Ankylosierende Spondylitis

Background

Spine fractures in ankylosing spondylitis (AS) are extremely unstable and associated with a high complication rate. The aim of this retrospective study was to evaluate the therapy and complications of these fractures in AS for a better understanding and management.

Patients and methods

A total of 32 patients with 34 traumatic spine fractures were treated from 1981 to 2002. Cause of trauma, fracture site, and neurological examination were assessed. Analyses of the management of the treatment and complications were performed.

Results

Banal traumas resulted mostly in spinal fractures at the C 5/6 and C 6/7 level. Two patients were treated conservatively, while the others were stabilized operatively. Before therapy was undertaken, six patients suffered from a cervical radiculopathy, ten patients had an incomplete and two a complete paraplegia. After therapy, neurological status improved in eight patients, but one had a deterioration of neurological symptoms.

Conclusions

Dorsal or combined dorsoventral stabilization of these fractures is necessary for better mobilization of these patients and to avoid further complications.     

Spinal cord injuries due to diving accidents

STUDY DESIGN: Retrospective study and data analysis. OBJECTIVE: To investigate and analyse the main features of spinal cord injuries due to diving accidents accepted in our Centre from June 1978 to December 2002. SETTING: Regional Spinal Unit of Florence, Italy. INTRODUCTION: Diving accidents mostly occur in a young and healthy population and most of the patients develop tetraplegia with a severe lifelong disability. From 1978 to 2002, 65 patients with spinal injuries due to diving accidents were admitted to the Regional Spinal Unit of Florence. MATERIAL AND METHODS: A retrospective study was conducted by analysing data stored in our local computerized database. We considered the vertebral injury, ASIA-ISCOS neurological classification on admission and discharge, gender, age at the time of injury, month of injury, treatment of vertebral lesion, length of stay in the Spinal Unit, neurological outcome, and complications. Data were analysed statistically by using the Fisher's exact test and logistic regression. RESULTS: In all, 62/65 patients were males (95%). Mean age at injury time: 22 years. On admission, 35/65 were neurologically complete ASIA A (54%), while 16 were classified ASIA B, 7 ASIA C and 7 ASIA D, according to the ASIA-ISCOS neurological standard of classification. C6 was the most common neurological motor level (40%) and C5 the most common vertebral injury level. In all, 36/65 (55%) patients underwent surgical treatment. Mean hospitalization time was 5 months. No neurological deterioration was recorded. In all, 20/65 (31%) patients improved neurologically and 16/20 (80%) of those had received surgical treatment. In all, 15/65 (23%) patients had complications and one patient died during the hospitalization period. CONCLUSIONS AND DISCUSSION: Patients whose vertebral lesions were surgically treated had a better neurological outcome than conservatively treated ones. Teardrop fractures showed worse neurological outcome as compared with burst fractures. Neurological improvement was more present in initially incomplete lesions. Treatment with high dose methylprednisolone during the first 8 h after trauma seemed to influence the neurological outcome positively. Age was also an important factor in influencing the neurological outcome.     

强直性脊柱炎合并颈胸段脊柱骨折脱位的诊治

目的：探讨强直性脊柱炎（AS）合并颈胸段脊柱骨折脱位的病理临床特点、治疗方法及围手术期注意事项。方法：回顾分析2001年1月至2009年3月收治手术的13例AS合并颈胸段脊柱骨折脱位病例,男11例,年龄33-60岁,平均46岁;女2例,年龄36-59岁,平均47．5岁。AS病程12—27年,平均14．5年。主要临床表现为颈肩部疼痛,可伴有四肢肌力减弱、上肢感觉麻木等,X线片示颈胸段脊柱连续性中断,HIA—B27阳性。观察术后骨折愈合及脊髓神经功能改善情况（ASIA评分）。结果：13例中,6例行颈前路单间隙减压内固定术,4例行颈前路椎体次全切减压内固定术,1例行颈后路全椎板减压侧块螺钉内固定术,2例行前后联合入路复位减压内固定术。术后随访12～43个月,平均35．6个月,骨折脱位复位良好,均获得骨性融合。术后神经功能除1例A级无明显改善外,其余均有不同程度恢复。围手术期并发症5例。结论：AS合并颈胸段脊柱骨折多为不稳定的三柱骨折,常需手术治疗,术前合理选择手术适应证及术式,可减少并发症,获得较好的神经功能恢复。     

