Cervical Brace Research Articles

The Effect of a Cervical Brace on Postoperative Axial Symptoms Following Single-level Anterior Cervical Discectomy and Fusion.

Retrospective study. This study aims to investigate the effect of cervical brace utilization on postoperative axial symptoms in patients undergoing single-segment anterior cervical discectomy and fusion (ACDF). Anterior cervical discectomy and fusion (ACDF) is the most commonly used surgical method in the treatment of cervical spondylosis. For patients with single-segment ACDF. The absence of a neck brace after surgery is safe and does not affect the outcome of surgery. However, the effect on the incidence of AS is unclear. Patients who underwent anterior cervical single-segment ACDF between May 2020 and August 2021 were retrospectively analyzed. Participants were divided into brace group and nonbraced groups. The incidence of axial symptoms, cervical mobility, and postoperative quality of life were then compared between the 2 groups. A total of 121 patients were included in this study: 62 in the brace group and 59 in the nonbraced group. There were no statistically significant variations observed in the overall demographic characteristics, including age, sex, body mass index, smoking status, and disease duration. The study findings showed that there was a significant decrease in the occurrence of axial symptoms among patients in nonbraced group, in addition to a considerable increase in cervical mobility 1 month following the surgery. The omission of a cervical brace following surgery in patients undergoing single-segment ACDF reduced the incidence of early postoperative axial symptoms, improved their overall quality of life, and facilitated the recovery of postoperative cervical mobility.

Is it necessary to use a cervical brace after single- or double-level ACDF?

Although anterior cervical discectomy and fusion (ACDF) is one of the most frequently performed spinal surgeries, there is no consensus regarding the necessity of prescribing a cervical brace after surgery. This study aimed to investigate any difference in radiological and clinical outcomes when wearing or not wearing cervical braces after single- or double-level ACDF. We examined 2 cohorts of patients who underwent single- or double-level ACDF surgery with and without a cervical brace: patients who underwent ACDF between March 2018 and December 2019 received a cervical brace, while patients who underwent ACDF between January 2020 and May 2021 did not. Each patient was evaluated radiologically and functionally using plain X-ray, modified Japanese Orthopedic Association score, and visual analog scale for neck and arm until 12 months after surgery. Fusion rate, subsidence, and postoperative complications were also evaluated. Eighty-three patients were included in the analysis: 38 were braced and 45 were not. The demographic characteristics and baseline outcome measures of both groups were similar. There was no statistically significant difference in any of the clinical measures at baseline. The modified Japanese Orthopedic Association score and visual analog scale for neck and arm were similar in both groups at all time intervals and showed statistically significant improvement when compared with preoperative scores. In addition, fusion rate, subsidence, and postoperative complications were similar in both groups. Our results suggest that the use of cervical braces does not improve the clinical outcomes of individuals undergoing single- or double-level ACDF.

Effects of Cervical Bracing on Elderly Patients With Dysphagia.

This study aimed to determine if cervical bracing with a PMT collar increases risk of airway invasion and pharyngeal residue in elderly patients with dysphagia. Additionally, it aimed to identify patient preference for cervical bracing during deglutition. Twenty-one patients underwent a videofluoroscopic swallow study. Thin liquid, nectar thick liquid, pudding, and cracker were administered with cervical collar on and off with order of condition randomized. The Penetration-Aspiration Scale (PAS) was used to grade swallows, with McNemar's test of symmetry used to determine whether the categorical PAS score was similar between conditions. Pharyngeal residue was measured following swallows. Patients were asked which condition they preferred, and which was more comfortable with "no difference" being a selection. No significant difference in PAS categorization score was measured for any consistency (p = .317-.919). Significantly more pyriform sinus residue was measured in the collar off condition (p = .003), albeit amounts were within normative range, with no difference measured in vallecula residue between conditions (p = .939). Forty-five percent of participants preferred to swallow with the collar off, while 55% indicated no preference. Forty-one percent of participants indicated increased comfort with collar off, while 59% indicated no difference in comfort. No participant preferred swallowing or indicated increased comfort with the collar on. Presence of a cervical collar in elderly patients with dysphagia did not result in a significant difference in airway invasion or total pharyngeal residue. There was significantly more residue in the pyriform sinuses when cervical bracing was removed. The majority of patients did not indicate a difference in preference or comfort between collar on/off conditions.

