Philadelphia Collar Research Articles

Comparison of a SAM Splint-Molded Cervical Collar with a Philadelphia Cervical Collar

To compare the effectiveness of a SAM splint molded into a cervical collar with that of a Philadelphia cervical collar at limiting movement of the cervical spine in 5 different movements. This study was prospectively carried out in 13 healthy volunteer subjects. A hand-held goniometer was then used to measure degrees of maximal extension (starting in a maximally flexed position), rotation (left and right), and lateral flexion (left and right) with each collar. The results were then analyzed for the 5 independent movements using the paired t test to determine the effectiveness of the SAM splint compared with that of the Philadelphia collar. There was no statistically significant difference between the Philadelphia collar and the SAM splint at limiting movement of the cervical spine in any of the measured movements or in total allowed degrees of movement. The results of this study suggest that the SAM splint, when molded into a cervical collar, is as effective as the Philadelphia collar at limiting movement of the cervical spine.

In Vivo Analysis of Atlantoaxial Motion in Individuals Immobilized With the Halo Thoracic Vest or Philadelphia Collar

In vivo biomechanical comparison of the halo thoracic vest (HTV) and the Philadelphia collar (PC). To delineate the capacity of both orthoses for immobilization of the atlantoaxial complex (AAC), e.g., for their use in odontoid fracture care. Stable odontoid fractures can be treated with external immobilization using, e.g., a PC or a HTV. Although the HTV confers higher morbidity, particularly in elderly patients, with a similar union-rate in odontoid fracture care compared with the PC, many surgeons are still prone to use the HTV instead of the PC because the former is thought to accomplish increased rigidity at the AAC. Because application of the HTV using pins is an invasive procedure, there is a lack of biomechanical in vivo data on the "real" rigidity conferred by a HTV in comparison with a PC. Twenty volunteers were subjected to flexion/extension radiographs immobilized in a modified HTV or a PC. The radiographs were performed in extreme position of flexion in sitting position and extension in standing position. The PC was fitted as usual. The 4 cortical pins of a normal clinically used HTV were replaced by 12 modified distance pins. The halo-ring was fixed to the head by tightening of the 12 pins in an alternating fashion, thus yielding a hexapod-like strong fixation between the head and the HTV. The procedure was uncomfortable but there were no adverse events from the HTV placement. Radiographs were analyzed for the segmental rotation angle of C1-C2 in sagittal plane (SRA C1-C2) and the absolute rotation angle of C2-C7 (ARA C2-C7) using the Harrison tangent method. Separation angles (rSRA C1-C2 and rARA C2-C7) were calculated from flexion/extension views. Two observers measured all angles. The means of the measurements were used for statistical analysis. The interobserver reliability was expressed by calculating intraclass correlation coefficients (ICCs). RESULTS.: Mean age of 20 volunteers was 30.9 +/- 4.2 years. Calculation of the ICCs showed good to excellent interobserver reliability for all angular measurements (ICC = 0.95-0.98). Concerning restriction of subaxial sagittal plane motion, the HTV was more effective than the PC. The difference for the rARA C2-C7 between the PC (mean 20.7 degrees) and HTV (mean 9.2 degrees) yielded significance (P = 0.01). But, concerning restriction of flexion/extension at the AAC, there was no statistical significant difference for the rSRA C1-C2 between the PC and HTV (P = 0.3). The PC (mean 1.3 degrees) was even superior to the HTV (mean, 3.3 degrees) in restricting sagittal motion at C1-C2. In comparison to normal atlantoaxial motion was restricted by 88.5% with the PC and 70.8% with the HTV. In light of the results and a selected review of literature, a treatment algorithm for the elderly patient with odontoid fracture is presented. Under the extremes of flexion and extension bendings, the current study demonstrated that there was no significant difference in restriction of sagittal motion at C1-C2 when using the PC instead of the HTV in a group of 20 young normal adults. In light of the current biomechanical data and a selected review of literature, it is concluded that the use of a PC is sufficient for the treatment of stable odontoid fractures.

