Drug treatment for spinal muscular atrophy type I - Bosboom W.M.J.; Van Den Berg L.H.; Iannaccone S.T.; Vrancken A.F.J.E.; Wokke J.H.J. (Cochrane Database of Systematic Reviews, 2006)
This is the protocol for a review and there is no abstract. The objectives are as follows: To review systematically the evidence from randomised controlled trials concerning the efficacy and safety of any drug therapy designed to slow or arrest the progress of the disease in SMA type I. We will perform a separate Cochrane review on SMA type II and III. Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Keywords: air conditioning; child development; clinical trial; Cochrane Library; developmental screening; disease course; drug efficacy; drug safety; human; outcome assessment; review; sitting; spinal muscular atrophy; Werdnig Hoffmann disease; standing; systematic review; tracheostomy

Spinal muscular atrophy with respiratory disease (SMARD): An ethical dilemma - Bush A. (Intensive Care Medicine, 2006)
Keywords: clinical research; coughing; editorial; human; Internet; medical information; medical practice; respiratory tract disease; spinal muscular atrophy; tracheostomy

Airway management of a patient with Forestier's disease - Ozkalkanli M.Y.; Katircioglu K.; Ozkalkanli D.T.; Savaci S. (Journal of Anesthesia, 2006)
Forestier's disease, also called diffuse idiopathic skeletal hyperostosis (DISH), is a noninflammatory enthesopathy, ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Intubation difficulty and spinal cord injury are potential problems when managing the airway in DISH patients. We report a patient with Forestier's disease who was admitted for osteophyte resection. After taking a detailed history, we evaluated the airway carefully. Also, preparation for difficult intubation was done. After a rapid sequence induction, we performed mask ventilation and laryngoscopy without hyperextension of the neck, to prevent spinal cord injury. Although the worldwide standard for management of the airway in DISH patients is awake fiberoptic intubation, we chose conventional laryngoscopy because a fiberoptic bronchoscope was not available. © JSA 2006.
Keywords: fentanyl; flumazenil; midazolam; naloxone; nitric oxide; oral antidiabetic agent; propofol; suxamethonium; aged; anesthesia induction; ankylosing hyperostosis; article; case report; coughing; diabetes mellitus; dysphagia; dysphonia; dyspnea; elective surgery; extubation; general anesthesia; hospital admission; human; intubation; laryngeal mask; laryngoscopy; male; operation duration; osteophyte; spinal cord injury; tracheostomy

Study of the effectiveness of bronchial clearance in subjects with upper spinal cord injuries: Examination of a rehabilitation programme involving mechanical insufflation and exsufflation - Pillastrini P.; Bordini S.; Bazzocchi G.; Belloni G.; Menarini M. (Spinal Cord, 2006)
Study design: Randomized controlled trial. Objectives: To establish whether the use of mechanical insufflation/exsufflation leads to a significant improve in tracheostomy subjects with upper spinal cord injuries (C1-C7), ASIA classification grade A and bronchial hyper secretion the following parameters: forced vital capacity (FVC), forced exspiratory volume on the first second (FEV1), FEV1/FVC, peak exspiratory flow (PEF), arterious pressure of O 2 (Pa O2), arterious pressure of CO2 (Pa CO2), pH, saturation of O2 (Sa O2). Setting: Spinal Cord Unit, Montecatone Rehabilitation Institute, Imola, Italy. Methods: The patients were split into two groups: the experimental group (EG) and the control group (CG). Each patient was given 10 treatments: the EG was given manual respiratory kinesitherapy associated with mechanical insufflation/ exsufflation with inhale and exhale pressure between 15 cm H2O and 45 cm H2O, while the CG was only given manual kinesitherapy. The treatment sessions covered the necessary amount of time in order to achieve sufficient clearance. The study has been approved by the local ethic committee. The patients were informed before being enrolled in that study and gave their written consent. Results: At the end of the treatment associated with the mechanical insufflation/exsufflation, the EG showed a significant increase in FVC, FEV1 and PEF, although it was not possible to compare the latter with the CG. The other parameters were also subject to variations, although not statistically significant. The CG did not show signs of any significant change. Conclusion: The use of mechanical insufflation/exsufflation in subjects with the aforementioned characteristics is shown to be an effective adjunct to manual respiratory kinesitherapy, since it makes it possible to achieve adequate bronco-pulmonary clearance, even removing thick, deep secretions and making it possible to insufflate any areas affected by atelectasis. © 2006 International Spinal Cord Society. All rights reserved.
Keywords: adult; aged; arterial carbon dioxide tension; arterial oxygen tension; arterial pH; article; artificial ventilation; atelectasis; bronchus secretion; cervical spinal cord injury; clinical trial; controlled clinical trial; controlled study; exhalation; female; forced expiratory volume; human; inhalation; kinesiotherapy; male; oxygen saturation; peak expiratory flow; priority journal; randomized controlled trial; tracheostomy

Cervical spine hyperostosis: An unusual cause of difficult intubation during coronary artery bypass grafting - Arora D.; Sharma K.K.; Mehta Y.; Chaudhury A.; Trehan N. (Journal of Anaesthesiology Clinical Pharmacology, 2006)
Keywords: bupivacaine; fentanyl citrate; propofol; suxamethonium; thiopental; vecuronium; akinesia; anamnesis; angiocardiography; article; cardiomegaly; case report; cervical spine; clinical feature; computer assisted tomography; coronary artery bypass graft; echocardiography; endotracheal intubation; fiberoptic bronchoscopy; heart left ventricle ejection fraction; heart left ventricle hypertrophy; human; hyperostosis; hyperventilation; hypokinesia; in-stent restenosis; intubation; laryngoscopy; lung blood vessel; lung function test; lung ventilation; male; minimally invasive cardiac surgery; osteophyte; physical examination; positive end expiratory pressure; postoperative pain; robotics; school child; skin incision; sternotomy; surgical technique; thorax radiography; trachea stenosis; trachea tumor; tracheostomy

Neuromuscular disease in respiratory and critical care medicine - Hill N.S. (Respiratory Care, 2006)
Neuromuscular diseases that affect the respiratory system are a major cause of morbidity and mortality in both acute and long-term settings. This conference examined the pathophysiology and management of neuromuscular diseases in both settings. Presentations by experts representing respiratory, physiologic, pediatric, neurologic, and intensive-care disciplines covered a broad range of topics. This summary of the conference briefly describes the main points of each presentation and highlights areas that need addressing in the future. Major topics covered include the basic respiratory pathophysiology of neuromuscular disease; respiratory complications and management of amyotrophic lateral sclerosis; techniques of noninvasive ventilation and secretion removal; and evaluation and management of neuromuscular-induced respiratory failure in the acute-care setting, including Guillain-Barré syndrome, myasthenic crisis, and critical-illness myoneuropathy. © 2006 Daedalus Enterprises.
Keywords: amyotrophic lateral sclerosis; artificial ventilation; bronchus secretion; clinical feature; conference paper; critical illness; diaphragm injury; dyspnea; Guillain Barre syndrome; human; intensive care; long term care; lung function; morbidity; mortality; motoneuron; myasthenia gravis; neuromuscular disease; neuropathy; non invasive procedure; pathophysiology; respiratory tract disease; spinal cord injury; tracheostomy; ventilator