Late esophageal perforation complicating anterior cervical plate fixation in ankylosing spondylitis: a case report and review of the literature

Esophageal perforation in ankylosing spondylitis (AS) is a rare complication in anterior cervical spine surgery and has not been reported before. A 50-year-old patient with AS developed incomplete tetraplegia after minimal trauma. C5 pedicle fracture was diagnosed and treated predominantly by physical therapy until neurological symptoms progressed. Cervical spine MRI showed C6/7 fracture and spinal cord compression. The patient underwent dorsal laminectomy, C5–7 anterior cervical fusion using allograft iliac crest and CASPAR-plate fixation. Delayed esophageal perforation appeared 10 months postoperatively when he came first to our hospital. He complained of dysphagia and developed acute dyspnea. Posterior stabilization with two plates was performed followed by removal of the ventral plate and screws. The esophageal laceration was sutured. The patient was treated with antibiotics and percutaneous endoscopic gastrostomy. Position of fracture and implants were accurate at 18 months postoperatively. The patient had persistent minor neurological deficits (Frankel D) at last follow-up. We conclude that esophageal perforation after anterior spinal fusion is a rare complication. Minor traumas in patients with AS are unstable and can result in significant spinal injury. Dorsoventral stabilization should be performed to avoid further complications.     

Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis

Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine fractures. Long-standing pain may mask the symptoms of the fracture. Radiological imaging of the cervical spine may fail to identify the fracture due to the distorted anatomy, ossified ligaments and artefacts leading to delay in diagnosis and increased risk of neurological complications. The objectives are to identify the incidence and risk factors for delay in presentation of cervical spine fractures in patients with AS. Retrospective case series study of all patients with AS and cervical spine fracture admitted over a 12-year period at Queen Elizabeth National Spinal Injuries Unit, Scotland. Results show that total of 32 patients reviewed with AS and cervical spine fractures. In 19 patients (59.4%), a fracture was not identified on plain radiographs. Only five patients (15.6%) presented immediately after the injury. Of the 15 patients (46.9%) who were initially neurologically intact, three patients had neurological deterioration before admission. Cervical spine fractures in patients with long-standing AS are common and usually under evaluated. Early diagnosis with appropriate radiological investigations may prevent the possible long-term neurological cord damage.     

Spinal fractures in patients with ankylosing spondylitis

Thirty-one consecutive patients with ankylosing spondylitis and spinal fractures were reviewed. There were 6 women and 25 men with a mean age of 60±11 years; 19 had cervical and 12 had thoracolumbar injuries. Of the patients with cervical fracture, two had an additional cervical fracture and one had an additional thoracic fracture. Three trauma mechanisms were identified: high-energy trauma in 13 patients, low-energy trauma in 13 and insufficiency fracture in 5. One-third of the patients suffered immediate neurological impairment, a further one-third developed neurological impairment before coming for treatment and only one-third remained intact. Two patients with thoracolumbar fractures had deteriorated neurologically due to displacements during surgery at other hospitals. All patients were treated operatively except the two patients with two-level cervical fractures, who were managed in halo vests. In the cervical spine both anterior and posterior approaches were employed. In the thoracolumbar spine the majority of the patients were initially treated using a posterior approach only. Complications were common. Of the 27 patients with neurological compromise, 10 had remained unchanged; 12 had improved one Frankel grade; 4 had improved by two Frankel grades; 1 had improved by four Frankel grades. We conclude that even minor trauma can cause fracture in an ankylosed spine. A high proportion of patients with spinal fractures and ankylosing spondylitis have neurological damage. The risk of late neurological deterioration is substantial. As the condition is very rare and the treatment is demanding and associated with a very high risk of complications, the treatment of these patients should be centralised in special spinal trauma units. A combined approach that stabilises the spine from both sides is probably beneficial.     