C2-fractures: part II. A morphometrical analysis of computerized atlantoaxial motion, anatomical alignment and related clinical outcomes.

Knowledge on the outcome of C2-fractures is founded on heterogenous samples with cross-sectional outcome assessment focusing on union rates, complications and technical concerns related to surgical treatment. Reproducible clinical and functional outcome assessments are scant. Validated generic and disease specific outcome measures were rarely applied. Therefore, the aim of the current study is to investigate the radiographic, functional and clinical outcome of a patient sample with C2-fractures. Out of a consecutive series of 121 patients with C2 fractures, 44 met strict inclusion criteria and 35 patients with C2-fractures treated either nonsurgically or surgically with motion-preserving techniques were surveyed. Outcome analysis included validated measures (SF-36, NPDI, CSOQ), and a functional CT-scanning protocol for the evaluation of C1-2 rotation and alignment. Mean follow-up was 64 months and mean age of patients was 52 years. Classification of C2-fractures at injury was performed using a detailed morphological description: 24 patients had odontoid fractures type II or III, 18 patients had fracture patterns involving the vertebral body and 11 included a dislocated or a burst lateral mass fracture. Thirty-one percent of patients were treated with a halo, 34% with a Philadelphia collar and 34% had anterior odontoid screw fixation. At follow-up mean atlantoaxial rotation in left and right head position was 20.2 degrees and 20.6 degrees, respectively. According to the classification system of posttreatment C2-alignment established by our group in part I of the C2-fracture study project, mean malunion score was 2.8 points. In 49% of patients the fractures healed in anatomical shape or with mild malalignment. In 51% fractures healed with moderate or severe malalignment. Self-rated outcome was excellent or good in 65% of patients and moderate or poor in 35%. The raw data of varying nuances allow for comparison in future benchmark studies and metaanalysis. Detailed investigation of C2-fracture morphology, posttreatment C2-alignment and atlantoaxial rotation allowed a unique outcome analysis that focused on the identification of risk factors for poor outcome and the interdependencies of outcome variables that should be addressed in studies on C2-fractures. We recognized that reduced rotation of C1-2 per se was not a concern for the patients. However, patients with worse clinical outcomes had reduced total neck rotation and rotation C1-2. In turn, C2-fractures, especially fractures affecting the lateral mass that healed with atlantoaxial deformity and malunion, had higher incidence of atlantoaxial degeneration and osteoarthritis. Patients with increased severity of C2-malunion and new onset atlantoaxial arthritis had worse clinical outcomes and significantly reduced rotation C1-2. The current study offers detailed insight into the radiographical, functional and clinical outcome of C2-fractures. It significantly adds to the understanding of C2-fractures.

Outcome of treatment for congenital muscular torticollis: a study on ages for treatment, treatment methods, and postoperative therapy

The objective of this study is to review the clinical course after surgical treatment of congenital muscular torticollis and investigate the problems. Based on the treatment strategy of our institution for patients with congenital muscular torticollis, we treated young children with unipolar tenotomy of the sternocleidomastoid muscle, with postoperative use of our original brace, and school age or older children with bipolar tenotomy of the sternocleidomastoid muscle and postoperative use of a simple immobilizing brace, mainly a Philadelphia collar. This study included nine patients who underwent unipolar or bipolar tenotomy of the sternocleidomastoid muscle in our department between November 1990 and April 2006. Of these, four were boys and five were girls. Seven had right and two had left torticollis. The age at surgery ranged from 1 year 6 months to 24 years. Five underwent unipolar tenotomy and four underwent bipolar tenotomy. The study period from the first visit to the present ranged from 1 year 6 months to 18 years 9 months. The evaluation was based on the presence of recurrence and the assessment criteria described by Tanabe (Arch Orthop Trauma Surg 122:489–493, 2002). Three of five patients treated with unipolar tenotomy had a second surgery due to recurrence. None of those treated with bipolar tenotomy experienced recurrence. According to Tanabe’s criteria, among the five patients treated with unipolar tenotomy, two were graded as excellent, two fair, and one poor. And among the four treated with bipolar tenotomy, three were graded as excellent and one fair. Although this study included only nine patients treated and followed-up, more than half of those treated with unipolar tenotomy of the sternocleidomastoid muscle experienced recurrence requiring further surgery. Among those treated with bipolar tenotomy, the outcomes were generally good, and no recurrence was observed. Unipolar tenotomy of the sternocleidomastoid muscle in young children requires special attention with regard to recurrence. We decided to conduct bipolar tenotomy in young children and investigate future outcomes.