Neurological and functional outcome after unstable cervicothoracic junction injury treated by posterior reduction and synthesis - Lenoir T.; Hoffmann E.; Thevenin-Lemoine C.; Lavelle G.; Rillardon L.; Guigui P. (Spine Journal, 2006)
Background context: Unstable lesions of the cervicothoracic junction present a severe clinical problem for diagnosis, treatment, and prognosis. Purpose: The objective of the present study was to evaluate the neurological and functional outcomes following surgical treatments which combine in all cases posterior reduction and stabilization. Study design: Retrospective clinical and radiological study. Patient samples: Between September 1996 and September 2003, 30 patients underwent surgery for unstable fracture at the cervicothoracic junction. This group included 23 patients who sustained a motor vehicle accident, 5 who had fallen from a height, 1 case of ballistic trauma, and 1 person injured by diving in shallow water. There were 22 male and 8 female patients aged between 18 and 80, with an average age of 49. In 18 cases the lesion level was vertebra C7, in 5 cases vertebra T1, in 2 cases vertebra T2, and in 5 cases vertebra T3. Neurologically, on initial clinical examination 16 patients were classified Frankel A, 6 Frankel B, 2 Frankel C, and 6 Frankel D. Surgically, all the patients underwent posterior reduction and synthesis. Posterior stabilization was performed using rods and screws 3 times, plate-screw fixation 25 times, and rods and screws at the thoracic level linked to plate-screw at the cervical level 2 times. Spinal cord compression of more than two levels was associated with 25 cases. In these 25 cases, spinal cord decompression was associated with reduction and stabilization. Outcome measures: Clinical outcome using neurological scale of Frankel, radiological outcomes using computed tomographic (CT) scans and plain X-ray evaluations. Methods: Follow-up periods ranged from 11 to 48 months, with an average of 18 months. Seven patients died as a result of cardiopulmonary insufficiency within 4 months postoperative. Twenty-eight CT scans with sagittal and frontal slides were examined to evaluate postoperative reduction and to control screw placement. Results: The observed reductions were satisfactory in 27 cases. In one case, reduction was satisfactory in the sagittal plane but lateral translation persisted in the frontal plane. Two mechanical failures with delayed mobilization of implants occurred. Bony fusion was recorded in all cases on CT scan evaluation. Complete or partial neurological recovery was observed in only 10 of 14 patients. The initial neurological status of these 14 patients was Frankel B, C, or D. Conclusion: The surgical procedure was chosen according to the particularity of the anatomical region and the possibility of associated medullar decompression. Insertion of pedicle screws in the upper thoracic portion in T1, T2, and T3 requires a careful technique and knowledge of the posterior projection points of the pedicles and their orientation in space. The high rate of fusion observed in these patients justified posterior reduction and stabilization. The high death rate and the low rate of neurological recovery in this group of patients emphasizes the severe prognosis of unstable injuries of the cervicothoracic junction. Considering the few mechanical failures observed at the last examination, the choice of the posterior approach was appropriate as the one stage procedure. Plate synthesis is preferable in fractures that do not require extension of synthesis beyond T2, whereas screws and rods systems are more appropriate for superior thoracic injuries. Despite early diagnosis and surgical treatment, the presence of neurological or pulmonary lesions resulted in increased mortality of the operated patients. © 2006 Elsevier Inc. All rights reserved.
Keywords: antibiotic agent; adult; aged; article; biomechanics; bone screw; cardiopulmonary insufficiency; cervical spine fracture; cervical spine radiography; clinical article; computer assisted tomography; controlled study; death; disease severity; dysphagia; falling; female; follow up; fracture fixation; functional status; gunshot injury; human; lung infection; lung injury; male; mortality; neurologic disease; postoperative infection; postoperative period; priority journal; prognosis; prosthesis complication; retrospective study; spinal cord compression; spinal cord decompression; spine fusion; spine injury; spine stabilization; surgical technique; tracheotomy; traffic accident; treatment outcome

Percutaneous tracheostomy in patients with cervical spine fractures - Feasible and safe - Nun A.B.; Orlovsky M.; Best L.A. (Interactive Cardiovascular and Thoracic Surgery, 2006)
The aim of this study is to evaluate the short and long-term results of percutaneous tracheostomy in patients with documented cervical spine fracture. Between June 2000 and September 2005, 38 consecutive percutaneous tracheostomy procedures were performed on multi-trauma patients with cervical spine fracture. Modified Griggs technique was employed at the bedside in the general intensive care department. Staff thoracic surgeons and anesthesiologists performed all procedures. Demographics, anatomical conditions, presence of co-morbidities and complication rates were recorded. The average operative time was 10 min (6-15). Two patients had minor complications. One patients had minor bleeding (50 cc) and one had mild cellulitis. Nine patients had severe paraparesis or paraplegia prior to the PCT procedure and 29 were without neurological damage. There was no PCT related neurological deterioration. Twenty-eight patients were discharged from the hospital, 21 were decannulated. The average follow-up period was 18 months (1-48). There was no delayed, procedure related, complication. These results demonstrate that percutaneous tracheostomy is feasible and safe in patients with cervical spine fracture with minimal short and long-term morbidity. We believe that percutaneous tracheostomy is the procedure of choice for patients with cervical spine fracture who need prolonged ventilatory support.
Keywords: adult; aged; anesthesist; article; assisted ventilation; bleeding; cellulitis; cervical spine; cervical spine fracture; clinical article; comorbidity; controlled study; demography; feasibility study; female; follow up; hospital discharge; human; intensive care unit; long term care; male; neurologic disease; operation duration; paraplegia; priority journal; risk assessment; thorax surgery; tracheostomy