The Role of Orthoses in Chronic Axial Spinal Conditions.

Bracing represents a prevalent conservative, non-surgical approach used in the management of chronic spinal conditions such as spondylosis, degenerative disc disease, and spondylolisthesis. A wide variety of orthoses are available to aid in addressing cervical, thoracic, lumbar, thoracic, and SI joint pain. In this review, we aim to comprehensively examine brace types with their current applications and implications of usage. There are multiple cervical bracing options, such as soft and rigid collars, to assist in managing acute trauma and chronic degenerative conditions. The review highlights the nuanced decision-making process between hard and soft collars based on the severity of bone or ligamentous injury and neurological findings. Orthoses for low back pain are commonly used. The review highlights the challenges of chronic neck and lower back pain, emphasizing the importance of clinicians exploring all treatment strategies including braces which can improve function and reduce pain.

Trends in Spinal Orthosis Utilization Among Patients Insured Through Medicare Part B.

Retrospective population-based database analysis from the Physician/Supplier Procedure Summary Medicare/Medicaid Data Set. To provide a comprehensive analysis of trends in spinal orthosis utilization over a 12-year period. Widespread prescription of spinal orthosis persists, despite evidence suggesting equivocal efficacy in many spinal conditions. The utilization of spinal orthosis on a national level, including prescribing specialty data, has not been previously analyzed. Health care common procedure coding system codes for cervical (CO), thoracic-lumbar-sacral (TLSO), lumbar (LO), lumbar-sacral (LSO), and cervical-thoracic-lumbar-sacral (CTLSO) orthosis were used to determine spinal orthosis utilization from 2010 to 2021. Provider specialty codes were utilized to compare trends between select specialties. In addition, a neurosurgical CO analysis based on subclassifications of cervical bracing was performed. Linear trendlines were implemented to elucidate and present trends by slope (β). Among 332,241 claims, decreases in CO (β=-0.3387), TLSO (β=-0.0942), LO (β=-0.3485), and LSO (β=-0.1545) per 100,000 Medicare Part B enrollees and CTLSO (β=-0.052) per 1,000,000 Medicare Part B enrollees were observed. Decreases among neurosurgery (β=-7.9208), family medicine (β=-1.0097), emergency medicine (β=-2.1958), internal medicine (β=-1.1151), interventional pain management (β=-5.0945), and chiropractic medicine (β=-49.012), and increases among orthopedic surgery (β=5.5891), pain management (β=30.416), physical medicine and rehabilitation (β=4.6524), general practice (β=79.111), and osteopathic manipulative medicine (β=45.303) in total spinal orthosis use per 100,000 specialty claims were observed. Analysis of subclassifications of cervical orthosis among neurosurgeons revealed decreases in flexible (β=-1.7641), semirigid (β=-0.6157), and collar bracing (β=-2.7603), and an increase in multipost collar bracing (β=2.2032) per 100 neurosurgical cervical orthosis claims. While utilization of spinal orthosis decreased between 2010 and 2021, increased utilization was observed among a subset of specialties. Identifying these specialties allows for focused research and educational efforts to minimize unnecessary durable medical equipment use for effective health care spending.

Late-developing posttraumatic dural arteriovenous fistula of the vertebral artery: illustrative case.

A dural arteriovenous fistula (dAVF) involving the vertebral artery (VA) is a rare vascular pathology that can result from damage to the VA, most frequently following cervical spine trauma. In most traumatic cases, the dAVF develops and manifests shortly after trauma. A patient was admitted after a fall from the stairs causing neck pain. Computed tomography of the cervical spine revealed a Hangman's fracture, and angiography showed a left VA dissection. The patient was treated with a cervical brace and clopidogrel. Three weeks after trauma, the patient was admitted because of bilateral leg ataxia, dizziness, and neck pain. Repeat imaging revealed increased displacement of the cervical fracture and a dAVF from the left VA with retrograde filling of the dAVF from the right VA. Embolization of the dAVF using coils proximally and distally to the dAVF was performed prior to placing a halo brace. At 6 months, all symptoms had disappeared and union of the cervical spine fracture had occurred. This case report emphasizes the need for follow-up angiography after traumatic VA injury resulting from cervical spine fracture and underlines important treatment considerations for successful obliteration of a dAVF of the VA.

