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Background Osteoarthrosis of the lateral atlanto-axial joint (LAAJ) may be a cause of upper neck pain and headache. Intra-articular injection of steroids may provide only short-lasting relief. For intractable pain, arthrodesis of the joint might be considered. Objective To determine the success rates of arthrodesis of the lateral atlanto-axial joint for relieving neck pain and disability. Design Practice audit. Setting Private practice of senior author. Subjects Prospective series of 23 consecutive patients. Methods Outcomes were measured using a numerical rating scale for neck pain, and the Neck Disability Index for disability. Success rates were calculated for various degrees of improvement of neck pain at long-term follow-up (8–40 months), and for achieving various combinations of improvement of both neck pain and disability. Results Complete relief of pain was achieved in 40% of patients, with a further 40% achieving at least 50% relief. At long-term follow-up, 30% of patients had no neck pain and no disability, and a further 25% had only minimal pain, minimal disability, or both. Conclusions The present study did not corroborate earlier studies that claimed outstanding outcomes for arthrodesis of the LAAJ, but its outcomes are consonant with more recent studies that provided transparent outcome data. These studies provide Pain Physicians with empirical data on success rates and outcomes, upon which they can base their consideration of referral for arthrodesis. [ABSTRACT FROM AUTHOR]

Cerebellopontine angle (CPA) meningiomas commonly involve the internal auditory canal (IAC). We report a case of a 68-year-old lady with idiopathic profound bilateral deafness with a meningioma which was discovered on workup for cochlear implantation. We performed simultaneous excision of her CPA and IAC meningioma with insertion of a cochlear implant (CI). She regained functional hearing with marked improvement in quality of life. Intraoperative electrophysiological testing can be used to confirm preservation of the cochlear nerve enabling simultaneous implantation which is preferable for clinical and logistical reasons. This creates an option for hearing rehabilitation at the time of IAC/CPA tumour surgery in appropriate patients. [ABSTRACT FROM AUTHOR]

Background: Management of the cervical spine following blunt trauma is commonplace. In 2013, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) published practice guidelines drawn from evidence dating to 2011. Since then, further publications have emerged that are reviewed, and a simple management algorithm produced to assist practitioners in Australian trauma centres. These publications attempt to shed light on two controversial scenarios, those being the management of symptomatic patients with negative computed tomography (CT) and management of the obtunded patient. Methods: The search strategy mirrored that of the AANS/CNS guidelines. A search of the National Library of Medicine (PubMed) database for manuscripts published between January 2011 and October 2014 was conducted. One reviewer extracted data from studies assessing the performance of various imaging modalities in identifying traumatic cervical spine injuries. In clinical scenarios where little evidence has emerged since the AANS/CNS guidelines, key manuscripts published prior to 2011 were identified from bibliographies. Results: Awake, asymptomatic patients may be 'cleared' without further imaging. Awake, symptomatic patients without pathology on CT and without neurological deficit can safely be 'cleared' without magnetic resonance imaging. There is no longer a role for flexion-extension films. In the obtunded patient, findings remain conflicting. Conclusion: Several of these findings represent a departure from previous practices, including clearance of patients with non-neurological symptoms on the basis of CT and the exclusion of flexion-extension film in detecting injury. Management of the obtunded patient remains controversial. [ABSTRACT FROM AUTHOR]

Background. Transforaminal injection of steroids is used to treat lumbar radicular pain. Not known is whether the route of injection or the agent injected is significant. Study Design. A prospective, randomized study compared the outcomes of transforaminal injection of steroid and local anesthetic, local anesthetic alone, or normal saline, and intramuscular injection of steroid or normal saline. Patients and outcome evaluators were blinded as to agent administered. Methods. The primary outcome measure was the proportion of patients who achieved complete relief of pain, or at least 50% relief, at 1 month after treatment. Secondary outcome measures were function, disability, patient-specified functional outcomes, use of other health care, and duration of relief beyond 1 month. Results. A significantly greater proportion of patients treated with transforaminal injection of steroid (54%) achieved relief of pain than did patients treated with transforaminal injection of local anesthetic (7%) or transforaminal injection of saline (19%), intramuscular steroids (21%), or intramuscular saline (13%). Relief of pain was corroborated by significant improvements in function and disability, and reductions in use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. Over time, the number of patients who maintained relief diminished. Only some maintained relief beyond 12 months. The proportions of patients doing so were not significantly different statistically between groups. Discussion. Transforaminal injection of steroids is effective only in a proportion of patients. Its superiority over other injections is obscured when group data are compared but emerges when categorical outcomes are calculated. Over time, the proportion of patients with maintained responses diminishes. [ABSTRACT FROM AUTHOR]

The article presents a study on the evaluation of the effect of graft subsidence with the use of dynamic plates in anterior cervical fusion surgery. It states that fifty-five spondylitic myelopathy and radiculopathy patients undergo the surgical treatment by which the fusion rate was assessed before, immediately after, and after 6 months. Findings show that fusion was observed in 96% of patients and the loss of lordosis was achieved.

