Cases reported "Spinal Fractures"

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1/63. 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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2/63. Neurologic compromise after an isolated laminar fracture of the cervical spine.

    STUDY DESIGN: Report of a rare fracture of the cervical spine. OBJECTIVES: To illustrate the importance of the cervical spinolaminar line in the diagnosis of this unusual injury and to comment on appropriate investigations, management, and outcome. SUMMARY OF BACKGROUND DATA: Laminar fractures of the cervical spine are uncommon and are often missed. They usually occur after a hyperextension injury. It is unusual for these injuries to cause neurologic compromise. The injury reported here differs in that it was a result of direct trauma to the posterior aspect of the neck, and there was a significant neurologic deficit. methods: The clinical findings, roentgenographic appearance, treatment, complications, and follow-up assessment are presented and discussed. RESULTS: Initial neurologic examination revealed a right hemiparesis. Radiographs showed disruption of the spinolaminar line at C5 and a computed tomography scan revealed a fracture of the lamina of C5 with spinal canal encroachment. Management included high-dose corticosteroid administration and a posterior spinal decompression. The patient's initial postoperative course was complicated by acute pulmonary edema, which responded well to intravenous furosemide and ventilation. Follow-up assessment showed significant neurologic improvement. CONCLUSIONS: The satisfactory outcome in the case of this rare injury was the result of a prompt, accurate diagnosis and appropriate management.
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3/63. A case of traumatic high thoracic myelopathy presenting dissociated impairment of rostral sympathetic innervations and isolated segmental sweating on otherwise anhidrotic trunk.

    A 3 year-old boy developed flaccid paraplegia, anesthesia below T3 and impaired vesical control immediately after a car accident. Three months later, the pupils and their pharmacological reactions were normal. Thermal sweating was markedly reduced on the right side of the face, neck, and shoulder and on the bilateral upper limbs, and was absent below T3 except for band like faint sweating on T7 sensory dermatome. The left side of the face, neck and shoulder showed compensatory hyperhidrosis. Facial skin temperature was higher on the sweating left side. Cervico-thoracic MRI suggested almost complete transection of the cord at the levels of T2 and T3 segments. We discussed the pathophysiology of the dissociated impairment of rostral sympathetic innervations and isolated segmental sweating on otherwise anhidrotic trunk.
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4/63. Missed cervical spine fracture: chiropractic implications.

    OBJECTIVE: To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination. CLINICAL FEATURES: A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views. INTERVENTION AND OUTCOME: The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment. CONCLUSION: After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.
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5/63. Patterns of maxillofacial injuries in powered watercraft collisions.

    Because of the widespread popularity of water sports, plastic and reconstructive surgeons can expect to manage an increasing number of injuries associated with these activities, particularly those related to powered watercraft vehicles. Although seat belts for motorists and helmets for motorcyclists may be efficacious, such devices currently do not serve a similar role in powered watercraft sports. In this study, a retrospective chart review of 194 consecutive patients who presented to the University of Miami/Jackson Memorial Hospital (Level I trauma center) as a result of powered watercraft collisions is presented. The purpose of this investigation was to assess the incidence, cause, demographics, and available management options for head and neck injuries secondary to powered watercraft. Identified were 194 patients who presented because of watersports-related injuries during the period January 1, 1991, through December 31, 1996. From this group, 81 patients (41.8 percent) sustained injuries directly attributable to powered watercraft collisions, including 41 personal watercraft collisions (50.6 percent), 39 boat collisions (48.1 percent), and 1 airboat collision (1.2 percent). The patient population, as expected, tended to be young and male with an average age of 29 years (range, 8 to 64 years old). Interestingly, 41 of the patients (50.6 percent) who presented to this trauma center as a result of powered watercraft collisions also sustained associated head and neck trauma. Of 74 injuries 24 were facial fractures (32.4 percent), 18 were facial lacerations (24.3 percent), 14 were closed head injuries (18.9 percent), 8 were skull fractures (10.8 percent), 4 were scalp lacerations (5.4 percent), 4 were C-spine fractures (5.4 percent), 1 was an ear laceration (1.4 percent), and 1 was a fatality (1.4 percent). Le Fort fractures were the most commonly identified facial fracture in this series. The number of these injuries seen in hospital emergency rooms will most likely increase in the future as the popularity of water-related recreational activities becomes even more widespread. Based on these findings, it is strongly recommended that future efforts be directed toward the prevention of these injuries through patient education and the eventual development of efficacious and safe protective equipment.
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6/63. 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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7/63. Scratched pustule or gunshot wound? A medical odyssey.