Airway Scope and StyletScope for Tracheal Intubation in a Simulated Difficult Airway

Direct laryngoscopy is difficult when the cervical spine is immobilized. The Airway Scope and StyletScope are new laryngoscopes designed to facilitate intubation under these circumstances. Thus, in patients wearing a rigid cervical collar to simulate a difficult airway, we tested the hypothesis that the intubation success rates of the Airway Scope and StyletScope are similar, but that intubation with Airway Scope is faster. Adult patients requiring tracheal intubation as part of anesthesia were enrolled. After anesthesia induction and muscle relaxation, patients' necks were stabilized with a rigid Philadelphia collar and patients were randomly assigned to tracheal intubation with Airway Scope (n = 50) or StyletScope (n = 50). Overall intubation success rate, time required for intubation, the number of attempts required for successful intubation, and airway complications related to intubation were recorded. Overall intubation success rates were 98% with Airway Scope and 96% with StyletScope. Intubation was 19 s faster with Airway Scope (32[8] s; mean) versus StyletScope (51[29] s). The number of required intubation attempts was similar with each device: 26/18/5 (first/second/third attempt) for Airway Scope versus 26/17/5 for StyletScope. The incidence of mucosal trauma and lip injury was similar, except esophageal intubation occurred only with StyletScope (n = 6); neither dental injury nor hypoxia occurred. Both the Airway Scope and StyletScope offer high success rates in a simulated difficult airway achieved by a rigid collar. However, the Airway Scope is faster and less likely to cause esophageal intubation.

Fibular allograft and anterior plating for dislocations/fractures of the cervical spine

Background:Subaxial cervical spine dislocations are common and often present with neurological deficit. Posterior spinal fusion has been the gold standard in the past. Pain and neck stiffness are often the presenting features and may be due to failure of fixation and extension of fusion mass. Anterior spinal fusion which is relatively atraumatic is thus favored using autogenous grafts and cages with anterior plate fixation. We evaluated fresh frozen fibular allografts and anterior plate fixation for anterior fusion in cervical trauma.Materials and Methods:Sixty consecutive patients with single-level dislocations or fracture dislocations of the subaxial cervical spine were recruited in this prospective study following a motor vehicle accident. There were 38 males and 22 females. The mean age at presentation was 34 years (range 19-67 years). The levels involved were C5/6 (n = 36), C4/5 (n = 15), C6/7 (n = 7) and C3/4 (n = 2). There were 38 unifacet dislocations with nine posterior element fractures and 22 were bifacet dislocations. Twenty-two patients had neurological deficit. Co-morbidities included hypertension (n = 6), non-insulin-dependent diabetes mellitus (n = 2) and asthma (n = 1). All patients were initially managed on skull traction. Following reduction further imaging included Computerized Tomography and Magnetic Resonance Imaging. Patients underwent anterior surgery (discectomy, fibular allograft and plating). All patients were immobilized in a Philadelphia collar for eight weeks (range 7-12 weeks). Eight patients were lost to follow-up within a year. Follow-up clinical and radiological examinations were performed six-weekly for three months and subsequently at three-monthly intervals for 12 months. Pain was analyzed using the visual analogue scale (VAS). The mean follow-up was 19 months (range 14-39 months).Results:Eight lost to followup, hence 52 patients were considered for final evaluation. The neurological recovery was 1.1 Frankel grades (range 0-3) and two patients with root involvement recovered. At six months bony trabeculae at the graft-vertebrae interface were noted. There were 12 (20 %) cases of graft collapse and one case of angulation which showed no progression. At six months the VAS was 3 (range 0-6). There was no limitation of neck motion at six months in 47 patients.Conclusion:Fresh frozen fibular allografts are suitable and cost-effective for anterior fusion in cervical trauma.

