Anesthesia induction for laryngeal mask insertion--comparison of propofol with midazolam and propofol with thiopental

STUDY DESIGN: Radiographs and charts of 61 patients sustaining cervical spine trauma were studied prospectively to determine the incidence of vertebral artery injuries and possible correlative factors. Statistical analysis was conducted using chi-square testing of a two-way classification system. OBJECTIVES: To elucidate the incidence of vertebral artery injuries associated with cervical spine trauma, and to determine the value of various factors in predicting the existence of a vertebral artery injury. SUMMARY OF BACKGROUND DATA: During a 7-month period, 61 patients (41 male patients, 20 female; average age, 40.3 years) with cervical spine trauma were studied. METHODS: All patients admitted to the authors' hospital with cervical spine injuries underwent magnetic resonance imaging and magnetic resonance angiography of their cervical spine. All magnetic resonance angiographies were examined for vertebral artery injury. Data on demographics and the injury were recorded. RESULTS: Complete disruption of blood flow through the vertebral artery was demonstrated by magnetic resonance angiography in 12 of the 61 patients (19.7%). Ten of the 12 patients (83%) had either flexion distraction or flexion compression injuries. Age, sex, mechanism of injury, neurologic impairment, and associated injuries were not statistically significant in predicting the presence of a vertebral vessel occlusion. CONCLUSION: The findings in this study may support the need for vertebral vessel evaluation in selective patients, particularly those with flexion injuries and with neurologic symptoms consistent with vertebral artery insufficiency syndrome that do not correlate with the presenting bone and soft-tissue injuries.     

Cervical vertebral fusion (Klippel-Feil) syndrome with consanguineous parents

We describe a female infant with the cervical vertebral fusion (Klippel-Feil) syndrome whom we recognized at birth because of her short neck, restriction of cervical movement, and low posterior hairline. X-ray examination showed anomalies of C1, and between C2-3 and C3-4; thus, we classified her as type II, with variable cervical fusion. At 24 months she was small and manifested hearing deficiency. The mother and father were consanguineous with five common ancestors four generations ago, which resulted in a coefficient of inbreeding equivalent to a second cousin relationship. The parents and grandparents were phenotypically normal, and the parents were radiologically normal. This form of the syndrome has previously been said to be autosomal dominant. Our conclusion of determination by a single autosomal recessive gene is evidence of genetic heterogeneity.     

Multiple pterygium syndrome

We describe a sporadic case and four sibs from a consanguineous Nicaraguan family affected with the multiple pterygium syndrome. Clinical manifestations included normal intelligence; short stature; pterygia of neck, axillary, antecubital, popliteal, digital, and intercrural areas; multiple joint contractures with a crouched stance; a flat, sad, motionless facial appearance; and cleft palate. Males had small penis and scrotum and cryptorchidism; females had apparent aplasia of labia majora and small clitoris. Skeletal anomalies included fusion of cervical vertebrae, scoliosis, flexion contractures of fingers and "rocker-bottom" feet with vertical talus. This review documents genetic heterogeneity: Autosomal recessive inheritance in many cases, autosomal dominant determination in others, and sporadic occurrence.     

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.     

Effect of valve holder flexibility on cavitation initiation with mechanical heart valve prostheses: an in vitro study

The records of 98 patients with 160 hypoplastic thumbs seen between 1923 and 1993 were reviewed to determine the salient characteristics of this population. Physical findings, photographs, and x-ray films were studied. Sixty-three percent of patients were male, and 63% had bilateral thumb hypoplasia, 59% had radial dysplasia, and 86% had other anomalies. An associated syndrome, most commonly the vertebral, anal, tracheosophageal, renal, and radial limb anomalies association or Holt-Oram syndrome, was present in 44%. Patients with spine, genitourinary, or gastrointestinal anomalies were most likely to have the vertebral, anal, tracheosophageal, renal, and radial limb anomalies association, those with cardiac anomalies were most likely to have Holt-Oram syndrome, and those with lower extremity anomalies were most likely to have a different syndrome. One hundred thirty-nine thumbs were classifiable, using a modification of Blauth's classification; 19% were types 1 and 2, 23% were type 3, and 58% were types 4 and 5. One hundred seven operations were performed on 63 upper limbs, including 24 thumb reconstructions and 35 pollicizations. These patients must be carefully examined for bilaterality, other anomalies, and syndromes. Classification using a modification of Blauth's criteria is useful and helps the surgeon determine a treatment plan.     