Refining the role of cervical spine immobilization and stabilization in pediatric non-accidental trauma, a retrospective series of 1008 patients.

Prompt detection of traumatic cervical spine injury is important as delayed or missed diagnosis can have disastrous consequences. Given the understood mechanism of non-accidental trauma (NAT), it is reasonable to suspect that cervical spine injury can occur. Current management of young children being evaluated for NAT includes placement of a rigid collar until clinical clearance or an MRI can be obtained. Currently, there exists a lack of robust data to guide cervical bracing. Anecdotally, our group has not observed a single patient with a diagnosis of NAT who required operative stabilization for cervical spine instability. This study will be the largest series to date and aims to systematically investigate this observation to determine the likelihood that children with a diagnosis of NAT harbor cervical spine instability related to their injuries. Patient data from the Children's Hospital Colorado Trauma Registry diagnosed with non-burn-only NAT were reviewed retrospectively. Children less than 4years of age pulled from the registry from January 1, 2005, to March 31, 2021, were included. Demographic, admission/discharge, imaging, and clinic management data were collected for each patient and analyzed. There were 1008 patients included in the cohort. The age at presentation ranged from 5days to 4years (mean 10.4months). No patient had X-ray or CT findings concerning for cervical instability. Three patients had MRI findings concerning for cervical instability. Two of these underwent external bracing, and the third died from unrelated injuries during their hospitalization. Only four patients were discharged in a cervical collar, and all were ultimately cleared from bracing. No patient underwent a spinal stabilization procedure. While the mechanism of injury in many NAT cases would seem to make significant cervical spine injury possible, this single-center retrospective review of a large experience indicates that such injury is exceedingly rare. Further study is merited to understand the underlying pathophysiology. However, it is reasonable to consider cervical collar clearance in the setting of normal radiographs and a reassuring neurological exam. Furthermore, if concerns exist regarding cervical spine instability on MRI, an initial trial of conservative management is warranted.

Is brace necessary after cervical surgery: A meta-analysis of randomized controlled trials.

Background:Currently, there are increasing surgical treatments for neck pain. However, whether to use cervical brace after operation remains poorly defined. We aim to clear the clinical efficacy of the use of cervical brace after cervical surgery.Methods:We searched for relevant studies in 8 electronic databases up to March 2021. The mean difference and 95% confidence intervals were used for continuous data. Cochrane Collaboration’s tool was used to assess the risk of bias. The data were collected and input into the Review Manager 5.3 software (The Cochrane Collaboration, Copenhagen, Denmark).Results:Four randomized controlled trials were finally included in our study. For pain, the pooled analysis showed that postoperative neck brace compared with no brace can relieve neck pain at all follow-up periods except 6 months. For neck disability index, the result showed that postoperative neck brace compared with no brace can improve neck disability index during the 3 to 12 month follow-up period. However, no significant difference was identified between 2 groups within the follow-up of 6 weeks after surgery. In addition, the result tends to get the opposite at follow-up of 24 months. For 36-Short form health survey Physical Component Summary, there was no significant difference between 2 groups in the early 3 weeks after surgery, but the results were changed after 3 weeks. For 36-short form health survey Mental Component Summary, there appears to be no significant change between 2 groups at all time intervals.Conclusion:Wearing a cervical brace after cervical surgery is conducive to improving symptoms after cervical surgery at different stages. However, there is no relevant evidence indicating it can improve the mental health of postoperative patients. Higher quality, large prospective randomized studies are needed to verify the current conclusions.