Conservative treatment of an atlantoaxial degenerative articular cyst: case report

Background Atlantoaxial degenerative articular cysts are rare lesions that can cause extradural compression of the cervicomedullary junction. When symptomatic, they usually require surgical treatment. We report an unusual case of spontaneous regression of an atlantoaxial degenerative articular cyst after conservative treatment with an external cervical brace along with a systemic therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids. We also discuss the potential pathogenetic mechanisms involved. Purpose To describe a case of significant volume reduction of an atlantoaxial articular degenerative cyst in a patient treated with a Philadelphia collar and anti-inflammatory drugs. Study design Case report with analysis of the literature. Methods A 80-year-old patient was admitted to our institution with a history of progressive tetraparesis, ataxic gait, and cervical pain. A cervical spine magnetic resonance imaging (MRI) scan showed an extradural mass lesion behind the dens of C2 causing significant compression of the cervicomedullary junction, suggesting the diagnosis of atlantoaxial degenerative articular cyst. The patient refused surgery in favour of a conservative treatment with a Philadelphia collar and a short-term course of NSAIDs and corticosteroids. Results After 6 weeks, the patient's neurological condition improved, and a 6-month follow-up cervical spine MRI scan revealed an almost complete regression of the atlantoaxial cystic lesion. At a 1-year follow-up, his clinical condition was further improved. Conclusions Atlantoaxial articular degenerative cysts are rare lesions that should be included in the differential diagnosis of those extradural lesions that can cause a ventral or ventrolateral compression of the cervicomedullary junction. They most commonly occur in elderly female patients affected by diffuse arthrosic degeneration of the cervical spine, with or without clear radiological signs of atlantoaxial instability, and have a typical appearance on MRI imaging. Surgery, with direct excision of the cyst and/or a C1–C2 fusion, is the first treatment of choice. Nevertheless, our report points out the possibility of a significant spontaneous regression of these lesions following a simple conservative strategy based on the use of an external cervical brace together with a systemic anti-inflammatory therapy.

Medically treated paravertebral Brucella abscess presenting with acute torticollis: case report

Background Atlantoaxial subluxation secondary to a paravertebral (retropharyngeal) abscess is a well known but rare event in children. Case Description The authors describe the clinical and radiologic findings of a case of 6-year-old child who presented with acute torticollis (duration, 4 days). Type 2 atlantoaxial rotatory fixation and upper cervical paravertebral (retropharyngeal) abscess were diagnosed on radiologic examination. Laboratory test results showed positive agglutination titer for Brucella melitensis, in the rate of 1/640 dilution. This is the first reported case of Brucella-related atlantoaxial subluxation in a child in the pediatric literature. The patient was treated successfully with anti-inflammatory drugs, Brucella-specific antibiotic regimen, and Philadelphia collar application. Possibly, effusion of the atlantoaxial joint, due to Brucella infection, led to the laxity of the ligaments and contributed to subluxation. Conclusions Brucella abscess should be kept in mind for the differential diagnosis of retropharyngeal mass, and the torticollis may be the only presenting sign. The authors recommend a trial of medical treatment with adequate dosages for a reasonable length of time and immobilization before considering surgical intervention for the spinal paravertebral Brucella abscess and related atlantoaxial subluxation.

Rare Bilateral C6 Spondylolysis and Spondylolisthesis in an Adolescent Athlete

Case report. To show a rare case of cervical spondylolysis and spondylolisthesis secondary to bilateral stress fractures at the pedicle laminar junction of C6 in a 16-year-old athlete playing high school baseball. The patient presented with 3 months of neck pain and intermittent right arm radicular symptoms. Plain radiographs and multidetector computerized tomography (CT) of the cervical spines. Plain radiographs revealed loss of lower cervical lordosis. Multidetector CT indicated bilateral C6 spondylolysis. Magnetic resonance imaging showed bilateral marrow edema at the pedicle laminar junction of C6. Treatment included placing his neck in a Philadelphia collar for 6 weeks. Follow-up CT revealed progression of healing. Early diagnosis and appropriate management of these cases are important to promote healing.