Respiratory dysfunction and management in spinal cord injury - Brown R.; DiMarco A.F.; Hoit J.D.; Garshick E. (Respiratory Care, 2006)
Respiratory dysfunction is a major cause of morbidity and mortality in spinal cord injury (SCI), which causes impairment of respiratory muscles, reduced vital capacity, ineffective cough, reduction in lung and chest wall compliance, and excess oxygen cost of breathing due to distortion of the respiratory system. Severely affected individuals may require assisted ventilation, which can cause problems with speech production. Appropriate candidates can sometimes be liberated from mechanical ventilation by phrenic-nerve pacing and pacing of the external intercostal muscles. Partial recovery of respiratory-muscle performance occurs spontaneously. The eventual vital capacity depends on the extent of spontaneous recovery, years since injury, smoking, a history of chest injury or surgery, and maximum inspiratory pressure. Also, respiratory-muscle training and abdominal binders improve performance of the respiratory muscles. For patients on long-term ventilation, speech production is difficult. Often, practitioners are reluctant to deflate the tracheostomy tube cuff to allow speech production. Yet cuff-deflation can be done safely. Standard ventilator settings produce poor speech quality. Recent studies demonstrated vast improvement with long inspiratory time and positive end-expiratory pressure. Abdominal binders improve speech quality in patients with phrenic-nerve pacers. Recent data show that the level and completeness of injury and older age at the time of injury may not be related directly to mortality in SCI, which suggests that the care of SCI has improved. The data indicate that independent predictors of all-cause mortality include diabetes mellitus, heart disease, cigarette smoking, and percent-of-predicted forced expiratory volume in the first second. An important clinical problem in SCI is weak cough, which causes retention of secretions during infections. Methods for secretion clearance include chest physical therapy, spontaneous cough, suctioning, cough assistance by forced compression of the abdomen ("quad cough"), and mechanical insufflation-exsufflation. Recently described but not yet available for general use is activation of the abdominal muscles via an epidural electrode placed at spinal cord level T9-L1. © 2006 Daedalus Enterprises.
Keywords: artificial ventilation; assisted ventilation; breathing muscle; bronchoscopy; cigarette smoking; conference paper; diabetes mellitus; disease association; dyspnea; forced expiratory volume; human; laparoscopy; lung compliance; lung function; mechanoreceptor; morbidity; mortality; phrenic nerve; positive end expiratory pressure; respiratory failure; smoking cessation; spinal cord injury; thorax injury; vital capacity

Pediatric acute spinal cord injury - Claret Teruel G.; Trenchs Sáinz De La Maza V.; Palomeque Rico A. (Anales de Pediatria, 2006)
Introduction: Pediatric acute spinal cord injury is rare but is often associated with significant disability and prolonged stay in the intensive care unit (ICU). Objectives: The main objective of this study was to determine the epidemiology, initial clinical abnormalities, diagnostic studies, treatment and outcome of acute spinal cord injuries in a tertiary level pediatric hospital. A second objective was to analyze whether early tracheostomy allows earlier discharge of these patients. Patients and methods: A retrospective analysis of patients with acute spinal cord injuries admitted to our pediatric ICU since 1992 was performed. Results: We included 16 patients in the study, 12 of whom were boys (75 %). The patients were aged from birth to 19 years on admission to the ICU. The length of stay in the ICU was between 12 hours and 6 years. The cause of the lesion was birth trauma in four patients; one died and the remaining three live at home under mechanical ventilation. Traumatic injuries occurred in seven patients, two of whom died; a further two live in a long-term care facility and the remaining three live at home. Vascular spinal malformation occurred in two patients, and the three remaining injuries occurred during the acute postoperative period following spinal surgery. Of the 16 children, 56.2% were tracheostomized and 83% of the survivors live at home. Conclusions: Early tracheostomy, the availability of invasive ventilation for home use and parent education permit earlier discharge of these patients and allow more of them to live at home.
Keywords: adolescent; article; artificial ventilation; birth injury; child; clinical article; clinical feature; controlled study; diagnostic procedure; female; hospital admission; hospital discharge; hospitalization; human; infant; intensive care unit; long term care; male; newborn; overall survival; postoperative period; spinal cord injury; spine malformation; spine surgery; tertiary health care; tracheostomy; treatment outcome

Discussion - Jubran; Benditt; Hill; Brown; Lechtzin; Upinder Dhand (Respiratory Care, 2006)
Keywords: carbon dioxide; glucose; lipid; amyotrophic lateral sclerosis; atherosclerosis; carbon dioxide tension; cardiovascular disease; chronic respiratory failure; conference paper; Duchenne muscular dystrophy; exercise; glucose tolerance test; human; lipid blood level; mortality; positive end expiratory pressure; respiratory care; spinal cord injury; tracheostomy; ventilator

Respiratory effects of amyotrophic lateral sclerosis: Problems and solutions - Lechtzin N. (Respiratory Care, 2006)
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease. Most patients die from respiratory complications. Fortunately, there are a growing number of treatment options that can improve both survival and quality of life for patients with ALS. This review discusses the respiratory evaluation and treatment of patients with ALS, about which a great deal is known. It also includes material on related problems, such as speech and swallowing difficulties and end-of-life care. © 2006 Daedalus Enterprises.
Keywords: influenza vaccine; oxygen; Streptococcus vaccine; amyotrophic lateral sclerosis; artificial ventilation; balloon catheter; carbon dioxide tension; conference paper; degenerative disease; esophagus; human; infection prevention; influenza vaccination; larynx spasm; lung function test; magnetic stimulation; muscle strength; nonhuman; physiotherapy; positive end expiratory pressure; quality of life; REM sleep; respiratory function; respiratory tract infection; speech disorder; spinal cord injury; stomach tube; Streptococcus pneumoniae; total lung capacity; tracheostomy

Discussion - Pierson D.J.; Benditt; Hill; Lechtzin; Brown (Respiratory Care, 2006)
Keywords: amyotrophic lateral sclerosis; artificial ventilation; conference paper; coughing; Duchenne muscular dystrophy; face mask; human; intensive care unit; lung edema; muscular dystrophy; neuromuscular disease; respiratory care; spinal cord injury; tracheostomy

Spinal muscular atrophy type 1: What are the ethics and practicality of respiratory support? - Mitchell I. (Paediatric Respiratory Reviews, 2006)
Spinal Muscular Atrophy Type I (SMA I) is the most severe form of SMA. It presents in infancy and without treatment death occurs by 2 years. Treatments in use address respiratory and nutritional issues but even with aggressive treatment death is still likely in childhood. Thus their use is not obligatory. However, pediatric respirologists must be willing and comfortable at presenting all treatment options, including the option of palliative care, to families and then supporting the family's choice. Whatever the chosen treatment regimen, decision making is difficult for families. Support and help must be provided from the time of presentation till death by a knowledgeable and compassionate team. © 2006 Elsevier Ltd. All rights reserved.
Keywords: artificial ventilation; assisted ventilation; childhood; clinical protocol; death; disease severity; family; human; infancy; interpersonal communication; medical decision making; medical ethics; nutritional support; palliative therapy; priority journal; respiratory failure; respiratory tract disease; review; spinal muscular atrophy; tracheostomy