Summary objective Whereas cardiac hormones increase after subarachnoid haemorrhage (SAH), and may contribute to sodium wastage and hyponatraemia, there is controversy concerning the relative roles of atrial natriuretic peptide (ANP) vs. brain natriuretic peptide (BNP) and the factors initiating their secretion. Noting previous work linking stress hormone responses with cardiac injury after SAH, we have studied responses in stress hormones, markers of cardiac injury and the temporal changes in ANP and BNP and related them to changes in sodium status post ictus and during recovery from acute SAH. design, patients, measurements Eighteen patients with verified SAH of variable severity were studied in a single unit for a 14-day period post ictus under controlled conditions of sodium and fluid intake. All received a standardized protocol of daily dexamethasone and nimodipine throughout the study. Severity was graded using criteria of Hess and Hunt at admission. Stress hormones (AVP, catecholamines and admission plasma cortisol), markers of cardiac injury (ECG and daily plasma troponin T) and cardiac hormones (ANP and BNP) were measured daily and related to severity, plasma sodium and renin–aldosterone activity. Hormone levels (ANP, BNP and endothelin) in cerebrospinal fluid (CSF) were also measured in nine patients. results Intense neurohormonal activation (AVP, cortisol and catecholamines) at admission was associated with increased levels of both plasma ANP and BNP whereas levels in CSF were unaffected. In individual patients plasma levels of ANP and BNP were strongly correlated (P < 0·001). Cardiac events (abnormal ECG and/or elevated troponin) occurred in six of seven patients graded severe but neither stress hormones nor cardiac peptides differed significantly in patients with mild (n = 11) vs. severe (n = 7) SAH. During the course of a progressive fall in plasma sodium concentration (P = 0·001), there was a delayed activation of... [ABSTRACT FROM AUTHOR]

Objective: Compare short-term mortality rates following operative and nonoperative management of geriatric patients following an acute type II odontoid process fracture. Methods: One hundred forty-one patients with a type II odontoid fracture were identified from a single centre between 2002 and 2018. Patient demographics, details of injury and management, plus mortality data were collected. The incidence of mortality at 3 and 12 months was calculated, and a multivariate model built which included the treatment modality variable and allowed adjustment for six individual confounders. Results: Of the 141 patients with a type II odontoid process fracture, 39 were managed operatively, while 102 were managed nonoperatively. Relative to the nonoperative group, the operative group was younger (79.0 ± 7.0 vs. 83.7 ± 7.6), more likely to have odontoid angulation > 15° (74.4% vs. 43.1%, p < 0.01), and a greater proportion having fracture displacement > 2 mm (74.4% vs. 31.4%, p < 0.01). Both groups were comparable for gender, comorbidities, and associated injuries. On univariate analysis of treatment modality, the odds ratio of 3-month mortality with nonoperative management was 2.55 (95% CI: 0.82–7.92; p = 0.08), whilst at 12-months it was 3.12 (95% CI: 1.11–8.69; p = 0.02). On multivariate analysis of 12-month mortality, however, treatment modality was not found to be significant. This multivariate analysis suggested that increasing age, male gender, and injury severity were significant predictors of 12-month mortality. Conclusion: In contrast to the findings of a number of previous studies, operative management may not influence survival at 3- and 12-months. [ABSTRACT FROM AUTHOR]

