Chris Barrett

Conservative management of type II and III odontoid fractures in the elderly at a regional spine centre: A prospective and retrospective cohort study.

Abstract Background. The optimal management of odontoid fractures in the elderly population is unclear and management of this group of patients is complicated by multiple co-morbidities. This study aimed to determine the outcomes after conservative management strategies were applied in this patient group. Methods. We carried out retrospective and prospective analyses of all patients with axial cervical spine injuries, at a single centre. We included patients aged over 60 years with type II and III odontoid fractures. Information was gathered on demographics, ASA grading-associated injuries and complications. The outcome measures were rates and type of union, pain and neurological functions, specifically ambulation. Results. Fifty-seven adult patients with a median age of 78 years (range 60–92 years) were included. There were 42 type II and 15 type III odontoid fractures. Three patients required surgical fixation due to displaced fractures, which could not be reduced with manual traction. Twenty-four (41%) patients were managed with a rigid pinned halo orthosis to obtain adequate reduction and immobilisation. The remaining 30 (53%) were managed in a hard cervical collar. Patients managed with a halo were significantly younger and had more associated injuries than patients managed in a collar (age: t-test = 4.05, p < 0.01, associated injuries: Chi-square = 4.38, p < 0.05). At a mean follow-up of 25 weeks, 87% of type II and 100% of type III fractures had achieved bony union or stable, fibrous non-union. There were no statistical differences in fracture type, follow-up or neurological outcomes between the halo and collar groups. However, overall more patients managed in a collar developed stable fibrous non-union than bony fusion (Fishers exact test, p < 0.05), although this was not significant when analysed by each fracture type individually. A regression model was constructed and identified fracture type as the only independent predictor of time to union, with type III fractures healing faster than type II. Conclusions. High rates of bony union and stable fibrous non-union with a good functional outcome can be achieved in the elderly population sustaining type II or III odontoid fractures, when managed non-surgically. Halo orthosis may not offer any clear advantage over hard collar in this group. Close follow-up is needed for late complications and there must be a willingness to perform surgery if conservative measures fail.

Applications of the ultrasonic bone cutter in spinal surgery – our preliminary experience

Abstract Objective. To present our experience with the Misonix Ultrasonic Bone scalpel in spinal surgery, highlighting its potential applications and advantages. Methods. Between March and December 2011, a total of 937 spinal cases were performed at a single centre. The Misonix Bone Scalpel (MBS) was used in 62 of these cases. Data were collected prospectively using the Spine Tango registry. Patient demographics, disease type, surgery performed and complications were all recorded along with pre- and post-operative core measures outcome index (COMI). Results. The majority of cases were for spinal degenerative disorders, in particular, revision cases. The bone cutter was also used to achieve laminotomies for access to intradural tumours, corpectomies and a mixture of other pathologies. Of the 62 patients only 1 (1.6%) experienced a blood loss greater than 500 ml, and there was only 1 dural tear (1.6%) as a direct result of the MBS. Four illustrative cases are discussed. Conclusions. The MBS is a useful adjunct in spinal surgery with particular value in revision cases where scar tissue distorts the normal anatomy. There was a low complication rate with a trend to reduced blood loss. This was most apparent to the senior authors during cervical and thoracic corpectomies.

Anterior thigh compartment syndrome after prone positioning for lumbosacral fixation.

We report a case of a patient who developed anterior thigh compartment syndrome after being positioned prone for instrumented lumbar spine surgery. Although rare, clinicians should be aware that compartment syndrome is a possible complication of spinal surgery.

Overtightening of halo pins resulting in intracranial penetration, pneumocephalus, and epileptic seizure

A 60-year-old man sustained an undisplaced type III odontoid fracture following a fall down a full flight of stairs. His medical history was remarkable for a partial pancreatectomy and splenectomy in 2006 for chronic pancreatitis. This had rendered him diabetic, on insulin, and he required long-term administration of penicillin V. The fracture was treated with a halo vest, and, unknowing of its potentially serious consequences, the patient continued to tighten the halo pins himself. He presented 1 month later following a witnessed seizure. A computed tomography scan was performed, which demonstrated 2 cranial perforations, with the halo pins penetrating the cranium and resultant pneumocephalus. He was started on antiepileptic medication and was placed in a pinless halo system. He had no further seizures and has made an uneventful neurological recovery. This paper serves to highlight the potential complications which may arise from the use of a halo vest. Proper patient education is essential to avoid these serious yet avoidable events, and patients with low bone density and the immunosuppressed should be monitored closely.

Pin site allergic contact dermatitis: an unusual complication of halo fixation

We report a case of halo pin site allergic contact dermatitis, a rare complication of halo vest immobilisation (HVI), necessitating device removal. Although uncommon, pin site allergic contact dermatitis should be considered in patients who develop an acute dermatitis within hours to days of HVI application.

The utility of myelography in lumbar canal stenosis

Received for publication 6 December 2011; accepted 1 February 2012 walking distance of 40 m, after which he had to stop and rest for 2 minutes before continuing. Peripheral vascular disease had previously been ruled out by the vascular surgeons. An MRI of his lumbar spine revealed a very mild degree of lumbar canal stenosis at L3/4 with bilateral foraminal stenosis (Figs. 1 and 2). Th e gentleman, therefore, underwent plain and CT myelography. Both these modalities revealed signifi cant lumbar canal stenosis at L3/4 in keeping with the severity of his clinical syndrome (Figs. 3 and 4). Th e patient was off ered L3/4 decompression, but after discussion, he wished for the time being to be managed conservatively.