    The diagnosis of a gunshot wound can be difficult especially if the morphology is not typical. In the case presented a neck injury was not recognised as a gunshot wound by several clinicians and radiologists although the bullet could be seen at the base of the patient's tongue and on all x-rays taken. This misinterpretation may have been caused by a "professional blinkers phenomenon".
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8/63. Salvage of a malpositioned anterior odontoid screw.

    STUDY DESIGN: Description of surgical technique with case correlation. OBJECTIVE: This article presents an alternative approach to anterior odontoid screw salvage in a patient with established nonunion. SUMMARY OF BACKGROUND DATA: Type II odontoid fractures are often treated surgically because of their risk of nonunion. Anterior odontoid screw fixation offers stable fixation without loss of atlantoaxial motion. treatment failure may occur despite adequate screw placement but is more likely when fixation is inadequate. The traditional solution is a posterior fusion. In selected cases the surgeon may want to revise the anterior instrumentation with the hope of retaining as much C1-C2 motion as possible. methods: A 43-year-old man presented 16 months after Type II odontoid fracture treated by anterior odontoid screw fixation. He had neck pain, instability, and a pseudarthrosis confirmed on radiographs. The screw was excessively long, piercing the C3 vertebral body and providing inadequate fixation. To avoid posterior fusion, a modified anterior approach was used. An entry point was selected 10 mm lateral to the midline, along the anterior rim of the C2 vertebral body. A large-diameter lag screw was then passed to the tip of the fragment. An angled curette was introduced into the fracture gap through the interval between the odontoid and the C1 ring. Autogenous bone was packed into the gap and along the old screw tract. RESULTS: At the 2-year follow-up the patient had a solid union with no neck pain, no headaches, no radicular symptoms, and excellent range of motion. The approach is described. CONCLUSION: In properly selected patients an anterior revision approach can provide a better outcome than posterior cervical fusion. This modified approach allows placement of an adequate fixation screw in a vertebra damaged by previous screw failure.
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9/63. Recovery from severe glucocorticoid-induced osteoporosis in an adolescent boy.

    An 18-yr-old boy presented with extreme back pain as the result of multiple vertebral fractures. At age 16 he had developed a tumor of the mesencephalon. A ventriculoperitoneal shunt was established surgically. One year later, he developed progressive neurologic deficits in his upper and lower limbs with an increase in the size of the tumor. He was treated by irradiation and high doses of glucocorticoids. Although the neurologic deficits progressively improved, he developed severe back pain resulting in complete immobilization for 3 mo in spite of neurologic recovery. Multiple vertebral fractures were diagnosed by X-ray. bone density was extremely low (Z-score of -5.5 in the spine and -3.1 in the femoral neck). The patient was treated with calcium and vitamin d, calcitonin, bisphosphonates, physiotherapy, and progressive mobilization. glucocorticoids were decreased and could be stopped as the neurologic deficits fully recovered. After 1 yr of treatment with intermittent i.v. pamidronate, bone density had increased by 40% in the spine and by 25% in the femoral neck despite growth arrest. He progressively recovered from back pain and is now, at age 20, fully ambulant, studying mechanical engineering, without neurologic sequelaes and free of glucocorticoids. magnetic resonance imaging revealed that the tumor had disappeared. This case proves that treatment of symptomatic glucocorticoid-induced osteoporosis during puberty can be rewarding, even when multiple and invalidating vertebral fractures already exist.
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10/63. Isolated anterior arch fracture of the atlas: child case report.

    STUDY DESIGN: The authors report a case of an atlas fracture at the anterior arch. OBJECTIVE: To discuss the difficulty in diagnosing this type fracture. SUMMARY OF BACKGROUND DATA: Fractures of the atlas are not uncommon, and actually constitute 10% of all cervical spine injuries in adults. However, in the pediatric population, fractures of atlas are extremely rare, and only a few cases have been described. Only two isolated anterior arcus fractures of the atlas have been reported previously. methods: A 2.5-year-old girl was admitted to the authors' department with neck pain and head tilt 2 days after falling from a wall onto the top of the head. Radiographs of the cervical spine reportedly showed no abnormality. Computed tomography of the upper cervical spine showed a fracture in left anterior arch of the C1 vertebra with a 2-mm separation. She was placed in a firm cervical collar and instructed to reduce her daily physical activities. A repeat scan 3 months later showed fusion at the fracture site. RESULTS: The patient was treated with a firm cervical collar, and fusion of the fracture site was documented with computed tomography scan at 12 weeks after the injury. Her cervical collar was removed, and she has been fully active with no restrictions. CONCLUSIONS: On plain radiographs, fractures of the atlas and anterior aspect in particular may remain occult. Accurate diagnosis of atlas fractures depends on further radiologic investigations including computed tomography and magnetic resonance imaging. Experience in treating atlas fractures is insufficient because of a paucity of literature. immobilization with a firm cervical collar is the treatment of choice in stable atlas fracture.
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