Dynamic anterior cervical plates for multilevel anterior corpectomy and fusion with simultaneous posterior wiring and fusion: Efficacy and outcomes - Epstein N.E. (Spinal Cord, 2006)
Study design: To prospectively evaluate major complications associated with the application of dynamic ABC plates (Aesculap, Tuttlingen, Germany) to multilevel Anterior Corpectomy/Fusion (ACF) followed by posterior fusion (C2-C7 PF). Objectives: To determine whether dynamic ABC (Aesculap, Tuttlingen, Germany) plates would minimize major complications (plate/graft extrusion, pseudarthrosis) while maximizing neurological outcomes in 40 consecutive patients undergoing simultaneous multilevel ACF/PF with halo application. Setting: USA. Methods: Patients averaged 53 years of age and preoperatively exhibited severe myeloradiculopathy (Nurick Grade 3.9). MR/CT studies documented marked ossification of the posterior longitudinal ligament/spondylostenosis. Surgery included two to four level ACF utilizing fibula strut allograft and ABC plates. Posterior spinous process wiring/fusions utilized braided titanium cables. The average operative time was 8.9 h. Fusion was confirmed on dynamic X-rays/CTs (3-12 months postoperatively). The average follow-up interval was 2.7 years. Outcomes (3 months-2 years postoperatively) were assessed utilizing Odom's Criteria, Nurick Grades, and SF-36 questionnaires. Results: Major complications included one pseudarthrosis requiring secondary PWF. Minor complications in six patients included two pulmonary emboli (PE), two tracheostomies, and five superficial wound infections. At 1 year postoperatively, marked improvement was observed in all patients utilizing Odom's criteria (38 excellent/good), Nurick Grades (mild radiculopathy 0.4), and the SF-36 (3 Health Scales; Role Physical (12.5-38.6), Bodily Pain (39.9-65.5), and Role Emotional (53.8-75.8)]. The 2-year postoperative data showed minimal additional improvement. The average time to fusion was 6.3 months. Conclusion: Patients undergoing multilevel ACF/PF demonstrated marked neurological improvement (SF-36), and only one of 40 developed a delayed pseudarthrosis. © 2006 International Spinal Cord Society All rights reserved.
Keywords: adult; aged; anterior spine fusion; article; bone graft; bone plate; clinical article; devices; female; follow up; human; lung embolism; male; multilevel anterior corpectomy and fusion; myeloradiculopathy; neurological complication; outcomes research; priority journal; pseudarthrosis; spine surgery; tracheostomy; wound infection; ABC

Molecular mechanism of rigid spine with muscular dystrophy type 1 caused by novel mutations of selenoprotein N gene - Okamoto Y.; Takashima H.; Higuchi I.; Matsuyama W.; Suehara M.; Nishihira Y.; Hashiguchi A.; Hirano R.; Ng A.R.; Nakagawa M.; Izumo S.; Osame M.; et al. (Neurogenetics, 2006)
Mutations of selenoprotein N, 1 gene (SEPN1) cause rigid spine with muscular dystrophy type 1 (RSMD1), multiminicore disease, and desmin-related myopathy. We found two novel SEPN1 mutations in two Japanese patients with RSMD1. To clarify the pathomechanism of RSMD1, we performed immunohistochemical studies using a newly developed antibody for selenoprotein N. Selenoprotein N was diffusely distributed in the cytoplasm of the control muscle, but was reduced and irregularly expressed in the cytoplasm of a patient with RSMD1. The expression pattern was very similar to that of calnexin, a transmembrane protein of the endoplasmic reticulum. Selenoprotein N seems to be an endoplasmic reticulum glycoprotein, and loss of this protein leads to disturbance of muscular function. One of the families had the SEPN1 homozygous mutation in the initiation codon 1_2 ins T in exon 1 and showed truncated protein expression. The other had a homozygous 20-base duplication mutation at 80 (80_99dup, frameshift at R27) which, in theory, should generate many nonsense mutations including TGA. These nonsense mutations are premature translation termination codons and they degrade immediately by the process of nonsense-mediated decay (NMD). However, truncated selenoprotein N was also expressed. A possible mechanism behind this observation is that SEPN1 mRNAs may be resistant to NMD. We report on the possible molecular mechanism behind these mutations in SEPN1. Our study clarifies molecular mechanisms of this muscular disorder. © Springer-Verlag 2006.
Keywords: calnexin; glycoprotein; membrane protein; selenoprotein; selenoprotein n; unclassified drug; adult; anamnesis; antibody response; article; artificial ventilation; case report; clinical feature; codon; cytoplasm; disease classification; electrocardiography; electromyography; endoplasmic reticulum; exon; female; function test; gene expression; gene mutation; homozygosity; human; human tissue; immunohistochemistry; Japan; male; multigene family; muscle biopsy; muscle function; muscular dystrophy; mutational analysis; nonsense mutation; pathophysiology; pneumonia; priority journal; protein depletion; protein expression; protein family; protein function; respiratory failure; rigidity; spine; thorax radiography; tracheotomy; ventilator

Cervicomedullary Compression and Occipitocervical Instability - Kaiser M.G.; Haid R.W. (Neurosurgery Clinics of North America, 2006)
Decompression of the cervicomedullary junction and stabilization from the occiput to the cervical spine pose significant challenges for a spine surgeon. Unrecognized progression of these disorders may result in permanent neurologic deficits and increase the complexity of surgical intervention. Careful attention to detail, including preoperative planning and surgical technique, are required to ensure success. Specific complications should be anticipated and preventive measures incorporated into the surgical plan. The consequences of these complications are dramatic, compromising the surgeon's ability to achieve the operative goals and leading to devastating clinical outcomes. Careful attention to detail decreases the incidence of these complications, however, and provides the surgeon with an effective management strategy to cope with these complications. © 2006 Elsevier Inc. All rights reserved.
Keywords: antibiotic agent; bone cement; bone morphogenetic protein; cephalosporin; contrast medium; hydrocortisone; penicillin G; steroid; adrenoleukodystrophy; air embolism; amyotrophic lateral sclerosis; angiography; atlantooccipital joint; blood vessel injury; bone plate; bone screw; brain stem; cerebrospinal fluid; clinical feature; computer assisted tomography; cranial nerve injury; differential diagnosis; dura mater; dysphagia; endotracheal tube; extubation; fluoroscopy; human; hypoglossal nerve; hypoglossal nerve disease; devices; intensive care unit; joint instability; multiple sclerosis; neurologic disease; neurosyphilis; nuclear magnetic resonance imaging; nutrition; occipital bone; patient education; pharyngitis; postoperative infection; priority journal; pseudarthrosis; radiography; review; spinal cord compression; spinal cord decompression; spinal cord surgery; stomach tube; surgical technique; T lymphocyte; tongue swelling; tracheostomy; treatment planning; vertebral artery; vertebral canal; wound dehiscence; X ray; X ray film

Airway management in adults after cervical spine trauma - Crosby E.T. (Anesthesiology, 2006)
Cervical spinal injury occurs in 2% of victims of blunt trauma; the incidence is increased if the Glasgow Coma Scale score is less than 8 or if there is a focal neurologic deficit. Immobilization of the spine after trauma is advocated as a standard of care. A three-view x-ray series supplemented with computed tomography imaging is an effective imaging strategy to rule out cervical spinal injury. Secondary neurologic injury occurs in 2-10% of patients after cervical spinal injury; it seems to be an inevitable consequence of the primary injury in a subpopulation of patients. All airway interventions cause spinal movement; immobilization may have a modest effect in limiting spinal movement during airway maneuvers. Many anesthesiologists state a preference for the fiberoptic bronchoscope to facilitate airway management, although there is considerable, favorable experience with the direct laryngoscope in cervical spinal injury patients. There are no outcome data that would support a recommendation for a particular practice option for airway management; a number of options seem appropriate and acceptable. © 2006 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Keywords: airway; anesthesist; arterial insufficiency; assisted ventilation; atlantoaxial joint; atlantooccipital joint; biomechanics; blunt trauma; breathing disorder; central cord syndrome; cervical spine; cervical spine injury; clinical practice; computer assisted tomography; endotracheal intubation; fiberoptic bronchoscopy; Glasgow coma scale; hospital admission; human; immobilization; intubation; laryngeal mask; laryngoscopy; ligament injury; medical practice; neurologic disease; nuclear magnetic resonance imaging; orthosis; outcome assessment; priority journal; resuscitation; review; spinal cord; spinal cord injury; spine instability; spine mobility; spine radiography; spine stabilization; tracheotomy; vein thrombosis; vertebral canal; X ray