Medicated Supportive Braces: A Synergy of Treatments for Joint Pain Relief

Background and objectives: The present study unveils a simple but innovative combina-tion of existing treatments of three different domains with unique logical aspects. Joint pain is the major cause of disability, especially for older adults. Currently, two widely practiced treatment op-tions are combined to produce simultaneous treatments that overcome the drawbacks of individual treatment and improve patient compliance. Moreover, a third treatment option of cooling and coun-terirritant material (Menthol) for pain relief was also explored successfully as a substitute treatment. Method: In the present study, we formulated and optimized an adhesive topical patch of the model drug diclofenac sodium, a widely used medicine for pain relief and menthol, a cooling and counter-irritant substance to aid pain relief. Combinations of two polymers, PVP-K30 and PVA, selected by trial batches, were further optimized by applying a 3x2 full factorial design. Two factors, X1 (PVP-K30) and X2 (PVA), were optimized using three responses, R1 (Q2), R2 (Q4), and R3 (Q12). De-rived mathematical models for responses were validated using checkpoint batches. The final opti-mized batch was derived based on the desirability function. Factorial batches were also evaluated for relevant parameters. Results: Results obtained by checkpoint batches were in line with the experimental results with 5% relative error, revealing that the derived models were valid for the design. The final optimized batch obtained by the desirability function followed all set criteria. Medicated patch prepared by opti-mized formulation was incorporated into the knee brace using an in-house patch holder mechanism. Conclutions: Combined treatment offers better patient compliance for the patient and the healthcare provider, which can be extended to other pain-relieving supportive treatments like elbow braces, waist brace, back support belt, cervical brace, etc.

Comparative Study Between the Results of Anterior Cervical Discectomy and Fusion Using Philadelphia or Soft Collar Postoperatively

Background data: Anterior cervical discectomy and fusion (ACDF) is a well-known operative technique for treating cervical disc diseases causing myelopathy and/or radiculopathy. Postoperative immobilization with a rigid cervical brace is widely followed after ACDF using a standalone cage and soft braces frequently. Some authors have recommended using postoperative cervical braces while others do not, and among surgeons who agree with postoperative collar usage, the type of cervical orthoses and the duration of use are also issues of debate. Purpose: This study aims to compare between results of ACDF by using the Philadelphia collar and soft collar postoperatively. Study design: A prospective study. Patient and Methods: This study included 60 patients with ACDF: 28 used Philadelphia collar (group I) and 32 used soft collar (group II). Cases with single-level ACDF to 4 levels are included, and revision and deformity cases are excluded. For one year, both groups were followed up regarding fusion rate, subsidence, cage migration, neck disability index (NDI), and visual analog score (VAS) of the neck and arm pain. Results: Neck and arm pains using VAS scores preoperatively and 3 months, 6 months, and 12 months postoperatively also showed no significant difference between both groups. Subsidence was noticed among two patients (7.1%) in group I and one patient in group II (3.1%). No significant differences in fusion rates were found between both groups. After a 12-month follow-up in more than two-level procedures, the NDI score among group II was significantly lower (p = 0.045). Linear regression analysis revealed that preoperative NDI, age, BMI, and operation level were the predictors of postoperative NDI, excluding the presence of diabetes mellitus (DM) and brace type. Conclusion: Cervical brace after ACDF either by Philadelphia or soft collar does not affect the fusion rate, cage subsidence, or outcomes of the neck and arm pain. (2021ESJ255)

Hirayama Disease: Review on Pathophysiology, Clinical Features, Diagnosis and Treatment

Hirayama disease is a relatively unusual cause of cervical myelopathy characterized by uni- or bilateral asymmetric weakness, fasciculations and atrophy of the distal upper limbs, mostly seen in young males. The insidious weakness progresses over 3–5 years, after which it stops. Hirayama disease results from the abnormal anterior shifting of the posterior cervical dura that occurs during cervical flexion, leading to cord impingement. Electrophysiologic studies reveal denervation of C7–T1 myotomes and absence of sensory involvement. Dynamic magnetic resonance imaging of the cervical spine is essential in confirming the diagnosis. Treatment is aimed at primarily avoiding neck flexion, which is achieved with the help of a cervical brace; however, progressive disease calls for surgical intervention. Although the disease is self-limiting, it causes many functional impairments in affected individuals. In this review, we describe the epidemiology, pathophysiology, clinical manifestations, imaging characteristics, electrophysiologic findings, differential diagnoses and updates in the treatment of Hirayama disease. This review also aims to improve the awareness of this disease among clinicians, enabling early suspicion, diagnosis and management.