Occipitocervical fusion with C1 laminectomy in children

STUDY DESIGN: Eight children in whom atlantoaxial dislocation had developed underwent occipitocervical fusion using a rectangular rod. The postoperative results are presented, and the postoperative growth and deformation of the cervical spine were determined radiographically. OBJECTIVES: To investigate in a relatively long-term follow-up study whether occipitocervical fusion affects the growth of the cervical spine and induces spinal deformation. SUMMARY OF BACKGROUND DATA: It has been reported that children who have undergone C1-C2 posterior fusion are likely to develop abnormal curvature or deformation of the cervical spine as a result of a disturbance of growth of the fused vertebrae. There have been no studies, however, to confirm that these changes occur after occipitocervical fusion in children. METHODS: The subjects were one boy and seven girls who had undergone occipitocervical posterior fusion during childhood. The average age at the time of surgery was 8.3 years, and the average follow-up period was 5.9 years. The following were assessed radiographically: redislocation of the atlas, bone union, changes in the curvature of the cervical spine, the height and width of the vertebral bodies, and the anteroposterior diameter of the spinal canal. RESULTS: Solid bone union was achieved in all patients with maintenance of the reduced position at the time of surgery. None of the patients exhibited abnormal curvature of the cervical spine. The rate of increase in height of the C2 vertebral body was significantly less than that of vertebral bodies below C3. The rate of increase in width of the vertebral body and the anteroposterior diameter of the spinal canal of the C2 vertebral body and vertebral bodies below C3 did not differ significantly. CONCLUSIONS: Occipitocervical fusion with a rectangular rod is useful for treating atlantoaxial dislocation in children and yields excellent results because of the firm internal fixation it achieves. This surgery induced no apparent postoperative spinal deformations.     

Alagille syndrome: family studies

Alagille syndrome (AGS) is one of the major forms of chronic liver disease in childhood with severe morbidity and a mortality of 10 to 20%. It is characterised by cholestasis of variable severity with paucity of interlobular bile ducts and anomalies of the cardiovascular system, skeleton, eyes, and face. Previous studies suggest a wide variation in the expression of the disease and a high incidence of new mutations. To determine more accurately the rate of new mutations and to develop criteria for detecting the disorder in parents we systematically investigated parents in 14 families with an affected child. Clinical examination was supplemented by liver function tests, echocardiography, radiographic examination of the spine and forearm, ophthalmological assessment, and chromosome analysis. Six parents had typical anomalies in two or more systems pointing to the presence of autosomal dominant inheritance. Systematic screening of parents for the features defined in this study should improve the accuracy of genetic counselling.     

Carpal tunnel syndrome, humeral epicondylitis, and the cervical spine: a study of clinical and dimensional relations

Forty-three patients with idiopathic carpal tunnel syndrome, confirmed by nerve conduction studies and treated by surgery, were compared clinically and radiologically with 43 age- and sex-matched control patients. Patients with carpal tunnel syndrome had a significantly greater prevalence of lateral humeral epicondylitis (tennis elbow) (33%) than controls (7%). Randomised reading of the cervical spine radiographs in ignorance of the groups to which they belonged showed no significant difference in the prevalence of either intervertebral disc degeneration or intraforaminal osteophyte protruion using conventional grading methods. Measurement of the minimum anteroposterior diameter of the cervical spinal canal, the anteroposterior diameters of the cervical vertebral bodies, and the ratio of intervertebral disc height to adjacent vertebral body height in the cervical spine, however, showed a consistent trend to smaller measurements in the carpal tunnel group. Differences were significant at several vertebral levels in each of these dimensions. The narrowing of the intervertebral discs relative to the vertebral bodies in patients with carpal tunnel syndrome may indicate connective tissue changes, which might also occur in the common extensor origin at the elbow or in the contents of the carpal tunnel.     

