We investigated the incidence of anomalies in the vertebral arteries and Circle of Willis with three-dimensional CT angiography in 55 consecutive patients who had undergone an instrumented posterior fusion of the cervical spine.

We recorded any peri-operative and post-operative complications. The frequency of congenital anomalies was 30.9%, abnormal vertebral artery blood flow was 58.2% and vertebral artery dominance 40%.

The posterior communicating artery was occluded on one side in 41.8% of patients and bilaterally in 38.2%. Variations in the vertebral arteries and Circle of Willis were not significantly related to the presence or absence of posterior communicating arteries. Importantly, 18.2% of patients showed characteristic variations in the Circle of Willis with unilateral vertebral artery stenosis or a dominant vertebral artery, indicating that injury may cause lethal complications. One patient had post-operative cerebellar symptoms due to intra-operative injury of the vertebral artery, and one underwent a different surgical procedure because of insufficient collateral circulation.

Pre-operative assessment of the vertebral arteries and Circle of Willis is essential if a posterior spinal fusion with instrumentation is to be carried out safely.

Cite this article: Bone Joint J 2014;96-B:535–40.

The June 2013 Spine Roundup³⁶⁰ looks at: the benefit of MRI in the follow-up of lumbar disc prolapse; gunshot injury to the spinal cord; the link between depression and back pain; floating dural sack sign; short segment fixation at ten years; whether early return to play is safer than previously thought; infection in diabetic spinal patients; and dynesis.

The April 2012 Trauma Roundup³⁶⁰ looks at fibula-pro-tibia plating, galeazzi fractures, distal radial fractures in the over 65s, transverse sacral fractures, acute dislocation of the knee, posterior malleolar fractures, immobilising the broken scaphoid, the terrible triad, lower limb amputation after trauma, and whiplash injuries

The October 2012 Spine Roundup³⁶⁰ looks at: a Japanese questionnaire at work in Iran; curve progression in degenerative lumbar scoliosis; the cause of foot drop; the issue of avoiding the spinal cord at scoliosis surgery; ballistic injuries to the cervical spine; minimally invasive oblique lumbar interbody fusion; readmission rates after spinal surgery; clinical complications and the severely injured cervical spine; and stabilising the thoracolumbar burst fracture.

The August 2012 Trauma Roundup³⁶⁰ looks at: pelvic fractures, thromboembolism and the Japanese; venous thromboembolism risk after pelvic and acetabular fractures; the displaced clavicular fracture; whether to use a nail or plate for the displaced fracture of the distal tibia; the dangers of snowboarding; how to predict the outcome of lower leg blast injuries; compressive external fixation for the displaced patellar fracture; broken hips in Morocco; and spinal trauma in mainland China.

The most common injury in rugby resulting in spinal cord injury (SCI) is cervical facet dislocation. We report on the outcome of a series of 57 patients with acute SCI and facet dislocation sustained when playing rugby and treated by reduction between 1988 and 2000 in Conradie Hospital, Cape Town. A total of 32 patients were completely paralysed at the time of reduction. Of these 32, eight were reduced within four hours of injury and five of them made a full recovery. Of the remaining 24 who were reduced after four hours of injury, none made a full recovery and only one made a partial recovery that was useful. Our results suggest that low-velocity trauma causing SCI, such as might occur in a rugby accident, presents an opportunity for secondary prevention of permanent SCI. In these cases the permanent damage appears to result from secondary injury, rather than primary mechanical spinal cord damage. In common with other central nervous system injuries where ischaemia determines the outcome, the time from injury to reduction, and hence reperfusion, is probably important.

In order to prevent permanent neurological damage after rugby injuries, cervical facet dislocations should probably be reduced within four hours of injury.

The effect of rheumatoid arthritis on the anatomy of the cervical spine has not been clearly documented. We studied 129 female patients, 90 with rheumatoid arthritis and 39 with other pathologies (the control group). There were 21 patients in the control group with a diagnosis of cervical spondylotic myelopathy, and 18 with ossification of the posterior longitudinal ligament. All had plain lateral radiographs taken of the cervical spine as well as a reconstructed CT scan. The axial diameter of the width of the pedicle, the thickness of the lateral mass, the height of the isthmus and internal height were measured. The transverse diameter of the transverse foramen (d1) and that of the spinal canal (d2) were measured, and the ratio d1/d2 calculated.

The width of the pedicles and the thickness of the lateral masses were significantly less in patients with rheumatoid arthritis than in those with other pathologies. The area of the transverse foramina in patients with rheumatoid arthritis was significantly greater than that in the other patients. The ratio of d1 to d2 was not significantly different. A high-riding vertebral artery was noted in 33.9% of the patients with rheumatoid arthritis and in 7.7% of those with other pathologies. This difference was statistically significant. In the rheumatoid group there was a significant correlation between isthmus height and vertical subluxation and between internal height and vertical subluxation.

Fracture of the atlas is rare in children. We report a case of fracture of the atlas through a synchondrosis of the anterior arch complicated by atlantoaxial rotatory fixation in a four-year-old girl.

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.