The clinical prognostic value of the Spinal Instability Neoplastic Score (SINS), in the context of vertebrectomy for neoplasia, has not yet been established. This retrospective study of 134 patients aims to evaluate the efficacy of the SINS to predict outcomes and survival after vertebrectomy for malignancy. The patients were classified into 2 groups: indeterminate stability (SINS 7–12) and unstable (SINS 13–18). Outcomes assessed included survival days after procedure, neurological function (modified Frankel grade), operative time, blood loss, complications, construct failure, and length of inpatient stay. The indeterminate group included 68 patients, whereas the unstable group included 66 patients. No patients were classified as stable (SINS 0–6). The median survival was 225 days (interquartile range, 81–522 days). There was a statistically significant difference (P < 0.001) in survival days after vertebrectomy between the indeterminate group (435 days) and the unstable group (126 days). The majority of patients (119) had a favourable Frankel grade after procedure with no significant difference between SINS groups (P = 0.534). There were no differences in the operative time (234 vs. 210; P = 0.130), inpatient hospital length of stay (10 days vs. 11 days; P = 0.152), complications, or need for intensive care admission (intensive care unit) between the 2 cohorts. There was a statistically significant difference (P = 0.006) for intraoperative blood loss between the indeterminate group (1400 mL) and the unstable group (850 mL). This study demonstrates a statistically significant increased survival in the indeterminate cohort. These results demonstrate the potential ability of the SINS to act as a clinical prognostic tool with regard to survival time. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort. Objective: To evaluate the effect of graft subsidence associated with the use of dynamic cervical plates on cervical alignment and clinical outcome of patients undergoing anterior cervical decompression and fusion. Summary and Background Data: Dynamic cervical plates allow graft loading which may enhance fusion. However, subsidence of the bone graft may result in changes in cervical alignment. The extent of settling of the graft and its impact on cervical alignment has not been determined. Also whether such change in alignment has an impact on clinical outcome is not known. Methods: Fifty-five patients with spondylitic myelopathy or radiculopathy underwent anterior cervical decompression and fusion using a dynamic plate for stabilization (ABC, Braun/Aesculap). The surgical indications included myelopathy (n = 21), radiculopathy (n = 30), or myeloradiculopathy (n = 4). Regional and local cervical angles, graft subsidence, and fusion rates were assessed before surgery, immediately after surgery and at 6 months after surgery. Visual analogue scores for neck and radicular pain, Neck Disability Indexes, and Nurick grades for myelopathy were recorded. Patients were observed up for at least 6 months with a median of 14 months (range: 6-48 months). Results: Radicular pain improved by a median of 5 points (P < 0.0001), whereas Neck pain improved by a median score of 3 (P < 0.0001). A median improvement in Neck Disability Index score of 18 (P < 0.0001) was observed. Nurick grades improved in 68% of patients with myelopathy. Fusion was achieved in 96% of cases. The mean graft subsidence at 6 months was 1.7 mm (range: 0-6 mm). A change of local cervical angle toward lordosis of 5.8 degrees (P < 0.0001) was obtained as a result of surgery. However, there was a loss of 2.7 degrees of lordosis in the first 6 months following surgery (P = 0.001). The extent of subsidence correlated with the local loss of lordosis (P = 0.0003). There was no change in the regional cervical angle in the 6 months following surgery. There was no significant association between clinical outcome and changes in cervical angles. Conclusion: Dynamic anterior cervical plating after anterior decompression and grafting provides comparable fusion rates to that reported following the use of rigid cervical plating. Immediate changes in cervical alignment towards lordosis are partially lost on follow-up. The loss of lordosis is related to the amount of graft settling. [ABSTRACT FROM AUTHOR]

Study Design: A prospective, Phase IV, multicenter, randomized study.Objective: The aim of this study was to compare vertebral fusion success rates following posterolateral fusion [(PLF)/posterolateral intertransverse fusion (PITF)] surgery. The surgical procedure combined posterior lumbar interbody fusion (PLIF) and PLF with internal fixation over one or two levels using silicated calcium phosphate (SiCaP) or bone morphogenetic protein (BMP)-2 as graft material in patients with a degenerative disorder of the lumbar spine.Summary Of Background Data: Few controlled trials have evaluated the bone graft materials available to surgeons treating patients with spinal disorders, including degenerative disc disease, spondylolisthesis, and disc herniation.Methods: Following randomization, the surgical procedure consisting of PLIF and PLF with internal fixation over one or two levels was performed using SiCaP or BMP-2. No other osteoconductive/osteoinductive graft materials were permitted. Spinal fusion was assessed radiographically at ≤24 months. Clinical outcomes (pain on visual analog scale, Oswestry Disability Index, SF-36) and adverse events (AEs) were monitored.Results: One hundred three patients were enrolled. At 12 months, fusion was achieved in 25 of 35 (71.4%) of the SiCaP and 20 of 27 (74.1%) of the BMP-2 group, respectively (P = 1.000). At 24 months, the fusion rate was 78.6% and 84.8% for SiCaP and BMP-2, respectively (P = 0.5613). Clinical outcomes improved similarly in both groups over time. AEs were consistent with this surgical population.Conclusion: SiCaP was safe and well tolerated in patients with degenerative spinal disorders requiring PLF and provided fusion rates similar to BMP-2.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]