Vertebral artery location in relation to the vertebral body as determined by two-dimensional computed tomography evaluation

STUDY DESIGN: This study analyzed the precise two-dimensional location of the vertebral artery within cervical vertebrae as determined by measurements obtained from axial computed tomographic images of the cervical spine. OBJECTIVE: To determine the margin of safety necessary to avoid vertebral artery laceration during central decompression and lateral nerve root decompression for cervical spinal stenosis. SUMMARY OF BACKGROUND DATA: Laceration of the vertebral artery is a rare but potentially catastrophic complication of anterior decompressive surgery of the cervical spine. METHODS: The mean, standard deviation, and 95% confidence interval of the mean of measurements localizing the vertebral artery within the vertebral body were calculated from 50 transaxial computed tomography images of each of the second through sixth cervical vertebrae. RESULTS: Both the mean interforaminal distance (from 25.90 +/- 1.89 mm at C3 to 29.30 +/- 2.70 mm at C6) and the average distance of the posterior border of the foramen transversarium from the ventral border of the spinal canal (from 2.16 +/- 1.18 mm at C3 to 3.53 +/- 1.56 mm at C6) increased from C3 to C6. CONCLUSIONS: According to our measurements, the risk of vertebral artery laceration is greater at more cephalad vertebrae during lateral extension of central decompressive procedures and lateral nerve root decompression. Because of the variability of these parameters between individuals, accurate individual preoperative localization of the vertebral arteries is recommended.     

The effect of post-injury spinal position on canal occlusion in a cervical spine burst fracture model

STUDY DESIGN: The canal space of burst-fractured, human cervical spine specimens was monitored to determine the extent to which spinal position affected post-injury occlusion. OBJECTIVE: To test the null hypothesis that there is no difference in spinal canal occlusion as a function of spinal positioning for a burst-fractured cervical spine model. SUMMARY OF BACKGROUND DATA: Although previous studies have documented the effect of spinal positioning on canal geometry in intact cadaver spines, to the authors' knowledge, none has examined this relationship specifically in a burst fracture model. METHODS: Eight human cervical spine specimens (levels C1 to T3) were fractured by axial impact, and the resulting burst injuries were documented using post-injury radiographs and computed tomography scans. Canal occlusion was measured using a custom transducer in which water was circulated through a section of flexible tygon tubing that was passed through the spinal canal. Any impingement on the tubing produced a rise in fluid pressure that was monitored with a pressure transducer. Each spine was positioned in flexion, extension, lateral (and off-axis) bending, axial rotation, traction, and compression, while canal occlusion and angular position were monitored. Occlusion values for each position were compared with measurements taken with the spine in neutral position. RESULTS: Compared with neutral position, compression, extension, and extension combined with lateral bending significantly increased canal occlusion, whereas flexion decreased the extent of occlusion. In extension, the observed mechanism of occlusion was ligamentum flavum bulge caused by ligament laxity resulting from reduced vertebral body height. CONCLUSIONS: Increased compression of the spinal cord after injury may lead to more extensive neurologic loss. This study demonstrated that placing a burst-fractured cervical spine into either extension or compression significantly increased canal occlusion as compared with occlusion in a neutral position.     

Isolation and characterization of a novel human pancreas-specific gene, pancpin, that is down-regulated in pancreatic cancer cells

We reviewed 19 children and adolescents with cervical spine congenital synostosis as in Klippel-Feil syndrome (KFS), with an average follow-up of 12.5 years. We paid particular attention to neurologic complications associated with cervical spine abnormalities. Five patients were affected by neurologic complications; four underwent a surgical procedure; and 14 had no neurologic finding. Two had hypermobility at one level, and one had hypermobility at two levels. We found that the more numerous the occipito-C1 abnormalities, the more significant the neurologic risk. In contrast, this risk was not related to the number of "mobile blocks" or to age. Various mechanisms of neural complications have been studied in the literature: medullary abnormality, spinal instability, narrowing of the cervical canal, and vascular dysfunction. Surgery is usually thought to be required in cases with neurologic complications. The indication for surgery is, however, less clear in cases of pure instability without neurologic involvement because surgery is likely to increase the future risks at mobile disks either above or below the fuse level. Careful clinical and radiologic observation is necessary in such patients. Magnetic resonance imaging (MRI) with lateral views in flexion and extension seem to be the best method for detecting impingement of the spine on the cord.     