Halo vest immobilization – an institutional review of safety in acute cervical spine injury from 2013 to 2017

Objective: Halo vest immobilization (HVI) remains an important treatment option for occipital-cervical injuries. It provides the surgeon with a safe and effective medical treatment options for challenging patients. The aim of this study was to evaluate the safety of HVI in these patients. Methods: This retrospective study identified adult patients treated with Halo vests immobilization (HVI) for acute cervical spine injury at our metropolitan level 1 trauma center from 2013 to 2017. This heterogenous cohort included 67 consecutive patients with acute cervical spine injury secondary to trauma or iatrogenic injury following surgical intervention with a mean age of 52 and a mean injury severity score (ISS) of 18. Forty-six percent of patients were treated with HVI as an adjunct therapy to surgical fixation (both short- and long-term immobilization), 45% of patients were treated with HVI as a primary medical treatment, and 9% of patients were treated with HVI instead of failed conservative medical treatment, such as cervical braces. Results: Pneumonia during the initial hospital stay was the most common complication (25%), followed by the correction of loose pins (22%) and pin site infections (18%). Overall, 51% of patients experienced at least one of these complications. There were significant associations between low initial GCS scores and the development of pneumonia (p < 0.001), high ISS scores and the development of pneumonia (p < 0.01), and duration of HVI and the occurrence of loose pins (p < 0.05). Four patients initially treated with HVI as primary medical treatment was converted to surgical treatment due to an intolerance of HVI or non-healing injuries. Conclusions:The HVI is a safe and effective treatment modality in a subset of patients with complex cervical junction and subaxial cervical spine pathology.

Skull Lesion in Myeloma Mistaken for Myeloma Deposit

We report the case of a 85 year old lady with multiple myeloma referred to our specialist spinal unit for treatment of multiple spinal fractures. She had an area of high signal on the occipital region seen on MRI and reported at a peripheral hospital as an erosive skull lesion in the occiput with protrusion of intracranial contents. The site of the erosion would mean that the upper margin of any cervical brace or collar would have potentially impinged on the defect and caused further damage. However on further evaluation at our tertiary myeloma unit the lesion turned out to be a normal variant requiring no further treatment.

Observation on the Efficacy of Autologous Blood Transfusion Combined with Controlled Hypotension in Patients with Spinal Internal Fixation during the Outbreak of New Coronavirus Pneumonia in Western Guangxi (in Guixi)

Objective: To explore the therapeutic effect of autologous blood reinfusion combined with controlled hypotension in surgical spinal fixation during the outbreak of COVID-19. Methods: 30 patients with spinal internal fixation autologous blood transfusion combined with controlled hypotension were selected as the subjects during the epidemic period from December 2019 to June 2020 in our hospital and during the operation, on the basis of routine blood pressure reduction, the American Haemonetice Corporation autologous blood continuous reinfusion system was used to infuse the blood recovered during the operation to the patient through filtration and other procedures. Results: 30 patients had no complications such as fever and hemolysis; And after the operation, the tube was dialed according to the drainage volume, the cervical thoracic and lumbar brace was customized, and the patient walked on the ground for one week; After no abnormalities, the patient was discharged. Intraoperative comparison of white blood cells (WBC), red blood cells (RBC), red blood cell pressure (HCT), hemoglobin (HGB), and coagulation time (PT) of patients with autologous blood before and after transfusion showed statistically significant differences before and after surgery (P < 0.001). Conclusion: During the new coronavirus pneumonia epidemic, the internal fixation of spinal surgery used a recovery machine to collect intraoperative blood for reinfusion. Intraoperative antihypertensive drugs were used to control blood pressure within a certain safe range. The postoperative clinical observation effect was significant and safe; especially at present the clinical significance during the epidemic was significant.

