1. The literature on paraplegia complicating hyperextension injuries of the cervical spine is reviewed, and the lack of any definite explanation of the mode of interference with cord function is noted. 2. A case is described in which a detailed dissection of the post-mortem specimen was carried out. On the basis of the findings it is suggested that one cause of the suppression of cord function in such injuries is thrombosis of the spinal arteries and liquefaction-necrosis of the cord

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

1. Paraplegia from fracture-dislocation at the thoraco-lumbar junction is a mixed cord and root injury. The root damage can be distinguished from cord damage by neurological examination and by comparison of the neurological level with the fracture level. 2. Even though the cord injury is complete, as it usually is, the roots often escape or recover. 3. Fracture-dislocations can be divided into stable and unstable types. Because of the possibility of root recovery care must be taken to prevent further damage to the roots by manipulation of the spine or during treatment. For this reason unstable fracture-dislocations are fixed internally by plates. 4. Internal fixation also assists in the nursing of the patient. The nursing technique and the care of the bladder are described

In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision. . A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings. At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system. We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful. . 3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision. Cite this article: Bone Joint J 2015; 97-B:899–904

Aims

Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure.

A new technique for the transthoracic removal of a prolapsed intervertebral disc in the mid or lower thoracic spine is described. Investigations before operation include thoracic myelography, selective spinal angiography and CT scanning. Image intensification is used at operation to check the level of the prolapse. A tunnel in the coronal plane (vertebrotomy) is made through the posterolateral part of the disc and the adjacent vertebral bodies, to reach the spinal canal at the site of the prolapse. This gives good exposure and enables gentle removal of the disc prolapse and any associated osteophytes, under direct vision without need for retraction or pressure on the dura or spinal cord. Spinal stability is not compromised, and the blood supply of the cord is not disturbed. Five consecutive patients are reported, including one in whom the disc prolapse was calcified and had herniated into the spinal cord. All were treated successfully

Dislocations of the cervicothoracic junction are frequently missed. Experience of this rare injury over 27 years at the Spinal Injuries Unit in Sheffield confirms that nearly two-thirds were not properly diagnosed on admission. Only two of the 14 dislocations studied were reduced by conservative methods and these were both associated with fractures of the posterior bony elements. Open reduction is necessary to replace pure dislocations at the C7-T1 level. It seems likely that the spinal cord lesion is not influenced by reduction of the displacement. The three patients who had an incomplete lesion of the spinal cord made excellent neurological recoveries although none of the dislocations was reduced. It is concluded that on theoretical grounds it is justified to embark on operative reduction of displacements at this spinal level only if the cord lesion is incomplete, nerve root recovery therefore possible, and if the operation can be brought about soon after the injury

1. A syndrome resulting from congenital lesions affecting the spinal cord and cauda equina, associated with spina bifida occulta, is described. 2. The syndrome consists of a progressive deformity of the lower limbs in children. One foot and the same leg grow less rapidly than the other. The foot develops a progressive deformity which begins as a cavo-varus and becomes a valgus one. Both lower limbs may be affected. There may be progression to sensory loss, trophic ulceration, disturbance of function of bowel and bladder and even paraplegia. 3. Methods of investigation including myelography are described. 4. Exploration of the spinal cord has been undertaken in twenty-four patients so affected. Extrinsic congenital lesions causing traction or pressure or a combination of traction and pressure on the spinal cord have been found in twenty-two of these. 5. In two-thirds of the patients some degree of improvement has followed operation

The subject of central nervous system damage includes a wide variety of problems, from the slow selective ‘picking off’ of characteristic sub-populations of neurons typical of neurodegenerative diseases, to the wholesale destruction of areas of brain and spinal cord seen in traumatic injury and stroke. Experimental repair strategies are diverse and the type of pathology dictates which approach will be appropriate. Damage may be to grey matter (loss of neurons), white matter (cutting of axons, leaving neurons otherwise intact, at least initially) or both. This review will consider four possible forms of treatment for repair of the human central nervous system

We recorded compound muscle action potentials (CMAPs) from the diaphragm in 15 normal volunteers, nine patients with lesions of the lower cervical cord (C5 to C8), one completely quadriplegic patient (C6) and seven patients with lesions at a higher cervical level (C1 to C4). Transcranial magnetic stimulation and electrical stimulation of the phrenic nerve were carried out. When the centre of the coil was placed on the interauricular line at a point 3 cm lateral to the vertex on the scalp, the CMAPs from the diaphragm had the largest amplitude and the shortest latency. There was no difference in the mean latency of the CMAPs recorded by transcranial magnetic stimulation in the normal volunteers and in the patients with lesions of the lower cervical cord. In the quadriplegic patient, the latency of the CMAPs was not delayed, but was prolonged in the patients with lesions at a higher level. Those evoked by electrical stimulation of the phrenic nerve were not prolonged in the patients with higher lesions. Our findings suggest that the prolongation of the latency by transcranial magnetic stimulation reflects dysfunction of the higher cervical cord. The combination of transcranial magnetic stimulation and electrical stimulation of the phrenic nerve can detect the precise level of the lesion in the motor tract to the diaphragm