Fracture luxation of the cervical spine in patients with ankylosing spondylitis: six cases

BACKGROUND AND PURPOSE: Treatment of cervical spine fracture in patients with ankylosing spondylitis is difficult. Biomechanical changes related to ossified ankylosing spondylitis spine make cervical spine fractures highly unstable. They cover the entire width of the spine inducing multidirectional instability and the risk of neurological injuries. Treatment is more difficult that in the nonossified spine. Different treatments have been proposed including anterior stabilization, posterior stabilization, or both. METHODS: We reviewed retrospectively six cases of cervical fracture dislocation in patients with ankylosing spondylitis. RESULTS: There were five cases of C6C7 fracture dislocation and one case of C4C5 fracture dislocation. Four patients had neurological impairment at diagnosis. All patients underwent surgery. Two had anterior stabilization: one patient died and the other achieved bone healing. Four patients had anterior and posterior stabilization combined with a cervical brace for three months, for two and a halo cast for two, others because of persistent instability, with neurological injury in one. A neurological improvement was obtained in four patients. One patient was lost to follow-up. CONCLUSION: Surgical management of selected patients with ankylosing spondylitis and cervical spine fractures is challenging. Combined anterior and posterior stabilization should be considered for these fractures. A cervical brace must be associated with surgical treatment. With appropriate management, outcome can be favorable.     

Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications

The ankylosed spine is prone to fracture after minor trauma due to its changed biomechanical properties. Although many case reports and small series have been published on patients with ankylosing spondylitis (AS) suffering spine fractures, solid data on clinical outcome are rare. In advanced diffuse idiopathic skeletal hyperostosis (DISH), ossification of spinal ligaments also leads to ankylosis. The prevalence of AS is stable, but since DISH may become more widespread due to its association with age, obesity and type 2 diabetes mellitus, a systematic review of the literature was conducted to increase the current knowledge on treatment, neurological status and complications of patients with preexisting ankylosed spines sustaining spinal trauma. A literature search was performed to obtain all relevant articles concerning the outcome of patients with AS or DISH admitted with spinal fractures. Predefined parameters were extracted from the papers and pooled to study the effect of treatment on neurological status and complications. Ninety-three articles were included, representing 345 AS patients and 55 DISH patients. Most fractures were localized in the cervical spine and resulted from low energy impact. Delayed diagnosis often occurred due to patient and doctor related factors. On admission 67.2% of the AS patients and 40.0% of the DISH patients demonstrated neurologic deficits, while secondary neurological deterioration occurred frequently. Surgical or nonoperative treatment did not alter the neurological prospective for most patients. The complication rate was 51.1% in AS patients and 32.7% in DISH patients. The overall mortality within 3 months after injury was 17.7% in AS and 20.0% in DISH. This review suggests that the clinical outcome of patients with fractures in previously ankylosed spines, due to AS or DISH, is considerably worse compared to the general trauma population. Considering the potential increase in prevalence of DISH cases, this condition may render a new challenge for physicians treating spinal injuries.     

Thoracic spine fractures: injury profile and outcomes of a surgically treated cohort

There are only few reports in literature about the treatment of traumatic lesions of the thoracic spine. They have been grouped together with thoracolumbar fractures, ignoring the particular biomechanics of the thoracic segment. The objective of this retrospective cohort is to describe the clinical presentation and outcomes of surgically treated patients with these injuries. Data were obtained from the institutional database of medical registries, identifying all the patients who had been treated for thoracic spine fractures, from January 1, 1995 through December 31, 2005 in our institution. The study group included the 51 surgically treated patients. General and surgery-related complications were considered as clinical outcomes and injury-related disability was also assessed. Statistical analysis evaluating possible associations with timing and type of surgery, neurological impairment and associated injuries was carried out. Motor vehicle accident was the most frequent mechanism of injury. Six patients had an incomplete neurological deficit, whereas 22 had a complete lesion. Thirty-two patients presented at least one complication. Five of the neurologically intact patients, while 20 of those with neurological impairment presented general complications (p = 0.0001). None of the patients’ neurological status deteriorated after surgery. All patients with complete spinal cord injury and those with incomplete cord injury with partial functional recovery received disability compensation. Short pedicle instrumentations should be used whenever possible, but also long instrumentations and mixed constructs may be necessary for the management of such unique fractures.     

手术治疗强直性脊柱炎合并颈椎骨折脱位的临床研究

目的探讨强直性脊柱炎（AS）合并外伤性颈椎骨折脱位的病理特点,评价前后路联合手术疗效。方法回顾性分析2000年1月至2006年1月治疗的18例AS合并外伤性颈椎骨折脱位患者。AS平均病程14．5年,3例既往行腰椎截骨矫形手术。术前Frankel分级：A级4例,B级3例,C级9例,D级2例。均为前后路联合手术。结果应用前-后入路4例,前-后-前入路8例,后-前入路6例。一期手术7例,分期11例。术后神经功能除4例A级随访无改善外,其余14例均有不同程度恢复。平均随访21．2个月,术后平均3．6个月植骨获得融合,无内固定失败。围手术期并发症4例,远期1例。结论本研究提示前后路联合手术能取得即刻脊柱三维稳定,有效解除脊髓前后方压迫,是累及三柱的AS合并颈椎骨折脱位的合理外科治疗方式。     