Effect of self- care exercises in forward head posture on craniovertebral angle and craniocervical flexion endurance: A pilot study

Background: Forward head posture (FHP) is the most frequently attained attitude of the head associated with rounded-shoulder posture (RSP) that leads to muscle imbalances. This needs to be corrected to prevent neck pain. Self-care exercises are home exercises that work positively for the prevention of the secondary effects of RSP. Aims: The aim of this study is to determine the effects of two self-care exercises, namely Bruegger's postural relief position and quadruped track cervical brace exercise in the management of asymptomatic FHP in terms of craniovertebral angle (CVA) and craniocervical flexion endurance (CCFE). Settings and Design: A single-group pre–post study design was conducted on physiotherapy volunteer student population of the Health Science University, Belagavi. Materials and Methods: Fifteen participants with asymptomatic FHP ( Results: The mean age of the participants was 23.00 years (standard deviation = 1.56). The comparison of pre- and postintervention scores for CVA and CCFE outcomes demonstrated a statistically significant improvement (P Conclusions: The two self-care exercises showed an effective reduction of CVA and increased deep cervical flexor strength in FHP. Once learned by the patients, the exercises can be self-administered and can be performed independently by the patients.

Current management of juvenile idiopathic arthritis affecting the craniovertebral junction.

Craniovertebral instability is a rare and serious problem. While previously treated surgically, better understanding of disease processes has permitted the field to move towards conservative management. Juvenile idiopathic arthritis (JIA) is one cause of pediatric craniovertebral instability. Early recognition and institution of appropriate medical therapy and bracing in a multidisciplinary fashion is critical to avoid long-term instability, joint abnormalities, or morbid surgical procedures. We seek to highlight cases of this rare problem and provide a principled approach to management decisions. We review 6 cases that have presented over the last 6years and highlight 3 cases in particular regarding craniovertebral instability as a presentation of JIA. We reviewed the clinical records and radiographic features with particular emphasis of the stability of the craniovertebral junction. Age range of the subjects was from 5 to 12. All patients presented with neck pain and abnormal head rotation. Four of the patients responded to medical management and/or cervical bracing with no long-term sequelae or instability. Two patients had refractory rotary subluxation, one that responded to manual reduction under pharmacological paralysis and bracing; the other had an incompetent transverse ligament requiring surgical reduction and fixation. Neck pain and abnormal head rotation in an older child is rare finding but should prompt suspicion as a manifestation of JIA to the general pediatrician or initial provider. Appropriate serologic studies and MRI studies with contrast at the craniovertebral junction is necessary for evaluation. Early institution of medical management and cervical bracing under a multidisciplinary team of pediatric rheumatology and neurosurgery is key to avoiding surgical intervention and long-term abnormalities at the craniovertebral junction.

Cervical subaxial spine uni-facet dislocation occurring in an infant

Abstract While pediatric spinal injuries account for between 1 and 10% of all spinal injuries A six month old male infant presented to our unit with the history that the child had fallen down two stairs whilst in his walker. The child's mother reported that since the event the child was irritable and had pain in his neck that seemed to be getting worse. Examination of the infant's neck revealed a 10 degree rotational deformity to the left and lower cervical posterior midline tenderness. There was no obvious step palpable. The rest of his neurological examination was normal. A computed tomographic scan of his cervical spine confirmed a left C6/C7 unifacet dislocation. The unifacet dislocation was successfully reduced under conscious sedation, using a halter, with serial imaging being performed. A post-reduction MRI confirmed the successful reduction and excluded cord compression. The infant was placed in a rigid cervical collar for 3 weeks and re-imaged with flexion/extension views. Fortunately the infants imaging excluded instability and he made a full recovery. In conclusion this case report gives an account of a sub-axial cervical spine injury pattern commonly seen in adults and very rarely encountered in infants. Closed reduction and a cervical brace were used to successfully manage this very rare injury.

Traumatic spinal injuries in the Kingdom of Saudi Arabia: a study of associated injuries, management and mortality.

