Postural Reduction Research Articles

Percutaneous Treatment of Vertebral Body Pathology

Percutaneous vertebral body injection procedures currently are used to stabilize and reinforce weakened or fractured bone resulting from metastatic disease and severe osteoporosis. Both vertebroplasty and kyphoplasty can reinforce the structure of a vertebral body and provide pain relief, but the procedures have technical differences. Kyphoplasty improves vertebral height to varying degrees in nearly three quarters of patients. Kyphosis is improved more effectively when the procedure is performed within 3 months from the onset of fracture pain. To date, it is unknown whether vertebroplasty with preprocedure postural reduction can provide similar improvement of deformity. Complications are relatively infrequent with both vertebroplasty and kyphoplasty. Cement leakage from the vertebral body is more likely with vertebroplasty than with kyphoplasty. Leakage is more common in the treatment of pathologic fractures resulting from metastatic disease. Clinical complications caused by cement leakage and neural compression are infrequent. Specific indications for these injection procedures need to be more clearly refined. Long-term outcomes, including the fate of the injected material and the effect on adjacent vertebrae, have yet to be determined.

Pulsatile ocular blood flow in primary open-angle glaucoma and ocular hypertension

Purpose To compare pulsatile ocular blood flow measurements in untreated ocular hypertensive (OHT) subjects and primary open-angle glaucoma (POAG) patients. Design A prospective observational study in an institutional setting. Methods A total of 97 subjects were recruited to the study (50 ocular hypertensives, 24 glaucoma patients, and 23 normal subjects). “High-risk” OHT had intraocular pressure (IOP) > 25 mm Hg; “low-risk” OHT had IOP ≤ 25 mm Hg. Pulsatile ocular blood flow (POBF) measurements were made with a pneumotonometer in sitting, standing, and supine positions. Intraocular pressure was measured with Goldmann tonometry. Twenty-six patients were started on topical treatment to reduce intraocular pressure, and the measurements were repeated at a review visit. Results Untreated POAG patients and high-risk OHT had reduced POBF ( P < .001) and pulse volume ( P < .001) compared with both normals and low-risk OHT. Women had higher POBF than men ( P = .009, two-way analysis of variance). Subjects with pharmacologically lowered IOP had a significant increase in mean POBF (+80.9 μl/min, P = .02) and a significant reduction in mean arterial blood pressure (−11.0 mm Hg, P = .003). Postural reduction in POBF (from sitting to supine) increased and became statistically significant in POAG and OHT subjects on treatment ( P < .0001). Conclusion High-risk ocular hypertensives have reduced POBF when compared with low-risk ocular hypertensives and normals and do not differ significantly from POAG patients. Our findings support the clinical impression that ocular hypertensive subjects with IOP of over 25 mm Hg should be monitored closely and may benefit from prophylactic treatment to lower intraocular pressure.

Exercise training and orthostatic intolerance: a paradox?

Exercise training and orthostatic intolerance: a paradox?

Radiographic parameters for evaluating the neurological spaces in experimental thoracolumbar burst fractures.

It is important to know the condition of neural spaces during the nonoperative treatment of thoracolumbar burst fractures. The goals of the current study were to identify the correlation between the degree of deformity of a fractured vertebra and the encroachment of neural spaces, and to determine how the encroachment and the deformity can be improved by the extension posture simulating the postural reduction. Experimental burst fractures were produced in L1 vertebrae of nine human thoracolumbar spine segments (T11-L3) with neural spaces lined with tiny steel balls. Lateral radiographs were taken in neutral and extended posture before and after the trauma. Anterior vertebral height, posterior vertebral height, vertebral height ratio, vertebral kyphotic angle, posterior vertebral body angle, and the cross diagonal angle were the geometric parameters used to describe the vertebral deformity. The canal diameter and superior and inferior intervertebral foramen areas were defined as the neural spaces. All parameters were measured on the scanned images of radiographs, as seen on the computer screen. Among the vertebral body parameters, the posterior vertebral height, posterior vertebral body angle, and cross diagonal angle showed significantly higher correlations with the canal encroachment. The extended posture did not improve the canal and intervertebral foramen encroachments. The kyphotic deformity (vertebral kyphotic angle and anterior vertebral height) was improved but the deformity of the vertebral posterior wall (posterior vertebral height and posterior vertebral body angle) was not improved because of the extended posture.

Can the Green Laser Doppler Measure Skin-Nutritive Perfusion in Patients with Peripheral Vascular Disease?