Multicentre collaborative cohort study of the use of Kirschner wires for the management of supracondylar fractures in children

Purpose: Supracondylar fractures of the humerus cause significant morbidity in children. Nerve damage and loss of fracture reduction are common recognised complications in patients with this injury. Un certainty surrounds the optimal Kirschner wire configuration and diameter for closed reduction and pinning of these fractures. This study describes current practice and examined the association between wire configuration or diameter and outcomes (clinical and radiological) in the operative management of paediatric supracondylar fractures. Methods: Children presenting with Gartland II or III supracondylar fractures at five hospitals in south west England were eligible for inclusion. Collaborators scrutinised paper and electronic case notes. Outcome measures were maintenance of reduction and iatrogenic nerve injury. Results: Altogether 209 patients were eligible for inclusion: 15.7% had a documented neurological deficit at presentation; 3.9% who were neurologically intact at presentation sustained a new deficit caused by treatment and 13.4% experienced a clinically significant loss of reduction following fixation. Maintenance of reduction was significantly better in patients treated specifically with crossed 3 Kirschner wire configuration compared to all other configurations. The incidence of iatrogenic nerve injury was not significantly different between groups treated with different wire configurations. Conclusion: We present a large multicentre cohort study showing that crossed 3 Kirschner wires are associated with better maintenance of reduction than crossed 2 or lateral entry wires. Greater numbers would be required to properly investigate nerve injury relating to operative management of supra condylar fractures. We found significant variations in practice and compliance with the British Ortho paedic Association Standard for Trauma (BOAST) 11 guidelines.     

Wirbels?ulenfraktur bei ankylosierender Spondylitis

Introduction

The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well ?C established procedure. This study was to evaluate the surgical outcome of 119?patients with AS associated spine fractures.

Methods

From 07/96 to 01/10, 119?patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis.

Results

The median age was 67?years (37?C95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18?patients (15%) and stable fractures in 15?patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32?patients ventral instrumentation, in 82?patients dorsal and in 15?patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required.

Conclusion

Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.     

Traumatic fractures of the craniovertebral junction. Management of 23 cases

Twenty-three consecutive cases of traumatic C1-C2 fractures treated at the Department of Neurosurgery, University of Milano, are reported. Of these there were 13 cases of odontoid fractures, 6 hangman fractures, 2 anterior inferior corner fractures, 2 atlas-axis combination fractures and 2 Jefferson fractures. Almost all the patients were young people involved in motor vehicle accidents. Nineteen patients were treated with external immobilization (halo vest, Minerva) for 3-6 months while 4 odontoid fractures underwent early surgical posterior stabilization. At follow-up, 20 patients had a good fusion while 3, aged over 75 years, died due to cardiopulmonary or septic complications. The appropriate management of this type of lesion is still a matter of discussion. In our opinion the Halo device allows good stabilization after correct fracture reduction.     

Adult distal humeral metaphyseal fractures: epidemiology and results of treatment

OBJECTIVES: To examine the epidemiology and results of treatment of fractures of the distal humeral metaphysis. DESIGN: Observational cohort study. SETTING: An orthopaedic trauma unit, which provides all the fracture care for a well-defined catchment population. PATIENTS/PARTICIPANTS: A consecutive series of 320 patients with distal humeral fractures admitted to the unit between January 1988 and June 1997. INTERVENTION: We adopted a protocol of open reduction and fixation of all displaced fractures (greater than 5 mm of displacement in any plane) in patients who were medically fit for anesthesia. Postoperative immobilization was a cylinder cast for 6 weeks. Patients with undisplaced fractures or who were medically unfit were also treated nonoperatively in cylinder casts for 6 weeks. MAIN OUTCOME MEASUREMENTS: Epidemiological examination of patient subgroups and the incidence of complications of treatment. RESULTS: The overall incidence of distal humeral fractures in adults during this time was 5.7 cases per 100,000 in the population per year with an almost equal male to female ratio. There was a bimodal age distribution, simple falls were the most common overall cause of fracture, and the majority of the fractures were extra-articular (AO/OTA type A) or complete articular fractures (AO/OTA type C). The risk of complications during treatment was generally low in most patients, and the majority healed their fractures uneventfully. Overall, 90.6% of fractures united within 12 weeks and just under half of the remaining 9.4% patients with union complications healed without requiring further operative intervention by 24 weeks. The risk of union complications was higher following high-energy injuries, open fractures, and nonoperative treatment. Although the AO/OTA classification was not predictive of union complications, the "low" transcondylar (type A2.3 and A3) and simple intercondylar fracture (type C1.3) configuration had a greater risk of union complications than the "high" subtype. The rate of infection, myositis ossificans, and other implant-related complications were higher following operative treatment of type C fractures than type A and B fractures. CONCLUSIONS: The epidemiology of a consecutive unselected series of adult distal humeral fractures is defined in this study. The majority of these fractures are best treated surgically by rigid open reduction and internal fixation, except for "low" Type A and C fractures, which have a higher risk of union complications. The role of total elbow arthroplasty to treat these more complex injuries requires further evaluation.     

