. CONCLUSION: Undisplaced fractures of the axis are not always stable. The transoral route allows good access for stabilization of displaced hangman's fractures. In special circumstances, a locking plate may prove useful in securing the bone graft. The cervical spine locking plate can be inserted transorally with no complications and by using standard instrumentation.
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ranking = 1
keywords = neck
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2/38. Unstable cervical spine without spinal cord injury in penetrating neck trauma.

    Cervical spine instability in the neurologically intact patient following penetrating neck trauma has been considered rare or non-existent. We present a case of a woman with an unstable C5 fracture without spinal cord injury after a gunshot wound to the neck. Considerations regarding the risk of cervical spine instability are discussed, as well as suggestions for a prudent approach to such patients.
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ranking = 6
keywords = neck
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3/38. Case study: acceleration/deceleration injury with angular kyphosis.

    OBJECTIVE: To discuss the case of a patient who received upper cervical chiropractic care after trauma-induced arcual kyphosis in the cervical spine. A practical application of conservative management for posttrauma cervical spine injury in the private office setting is described. Clinical Features: A 17-year-old female patient suffered an unstable C3/C4 motor segment after a lateral-impact motor vehicle collision. Additional symptoms on presentation included vertigo, tinnitus, neck and shoulder pain, and confusion. Intervention and Outcome: Conservative management consisted exclusively of upper cervical-specific adjustments guided by radiographic analysis and paraspinal bilateral skin temperature differential analysis of the cervical spine. During 10 weeks of care and 22 office visits, all symptoms subsided and the instability of C3/C4 motor segment appeared to be completely resolved. CONCLUSION: This study provides support for the use of upper cervical chiropractic management in cervical spine trauma cases. The clinical work-up consisted of physical examination, radiographic analysis, computer-administered and scored cognitive function testing, and audiometric examination. After conservative care, these examinations were repeated and demonstrated that the objective findings concurred with the subjective improvements reported by the patient.
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ranking = 1
keywords = neck
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4/38. Treatment of down syndrome-associated craniovertebral junction abnormalities.

    OBJECT: Operative intervention for craniovertebral junction (CVJ) instability in patients with down syndrome has become controversial, with reports of a low incidence of associated neurological dysfunction and high surgical morbidity rates. The authors analyzed their experience in light of these poor results and attempted to evaluate differences in management. methods: Medical and radiographic records of 36 consecutive patients with down syndrome and CVJ abnormalities were reviewed. The most common clinical complaints included neck pain (15 patients) and torticollis (12 patients). Cervicomedullary compression was associated with ataxia and progressive weakness. Hyperreflexia was documented in a majority of patients (24 cases), and 13 patients suffered from varying degrees of quadriparesis. Upper respiratory tract infection precipitated the presentation in five patients. Four patients suffered acute neurological insults after a minor fall and two after receiving a general anesthetic agent. Atlantoaxial instability was the most common radiographically observed abnormality (23 patients), with a rotary component present in 14 patients. Occipitoatlantal instability was also frequently observed (16 patients) and was coexistent with atlantoaxial dislocation in 15 patients. Twenty individuals had bone anomalies, the most frequent of which was os odontoideum (12 patients) followed by atlantal arch hypoplasia and bifid anterior or posterior arches (eight patients). Twenty-seven patients underwent surgical procedures without subsequent neurological deterioration, and a 96% fusion rate was observed. In five of 11 patients basilar invagination was irreducible and required transoral decompression. overall, 24 patients enjoyed good or excellent outcomes. CONCLUSIONS: The results of this series highlight the clinicopathological characteristics of CVJ instability in patients with down syndrome and suggest that satisfactory outcomes can be achieved with low surgical morbidity rates.
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keywords = neck
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5/38. Ventral cervical fusion at multiple levels using free vascularized double-islanded fibula - a technical report and review of the relevant literature.

    Reconstruction of the cervical spine using free vascularized bone flaps has been described in the literature. The reports involve either one level or, when multiple levels, they describe en bloc resection and reconstruction. Stabilization of different levels with a preserved intermediate segment with a single vascularized flap has not been described. We report on the case of a 55-year-old man, who had been operated several times using conventional techniques for cervical myelopathy and instability, who presented to us with severe neck pain. Diagnostic procedures showed pseudarthrosis of C3/4 and stress-overload of the C3/4 and C5/6 segments. The C4/5 fusion was adequately rigid, but avascular. We performed anterior cervical fusion at the C3/4 and C5/6 levels with a vascularized fibula flap modified as a double island. The rigidly fused C4/5 block was preserved and vascularized with the periosteum bridging the two fibular islands. The method and technique are described in detail. Fusion was adequate. Donor site morbidity was minimal and temporary. The patient is symptom free to date (25 months). The suggested method provides the possibility of vertebral fusion at different levels using a single vascularized flap. The indications for this procedure are (1) repeated failure of conventional methods, (2) established poor bone healing and bone non-union with avascular grafts and (3) a well-fused or preserved intermediate segment. The relevant literature is reviewed.
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ranking = 1
keywords = neck
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6/38. infection-related atlantoaxial subluxation in two adults: Grisel syndrome or not?