The recently developed green laser (GL; wavelength 543 nm) is thought to measure perfusion derived from a more superficial skin layer than does the standard near-infrared laser (RL; wavelength 780 nm). These lasers were used to investigate the disturbances in the different layers of skin perfusion in ischaemic legs before and after treatment and compared with capillary microscopy. Eighteen patients (20 legs) with different stages of leg ischaemia scheduled for a vascular intervention (11 males, 7 females; median age 73, range: 52–81 years; Fontaine stages II–IV) were investigated by means of capillary microscopy, visualising the nail fold capillary perfusion, and a laser Doppler, equipped with a special dual probe conducting both GL and RL. The probe was attached to the pulp and the dorsum of the big toe to assess skin perfusion at rest and during reactive hyperaemia, while sitting and while supine. Resting and hyperaemic perfusion using GL was low and significantly lower (p < 0.01) than with RL in both areas and positions. Laser Doppler perfusion was higher in the pulp than on the dorsum with both wavelengths (p < 0.05). The hyperaemia response was highest using GL and differed among the three techniques. Postural reduction of capillary and RL flow was reduced, but not with GL. After treatment, skin capillary perfusion improved more clearly than did the laser Doppler perfusion with either wavelength, while postural vasoconstriction improved only when measured with the capillary microscope. The differences found between RL and GL Doppler perfusion, but also between GL and capillary microscopy measurements suggest that the GL does measure the more superficial, but not exclusively the nutritive skin perfusion. Clinically, the use of the green laser in its present form in patients with leg ischaemia offers no advantage over the red laser.

Contributions of MSNA and stroke volume to orthostatic intolerance following bed rest.

We examined whether the altered orthostatic tolerance following 14 days of head-down tilt bed rest (HDBR) was related to inadequate sympathetic outflow or to excessive reductions in cardiac output during a 10- to 15-min head-up tilt (HUT) test. Heart rate, blood pressure (BP, Finapres), muscle sympathetic nerve activity (MSNA, microneurography), and stroke volume blood velocity (SVV, Doppler ultrasound) were assessed during supine 30 degrees (5 min) and 60 degrees (5-10 min) HUT positions in 15 individuals who successfully completed the pre-HDBR test without evidence of orthostatic intolerance. Subjects were classified as being orthostatically tolerant (OT, n = 9) or intolerant (OI, n = 6) following the post-HDBR test. MSNA, BP, and SVV during supine and HUT postures were not altered in the OT group. Hypotension during 60 degrees HUT in the post-bed rest test for the OI group (P < 0.05) was associated with a blunted increase in MSNA (P < 0.05). SVV was reduced following HDBR in the OI group (main effect of HDBR, P < 0.02). The data support the hypothesis that bed rest-induced orthostatic intolerance is related to an inadequate increase in sympathetic discharge that cannot compensate for a greater postural reduction in stroke volume.

Altered sympathetic and vagal modulations of the cardiovascular system in patients with pheochromocytoma: Their relations to orthostatic hypotension

To examine sympathetic and vagal cardiovascular regulatory mechanisms in the pathogenesis of orthostatic hypotension in pheochromocytoma, we continuously monitored blood pressure (Finapres) and RR interval (electrocardiogram) in supine and standing positions in 12 patients with pheochromocytoma, 43 patients with essential hypertension, and 30 normotensive subjects. Mayer wave power spectrum of systolic blood pressure variability (≈0.1 Hz) and respiratory power spectrum of the RR interval variability (≈0.25 Hz) were taken as measures of sympathetic vascular and cardiac vagal modulations, respectively. Systolic blood pressure decreased more upon standing in pheochromocytoma patients (−21 ± 7 mm Hg) than in normotensive subjects (−5 ± 2 mm Hg) or essential hypertensive patients (−3 ± 2 mm Hg) ( P < .005 for both), whereas heart rate tended to increase most in the pheochromocytoma group. Postural reduction in systolic blood pressure was highly correlated with postural increase in heart rate (reciprocal change in RR interval) in the pheochromocytoma group (r = 0.716, P < .01) suggesting that baroreflex is well functioning in those patients. The Mayer wave power spectrum in recumbency was extremely depressed in pheochromocytoma patients (1.1 ± 0.2 mm Hg 2) compared with normotensives (4.5 ± 0.8 mm Hg 2) or essential hypertensives (5.6 ± 0.6 mm Hg 2) ( P < .001 for both). This parameter increased significantly with standing in all groups but remained lower in patients with pheochromocytoma (5.1 ± 1.0 mm Hg 2) than in normotensives (7.1 ± 0.9 mm Hg 2, P = NS), whereas essential hypertensive patients demonstrated far greater value (19.2 ± 3.8, P < .01 for both). The respiratory power spectrum of the RR interval in recumbency of pheochromocytoma patients (189 ± 54 msec 2) was less than in normotensive subjects (714 ± 100 msec 2, P < .001) but did not differ from that in patients with essential hypertension (214 ± 41 msec 2). The respiratory power spectrum of the RR interval upon standing was markedly suppressed in pheochromocytoma patients (36.9 ± 16.7 msec 2) compared with normotensive subjects (129.5 ± 23.6 msec 2) or essential hypertensive patients (126.6 ± 28.6 msec 2) ( P < .001 for both). Postural decrement in the respiratory power spectrum of the RR interval correlated positively with postural increase in heart rate (r = 0.577, P < .05) in patients with pheochromocytoma. After successful surgery (n = 9), the Mayer wave power spectrum of the systolic blood pressure and the blood pressure response to orthostasis were normalized. These data suggest that altered sympathetic vascular regulation is central to the pathogenesis of orthostatic hypotension in pheochromocytoma, whereas cardiac vagal regulation acts to compensate.