强直性脊柱炎脊柱骨折的治疗

目的 了解强且性脊柱炎(AS)脊柱骨折治疗的特点及注意事项。方法对19例AS脊柱骨折病例进行回顾性分析硬随访,19例中颈椎骨折11例,9例发生在C5-7间;胸腰椎骨折8例,7例为应力骨折,均发生存T10-L2间。二柱骨折16例。9例并发脊髓损伤,其中8例为颈椎骨折。所有19例患者均接受了手术治疗。颈椎骨折或脱位采用了4种手术方式,其中9例做了前路间盘切除或椎体次全切除、椎间值骨加钢板内固定术。胸腰椎骨折也做了4种术式,其中5例的术式为后路长节段固定加前、后联合融合,结果术岳18例患者获得了平均46．4个月的随访。并发脊髓损伤的9例患者,术后8例的神经功能有恢复。18例患者的骨折部位均已骨性愈合一术中并发脊髓损伤2例,因脑血管意外死亡1例,并发肺炎2例。结论 AS脊柱骨折好发于下颈椎及胸腰段,大多为三柱骨折,颈椎骨折并发脊髓损伤的发生率较高。胸腰椎多为应力骨折一手术治疗可使大多数患者的骨折愈合良好,神经功能有不同程度的恢复。对颈椎骨折患者,可采用前路椎体问植骨、钢板内固定的术式;而对于胸腰椎骨折,主张后路长节段固定,前、后联合植骨融合,术中及术后均可能出现并发症,应注意预防或避免。     

Percutaneous vertebroplasty for pain relief and spinal stabilization

STUDY DESIGN: This was a retrospective review of 47 consecutive patients (1995-1998) in whom percutaneous intraosseous methylmethacrylate cement injection (percutaneous vertebroplasty) was used to treat osteoporotic vertebral compression fractures and spinal column neoplasms. OBJECTIVES: To present initial results regarding pain relief, spinal stabilization, and complications after treatment with percutaneous vertebroplasty. SUMMARY OF BACKGROUND DATA: Percutaneous vertebroplasty was developed in France in the late 1980s. Several European reports have described excellent results for treatment of compression fractures and neoplasms. The procedure was not performed in the United States until 1994. Only a single series of 29 patients treated in the United States has been reported. METHODS: A retrospective review was conducted of 47 consecutive patients with 84 vertebrae treated with percutaneous vertebroplasty. Thirty-eight patients with 70 vertebrae had symptomatic, osteoporotic fractures and had failed medical therapy. Eight patients with 13 vertebrae had primary or metastatic neoplasms. One patient had a hemangioma. Immediate and long-term pain response, spinal stability, and complications were evaluated. RESULTS: Among the 38 patients treated for osteoporotic fractures, 24 (63%) had marked to complete pain relief, 12 (32%) moderate relief and 2 (5%) no significant change. Only 4 of the 8 patients with malignancies had significant pain relief. In 7 of these patients, no further vertebral compression occurred, and spinal canal compromise was prevented. The patient with the hemangioma had no significant pain reduction. Minor complications occurred in 3 (6%) patients. CONCLUSIONS: Percutaneous vertebroplasty provided significant pain relief in a high percentage of patients with osteoporotic fractures. The procedure provided spinal stabilization in patients with malignancies but did not produce consistent pain relief. Complications were minor and infrequent. Percutaneous vertebroplasty is a promising therapy for patients with osteoporotic fractures and for selected vertebral column neoplasms.     