Regression of an atlantoaxial degenerative articular cyst associated with subluxation during conservative treatment

The presence of an atlantoaxial degenerative articular cyst is rare; when present this lesion extends posteriorly to the dens, causing cervicomedullary compressive myelopathy. The authors describe a symptomatic case of this lesion associated with atlantoaxial subluxation in a 76-year-old man. The patient's neurological symptoms resolved and corresponded to a reduction in the size of the cyst. After 8 months of continued conservative treatment, in which the patient wore a Philadelphia collar, the cyst spontaneously regressed. Subsequently, a C1-2 posterior fusion was performed to treat the atlantoaxial subluxation.

Mastication Causing Segmental Spinal Motion in Common Cervical Orthoses

In vivo fluoroscopic quantification of segmental cervical spinal motion in asymptomatic volunteers during mastication. To quantify the degree of segmental cervical spine motion in patients during mastication and while wearing several commonly used cervical orthoses. Cervical orthoses are routinely used to stabilize the cervical spine after trauma or cervical fusion and are, in some cases, prescribed to be worn at all times, including during eating. Seven volunteers with an average age of 31 years (range, 26-42 years) had 5 seconds of continuous lateral cervical fluoroscopic imaging while they chewed gum without any cervical orthosis (control) and while wearing a soft collar turned forward then backward, a Philadelphia collar, a Miami J collar, or a two-poster brace. Still images were created from the fluoroscopy video, which allowed for quantification of the amount of segmental motion. All cervical collars produced statistically greater motion at occiput-C1 and C1-C2 when compared with no collar. The motion was greatest at the occiput-C1 junction and decreased to the C4 level. No motion was detected in any subject in any brace below C4. The two-poster brace produced the most segmental motion at occiput-C1 (6.3 degrees +/- 2.0 degrees) compared with the soft collar turned backwards (1.9 degrees +/- 1.9 degrees). No subject had any segmental motion below C2 in the soft collar. No segmental spinal motion was observed without a cervical brace. To limit upper cervical spine segmental motion during mastication, for patients with unstable cervical spines, we propose a two-poster brace with removal of the mandibular component to allow for free mandibular action. For stable spines, we propose a soft collar turned backwards. Patients should be educated with this information.

Key points about atlanto-axial internal-fixation and fusion using Gallie's technique

To study the clinical problems about posterior atlanto-axial internal-fixation and fusion for atlanto-axial instability or dislocation. Surgical treatments of 138 cases with atlanto-axial instability or dislocation were reviewed. There were 62 cases of odentoid malformation, 54 cases of odentoid fracture or rupture of transverse ligament, 22 cases of subluxation and rotation. All cases were treated using Gallie's technique. Six cases were also fixed with transarticular screws, and protected with Philadelphia collar. Other patients were fixed with plaster paris brackets. The followed-up period was 1 to 12 years with an average of 3 year and 5 months. According to Sumi's criteria, excellent 70 cases (50.7%), good 40 cases (29.0%), fair 15 cases (10.9%), poor 13 cases (9.4%). 9 cases with bone graft postponed fusion were cured by enhance external-fixation. 2 cases with nonunion were treated with revision surgery. Complication of cord injury happened in 1 case. Gallie's fusion technique is an effective method to manage the atlanto-axial instability or dislocation. Skull distraction before operation and reliable external-fixation post operative are important assistant measures. Key points for successful operation are careful wiring or cable traversing, decortication of posterior arc of C1, and maintaining the physiological height between C1 and C2 posterior arc. Indications and objectives should be conformed before revision surgery for failure cases.