Upright posture reduces forearm blood flow early in exercise.

The hypothesis that upright posture could modulate forearm blood flow (FBF) early in exercise was tested in six subjects. Both single (2-s duration) and repeated (1-s work/2-s rest cadence for 12 contractions) handgrip contractions (12 kg) were performed in the supine and 70 degrees head-up tilt (HUT) positions. The arm was maintained at heart level to diminish myogenic effects. Baseline brachial artery diameters were assessed at rest in each position. Brachial artery mean blood velocity (MBV; Doppler) and mean arterial pressure (MAP) (Finapres) were measured continuously to calculate FBF and vascular conductance. MAP was not changed with posture. Antecubital venous pressure (Pv) was reduced in HUT (4.55 +/- 1.3 mmHg) compared with supine (11.3 +/- 1.9 mmHg) (P < 0.01). For the repeated contractions, total excess FBF (TEF) was reduced in the HUT position compared with supine (P < 0.02). With the single contractions, peak FBF, peak vascular conductance, and TEF during 30 s after release of the contraction were reduced in the HUT position compared with supine (P < 0.01). Sympathetic blockade augmented the FBF response to a single contraction in HUT (P < 0.05) and tended to increase this response while supine (P = 0.08). However, sympathetic blockade did not attenuate the effect of HUT on peak FBF and TEF after the single contractions. Raising the arm above heart level while supine, to diminish Pv, resulted in FBF dynamics that were similar to those observed during HUT. Alternatively, lowering the arm while in HUT to restore Pv to supine levels restored the peak FBF and vascular conductance responses, but not TEF response, after a single contraction. It was concluded that upright posture diminishes the hyperemic response early in exercise. The data demonstrate that sympathetic constriction restrains the hyperemic response to a single contraction but does not modulate the postural reduction in postcontraction hyperemia. Therefore, the attenuated blood flow response in the HUT posture was largely related to factors associated with diminished venous pressures and not sympathetic vasoconstriction.

Autonomic function in children with Type 1 diabetes mellitus

We investigated autonomic function in 58 children and young adults with Type 1 diabetes mellitus (aged 7–22 years, duration from 3 to 18, 8.6 ± 3.4 years) and in 74 healthy controls (6–21 years) using power spectral analysis of blood pressure and heart rate in addition to conventional standard autonomic function tests: deep breathing, the Valsalva manoeuvre, and a standing test. None of the diabetic patients were symptomatic. Reproducibility of the tests was assessed by determining the coefficient of variation in 9 controls (7.8–37.7 %). Thirteen per cent of the subjects had difficulty in adequately performing the Valsalva manoeuvre. After adjustment for age, sex, body mass index, and respiratory frequency, results of the Valsalva manoeuvre and deep breathing were not different between patients and controls and there was no significant postural reduction in systolic blood pressure (≥ 20 mmHg) in the patients. Heart rate variation in the supine position during natural breathing was low in patients, although power spectral analysis of heart rate variation did not show a significant decrease in the power density in the high and the low frequency in patients compared to healthy controls. Beat-to-beat blood pressure fluctuation was significantly lower in patients and correlated with metabolic control (mean annual haemoglobin A1c), but not with disease duration and was abnormal in 7 diabetic children (12 %). In contrast, tests of vagal activity were not impaired in the patients in this age range. We concluded that vagal involvement in Type 1 diabetic patients determined by spectral analysis of R–R intervals in addition to conventional tests is uncommon, but that beat-to-beat blood pressure variation was more likely to be affected. © 1998 John Wiley & Sons, Ltd.