Causes of morbidity and mortality from surgery of aneurysms of the distal basilar artery

Despite modern neurosurgical technology and neuroanesthetic care, treatment of aneurysms of the distal basilar artery remains fraught with complications. Between 1982 and 1988, 126 patients with aneurysms of the distal basilar artery who had been treated by 2 surgeons were retrospectively analyzed to determine the causes of morbidity and mortality from this disease and its treatment. Ten patients (8%) died, and 14 patients (11%) suffered permanent neurological disability after treatment. The causes of failed management could be grouped into the following categories: 1) direct effects of hemorrhage; 2) errors in surgical timing; 3) conceptual errors; 4) technical errors; 5) morbidity from delayed cerebral ischemia; and 6) complications of hypertensive/hypervolemic therapy for symptomatic vasospasm; a small group of patients who died despite having received what we consider excellent management were grouped under a seventh category, "bad luck." Frequently, patients who did poorly suffered from multiple complications, each of which contributed to their overall morbidity. It is our hope that increased awareness of these potential pitfalls and the further evolution of intravascular technique in selected cases will, in time, improve the outlook for patients suffering from these dangerous lesions.     

下腰椎骨折

目的 探讨下腰椎骨折的损伤特点及治疗。方法 对一组45例下腰椎骨折病例作回顾性分析,其中压缩性骨折24例,爆裂性骨折14例,屈曲分离性骨折3例,骨折脱位4例。完全性瘫痪3例,不完全性瘫痪9例,无神经损害33例。非手术治疗26例,手术治疗19例。结果 随访1～15年。神经功能改善程度优33例,良4例,可1例,无变化7例,非手术病例与手术病例神经功能改善程度无显著差异(P>0.05),但手术病例腰背疼痛程度明显低于非手术病例(P<0.05)。结论 由于解剖学和生物力学的特殊性,下腰椎骨折具有其相应的损伤特点。多数下腰椎压缩性骨折为稳定性骨折,可行非手术治疗。而对于爆裂性骨折及屈曲分离性骨折椎管狭窄及后凸畸形明显者以及骨折脱位则应行手术治疗。     

Low lumbar spinal fractures: management options

Fifty-four patients with low lumbar spinal fractures were retrospectively reviewed. Of these, there were 25 compression fractures, 21 burst fractures, three flexion-distraction fractures and five fracture-dislocations. Three patients had a complete neurological lesion, 17 sustained an incomplete neurological injury, and 34 were neurologically intact. Twenty-six patients were treated non-operatively and 28 underwent surgery. All patients were followed up for l-12 years. Forty-three patients (79.6%) have returned to their former employment or activity level. Four patients had experienced significant improvement but suffered from some limitation of activity. Five patients were unable to stand up and walk without support although they had some degree of improvement. Two remained completely paralyzed. There were no differences in neurologic function between patients treated non-operatively or operatively (P>0.05). The patients treated operatively had significantly less pain compared to the patients treated non-operatively (P<0.01). Because of the unique anatomy and biomechanics, fractures of the low lumbar spine are different from those in the remaining regions of spine. Most compression fractures are stable, and therefore conservative management is indicated. Surgery should be performed in those with burst fractures or flexion-distraction fractures, with severe spinal stenosis or kyphotic deformity, and fracture-dislocation.     

Epidural "sulmycin implant" coverage for local prevention of infection in surgical management of open craniocerebral injuries]

In various series reported in the literature on the operative management of severe head injuries with compound depressed skull fractures and penetrating wounds of the brain, the rates of infection differ from 1 to 17%. In this paper the operative experience with 22 cases of penetrating head injuries is discussed. In conventional operative therapy, depressed skull fracture and lacerated dura were covered by "Sulmycin Implant" containing Gentamycin as a helpful bacteriological barrier. 18 patients survived, 7 patients had severe neurological defects, 5 patients had mild neurological deficits and 6 patients recovered completely. There were no signs of suppurative complications in superficial wounds or in the brain. 4 patients died due to their severe brain damage with multiple contusional lesions. Postoperative complications were as follows: one patient suffered extradural and one patient subdural rebleeding. Another patient with a frontal base skull fracture suffered a pneumatocele because the fracture was not correctly covered. The revision was done successfully using the "Sulmycin Implant". Presently, however, the intradural use of "Sulmycin Implant" is not recommended without further testing for the level of gentamycin in the cerebrospinal fluid which is released by the "Sulmycin Implant".