Super-sub-ultra-specialisation – this far and no further?

‘ A specialist is someone who learns more and more about less and less until they know everything about nothing. ’ Specialisation of occupation in human society has been an ongoing process since the earliest civilisations. In Medicine, from the early dichotomy between the educated monastic healers and the barber-surgeons, came the modern categories of physician and surgeon, respectively. Each of these two primary specialties over time has fragmented into a myriad of sub-specialties generally based on a system or occasionally on a specifi c pathology. Th is process has on the whole been an organic or evolutionary one, driven by individual interests and preferences. Th is has almost certainly had a net positive eff ect: where dynamic individuals are allowed to pursue interests with enthusiasm and vigour often leads to the greatest advances. Just a few years ago, the idea that the already super-specialised area of neurosurgery would further sub-divide and fragment may have seemed outlandish, particularly from the traditional general surgery perspective. Nevertheless, the process has inevitably continued. Th ere is, however, one signifi cant diff erence about sub-specialisation in the modern era: it is no longer the organic process it once was, but is being driven by a number of outside factors, often by nonsurgeons or by surgeons with aims that are not medical or surgical, but political. Unfortunately, no-one seems to have a coherent view of the whole picture. Th e constrained, rigid and enforced sub-specialisation taking place currently has, in my opinion, a number of detrimental eff ects for the patient, the surgeon and the specialty. Th is is the central issue facing neurosurgery today, yet no real debate or discussion has taken place amongst the profession. Amazingly, for a specialty, supposedly known for its assertiveness, the process is driven principally by outsiders who have no real insight into surgery in general or neurosurgery in particular. I fi nd it curious that the refl ex ‘ No! ’ was not politely (or otherwise) off ered. Th e current wave of sub-specialisation appears to be principally driven by two fallacious axioms which are heretical to criticise: effi ciency and improved patient outcomes. Th e argument that sub-specialisation is effi cient appeals to a certain brand of managerial thinking: if it works in a car production-line, why not in surgery? Indeed why not go further, surgeons could in theory specialise in one operation, but in that case why have a surgeon at all, why not train a technician or a nurse specialist? It would certainly be cheaper and thus more effi cient. Th is is na ï ve optimisation of the worst kind. It assumes (incorrectly – from any study of history) that the current state of the art is the endpoint or the fi nal version. It allows no room for development, change or improvement. Neither does it allow the specialist to develop the necessary awareness and interest of other areas which allows for the cross-fertilisation of ideas, vital for any real medical advances. Conversely, it leads to ossifi cation and a disinterested, disengaged individual who inevitably will fi nd other things to occupy his or her time with. Regarding ‘ improved patient outcomes ’ : this is easily resolved by publishing the results. It has not yet been proved and should not be assumed. Furthermore, surgeons who profess to be superspecialists and who would restrict the practice of colleagues should have to demonstrate their superiority on an individual, not as a collective basis. Conversely, surgeons who can demonstrate their competence objectively should not have their practice restricted on any political grounds. It is signifi cant that the current wave of specialisation is driven by the diseaseor age-specifi c models that nonsurgical specialties tend to use: surgeons acquire skills and techniques that are almost always applicable across these categories and should be allowed to practice accordingly. If surgeons attempted to organise or constrain the working patterns of other specialties it would be (rightly) regarded as an outrageous breach of professional autonomy. Yet this is precisely what surgeons are currently submitting to! Th e risks of the current wave of specialisation fall into three broad categories:

Unusual presentation of Tuberculosis with multiple spinal deposits

We discuss the relevant imaging of an unusual case of disseminated tuberculosis presenting with multifocal spinal deposits.

Management of Giant Calcified Thoracic Disks and Description of the Trench Vertebrectomy Technique

Study Design Case series and review of the literature. Objective To review the management of giant calcified disks in our large cohort and compare with the existing literature. We discuss our surgical technique. Methods Twenty-nine cases of herniated thoracic disk between 2000 and 2013 were reviewed. Eighteen patients were identified as having giant calcified thoracic disks, defined as diffusely calcified disks occupying at least 40% of the spinal canal. Demographic data was collected in addition to presentation, imaging findings, operative details, and outcomes using the modified Japanese Orthopaedic Association (mJOA) scale. Results Giant calcified thoracic disks (GCTDs) are unique clinical entities that require special neurosurgical consideration owing to significant (≥40%) involvement of the spinal canal and compression of the spinal cord, often leading to myelopathy. The median age at diagnosis was 51.2 years (range 37 to 70) with the mean duration of presenting symptoms being 9.9 months (range 2 weeks to 3 years). Seventeen (94.4%) patients presented with at least one sign of myelopathy (hyperreflexia, hypertonia, bladder or bowel dysfunction) with the remaining 1 (5.6%) patient presenting with symptoms in keeping with radiculopathy. Thoracotomy was performed on 17 (94.4%) patients, and 1 (5.6%) patient had a costotransverse approach. Mean follow-up was 19.8 months (range 7 months to 2 years). mJOA score improved in 15 (83.3%) patients. mJOA scores in the other patients remained stable. Conclusions GCTDs are difficult neurosurgical challenges owing to their size, degree of spinal cord compression, and consistency. We recommend a trench vertebrectomy via a thoracotomy in their surgical management. This procedure safely allows the identification of normal dura on either side of the compressed segment prior to performing a diskectomy. Excellent fusion rates were achieved with insertion of rib head autograft in the trench.