Autonomic function in children with type 1 diabetes mellitus.

We investigated autonomic function in 58 children and young adults with Type 1 diabetes mellitus (aged 7-22 years, duration from 3 to 18, 8.6 +/- 3.4 years) and in 74 healthy controls (6-21 years) using power spectral analysis of blood pressure and heart rate in addition to conventional standard autonomic function tests: deep breathing, the Valsalva manoeuvre, and a standing test. None of the diabetic patients were symptomatic. Reproducibility of the tests was assessed by determining the coefficient of variation in 9 controls (7.8-37.7%). Thirteen per cent of the subjects had difficulty in adequately performing the Valsalva manoeuvre. After adjustment for age, sex, body mass index, and respiratory frequency, results of the Valsalva manoeuvre and deep breathing were not different between patients and controls and there was no significant postural reduction in systolic blood pressure (> or = 20 mmHg) in the patients. Heart rate variation in the supine position during natural breathing was low in patients, although power spectral analysis of heart rate variation did not show a significant decrease in the power density in the high and the low frequency in patients compared to healthy controls. Beat-to-beat blood pressure fluctuation was significantly lower in patients and correlated with metabolic control (mean annual haemoglobin A1c), but not with disease duration and was abnormal in 7 diabetic children (12%). In contrast, tests of vagal activity were not impaired in the patients in this age range. We concluded that vagal involvement in Type 1 diabetic patients determined by spectral analysis of R-R intervals in addition to conventional tests is uncommon, but that beat-to-beat blood pressure variation was more likely to be affected.

Treatment of fractures and dislocations of the thoracic and lumbar spine by fusion and Harrington instrumentation.

Thirty-three patients with fractures of the thoracolumbar spine were treated by fusion and Harrington instrumentation after early reduction and stabilisation by postural reduction or halo-bifemoral traction. The rod-long-fuse-short technique was used. Postoperatively, all patients were mobilised with an external support. The mean follow-up was 6 years (range 1-13 years). Twenty-eight patients were pain-free, three patients needed sporadic pain medication. One patient was not working due to pain in his leg. One patient had constant pain. Twenty-three patients returned to work. The mean kyphosis increased from 8 degrees postoperatively to 13 degrees at follow-up.

Early stabilization and decompression for incomplete paraplegia due to a thoracic-level spinal cord injury.

All patients treated between 1985 and 1990 for acute incomplete spinal cord injury between T2 and T11 were retrospectively studied. This level was chosen for study because by excluding cervical cord, conus, and cauda equina injuries, neurologic improvement could be attributed to improvement of spinal cord function. Only 14 patients with incomplete thoracic level paraplegia were identified, representing 1.2% of all spinal injuries. All 14 patients were treated by early operative reduction, stabilization, or decompression. Twelve patients had surgery within 24 hours of neurologic injury, one at 36 hours, and one at 5 days. Twelve patients had initial posterior instrumentation and fusion, one of whom subsequently had an anterior decompression. Two patients had initial anterior decompression and fusion. Both later had posterior instrumentation and fusion to treat progressive deformity. Follow-up averaged 20 months (range, 9-65 months). Neural function before surgery and at follow-up was given a Frankel grade and lower extremity motor index score. Of 13 surviving patients, seven were initially Frankel B and six Frankel C. Of the seven patients initially Frankel B, four recovered to Frankel E, two improved to Frankel D, and one remained Frankel B. Of the six patients originally Frankel C, five recovered to Frankel E and one improved to Frankel D. Average neurologic improvement was 2.2 Frankel grades per patient, lower extremity motor index improved from an average of 7 to 44. Early surgical reduction, stabilization, and decompression is safe and improves neurologic recovery in comparison to historical controls treated by postural reduction or late surgical intervention.

