Rigid External Immobilization Research Articles

Vertebral Fractures and Luxation in Dogs

Background: Vertebral fractures and luxations (VFL) are a major cause of neurologic injury in small animals. They are most commonly associated with severe external trauma from road traffic accidents, aggression, or falls from heights. There were few studies concerning VFL, mainly on results of treatments and sequelae. This retrospective work aimed to study patients with extrinsic trauma in the spinal cord that were treated at the Neurology and Neurosurgery Service of a Higher Education Institution in Brazil from 2007 to 2018, describing main etiologies, location of lesion, degree of neurological dysfunction, treatment, and results and sequelae after surgical or conservative therapy.Materials, Methods & Results: One hundred and nine dogs of various breed and ages were included in this study. The main etiology of the spinal cord injury in these dogs were fractures and/or dislocations caused by road traffic accidents (66%), followed by interaction with other animals (5.5%). The body region most frequently affected by the lesions were the thoracolumbar segment (T3-L3) of the vertebral spine (52.3%), followed the lumbosacral segment [L4-S3] (54.8%). The degrees of the most prevalent neurological dysfunctions for each of the segments were grade V in 73.7% of the dogs with lesions between T3-L3, and grade III in 54.8% of the dogs with lesions in L4-S3. Twenty-one tutors of dogs subjected to surgery and 20 tutors of dogs that underwent clinical treatment could be contacted by phone. Statistical analysis performed on data from these patients indicated that there was no significant correlation between the motor recovery and the type of treatment instituted. However, when the degree of motor dysfunction was analyzed in conjunction with recovery, milder grades were found to be accompanied by the best recovery results.Discussion: Road traffic accidents were the most common cause of damage to the spinal cord, a finding described in other studies on extrinsic trauma. Due to the retrospective nature of this study, the analysis of the patients' motor recovery was performed using data from only 41 patients whose tutors could be reached by phone. We found that, in dogs that had satisfactory or partially satisfactory recovery, the ability to walk was restored between two and six months independent of the type of treatment (clinical or surgical). The criteria taken into account to choose the therapeutic option were degree of neurological dysfunction and/or presence of vertebral instability based on the three-compartment theory and the choice of the tutor after information on prognosis, postoperative care, possible neurological sequelae, and costs. Even though rigid external immobilization is indicated for the conservative treatment of VFL, in this study, all dogs subjected to clinical treatment were kept in cages without the use of external immobilization. Rigid immobilization causes discomfort to the patient, as well as complications during use. Loss of deep pain sensation (nociception) may occur immediately after acute injury, and it may be recovered after stabilization. In some cases, patients may experience urinary and/or fecal incontinence. Urinary and/or fecal incontinence was the main sequela reported by tutors, and was the main reason for euthanasia of surviving patients. We believe that further studies on this subject are necessary in order to gather information that can be used to provide better assistance for future patients affected by medullary trauma due to extrinsic factors.

Radiographic Outcomes of Upper Cervical Fusion for Pediatric Patients Younger Than 10 Years.

Purpose: This study aimed to investigate radiographic outcomes after posterior spinal fusion (PSF) for pediatric patients younger than 10 years with upper cervical disorders. Methods: Thirteen patients (mean age at surgery, 5.9 years; range, 1 to 9 years) who underwent PSF with a minimum of 2 years of follow-up (mean, 5.8 years) were included. Diagnoses were atlanto-axial instability due to congenital disorders for 11 patients and atlanto-axial rotatory fixation for 2 patients. The fusion area was occipito-cervical for 7 patients and C1/2 for 6 patients. PSF was performed using rigid screw-rod constructs for 6 patients and conventional techniques for 7 patients. Ten patients required halo immobilization after surgery. Fusion status, perioperative complications, radiographic alignment, and range of motion (ROM) from C2 to C7 were evaluated. Results: Twelve patients successfully achieved bony fusion (fusion rate, 92%), but complications occurred in 5 patients. Regarding radiographic measures (preoperative/postoperative/final follow-up), the mean atlanto-dental interval was significantly reduced (8.0 mm/2.7 mm/3.5 mm) and the C2-7 ROM was increased (from 49.4 degrees to 66.0 degrees) at the final follow-up (both comparisons, p<0.05). Sagittal alignment was unchanged. Conclusion: Use of rigid screw-rod instrumentation in the upper cervical spine with careful radiological evaluation is amenable for pediatric patients younger than 10 years. However, conventional procedures such as wiring fixation with rigid external immobilization are still alternative options for preventing serious neurological and vascular complications.