Intubating laryngeal mask airway allows tracheal intubation when the cervical spine is immobilized by a rigid collar

An intubating laryngeal mask airway (ILMA) facilitates tracheal intubation with the neck in neutral position, which is similar to the neck position maintained by a rigid cervical collar. However, a cervical collar virtually obliterates neck movement, even small movements that normally facilitate airway insertion. We therefore tested the hypothesis that the ILMA will allow tracheal intubation even in patients wearing a rigid cervical collar. We performed blind tracheal intubation via an ILMA under general anaesthesia in 50 patients with a rigid Philadelphia collar in place undergoing cervical spine surgery and 50 general surgical patients. Time required for intubation, intubation success rate, and numbers and type of adjusting manoeuvres used were recorded. Inter-incisor distance was significantly smaller (4.1 (0.8) vs 4.6 (0.7) cm, mean (sd), P<0.01) and Mallampati scores were significantly greater (P<0.001) in the patients with collars. ILMA insertion took longer (30 (25) vs 22 (6) s), more patients required two insertion attempts (15 vs 3; P<0.005), and ventilation adequacy with ILMA was worse (P<0.05) in collared patients. However, there were no significant differences between the collars and control patients in terms of total time required for intubation (60 (41) vs 50 (30) s), number of intubation attempts, overall intubation success rate (96 vs 98%), or the incidence of intubation complications. Blind intubation through an ILMA is thus a reasonable strategy for controlling the airway in patients who are immobilized with a rigid cervical collar.

The effects of cervical bracing upon swallowing in young, normal, healthy volunteers.

The purpose of this study was to evaluate radiographically the effects of cervical bracing upon swallowing thin liquids and solid food in normal adults under three cervical bracing conditions. This was a prospective, repeated measures design study. Seventeen healthy adult volunteers between the ages of 30 and 50 were recruited from hospital staff. All subjects reported no previous history of swallowing difficulty or diseases that might affect swallowing. Subjects were radiographically observed swallowing thin liquids and solid food without cervical bracing and with three common cervical orthoses (Philadelphia collar, SOMI, and halo-vest brace). Order of bracing and type of bolus were randomized. Changes in swallowing function (point of initiation of swallow response, presence of pharyngeal residue, airway penetration, hyoid bone movement, diameter of oropharyngeal airway, and durational measurements) were analyzed by two independent raters. Eighty-two percent (14/17) of the subjects demonstrated radiographic changes under one or more of the bracing conditions. Forty-seven percent (8/17) of subjects demonstrated changes with point of initiation of the swallow response, 59% (10/17) demonstrated increased pharyngeal residue, and 23.5% (4/17) demonstrated changes with bolus flow with laryngeal penetration present. Aspiration did not occur under any of the bracing conditions. Changes noted in durational measurements for oral containment and total pharyngeal transit under the bracing conditions were not considered statistically significant. This study shows that cervical bracing does change swallowing physiology in normal healthy adults.

Hemi-Atlas: Presentación de cinco casos

C1 partial aplasia is a rare congenital deformity which can produce unacceptable progressive severe torticollis. Five such cases treated in two regional Pediatric Hospitals of Argentin are presented here. There were 4 girls and 1 boy, with a mean age of 6 years; four of them had formation defect of articular mass (Villa's Area 3) causing fixed torticollis in 3 who underwent surgery. In another case the defect consisted of a posterior hemi-arch (Area 2). Surgical procedures consisted on isolated posterior occipito-cervical arthrodesis in two cases, and associated with a posterior decompression by suboccipital craneotomy in the third, due to the presence of preoperative neurological deficit. Some internal fixation was achieved with sutures (non reabsorbibles in younger patient and wire suture in older ones). Average postoperative immobilisation with Halo-vest was 4.5 months, and it was followed with extended Philadelphia collar until complete consolidation. Non-operated patients responded to conservative therapy. Mean followup was 1 year 8 months. All patients presented correction of the deformity. The 3 surgically treated patients showed good arthrodesis and disappearance of preoperative delicit when present. In conclusion, the unilateral hipoplasias of C1 in children with unyielding deformity can be satisfactorily managed by means of CO-C2/C3 arthrodesis with or without decompression, always associated to external immobilization.