The correlation between surface measurement of head and neck posture and the anatomic position of the upper cervical vertebrae

STUDY DESIGN: Repeated measurements were made of surface postural angles registering the relative positions of the head and neck in photographs and of angles of the upper cervical vertebrae recorded in lateral cephalometric radiographs in the same subjects. For all registrations, subjects assumed the natural head rest position. OBJECTIVES: To examine the correlation between external measurement of head and neck posture and the anatomic positions of the upper four cervical vertebrae. SUMMARY OF BACKGROUND DATA: Interpretation of surface cervical posture measurement is confounded by lack of knowledge about the extent of the underlying compensatory adjustments among the upper cervical vertebrae that may accompany variation in head and neck posture. The correlation between surface measurement and postural characteristics of the upper cervical spine has not been reported to date. METHODS: The association between a set of angles describing the anatomic position of the four upper cervical vertebrae on lateral cephalometric radiographs and a surface measurement of head and neck posture, the craniovertebral angle, was studied in 34 young adult women aged between 17.2 and 30.5 years, mean age, 24.5 years. Anatomic positions of the upper four cervical vertebrae were expressed by angles relative to the true vertical or horizontal. Surface angles registering head and neck position for each subject were obtained from photographs recorded on two occasions. RESULTS: No strong correlation could be established between the angles taken from the lateral cephalometric radiographs measuring the extent of upper cervical lordosis, orientation of the atlas, vertebral inclination, or odontoid process tilt and surface angles recording head and neck position. This finding was attributed principally to the much greater positional variability demonstrated within the upper cervical spine when compared with the surface measurements of head and neck position. CONCLUSION: Anatomic alignment of the upper cervical vertebrae cannot be inferred from variation in surface measurement of head and neck posture. This is the case even in those people identified with more extreme head and neck postural tendencies.     

Further evidence that the Hajdu-Cheney syndrome and the "serpentine fibula-polycystic kidney syndrome" are a single entity

The Hajdu-Cheney syndrome (HCS) is a rare autosomal dominant disorder. It comprises a coarse face, short neck, hirsutism, joint laxity, and normal intelligence. Bone dysplasias, include acro-osteolysis, bathrocephaly, and vertebral anomalies. In 1988, Exner [1988: Eur J Pediatr 147:544-546] coined the term "serpentine fibula-polycystic kidney syndrome" (SFPKS) when he reported on a girl with short stature, unusual facial appearance, polycystic kidneys, and elongated curved fibulae. He postulated that it was a new entity different from the Melnick-Needles syndrome. Since his report, five similar cases have been published. Similarities between both HCS and SFPKS were noticed first by us and then by other authors. In this report we show that many clinical and radiological characteristics are shared by the HCS and the SFPKS and hypothesize that they represent a single entity with a variable degree of expression.     

Tethered cord and associated vertebral anomalies in children and infants with imperforate anus: evaluation with MR imaging and plain radiography

PURPOSE: To evaluate in children and infants with imperforate anus the prevalence and types of occult myelodysplasia that may result in tethered cord and the association of these lesions with vertebral anomalies. MATERIALS AND METHODS: Records and images were retrospectively reviewed in 86 patients who underwent spine magnetic resonance imaging and had either low-level imperforate anus (n = 30), intermediate-level imperforate anus (n = 15), or high-level imperforate anus (n = 41). RESULTS: Thirty-one of 86 patients (36%) had occult myelodysplasia suggestive of tethered cord (27% of all patients with low-, 33% of all patients with intermediate-, and 44% of all patients with high-level lesions). Of these 31 patients, 16(52%) were asymptomatic, 24, (77%) had a thickened fatty filum, 13 (42%) had normal conus position, and 23 (74%) had vertebral anomalies. Twenty-four of the 31 patients (77%) underwent surgical untethering. CONCLUSION: A substantial number of patients with all types of imperforate anus have occult myelodysplasia that may necessitate surgical intervention, including those patients with normal spine radiographs.     

The cervical spine in the skeletal dysplasias and associated disorders

The cervical spine is an especially important area, not only for the diagnosis of the skeletal dysplasias, but also for the management of the patient. By the "cervical spine" I refer not only to the vertebral bodies and posterior elements of this region, but also to the neural elements contained within, especially the cervical cord. The spine is supported by a group of ligaments both anteriorly and posteriorly, with special fixation of the odontoid and C2 by a ligament which normally affixes it firmly to C1. Multiple things may go wrong with the development of the cervical spine. There may be abnormal development of the "vertebrae" in this region, ranging from hypoplasia to developmental failure and/or abnormal ossification of the cervical vertebrae; associated or unassociated odontoid hypoplasia; poor ligamental fixation of C2 resulting in C1-2 subluxation; abnormal development of the posterior processes; abnormal ligamental development or laxity with abnormal cervical kyphosis or lordosis; and, in the case of more fragile/brittle bone development (osteoporosis or increased bone density), fractures can lead to cervical spine problems. The skeletal dysplasias that involve cervical spine problems constitute about 35 of the 150 well-described disorders. These include certain families of disorders like the type II collagenopathies, as well as many individual disorders. It is very important for the clinician to be able to pilot patients through the various appropriate imaging modalities - conventional radiographs of the cervical spine; lateral flexion/extension views; CT; MRI - so that proper management and therapy will result.     