Post-radiation intramedullary malignant peripheral nerve sheath tumor - Paolini S.; Raco A.; Di Stefano D.; Esposito V.; Ciappetta P. (Journal of Neurosurgical Sciences, 2006)
We report the intramedullary growth of a malignant peripheral nerve sheath tumour (MPNST). A 50-year-old man developed a severe tetraparesis over a 4-month period. Following irradiation of a chronic tonsillitis during his childhood, the patient had later experienced a number of post-radiation diseases, including a laryngeal cancer that required permanent tracheotomy. Before admission, a magnetic resonance imaging (MRI) study had disclosed a C4-C5 intramedullary lesion. On admission to our Department, the patient had a nearly complete tetraparesis. At surgery, the lesion was exposed through a posterior midline myelotomy. A friable neoplasm, with no clear plane of cleavage, was found. The tumour was subtotally resected. Histological examination, which intraoperatively had not yielded a specific diagnosis, eventually revealed a MPNST, grade intermediate, with ultrastructural and immunohistochemical features consistent with a schwannian differentiation. No postoperative radiotherapy was undertaken. The patient died 9 months later from pneumonial complications. MPNSTs may develop within the spinal cord similarly to their benign schwannian counterpart. The reported sequence of events might support a possible relation between irradiation of the spinal cord and induction, followed by malignant transformation, of intramedullary schwannosis. This unique case must be added to the growing list of radiation-induced spinal cord tumours.
Keywords: gadolinium; protein S 100; vimentin; adult; anamnesis; article; case report; cell differentiation; clinical feature; cordotomy; death; disease severity; histopathology; hospital admission; human; human cell; human tissue; immunohistochemistry; immunoreactivity; irradiation; male; malignant neoplasm; nerve sheath tumor; neurologic examination; nuclear magnetic resonance imaging; peripheral nerve tumor; postoperative care; quadriplegia; Schwann cell

Control of an ACC-1-producing Klebsiella pneumoniae outbreak in a physical medicine and rehabilitation unit - Ohana S.; Denys P.; Guillemot D.; Lortat-Jacob S.; Ronco E.; Rottman M.; Bussel B.; Gaillard J.-L.; Lawrence C. (Journal of Hospital Infection, 2006)
This article describes an outbreak of ACC-1-producing Klebsiella pneumoniae involving 40 patients. These were mainly men under 40 years old with a spinal cord injury, in a physical medicine and rehabilitation unit. The main risk factors were prolonged hospital stay, multiple-bed rooms, tracheostomy care and assisted defaecation. The outbreak was only controlled after the introduction of rigorous patient placement (i.e. single rooms or cohorting in the same room), while allowing the patients to have free access to the various technical services (e.g. physiotherapy and occupational therapy) and living spaces necessary for re-education. © 2005 The Hospital Infection Society.
Keywords: adult; aged; article; asymptomatic bacteriuria; bacterium isolation; clinical article; controlled study; defecation; disinfection; Enterobacteriaceae infection; epidemic; female; hand washing; health care access; hospital bed capacity; hospital department; hospitalization; human; infection control; Klebsiella pneumoniae; length of stay; male; occupational therapy; patient care; patient education; physical medicine; physiotherapy; pyelonephritis; rehabilitation medicine; risk factor; spinal cord injury; statistical analysis; tracheostomy; urinary tract infection

Unanticipated difficult endotracheal intubations in patients with cervical spine instrumentation - Schoenhage K.O.; Koenig H.M. (Anesthesia and Analgesia, 2006)
We present two cases of unanticipated difficult airway in patients requiring reoperation after cervical spine instrumentation. In both cases, the upper airway examination was normal, and fiberoptic-guided intubation proceeded with the patient sedated and breathing spontaneously. Cord visualization was difficult, but the scope was eventually advanced into the trachea and the endotracheal tube placed safely. Later review of radiographs showed the previously unrecognized protrusion of cervical hardware into the meso- and hypopharynx. We recommend that anesthesiologists review recent radiographic studies for potential airway compromise before approaching the airway of patients presenting for revision of cervical instrumentation. ©2006 by the International Anesthesia Research Society.
Keywords: benzocaine; cetacaine; lidocaine; midazolam; propofol; remifentanil; tetracaine; adult; aged; airway obstruction; anesthesist; article; case report; cervical spine; endotracheal intubation; female; fiber optics; general anesthesia; human; hypopharynx; devices; discectomy; job performance; male; neurologic examination; priority journal; radiculopathy; reoperation; sedation; spine fusion; spine surgery; procedures; tracheostomy

Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department - A systematic review - Ollerton J.E.; Parr M.J.A.; Harrison K.; Hanrahan B.; Sugrue M. (Emergency Medicine Journal, 2006)
Background: Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals. Objectives: To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation. Search strategy and methodology: Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.
Keywords: airway conductance; airway obstruction; algorithm; anesthesia induction; anesthesiological procedure; cervical spine injury; clinical trial; emergency treatment; emergency ward; endotracheal intubation; evidence based medicine; human; injury severity; intensive care; laryngeal mask; laryngoscopy; lung clearance; neuromuscular blocking; practice guideline; priority journal; resuscitation; review; staff training; systematic review; tracheotomy

Transarticular screw fixation in bilateral traumatic facet dislocation of C6-7 vertebral level: A case report - Er U.; Simsek S.; Yiǧitkanli K.; Bavbek M. (Turkish Neurosurgery, 2006)
Bilateral facet dislocations at subaxial levels in a flexion-distraction type trauma are three-column injuries. Early reduction of the locked facets and decompression is critical in preventing progressive secondary spinal cord injury. We present a case of traumatic bilateral facet dislocations treated with transarticular screw fixation. Transarticular screw insertion at the subaxial levels of the cervical spine can be performed safely and easily. The biomechanical strength is adequate.
Keywords: adult; arm weakness; article; assisted ventilation; bone allograft; bone screw; case report; cervical spine dislocation; cervical spine radiography; computer assisted tomography; fatality; fracture fixation; general anesthesia; human; discectomy; male; nuclear magnetic resonance imaging; open reduction (procedure); paraplegia; pneumonia; respiratory arrest; skin incision; spine fusion; spine stabilization; tracheostomy; traffic accident