Management of suspected cervical spine injuries – the paediatric perspective

Paediatric cervical spine immobilisation and management is one of the most difficult tasks to master in the paediatric trauma population. The Royal Children's Hospital – Melbourne has admitted 54 patients with diagnosed cervical spine injuries since January 1999. The management of such patients admitted to acute care facilities with suspected cervical spine injuries is inconsistent and at times sub-optimal. Management controversies centre around, application of cervical collars, clearance of the c-spine, patient movement and general care principles. In an endeavour to address these issues, the Royal Children's Hospital Trauma Service, in conjunction with the Emergency Department developed cervical spine guidelines. Teams consulted in the formulation of these guidelines included, Emergency Department, Intensive Care Unit, Orthopaedics, Neurosurgery, Radiology and General Surgery. These guidelines were developed as a clinical tool to guide management and standardise the approach of care for these patients. Specifically, the guidelines address: immobilisation of the paediatric cervical spine; radiology; clearing the cervical spine of injury; suspected or proven cervical spine injury; guidelines for times to fitting Philadelphia collar; ongoing care.

Segmental fracture of the dens

A 76-year-old man suffered a syncopal attack, fell and hit the right parietal region of his head against a doorframe. His only complaint was of mild aching over the posterior aspect of his neck. Examination revealed vague generalised neck tenderness only. He had no neurological symptoms or signs. Cervical spine radiographs suggested a transverse fracture of the base of the odontoid process. There were also degenerative changes at C4/5 with a reversed cervical lordosis. CT scan confirmed an undisplaced vertical fracture through the midline of the anterior arch of the atlas and two fractures of the odontoid process (Figs. 1 and 2). A displaced oblique apical type I fracture and an undisplaced transverse basal type II fracture are shown [1]. Due to general poor health, the patient was treated conservatively in a Philadelphia collar with back and chest extensions [2]. Ten months after injury, a CT scan showed no evidence of fracture union. Persistent mobility was confirmed on controlled flexion-extension views. Despite counselling, the patient refused operative intervention.

Cervical spine multilevel decompression/reconstruction with anterior/posterior internal fixation

Cervical spine multilevel decompression/reconstruction with anterior/posterior internal fixation

Calcitonin and Spinal Fusion

The authors report on the efficacy of nonsurgical treatment of an older patient with a fractured odontoid process. The patient, an 85-year-old woman, had multiple medical problems that put her at an increased surgery-related risk. Therefore, an alternative approach was elected, including immobilization with a Philadelphia collar and the provision of calcitonin nasal spray. Bone union and clinical recovery were achieved within 8 weeks of initiating the nasal calcitonin therapy (12 weeks postinjury). Considering the patient's age, comorbidities, and the severity of the fracture, the recovery period was unusually short. The authors believe that calcitonin played a pivotal role in the healing process of the fractured odontoid bone. There is no question that the fusion in this patient could be unrelated to the medical therapy. This description of one patient, as well as the lack of a large randomized study, precludes any scientific conclusions. Nevertheless, the authors believe that the development of a successful fusion in this high-risk patient should be reported as an observation that merits confirmation and study. The authors also discuss the physiological effects of calcitonin and the research and clinical experience with this hormone in different conditions affecting bone.

Indications of Philadelphia collar in the treatment of upper cervical injuries.

The principles of the management of upper cervical injuries remain controversial. The specific anatomical conditions render upper cervical injuries more problematic than lower cervical injuries. Here we present and discuss our experiences with upper cervical injury, comparing them with other treatment modalities. The 24 patients admitted to our department with upper cervical injury were treated surgically or conservatively according to their neurological and radiological status. Five patients were treated surgically due to neurological abnormality associated with compression to neural structures observed in computerized tomography/magnetic resonance imaging (CT/MRI). Patients with no neural compression were managed conservatively, with the Philadelphia collar. All patients showed stable fracture healing and experienced no additional clinical disability on follow-up after a minimum of 3 months, except one who died due to cardiac and respiratory failure. Regardless of the type of injury, indication for surgery in many cases of upper cervical injury is neurological abnormality associated with radiologically observed neural compression. It is our belief that, in the absence of both neurological abnormality and compression to neural structures observed in CT/MRI, treatment with the Philadelphia collar alone is safe, cost-effective and easily applicable for many cases of upper cervical injury.