Between 1978 and 1988 a total of 27 operations were performed on 26 patients for cervical myelopathy due to rheumatoid disease in the subaxial spine. Three different causes were recognised: the first group had cord compression due to subluxation of the cervical spine itself (6 patients); the second had cord compression occurring from in front, with rheumatoid lesions of vertebral bodies or discs (6); the third had compression from behind the cord due to granulation tissue within the epidural space (14). Group I was treated by closed reduction of the subluxation followed by surgical fusion either from in front or behind. Group II was decompressed by subtotal resection of the involved vertebral bodies and discs, followed by interbody fusion. The patients in group III were decompressed by laminectomy and excision of fibrous granulation tissue from the epidural space. Good recovery of neurological function was observed after 18 of the operations, fair recovery after five, poor recovery followed three, and one was worse. Myelopathy recurred in four patients, all of whom had had anterior interbody fusion

1. A twenty-six-year-old woman was paraplegic because of a benign giant-cell tumour which had destroyed the body of the twelfth thoracic vertebra completely and the bodies of the eleventh thoracic and first lumbar vertebrae partially. The tumour had expanded into both pleural cavities and displaced the aorta forward and to the left. The extent and topography of the tumour were evaluated before operation by angiography. The function of the spinal cord had not been improved significantly by laminectomy. It was therefore decided to attempt extirpation of the tumour by removing all remaining parts of the three vertebrae involved. 2. After the removal of the tumour, only the spinal cord with the thecal sac bridged the gap between the tenth thoracic and second lumbar vertebrae. The gap was bridged with struts of cortical bone from both tibiae and with two strong plates, all secured with steel wire. The metal was removed five months later because it had become loose. Gradual shortening and angulation of the spine then occurred, together with progressive resorption of the cortical grafts. Nevertheless, the operation restored the function of the spinal cord; the patient regained ability to walk and full control of the bladder

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

We studied a consecutive series of 58 patients with penetrating missile injuries of the brachial plexus to establish the indications for exploration and review the results of operation. At a mean of 17 weeks after the initial injury, 51 patients were operated on for known or suspected vascular injury (16), severe persistent pain (35) or complete loss of function in the distribution of one or more elements of the brachial plexus (51). Repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%). Of the 36 patients who underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%). Poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with associated injury of the spinal cord. Neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%). We consider that a vigorous approach is justified in the treatment of penetrating missile injury of the brachial plexus. Primary intervention is mandatory when there is evidence of a vascular lesion. Worthwhile results can be achieved with early secondary intervention in patients with debilitating pain, failure to progress and progression of the lesion while under observation. There is cause for optimism in nerve repair, particularly of the roots C5, C6 and C7 and of the lateral and posterior cords, but the prognosis for complete lesions of the plexus associated with damage to the cervical spinal cord is particularly poor

A combined anterior and posterior surgical approach is generally recommended in the treatment of severe congenital kyphosis, despite the fact that the anterior vascular supply of the spine and viscera are at risk during exposure. The aim of this study was to determine whether the surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach is feasible, safe and effective. We reviewed the records of ten patients with a mean age of 11.1 years (5.4 to 14.1) who underwent surgery either by pedicle subtraction osteotomy or by vertebral column resection with instrumented fusion through a single posterior approach. The mean kyphotic deformity improved from 59.9° (45° to 110°) pre-operatively to 17.5° (3° to 40°) at a mean follow-up of 47.0 months (29 to 85). Spinal cord monitoring was used in all patients and there were no complications during surgery. These promising results indicate the possible advantages of the described technique over the established procedures. We believe that surgery should be performed in case of documented progression and before structural secondary curves develop. Our current strategy after documented progression is to recommend surgery at the age of five years and when 90% of the diameter of the spinal canal has already developed. Cite this article: Bone Joint J 2013;95-B:1527–32

Aims

The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland.

The April 2012 Children’s orthopaedics Roundup. 360 . looks at osteonecrosis of the femoral head and surgery for dysplasia, femoral head blood flow during surgery, femoroacetabular impingement and sport in adolescence, the Drehmann sign, a predictive algorithm for septic arthritis, ACL reconstruction and arthrofibrosis in children, spinal cord monitoring for those less than four years old, arthroereisis for the flexible flat foot, fixing the displaced lateral humeral fracture, and mobile phones and inclinometer applications

We report a case of vertebral osteochondroma of C1 causing cord compression and myelopathy in a patient with hereditary multiple exostosis. We highlight the importance of early diagnosis and the appropriate surgery in order to obtain a satisfactory outcome