Treatment of Subaxial Cervical Spinal Injuries

SUBAXIAL CERVICAL FACET DISLOCATION INJURIES: Standards There is insufficient evidence to recommend treatment standards. Guidelines There is insufficient evidence to recommend treatment guidelines. Options Closed or open reduction of subaxial cervical facet dislocation injuries is recommended. Treatment of subaxial cervical facet dislocation injuries with rigid external immobilization, anterior arthrodesis with plate fixation, or posterior arthrodesis with plate or rod or interlaminar clamp fixation is recommended. Treatment of subaxial cervical facet dislocation injuries with prolonged bedrest in traction is recommended if more contemporary treatment options are not available. SUBAXIAL CERVICAL INJURIES EXCLUDING FACET DISLOCATION INJURIES: Standards There is insufficient evidence to recommend treatment standards. Guidelines There is insufficient evidence to recommend treatment guidelines. Options Closed or open reduction of subluxations or displaced subaxial cervical spinal fractures is recommended. Treatment of subaxial cervical spinal injuries with external immobilization, anterior arthrodesis with plate fixation, or posterior arthrodesis with plate or rod fixation is recommended.

An analysis of patient positioning during stereotactic lung radiotherapy performed without rigid external immobilization

Background and purposeIntra-fraction patient motion is incompletely understood and the optimum amount of support or immobilization during stereotactic body radiotherapy (SBRT) is unclear. Rigid immobilization is often advocated, but motion still occurs. In contrast, we deliver the vast majority of SBRT using simple supporting devices, simultaneously emphasizing comfort, frequent position checks and progressive reduction in treatment times. We report spine stability during lung SBRT. Materials and methodsPatients lie on a thin mattress with arms supported above their head and below-knee support. Stereoscopic spine X-rays before and after fraction delivery identified motion in three translational and three rotational directions. ResultsImages from 109 fractions in 30 patients resulted in 327 translational and 327 rotational pre- and post-fraction comparisons. Mean RapidArc® delivery time for variable fraction dose was 4.2min (SD=1.4). 92% and 97% of translational and rotational differences were ⩽1mm and ⩽1° in any direction and 98% of translational differences were ⩽1.5mm. Mean vertical, longitudinal and lateral motion was 0mm (SD=0.4), 0mm (0.6) and 0mm (0.6). 84% and 94% of the 109 fractions were delivered with ⩽1 and ⩽1.5mm translation in all three directions and 93% with ⩽1° of rotation. Two patients accounted for 10/17 fractions with >1mm translational motion. ConclusionsBased on pre and post-fraction X-ray imaging during fast lung SBRT, simple support devices can result in spine stability that is comparable to that reported with rigid external immobilization.

Evaluation of morbidity, mortality and outcome following cervical spine injuries in elderly patients

We analysed the morbidity, mortality and outcome of cervical spine injuries in patients over the age of 65 years. This study was a retrospective review of 107 elderly patients admitted to our tertiary referral spinal injuries unit with cervical spine injuries between 1994 and 2002. The data was acquired by analysis of the national spinal unit database, hospital inpatient enquiry system, chart and radiographic review. Mean age was 74 years (range 66-93 years). The male to female ratio was 2.1:1 (M = 72, F = 35). The mean follow-up was 4.4 years (1-9 years) and mean in-hospital stay was 10 days (2-90 days). The mechanism of injury was a fall in 75 and road traffic accident in the remaining 32 patients. The level involved was atlanto-axial in 44 cases, sub-axial in 52 cases and the remaining 11 had no bony injury. Multilevel involvement occurred in 48 patients. C2 dominated the single level injury and most of them were type II odontoid fractures. Four patients had complete neurology, 27 had incomplete neurology, and the remaining 76 had no neurological deficit. Treatment included cervical orthosis in 67 cases, halo immobilization in 25, posterior stabilization in 12 patients and anterior cervical fusion in three patients. The overall complication rate was 18.6% with an associated in-hospital mortality of 11.2%. The complications included loss of reduction due to halo and Minerva loosening, non-union and delayed union among conservatively treated patients, pin site and wound infection, gastrointestinal bleeding and complication due to associated injuries. Among the 28.9% patients with neurological involvement, 37.7% had significant neurological recovery. Outcome was assessed using a cervical spine outcome questionnaire from Johns Hopkins School of Medicine. Sixty-seven patients (70%) completed the form, 20 patients (19%) were deceased at review and 8 patients (7%) were uncontactable. Functional disability was more marked in the patients with neurologically deficit at time of injury. Outcome of the injury was related to increasing age, co-morbidity and the severity of neurological deficit. Injuries of the cervical spine are not infrequent occurrence in the elderly and occur with relatively minor trauma. Neck pain in the elderly patients should be thoroughly evaluated to exclude C2 injuries. Most patients can be managed in an orthosis but unstable injuries require rigid external immobilization or surgical stabilization.