Onychomadesis in a child with spinal muscular atrophy type I - Ruggiero G. (European Journal of Pediatric Dermatology, 2006)
A case of Werdnig-Hoffmann disease or spinal muscular atrophy in a 4-year-old child is reported. At this age the child presented onychomadesis of both halluces leading to the elimination of the distal fractured nail lamina within 8 months. Initially, a possible damage on the matrix induced by the saturimeter was hypothesized and led to move the latter from the halluces to the plantar region. However, onychomadesis relapsed on the right hallux a year after the suspension of contact with the saturimeter, ruling out this hypothesis. After having excluded infectious and traumatic causes, an idiopathic form possibly associated to spinal muscular atrophy was diagnosed.
Keywords: article; case report; hallux; hospitalization; human; intensive care unit; laboratory test; nail dystrophy; onychomadesis; percutaneous endoscopic gastrostomy; preschool child; pyoderma; respiratory distress; spinal muscular atrophy; tracheotomy; Werdnig Hoffmann disease

Delayed return of spontaneous respiration after cervical spinal cord injury. Case report - Zeliaś A. (Anestezjologia Intensywna Terapia, 2005)
Background. High cervical spinal injury has been associated with irreversible respiratory muscle paralysis requiring long-term ventilation. We describe a case of a car accident victim in whom spontaneous respiration returned one year after the injury. Case report. An 18 yr-old man was transferred to the ICU after a car accident and cardiac arrest. Initial examination revealed C2, C3 and C4 fractures with C2 dislocation resulting in quadriparesis and spinal shock. After initial resuscitation, he underwent surgical decompression at the C3-C4 level, reposition of the dislocated vertebrae and occipitocervical fusion. Immediately after surgery, he required controlled ventilation because of complete paralysis of the diaphragm and other respiratory muscles. Gradually, activity of the neck muscles returned, allowing short periods (1-2 hours) of spontaneous ventilation, after 5 months. 14 months after injury, the function of the right diaphragm returned and it was possible to wean the patient from the ventilator. He breathed spontaneously via a tracheotomy, with a tidal volume of 500 ml and vital capacity of 1200 ml. Discussion and conclusion. The outcome described in this case is rare. In most patients with high cervical injury, long-term home ventilation or implantation of phrenic nerve stimulators remain the only therapeutic possibilities. A sudden increase in tidal volume may indicate the return of diaphragm function and therefore should be checked regularly.
Keywords: adult; article; artificial ventilation; atlantooccipital joint; breathing; case report; cervical spinal cord injury; cervical spine dislocation; cervical spine fracture; decompression surgery; diaphragm; heart arrest; home care; human; intensive care unit; long term care; male; muscle function; nerve stimulation; patient monitoring; phrenic nerve; physical examination; postoperative care; quadriplegia; resuscitation; shock; spine fusion; tidal volume; tracheotomy; traffic accident; ventilator; vital capacity

Respiratory management following spinal cord injury: A clinical practice guideline for health-care professionals (Journal of Spinal Cord Medicine, 2005)
Keywords: anabolic agent; antibiotic agent; bicarbonate; bronchodilating agent; cromoglycate disodium; methylxanthine; mucolytic agent; steroid; vaccine; arterial gas; aspiration; atelectasis; carbon dioxide tension; clinical practice; dysphagia; forced expiratory volume; human; lung receptor; lung ventilation; medical decision making; oxygen saturation; pneumonia; positive end expiratory pressure; practice guideline; respiration control; review; risk assessment; sleep disordered breathing; spinal cord injury; spirometry; tidal volume; tracheostomy; vital capacity

Respiratory complications and mortality risk associated with thoracic spine injury - Cotton B.A.; Pryor J.P.; Chinwalla I.; Wiebe D.J.; Reilly P.M.; Schwab C.W.; Brundage S.; Duane T.M.; Yelon J. (Journal of Trauma - Injury, Infection and Critical Care, 2005)
Background: Cervical spinal cord injury (SCI) has a well-established association with a high risk of respiratory complications. We sought to determine whether high-thoracic (HT) SCI was associated with a similar increased risk of respiratory complications and death. Methods: This was a retrospective cohort study of all adult patients with thoracolumbar injuries entered into the Pennsylvania Trauma System Foundation registry between January 1993 and December 2002. Records were reviewed for the documentation of respiratory complications (intubation, tracheostomy, bronchoscopy, pneumonia) and mortality. The data were then evaluated controlling for age, sex, Glasgow Coma Scale, and Injury Severity Score. Results: In all, 11,080 patients met inclusion criteria: 4,258 patients had thoracic spine fractures and 6,226 patients had lumbar spine fractures, all without SCI; and 596 patients had thoracic SCI (T1 to T6, 231; T7 to T12, 365). Respiratory complications occurred in 51.1% of patients with T1 to T6 SCI (versus 34.5% in T7 to T12 SCI and 27.5% in thoracic fractures). The need for intubation, the risk of pneumonia, and risk of death were significantly greater for patients with T1-to T6-level spinal cord injuries. Among patients with an Injury Severity Score less than 17 (n = 6427), the relative mortality risk was 26.7 times higher among those who developed respiratory complications (9.9% versus 0.4%). Conclusion: Compared with patients with low thoracic SCI or thoracolumbar fractures, patients with HT-SCI have an increased risk of pneumonia and death. Respiratory complications significantly increase the mortality risk in less severely injured patients. The current findings suggest that HT-SCI patients warrant intensive monitoring and aggressive pulmonary care and attention, similar to that given for patients with cervical SCI. Copyright © 2005 by Lippincott Williams & Wilkins, Inc.
Keywords: adult; aged; article; bronchoscopy; cohort analysis; death; evaluation study; female; human; injury scale; major clinical study; male; medical documentation; mortality; pneumonia; priority journal; register; respiratory tract disease; respiratory tract intubation; retrospective study; risk assessment; risk factor; spine injury; thoracolumbar spine; tracheostomy; United States

Factors associated with dysphagia in individuals with high tetraplegia - Shem K.; Castillo K.; Naran B. (Topics in Spinal Cord Injury Rehabilitation, 2005)
The aim of this study was to identify the factors associated with dysphagia in individuals with high tetraplegia. The Santa Clara Valley Medical Center (SCVMC) has a high tetraplegia program utilizing experienced Speech Pathologists in the early evaluation of dysphagia and in appropriate intervention in individuals with high tetraplegia. The factors associated with dysphagia were ASIA impairment level, intubation, mechanical ventilation, and pulmonary infections. The earlier individuals were admitted to SCVMC, the less likely they were to have pulmonary complications, which may be a result of early screening by the SCVMC Speech Pathology Department for dysphagia. © 2005 Thomas Land Publishers, Inc.
Keywords: adolescent; adult; aged; article; artificial ventilation; diet; disability; dysphagia; early diagnosis; hospital admission; human; intubation; lung infection; major clinical study; medical specialist; quadriplegia; rehabilitation center; risk factor; speech pathologist; spinal cord injury; tracheostomy

