Cervical facet dislocation: management following delayed diagnosis

This study examined the influence of early versus late initial presentation of patients with cervical spine facet dislocation on presentation, neurologic deficit, and the success of closed reduction. Thirty-four patients were studied, and approximately 35% presented at least 72 hours following their injury. Compared with patients who presented early, this late group demonstrated less neurologic deficit, and closed reduction was less likely to be successful. These findings suggest that a distinction should exist in the management algorithm between early versus late presentation of cervical facet dislocation.     

Oropharyngeal morbidity following transoral approaches to the upper cervical spine

OBJECTIVE: A clinical definition of a hypertensive emergency is excessively high blood pressure in the presence of symptoms indicating end organ damage. Equally high blood pressure without symptoms is called a hypertensive crisis. Patients with hypertensive crisis or emergency need prompt, effective, and specific therapy and a controlled reduction of blood pressure. METHODS: We performed a randomized, double-blind multi-centre study, to compare the safety, efficacy and tolerability of an intravenous (i.v.) infusion of two dihydropyridine calcium channel blockers (either nifedipine or felodipine) in 122 patients, of whom 63 were diagnosed as hypertensive emergencies and 59 as hypertensive crisis, who had not reacted adequately (diastolic blood pressure <115 mmHg) to 5 mg of nifedipine PO. RESULTS: Both drugs lowered blood pressure adequately in more than 90% of the patients and were well tolerated. Only one patient had to be withdrawn, because of an excessive decrease in blood pressure. CONCLUSION: Patients with excessively high blood pressure who do not react to oral nifedipine can be treated equally effectively with felodipine and nifedipine IV. Felodipine is easier to handle because of its lack of light sensitivity.     

Role of facet asymmetry in lumbar spine disorders

The results and the related conditions of 250 undisplaced femoral neck fractures managed by percutaneous Knowles pinning were evaluated. All of the patients were over 59 years old, and the protocol of management and follow-up was determined prospectively. The duration from injury to management was 3.0 (range 1-12) days, the operation time was 20 (range 10-44) min, and most of the patients were discharged without hospitalization. The follow-up period was 74 (range 24-138) months. The final results showed 226 (90.4%) fractures with smooth course of union (mean union time: 24 weeks), 15 (6.0%) fractures with nonunion, and 9 (3.6%) fractures with implant problems. Eighteen (7.2%) hips developed avascular necrosis of femoral head after union. The analysis showed that the rate of complications was higher in elderly persons with undisplaced femoral neck fractures.     

Symptoms of the cervical spine in temporomandibular and cervical spine disorders

This study was performed to assess the prevalence of signs and symptoms related to cervical spine disorders (CSD) in subgroups of patients with temporomandibular disorders (TMD) and to compare TMD patients and CSD patients with regard to the results of orthopaedic cervical spine tests. One hundred and eleven consecutive patients with TMD and 103 consecutive patients with signs and symptoms of CSD were examined. The results indicated that there is a considerable overlap in the signs and symptoms of patients with TMD and patients with CSD. Signs and symptoms on neck extension occurred more often in CSD patients than in subgroups of TMD patients. No significant differences in upper cervical extension, neck flexion, and shoulder girdle function were found between CSD patients and subgroups of patients with TMD. Patients with CSD reported neck pain during active and passive movements of the neck more often than the subgroups of patients with TMD. TMD patients and CSD patients did not differ with regard to pain on shoulder girdle function and palpation of the shoulder girdle. Logistic regression analyses showed that orthopaedic tests of the cervical spine are of minor importance in discriminating between patients with TMD and patients with CSD. It is concluded that TMD with a myogenous involvement in contrast to TMD with only an arthrogenous involvement should no longer be viewed as a local disorder of the stomatognathic system. The upper quarter, including the stomatognathic system, cervical spine, and shoulder girdle, should be evaluated in patients with more complex or persistent symptoms in the head and neck region.     

Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography

STUDY DESIGN: A prospective study to determine the long-term outcome of traumatically induced vertebral artery injuries. Magnetic resonance angiography was performed at the time of cervical injury and at a follow-up office visit. OBJECTIVE: To determine the long-term outcome in terms of arterial flow competency of traumatically induced vertebral artery injuries. SUMMARY OF BACKGROUND DATA: Vertebral artery injury associated with cervical spine trauma has been well documented; however its healing or nonhealing potential has not been elucidated. METHODS: During the 7-month period from July 1993 to January 1994, all patients admitted to the authors' institution with cervical spine injuries underwent magnetic resonance imaging and magnetic resonance angiography of the cervical spine to determine the patency of their vertebral arteries. Magnetic resonance angiography was performed at the time of injury and at a follow-up office visit. Twelve of 61 patients were found to have a lack of signal flow within one of their vertebral vessels during this study period. RESULTS: Eighty-three percent of the patients (five of six) who were available for follow-up observation in this study did not manifest flow reconstitution of their vertebral arteries after an average 25.8-month follow-up period. CONCLUSIONS: According to these data, most patients with vertebral artery injuries after nonpenetrating cervical spine trauma do not reconstitute flow in the injured vertebral arteries. This lack of flow must be considered if future surgery in this region of the cervical spine is contemplated.     

Inflammatory disorders of the cervical spine

The most common inflammatory disorders affecting the cervical spine include adult and juvenile rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and psoriatic arthritis. These disorders are characterized by typical deformities and instabilities of the cervical spine that result from the destruction caused by synovitis in bony and ligamentous structures in the neck. The treatment of these inflammatory lesions differs from the treatment of similar lesions found in the posttraumatic or degenerative spine. This article attempts to outline the epidemiology, clinical manifestations, and natural history of these conditions. Various radiographic parameters for evaluating disease progression have been used over the years, and their usefulness is reviewed in the context of recent studies better defining the radiographic natural history of these lesions. An algorithm for the use of the various imaging methods including magnetic resonance scanning is provided, and recent progress in delineating the proper timing of surgical intervention and the predictors of neurologic recovery is presented. The current surgical procedures available to treat these conditions are discussed with emphasis on distinguishing those cases in which stabilization alone is required from those in which a decompression procedure is also necessary.     

Biomechanics of injury of the cervical spine

Whiplash injuries of the cervical spine are of special medical and socio-economic importance. Biomechanical studies of the injury have proven, that a hypertranslation of the capito-cervical region takes place first, leading to ligamentous hyperdistension and ruptures, when exceeding elastic deformation, thus possibly resulting in mechanical disturbance and rotatory malpositioning. Diagnosis of so called "functional disorders" bears difficulties concerning objective tests for structural lesions. This demands the definition of diagnostic parameters and clinical signs, which also consider vegetative phenomena. This paper aims at a systematic clinical and radiological check. Adequate therapeutic means have to be concordant to prognosis. Therefore functional parameters should already determine differential diagnosis. This is based on technical feasibilities and needs future scientific efforts.     

Sensory and autonomic innervation of the facet joint in the rat lumbar spine

The presence of sensory and autonomic nerves in the synovial membrane of the lumbar facet joint in rats was investigated by immunohistochemistry. Substance P and calcitonin gene-related peptide immunoreactivities, representing sensory nerves, were observed as varicose fibers in the synoviocyte layer. The fibers were predominantly nonvascular. The autonomic innervation was identified by the presence of neuropeptide Y- and tyrosine hydroxylase-positive fibers. Most of these fibers were found adjacent to or within blood vessel walls. Immunoreactivity to vasoactive intestinal polypeptide was seen in varicose nerve terminals in the synoviocyte layer, mostly unrelated to blood vessels. There is accumulating evidence of an involvement of both the sensory and sympathetic nervous systems in inflammatory joint disease. The neuropeptides now identified in lumbar facet joints may prove to play a significant role in the pathogenesis of low-back pain.     