    Grisel's syndrome involves the subluxation of the atlanto-axial joint from inflammatory ligamantous laxity following an infectious process in the head or neck. It is a rare disease usually affecting children, but infrequent adult cases do occur. Today, due to the widened use of antibiotics and availability of MR imaging, some cases presenting with neck pain, resulting from the infectious inflammation of C1 and C2 but without pronounced subluxation, can be a challenging problem for most neurosurgeons. Several theories have been proposed to explain the pathogenesis of inflammatory subluxation. The primary treatment of Grisel's syndrome is medical. The underlying infectious organism must be isolated and appropriate antibiotics must be prescribed. The subluxation is reduced in holter or skeletal traction. This paper reports two cases of infection-related atlanto-axial subluxation in two adults. The literature on this subject is briefly reviewed.
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ranking = 2
keywords = neck
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7/38. Odontoid hypoplasia presenting as torticollis: a discussion of its significance.

    Odontoid dysplasias are considered rare but are becoming increasingly recognized. patients may have no symptoms, localized neck pain, or neurologic symptoms. Because patients with odontoid anomalies have the potential for craniovertebral instability, recognition of the entity is essential. A discussion of the axis, its development and anomalies follows.
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ranking = 1
keywords = neck
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8/38. Spondyloepimetaphyseal dysplasia with multiple dislocations, leptodactylic type: report of a new patient and review of the literature.

    A 6-year-old boy with congenital hip dislocation, developmental delay, short stature, macrocephaly, low set ears, short neck, and hyperlaxity of the wrists and fingers is described. Radiographs disclosed mainly the presence of thoracic scoliosis, narrow interpedicular distances, metaphyseal vertical striations, very small irregular epiphyses, right hip dislocation, luxation of both elbows, and severe delay of ossification of the epiphyses and the carpal bones. These features are very close to the newly described entity: spondyloepimetaphyseal dysplasia and multiple dislocations. This patient brings to light the differential diagnosis and confirms the specificity of the radiological findings of this new entity.
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ranking = 1
keywords = neck
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9/38. Anterior instrumentation for traumatic C1-C2 instability.

    STUDY DESIGN: Technical note, case report. and review of literature. OBJECTIVE: Description of anterior transarticular internal fixation for traumatic C1-C2 instability. SUMMARY OF BACKGROUND DATA: The currently effective posterior approaches for instrumentation of the C1-C2 junction require considerable soft tissue dissection and prone patient positioning. Some medical and anatomic conditions restrict the posterior approach. MATERIALS AND methods: An odontoid screw and anterior transarticular C1-C2 screws were used to instrument an unstable injury at this junction. The lesion consisted of a type II dens fracture and C1 ring disruption. Two high-quality fluoroscopy machines, a radiolucent OSI fracture table, and the Synframe (Synthes, Paoli, PA) retraction system are used for this procedure. The implant of choice is the 4.0-mm cannulated titanium screw. RESULTS: At 4-month follow-up, successful stabilization without failure of hardware is documented. The patient's neurologic status is stable, with a minor residual left upper extremity motor deficit. The patient has restricted C-spine rotation but no neck pain with movement. CONCLUSION: Anterior stabilization through a standard Smith-Robinson approach of the C1-C2 junction with screws into the odontoid and the lateral masses of C1 is effective. Supine positioning and minimal soft tissue dissection are advantages of this method over standard posterior transarticular instrumentation. knowledge of the local anatomy, strict adherence to the operative protocol, and high-quality fluoroscopy avoid potential surgical complications.
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ranking = 1
keywords = neck
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10/38. head-neck disassembly of an uncemented revision stem treated by addition of a proximal spacer.

    A 67-year-old woman underwent revision total hip replacement with a long, distally fixed uncemented stem inserted through a transfemoral approach. Initial stability was not achieved and the stem subsided early. Probably due to a conflict with the minor trochanter, the prosthetic head detached from its neck. Instead of a re-revision of the stem, a proximal spacer was inserted to restore stability and to compensate for leg-length discrepancy. This has proved to be a stable and satisfactory solution after three years follow-up.
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ranking = 5
keywords = neck
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