Chiari malformation and odontoid panus causing craniovertebral stenosis in a child with Crouzon's syndrome - Dickerman R.D.; Lefkowitz M.; Arinsburg S.A.; Schneider S.J. (Journal of Clinical Neuroscience, 2005)
Crouzon's disease is a well-known disorder affecting multiple organ systems, specifically a craniofacial disorder with highly variable penetrance and severity of deformity. Crouzon's patients typically have anomalies of the skull base leading to gross distortion of the cranium and in some cases the cervicocranium. We present a 5-year-old girl with Crouzon's disease who suffered from an acquired Chiari I malformation after insertion of a ventriculoperitoneal shunt and a coexistent ventral odontoid panus. Both these lesions were causing cervicomedullary compression. The literature is controversial on the surgical management of anterior and posterior compression at the craniocervical junction. We review the literature on surgical options for decompression at the craniocervical junction and offer our surgical case as a treatment option for patients in this rare clinical situation. © 2005 Elsevier Ltd. All rights reserved.
Keywords: bone morphogenetic protein; anamnesis; article; bone density; brain; brain decompression; brain ventricle peritoneum shunt; case report; cerebrospinal fluid flow; Chiari Frommel syndrome; computer assisted tomography; craniectomy; craniofacial malformation; craniofacial synostosis; craniovertebral stenosis; Crouzon syndrome; developmental disorder; emergency ward; somatosensory evoked potential; exophthalmos; female; gait disorder; headache; human; hypertelorism; immobilization; intensive care; laminectomy; leg; lethargy; muscle weakness; nuclear magnetic resonance imaging; occipital bone; odontoid panus; orthosis; preschool child; priority journal; rib graft; spinal cord; spinal cord compression; spine disease; stomach tube; tracheostomy; traction therapy; ultrasound; walking

Bench-to-bedside review: Early tracheostomy in critically ill trauma patients - Shirawi N.; Arabi Y. (Critical Care, 2006)
A significant proportion of trauma patients require tracheostomy during intensive care unit stay. The timing of this procedure remains a subject of debate. The decision for tracheostomy should take into consideration the risks and benefits of prolonged endotracheal intubation versus tracheostomy. Timing of tracheostomy is also influenced by the indications for the procedure, which include relief of upper airway obstruction, airway access in patients with cervical spine injury, management of retained airway secretions, maintenance of patent airway and airway access for prolonged mechanical ventilation. This review summarizes the potential advantages of tracheostomy versus endotracheal intubation, the different indications for tracheostomy in trauma patients and studies examining early versus late tracheostomy. It also reviews the predictors of prolonged mechanical ventilation, which may guide the decision regarding the timing of tracheostomy. © 2005 BioMed Central Ltd.
Keywords: airway obstruction; artificial ventilation; blunt trauma; breathing mechanics; cervical spine injury; chronic lung disease; clinical trial; critically ill patient; early intervention; emergency care; endotracheal intubation; face fracture; face injury; head injury; hospital infection; human; incidence; infection risk; injury; intensive care unit; larynx injury; length of stay; long term care; lung dead space; maxillofacial injury; medical decision making; neck injury; nose injury; patient selection; penetrating trauma; pneumonia; priority journal; quality of life; respiratory distress syndrome; review; risk reduction; therapy delay; trachea injury; trachea stenosis; tracheostomy; tracheotomy; treatment contraindication; treatment indication; ventilator associated pneumonia

Characterizing the need for mechanical ventilation following cervical spinal cord injury with neurologic deficit - Como J.J.; Sutton E.R.H.; McCunn M.; Dutton R.P.; Johnson S.B.; Aarabi B.; Scalea T.M. (Journal of Trauma - Injury, Infection and Critical Care, 2005)
Background: Patients who sustain cervical spinal cord injury (C-SCI) with neurologic deficit may require a definitive airway and/or prolonged mechanical ventilation. The purpose of this study was to characterize factors associated with a high risk for respiratory failure and/or the need for mechanical ventilation in C-SCI patients. Methods: Patients with C-SCI and neurologic deficit admitted to a Level I Trauma Center between July 1, 2000 and June 30, 2002 were retrospectively reviewed for demographics, level and completeness of neurologic deficit, need for definitive airway, need for tracheostomy, need for mechanical ventilation at hospital discharge (MVDC), and outcomes. The level and completeness of injury were defined by American Spinal Injury Association standards. Results: One hundred nineteen patients with C-SCI and neurologic deficit were identified over this period. Of these, 45 were identified as complete C-SCI: 12 (27%) patients had levels of C1 to C4; 19 (42%) had a level of C5; and 14 (31%) had levels of C6 and below. There were 37 males and 8 females. There were 36 blunt and 9 penetrating injuries. The average age of these patients was 40+/-21, and the average ISS was 45+/-22. Eight of the patients with complete C-SCI died, for a mortality of 18%. Of the 37 survivors, 92% received a definitive airway, 81% received tracheostomy, and 51% required MVDC. All patients with complete injuries at the C5 level and above required a definitive airway and tracheostomy, and 71% of survivors required MVDC. Of the patients with complete injuries of C6 and below, 79% received a definitive airway, 50% required tracheostomy, and 15% of survivors required MVDC. Only 35% of incomplete injuries required a definitive airway, and only 7% required tracheostomy. Conclusions: The need for definitive airway control, tracheostomy, and ventilator dependence is significant, especially for patients with high complete C-SCI. Based on these results we recommend consideration of early intubation and tracheostomy for patients with complete C-SCI, especially for those with levels of C5 and above. Copyright © 2005 by Lippincott Williams & Wilkins, Inc.
Keywords: adult; aged; artificial ventilation; blunt trauma; cervical spinal cord injury; cervical spine; clinical article; demography; female; hospital discharge; human; intubation; male; mortality; neurologic disease; outcome assessment; penetrating trauma; priority journal; respiratory failure; retrospective study; review; risk factor; tracheostomy; tracheotomy

Editorial comment - Jallo J. (Journal of Trauma - Injury, Infection and Critical Care, 2005)
Keywords: artificial ventilation; cervical spinal cord injury; human; intubation; neurologic disease; note; patient care; priority journal; publication; retrospective study; tracheostomy

Traumatic retropharyngeal hematoma: A rare and critical pathology needed for early diagnosis - Duvillard C.; Ballester M.; Romanet P. (European Archives of Oto-Rhino-Laryngology, 2005)
Retropharyngeal hematoma occurs rarely. It is located just in front of the cervical spine. Many circumstances can lead to its development. A trauma and/or anticoagulants are often key factors. The assessment must be made extremely carefully as such a hematoma can induce an airway compromise. Trauma being a key factor, it can also present with cervical spine fractures, increasing the risks. Two different cases of retropharyngeal hematomas are reported. The first case required surgical management with tracheotomy, per-oral drainage and naso-gastric tube feeding. A total recovery was obtained in 2 weeks. The second patient underwent medical treatment (methylprednisolone), and recovery was obtained in 6 days. Surgery for retropharyngeal hematoma is not always mandatory. It becomes necessary when a major dysphagia or dyspnea occurs. In other cases, medical treatment and close observation are usually sufficient. © Springer-Verlag 2005.
Keywords: methylprednisolone; adult; aged; article; cancer surgery; case report; clinical feature; computer assisted tomography; hematoma; human; male; nose feeding; pharynx tumor; physical examination; priority journal; surgical drainage; tracheostomy; tumor diagnosis