Introductiontraumatic spinal fracture is a painful and disabling injury associated with poor long-term functional outcome. The objective of the present study was to assess the frequency of spinal fractures in road traffic accident (RTA) victims, their management, mortality rate and associated injuries. This study reveals and adds useful insights to the literature from Kingdom of Saudi Arabia (KSA) in terms of incidence of RTA-related spinal fractures, including their management and mortality rate.Methodsa cross-sectional study was conducted at King Khalid Hospital and Prince Sultan Center for Health Services (KKH & PSCHS) in AlKharj, KSA from September 2016 to June 2017. A total of 120 patients suffering from spinal/vertebral fractures due to RTAs were included in this study. The data was collected from patients' charts, including age, gender, region or distribution of the spinal fracture, associated fractures, number of fractures, degrees of shock, admission to intensive care unit (ICU), treatment modalities, along with the management of spinal fractures, days of hospital stay, referral and discharges or deaths.Resultsthe mean age of patients was 29.21. The most common anatomic region of the fracture was the cervical region (35%). Injuries associated with traumatic spinal fracture were predominated by clavicular fractures. More than half of the victims (58.30%) had a cervical brace applied before leaving the hospital. 29.20% patients required posterior stabilization with pedicle screws. Anterior corpectomy, grafting and plating was done to 4.30% patients.Conclusiontraumatic spinal fractures require prompt diagnosis and timely management in order to improve the outcome.

Treatment of the dens fractures in children

The anatomical and biomechanical features of the immature cervical spine make the upper segments at C1–3 especially susceptible to injury. Material and methodFrom 2000 to 2016, 10 patients (3 boys, 7 girls) with C2 dens fractures were treated. The average age of each child was 11 years (3–17). According to the Anderson classification, there were 6 patients with a type III fracture and 4 with a type II. 4 patients were treated conservatively using the Minerva cervical brace for 75 days (66–125) and 6 patients by means of the Halo-Vest for 79 days (64–87) and followed by the Schantz collar for 17 days (2–35). ResultsThe follow up lasted 78 months (12–180). The NDI (Neck Disability Index) score was calculated for each patient, except for section 8 (driving the car). The scores ranged from 1/45 (2.22%) to 20/45 (44.44%). The mean score for 9 out of the 10 patients (one patient died) was 4.77 (10.61%). ConclusionThe C2 dens fracture is a rare injury in children. The classification system of dens fractures developed by Anderson is useful in choosing the mode of treatment of dens fractures.

Decompression for botulinum toxin-exacerbated cervical myeloradiculopathy in the setting of congenital stenosis and Arnold-Chiari I malformation.

We present a case describing the management of a woman with severe, functionally limiting cervical myeloradiculopathy in the setting of congenital cervical canal stenosis and Arnold-Chiari I malformation. The subject is a 57-year-old woman with prior anterior cervical discectomy and fusion who presented with left-sided neck pain associated with radiculopathy, migraine, gait incoordination, and cervical dystonia. Cervical stenosis and Chiari malformation were confirmed using MRI. Conservative management with botulinum toxin, oral muscle relaxants, and cervical brace led to gradual exacerbation of symptoms. Due to failure of conservative management, surgical decompression with C3-C6 posterior laminoplasty was performed, resulting in complete resolution of all symptoms and markedly improved quality of life. This case reports a severe and nonspecific presentation of cervical myeloradiculopathy. Surgery for cervical myeloradiculopathy is controversial, and conservative therapy is initially preferred. However, in this case, conservative treatments likely led to paraspinal weakness, cervical hypermobility, and biomechanical instability, resulting in exacerbation of symptoms. Stretch/shear forces have been postulated to accelerate cervical myelopathy, and excessive cervical instability and range of motion are significant predictors of deterioration. In this case, surgical decompression with posterior cervical laminoplasty after 1 year of conservative management yielded significant pain relief and functional restoration, indicating the utility of this procedure even in the presence of Arnold-Chiari I malformation. This case illustrates that decompression can be effective for refractory cervical myeloradiculopathy associated with Chiari malformation, congenital stenosis, and prior anterior instrumentation, and highlights the potential risks of prolonged conservative management.