Spondylocostal dysostosis

Spondylocostal dysostosis is a rare condition characterized by short stature due to a short trunk, multiple morphological abnormalities of the vertebrae and ribs due to malsegmentation of the axial skeleton. Radiological features include reduced number of vertebrae and ribs, hemivertebrae, fused or sagitally cleft vertebrae or multiple rib fusions. Three distinct clinical entities are described. We report nine cases of this syndrome, seven were infants and presented with an abnormal shape of the thorax. Two of them had a meningocoele, and one succumbed to the CNS anomalies on the third day of life. The other two cases were two and eight years of age. Cardiac lesion was detected in one case and renal malformations in three cases. Reduction in the rib number was present in all cases, and rib fusion in seven cases. Thoracic vertebral dysegmentation was noted in all, lumbar in three and cervical in one case. This is the first large series from India. No clear single etiology was established.     

Plasticity of the visual system and learning]

Seckel syndrome is a clinical picture which associates four main features: intrauterine growth retardation, microcephaly often due to craniosynostosis, orofacial dysmorphology with bird headed appearance and variable mental retardation which is present after several months. Malformations of the central nervous system, limbs, and hair, may also be observed. On the basis of 78 cases reported in the literature, the authors discuss the validity of the morphological features of the syndrome. It is likely that the variability in the expressivity of each symptom explains its heterogeneity. According to the radiological abnormalities, three different forms of the syndrome have been described. Seckel syndrome is a genetic disorder with autosomal recessive inheritance. Its ethiopatogeny remains unclear. Hopefully linkage studies will allow to map the gene in order to determine the underlying abnormal protein.     

The pathomechanics of compression injuries in the cervical spine. Nondestructive and destructive investigative methods

Biomechanical analysis using nondestructive and destructive investigative methods was performed to evaluate the mechanisms of cervical compression injuries. These injuries produce two basic modes of failure: 1) anterior dislocation; and 2) rupture of the anterior ligamentous complex of the vertebral body. Distribution of these two failure patterns was determined by the initial cervical spine position; translational alignment did not have a significant effect. Different results were observed between spines positioned in flexion and extension, indicating that the most important factor determining the mode of failure was rotational alignment in the sagittal plane.     

Correlation between ossification of the stylohyoid ligament and osteophytes of the cervical spine

OBJECTIVE: To investigate the correlation between ligamentous ossification or osteophytes of the cervical spine and ossification of the styloid process and stylohyoid ligament, and to determine any relation between diffuse idiopathic skeletal hyperostosis (DISH) of the thoracic spine and ossification of the styloid process and stylohyoid ligament. METHODS: Four patients having cervical spine DISH, an elongated styloid process and/or variable patterns of stylohyoid ligament ossification, and clinical findings compatible with Eagle's syndrome are described. Cervical computed tomography scans of 100 patients who also had lateral radiographs of the thoracic spine were reviewed. Point biserial and Spearman rank correlation analysis, McNemar test, chi-squared test, and Fisher's exact test were used to determine correlation between elongation of the styloid process and/or ossification of the stylohyoid ligament and (1) ligamentous ossification or osteophytes of the cervical spine (the characteristic spinal manifestation of DISH), and/or (2) DISH of the thoracic spine. RESULTS: (1) Elongation of the styloid process and variable patterns of ossification of the proximal, middle, and distal parts of the stylohyoid ligament, and (2) enlargement of this ligament were significantly correlated with transverse and anteroposterior dimensions of ligamentous ossification or osteophytes of the cervical spine at various levels. The prevalence of such abnormalities of this process and ligament was not significantly different between the patients with and without thoracic spine DISH. CONCLUSION: Variable types of styloid process-stylohyoid ligament complex abnormalities have significant correlation with ligamentous ossification and osteophytes of the cervical spine.