Thoracolumbar Burst Fractures

There continues to be considerable controversy regarding the management of thoracolumbar burst fractures. Most feel that failure of the middle osteoligamentous complex, particularly with retropulsion of fragments into the spinal canal, is an indication for operative management. Others advocate postural reduction and prolonged bedrest for such injuries. The purpose of this study was to 1) review the clinical outcome and efficacy of closed management of thoracolumbar burst fractures; and 2) quantify what, if any, remodeling occurs in the bony canal as measured by serial CT. Forty-one patients who presented with a burst fracture of the thoracolumbar spine without neurologic deficit were reviewed clinically and radiographically following nonoperative management. At injury, canal compromise averaged 37% (range, 16-66%); 26 patients had at least 30% canal compromise. During treatment, one patient developed neurologic deterioration that prompted surgery; all other patients remained neurologically intact. At average follow-up of 2 years, an overall outcome evaluation indicated that 49% of the patients had excellent outcomes relative to pain and function; 17%, good; 22%, fair; and 12%, poor. Approximately 90% of the patients had a satisfactory work status relative to factors associated with their burst fracture. Serial roentgenograms documented significant progression in body collapse, which averaged 8% (P < 0.0001) from injury to follow-up. On the other hand, serial CTs documented significant improvement from injury to follow-up for canal compromise and midsagittal diameter. Average improvements in canal compromise and midsagittal diameter were 22% (P < 0.0001) and 11% (P < 0.0001), respectively. Only three patients had canal compromise greater than 30%, no patients had canal compromise greater than 40%, and no patients experienced canal area deterioration over time. On average, nearly two-thirds of the fragment occluding the canal resorbed, with most remodeling complete within one year. For patients with burst fractures presenting neurologically intact, we obtained the following findings: 1) nonoperative management yields acceptable results; 2) following nonoperative management, bony deformity (i.e., kyphosis and body collapse) progresses marginally relative to the rate of canal area remodeling; 3) incidence of subsequent neurologic deficits is quite low; and 4) initial radiographic severity of injury or residual deformity following closed management does not correlate with symptoms at follow-up. This pattern of results suggests nonoperative management as the preferred treatment in these circumstances.

Traumatic fractures of the thoraco-lumber spine

From 1986 to 1988, 171 patients with thoraco-lumbar vertebrae fructures were admitted to the Department of Orthopaedic Surgery and Traumatology clinic of Ege University. The stable fractures of 108 patients were treated with conservative methods, with a postural reduction, body cast and total contact plastic thoracolumbosacral orthosis. Unstable fractures of 63 patients underwent early surgical reduction and external fixation with double Harrington instrumentation. The decrease in angle of kyphosis were more significant in surgical cases than the conservative. The difference in decreasing of scoliosis was not important between surgical and conservative treatment The follow-up vertebral index was found similar in both of methods There were no significant neuorological recovery between two methods. The incidence of complications were higher in surgical cases. The reason. The reason is mostly the surgical cases were injured with more severe trauma.

Fractures and fractures-dislocations of the lumbar spine. A retrospective study of 70 patients.

A retrospective study was undertaken to analyse and compare the results of Harrington instrumentation with postural reduction and nursing in patients with fractures and fracture-dislocations of the lumbar spine. Thirty patients were treated by postural reduction and nursing, and 38 underwent early surgical reduction and internal fixation with Harrington instrumentation, together with a posterior fusion in three patients and an anterior fusion at the level of the fracture in another two patients. External splintage was used in only one patient in the series. At an average follow up of 5.9 years, bony deformity quantified by angulation, displacement and the vertebral wedge index was greater in the conservative group than in the group treated surgically. No significant difference was observed in comparing the rates of neurological recovery in the two groups. At follow up, patients with no symptoms had less severe bony deformity. Loss of fixation of Harrington instrumentation occurred in 46% of patients treated by this method. The incidence of other complications was not significantly different in the two groups. Despite the unacceptably high rate of local complications, Harrington instrumentation achieved better correction of bony deformity than postural reduction and nursing, prevented progression of deformity and decreased the incidence of symptoms at follow up. This study indicates that in these injuries bony deformity can be satisfactorily corrected by early Harrington instrumentation alone, without spinal fusion and bracing, provided an exacting surgical technique is employed.

The value of more aggressive management in traumatic paraplegia.