TECHNIQUES OF POSTERIOR C1–C2 STABILIZATION

Instability of the atlantoaxial complex may result from inflammatory, traumatic, congenital, neoplastic, or degenerative disorders and often requires surgical stabilization. Initial dorsal wiring techniques allow safe fixation but require rigid external immobilization and have been associated with high fusion failure rates. Rigid screw fixation techniques including transarticular screw fixation and C1-C2 rod-cantilever fixation offer higher fusion rates and less need for rigid immobilization but are more technically demanding. C1-C2 fixation using crossing C2 laminar screws offers rigid fixation but without the technical demands of C2 pars placement. The history and techniques of dorsal fixation of the atlantoaxial complex are reviewed, and the success rates and complications of each are discussed.

Tuberculosis of the Craniovertebral Junction: Is Surgery Necessary?

Tuberculosis of the craniovertebral junction is an uncommon entity and its optimal management remains controversial. In this study, we present the evolution of management protocol of this disease in our institute in the past 3 decades. A total of 51 patients with craniovertebral junction tuberculosis presenting as atlantoaxial dislocation from 1978 through 2004 were reviewed. The disease was rated from Stage I to Stage III, depending on the radiological findings. All patients received antitubercular treatment for 18 months. In the initial period of this study (1978-1986), all patients (n = 10) underwent surgery, usually a posterior fusion. In the second period (1987-1998), patients with less severe disease (Stages I and II, n = 14) were managed with external rigid immobilization, whereas patients with severe disease (Stage III, n = 11) underwent either a transoral decompression with or without posterior fusion or posterior fusion alone. More recently (1999-2004), all patients (n = 16) in all stages (Stages I-III) have been managed without surgery by a rigid external immobilization. Except for two patients who died (one because of miliary tuberculosis, the other because of acute hydrocephalus), clinical recovery occurred in all. Follow-up imaging demonstrated radiological healing as well, with regrowth of the destroyed bone. The mainstay of management of tuberculosis of the craniovertebral junction is prolonged antitubercular treatment with a rigid external immobilization. Surgery is not necessary, even in patients with advanced stages of disease. Complete clinical and radiological healing occurs in all patients with conservative treatment.

Surgical Management of Myelopathy

We have presented a comparative analysis of the ability of four surgical procedures to address adequately the problems sustained by a patient with symptomatic cervical myelopathy. AIA is a safe procedure whose effectiveness may be limited when the extent of disease is more than three intervertebral disk levels. ACA permits more direct and extensive access to the spinal cord and is the procedure of choice for cervical spondylotic myelopathy associated with spinal deformity. However, rigid external immobilization is necessary, and operative morbidity may be greater. Cervical laminectomy may be effective for decompressing the spinal cord when no associated spinal deformity or instability is present, provided that extensive resection of facet joints is avoided. Cervical laminaplasty is ideally suited for the patient with three or more levels contributing to a cervical myeloradiculopathy. Mild instability may be addressed by performing arthrodesis on the hinge side.

The Effect of the Thermoplastic Minerva Cervical Spine Motion

Abstract In order to determine the extent of cervical spine immobilization provided by the thermoplastic Minerva body jacket (TMBJ) 20 healthy male subjects underwent analysis of cervical spine motion before and after TMBJ placement. Maximal cervical flexion/extension and lateral bending were measured from lateral and anteroposterior roentgenograms, respectively. Maximal cervical rotation was measured from overhead photographs. The TMBJ significantly limited flexion/extension at each level of the cervical spine, as well as rotation and lateral bending (P&amp;lt; 0.001). Flexion/extension at each cervical level was found to be equal to that allowed by the halo with body jacket at most levels and less at the occiput-C1, C3-C4, and C6-C7 (as reported in studies using similar methodology). The present study suggests that the thermoplastic Minerva body jacket is a valuable option for rigid external immobilization of the cervical spine.

Contoured Harrington Instrumentation in the Treatment of Unstable Spinal Fractures The Effect of Supplementary Sublaminar Wires

Twenty-nine patients with major fractures and fracture-dislocations of the thoracic and lumbar spine were treated by spinal fusion and contoured Harrington distraction instrumentation. Two groups of patients were identified. Group I (16 patients) had sublaminar wires. Group II (13 patients) had no wiring. Satisfactory alignment was achieved in all patients. There were several complications in both groups. None of the patients in Group I had postoperative cast immobilization. The addition of sublaminar wiring appears to eliminate the need for rigid external immobilization and is beneficial only for patients who cannot tolerate body casts. This technique is a disadvantage, however, when a short-length fusion is desired.

The nonsurgical management of odontoid fractures in adults.

Twenty-five odontoid fractures that were treated nonsurgically at the University of Virginia Hospital in the last 5 years were reviewed. Motor vehicle accidents were the major cause of this injury in our series. Early recognition and firm external stabilization of Type I and Type III fractures of the odontoid resulted in union in 100% of our patients. There were 12 Type II fractures with a nonunion rate of 42%. Thus, an overall rate of union of 80% was obtained. It is suggested in the literature and by this series that early recognition, reduction, and rigid external immobilization of Types I and III fractures of the odontoid should promote bony union. Type II fractures may also be managed successfully by closed methods, although the outcome is less certain.