Reduction and positioning of cervical spine injuries

Prerequisites for successful reduction of cervical spine injuries are an exact analysis and classification of every lesion. In locked dislocations disc protrusion should be excluded prior to reduction by MRI or CT-scan. For manual reduction and closed manipulation by the trauma surgeon we use a halo-ring which is applied in local anaesthesia and fluoroscopic control. The anatomic position is maintained by a halo-fixator until surgery. Skeletal traction is used mainly for locked dislocations and late malalignements. Traction is provided by a halo-ring and weights up to 20 kg. Repeated clinical and neurological examinations are necessary to rule out overdistraction of the spine or neurologic deterioration. The weight may be reduced after reduction to 2 kg. For intraoperative positioning and reduction of cervical spine injuries we designed a special device which is connected to the halo ring and allows to fix the head and spine in any desired position. It may be used in prone or supine position of the patient. Operative reductions are rarely necessary on the cervical spine. Typical indication are fractures of posterior elements of the spine preventing closed reduction. Reduction manoeuvers depend on the kind of injury and are mainly composed of traction and a reversal of the trauma mechanism. The most severe complication is a neurologic deterioration. Reports in literature about 13 patients having sustained such a fate are showing the following: In most cases disc material dislocated in the spinal canal during reduction could be made responsible for the catastrophic course. Especially at risk are patients with open reduction from a posterior approach.     

Medicolegal aspects of athletic cervical spine injury

Here we describe properties of the P2-purinoceptor, which is involved in the regulation of the key enzyme of estrogen biosynthesis, aromatase cytochrome P-450, in stromal cells from human adipose tissue. Aromatase activity induced by cortisol and platelet-derived growth factor BB (PDGF-BB) is further increased by addition of ATP, ADP, AMP and, albeit with reduced potency, adenosine, GTP and adenosine(5')tetraphospho(5') adenosine. Stable P1-purinoceptor agonists are inactive, whereas P2X-purinoceptor agonists mimic the effects of purine(s) (nucleotides). Prior incubation of cells with a P2-purinoceptor antagonist, but not P1-purinoceptor antagonists, blocks augmentation of aromatase activity by all ligands. Nucleotides, but not adenosine, retain their ability to augment aromatase activity in the presence of adenosine deaminase, indicating that they do not act via their metabolite adenosine. These results lead to the conclusion, that at least one member of the P2-subclass of purinoceptors exists in adipose tissue and is involved in modulation of aromatase activity in vitro. The pharmacological profile of the P2-site differs from those reported for cloned P2-purinoceptors, but is similar to that of the P2X-subclass. Therefore, a combined response of different members of the P2X-purinoceptor subclass or of members of different P2-purinoceptor subclasses cannot be discounted. Purinoceptor activation triggers cytoplasmic calcium transients, which, in contrast to aromatase induction, are independent from the presence of cortisol and PDGF-BB. Therefore the involved P2-purinoceptor(s) seem(s) to be constitutively expressed in human adipose tissue stromal cells. P2-purinoceptor(s) might provide a direct link between sympathetic nerve activity and estrogen biosynthesis in human adipose tissue. Furthermore it (or they) may contribute to the regulation of lipolysis.     

Traumatic dislocation of the testis]

Dislocation of the testis is a rare injury, with only 73 cases having been reported in Japan. We herein add 6 cases. Lately, accidents involving teenage patients, primarily involving motorcycles, have been increasing. Closed reduction is recommended, but it was successful only 5 of 73 cases. The results of testicular biopsies suggest that early surgical management is required when closed reduction is unsuccessful.     

Clinical and technical assessment of the cervical spine

In analysis of the cervical and cervicobrachial syndrome with or without signs of compression of the nerve root or spinal cord, functional assessment of the cervical spine is of great importance. Comparisons between actively performed and passively induced motion can be verified by using standardized computer-assisted assessment allowing precise documentation of the range of motion and coupled motion. The age-related normal values should be considered. The neurological assessment includes not only the cranial nerves and upper extremities but also lower extremities to avoid overlooking the signs of cervical myelopathy. In patients with compression of nerve roots or the spinal cord neurophysiology might be helpful in identifying or verifying compression. In patients with suspected myelopathy sensory evoked potentials will allow assessment of the function of the ascending spinal pathways and motor evoked potentials, assessment of the function of the descending cortical spinal pathways.     

Sclerotic lesions of the cervical spine in sarcoidosis

Sarcoidosis is a common multisystem disorder characterized by noncaseating epithelial granulomata, with osseous involvement typically seen in 5% of patients. While the lace-like or cystic pattern frequently seen in radiographs of the phalanges is well appreciated, sclerotic lesions of the spine are uncommon. We review a case of sarcoidosis of the cervical spine with sclerotic changes that mimicked blastic metastatic disease.