In the last decade, operative decompression of cord and cauda, internal fixation with rods, bony fusion and early ambulation, have become more popular in the management of thoracolumbar injuries with neurological deficit. Computer-tomography, CT myelography and peroperative ultrasonography provided direct evidence, that, without surgical decompression, reduction of displaced bone and disc fragments, propelled into the spinal canal, is often incomplete, not only after postural reduction, but also after rod instrumentation. The percentage of patients with incomplete paraplegia who show improvement of neurological deficit after surgical reduction and stabilization, is probably greater than that noted with postural management. There are, however, shortcomings in the classification of neurological deficit, which hamper adequate comparison. Further research in this field is necessary. The value of the surgical approaches is mainly in immediate stabilization, which diminishes pain, facilitates nursing care and allows more rapid mobilization. This results in a shorter stay in hospital and earlier active rehabilitation. That decompression of the neural elements provides improved neurological recovery seems likely, but has so far not been proven. Management of these patients, preferably admitted to specialized units, should be carried out by an orthopedic surgeon and a neurosurgeon in cooperation. The orthopedic surgeon is mainly concerned with management of the spine; the neurosurgeon with management of the paraplegia, operations being carried out by both.

Results of reduction and stabilization of the severely fractured thoracic and lumbar spine.

From 1962 to 1976, ninety-five patients with fracture-dislocations of the spine were treated with Harrington instrumentation and fusion within ninety days of injury. This report presents the results of this procedure related to reduction, stabilization, return of neural function, and total hospital stay. Mean follow-up was twenty-one months. Reduction and stabilization were attained without a substantial number of complications, but no more return of neural function in the patients was evident than has been reported in the literature for patients treated with postural reduction and bed rest. Total hospital stay averaged 107 days from day of injury.

Neurological recovery distal to the zone of injury in 172 cases of closed, traumatic spinal cord injury.

The Southwest Regional System for Treatment of Spinal Cord Injury (Good Samaritan Hospital and St Joseph's Hospital, Phoenix, Arizona) treated 325 cases of traumatic spinal cord injury during the period June 1970 through December 1975. Of these, 172 met the study population criteria of the cases reported by Frankel et al. (1969) in their paper 'The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia'. These cases are compared with those reported by Frankel et al. (1969). Cases were divided into neurological categories. The demography of the two study populations was amazingly similar as was the neurological results. The means for the reported neurological changes show that the average recovery for patients treated at Stoke Mandeville was slightly greater for each neurological category; however, this difference was statistically significant only for cervical cases (P less than 0.01). One of the differences in the treatment given by the two centres was that the Southwest Regional System performed surgery on 39% of its cases and Stoke Mandeville none. The Southwest Regional System's non-operated cervical cases showed less average neurological recovery than Stoke Mandeville cervical cases (P less than 0.001). Comparison between the Southwest Regional System non-operated cases and operated cases revealed no significant differences within any neurological category. The average neurological change reported by both centres was relatively small, documenting that from the onset of injury the majority of people sustaining spinal cord injury are committed to living with paralysis, in most cases severe, for the rest of their lives.

Prospective analysis of the management of incarcerated and strangulated inguinal hernias

The mortality associated with incarcerated and strangulated inguinal hernias has not changed substantially in the past decade and remains high [I,2]. Kauffman and 0'Brien [3], in a collected series, found the mortality in emergency surgery for incarcerated and strangulated hernia with viable bowel to be approximately 10 per cent. This mortality figure is far higher than that encountered in elective herniorrhaphy [4]. Part of the problem for the incre~ised mortality has been ascribed to the advanced age and associated diseases in these patients [3]. Although the majority of authors o11 the subject have recommended prompt surgical reduction and repair for incarcerated inguinal hernia [1,5-7], others have advised selective reduction to be followed by elective herniorrhaphy after the associated diseases have received adequate treatment [3,8]. It is agreed by all, however, that selective nonoperative reduction can be carried out only in cases of incarcerated inguinal hernia with viable contents and for a limited period of time. It was the purpose of this study to find out (1) if there are any definite criteria by which incarcerat. ed hernias with viable contents can be differentiated from those with nonviable contents; (2) what are the chances of success with nonoperative postural reduction in incarcerated and strangulated inguinal hernias; (3)how long can this method be pursued with safety; (4) what are the morbidity and mortality with this method.

Laminectomy for spinal injury criticized.

To the Editor.— I have just read the article, Routine Laminectomy for Spinal Injury Criticized, in the MEDICAL NEWS section ofThe Journal( 211 :913, 1970). I would like to say, Hear! Hear!, and hope to see more articles of this type in the literature. There is probably no injury that more severely disrupts normal body physiology than a cervical cord injury and the loss of spine stability. Only one more neurological segment due laminectomy can make a world of difference in the rehabilitation and functioning of the disabled individual. It appears to me that many laminectomies are done, not on firm clinical indications, but rather due to an aspect of human nature, ie, many times it is harder to do nothing, than it is to do something. I would like to call your readers' attention to The Value of Postural Reduction in the Initial Management of Closed Injuries of