Cervical spine fracture in the ankylosing spondylitis patient [1] - Coleman J.A. (Journal of the American College of Surgeons, 2005)
Keywords: ankylosing spondylitis; cervical spine fracture; clinical feature; endotracheal intubation; endotracheal tube; fiber optics; hematoma; human; laryngoscope; letter; lung clearance; medical information; nurse; priority journal; senescence; stridor; tracheotomy

Letter to the editor (multiple letters) [1] - Kanna B.; Ayman H.A.; Soni A.; Arabi Y.; Haddad S.; Shirawi N.; Al Shimemeri A. (Critical Care, 2005)
Keywords: artificial ventilation; clinical practice; comorbidity; critical illness; endotracheal intubation; financial management; health care facility; health care personnel; hospital discharge; human; intensive care; intensive care unit; length of stay; letter; maxillofacial injury; multivariate analysis; patient care; patient selection; priority journal; resource management; spinal cord injury; spine stabilization; time; tracheostomy; treatment outcome

Respiratory management of the infant with type 1 spinal muscular atrophy - Bush A.; Fraser J.; Jardine E.; Paton J.; Simonds A.; Wallis C. (Archives of Disease in Childhood, 2005)
A recent paper has highlighted the differences in the respiratory management offered to infants with type 1 spinal muscular atrophy (SMA-1). Current views appear polarised between those who would offer nothing, to those who would proceed as far even as tracheostomy and long term invasive ventilation for these infants. Here we offer a personal view, as a possible template for managing a vexed and emotional problem. The complex nonrespiratory aspects of the holistic care of these infants will not be discussed.
Keywords: artificial ventilation; child health care; chronic obstructive lung disease; disease course; human; intermittent positive pressure ventilation; palliative therapy; patient care; priority journal; prognosis; quality of life; respiratory failure; review; spinal muscular atrophy; survival; tracheostomy; Werdnig Hoffmann disease

There are other ways to manage spinal muscular atrophy type 1 [10] - Bach J.R. (Chest, 2005)
Keywords: clinical practice; disease classification; disease severity; funnel chest; gastrostomy; human; letter; outpatient care; oximetry; patient care; positive end expiratory pressure; priority journal; respiratory failure; spinal muscular atrophy; tracheotomy; treatment outcome; vital capacity

There are other ways to manage spinal muscular atrophy type 1 [11] - Ioos C. (Chest, 2005)
Keywords: artificial ventilation; aspiration pneumonia; breathing exercise; dysphagia; funnel chest; human; International Classification of Diseases; letter; lung congestion; nose breathing; percussion; positive end expiratory pressure; priority journal; quality of life; respiratory distress; respiratory failure; spinal muscular atrophy; sudden death; tracheostomy; vital capacity

There are other ways to manage spinal muscular atrophy type 1. - Bach J.R. (Chest, 2005)
Keywords: child; hereditary spinal muscular atrophy; human; note; tracheotomy

Prediction of tracheostomy tube size for paediatric long-term ventilation: An audit of children with spinal cord injury - Behl S.; Watt J.W.H. (British Journal of Anaesthesia, 2005)
Background. There are no published data to predict tracheostomy tube size as growth proceeds in children requiring long-term ventilation. Methods. A retrospective audit was undertaken of children having long-term ventilation, managed from the Southport spinal injuries unit. The dates of step-up in size of tracheostomy tube were noted together with the tube inside and outside diameters (ID and OD) and the lateral tracheal diameter. The data were aggregated for each increment in tube size to calculate the Pearson correlation coefficients for age and weight of the children. Linear regression was then used to generate predictive equations based on age and weight. Results. Out of 12 children, data from seven boys and two girls, with a mean age of 5.9 (range 1.5-13.75) yr, were obtained. Average length of follow-up was 7 yr, with an average of 3.5 tube changes per patient equating to a larger tube every 2 yr. The inside and outside tracheal tube diameters, as well as the lateral tracheal diameter, correlated significantly with age and weight (P<0.01). The appropriate tracheostomy tube internal diameter is conveniently expressed by the formula: ID (mm)=(age yr)/3+3.5 Conclusions. The step-up in size of the tracheostomy tube as growth proceeds should be undertaken as a planned procedure at least every 2 yr to avoid nocturnal desaturation. Age appears to be a convenient and reliable predictor. © The Board of Management and Trustees of the British Journal of Anaesthesia 2004.
Keywords: adolescent; age; article; artificial ventilation; body weight; breathing circuit; calculation; child; circadian rhythm; clinical article; correlation coefficient; equipment design; female; follow up; human; linear regression analysis; long term care; male; mathematical analysis; clinical audit; oxygen saturation; pediatrics; prediction; priority journal; spinal cord injury; tracheostomy; United Kingdom; 6PDL; Biesalski; Blue line ultra; Blue line; Hyperflex; Silicone; Trac/comfort; Trac/flex

Airway management of mucopolysaccharidosis with cervical spine involvement - Sahin A.; Dal D.; Ocal T.; Aypar U. (Neurosciences, 2005)
Mucopolysaccharidoses are a group of inherited disorders occasionally accompanied by cervical spine involvement complicating tracheal intubation. In this study, we review and discuss 5 cases of mucopolysaccharidosis with cervical spinal involvement.
Keywords: atropine; diazepam; lidocaine; midazolam; propofol; sevoflurane; suxamethonium; thiopental; adolescent; adult; article; atlantoaxial subluxation; cervical spine; clinical article; clinical feature; diaphragm hernia; endotracheal intubation; funnel chest; human; limb malformation; male; micrognathia; Morquio syndrome; muscle hypotonia; pediatric anesthesia; pigeon thorax; school child; spine disease; symptom; faintness; tracheotomy; vertebral canal stenosis

Surgical management of a Klippel-Feil patient with basilar invagination and an intramedullary lipoma: A case report - Avci E.; Burke T.; Fossett D. (Turkish Neurosurgery, 2005)
Patients with Klippel-Feil syndrome (KFS) and associated craniocervical junction abnormalities are at high risk for the development of progressive neurologic deficits. A 60-year-old male patient with Klippel-Feil syndrome was admitted to the emergency room with an 8-year history of a progressive spastic quadraparesis which began with numbness in the right lower extremity. Neurologic status of the patient improved significantly following posterior decompression and stabilization. Dramatic resolution of his myelopathy with the initial procedure led to postponing the second procedure. Early post-operative improvement in neurologic function after the initial procedure may be misleading. For this reason, the two-staged ventral and dorsal decompression was suggested for the restoration and preservation of neurologic function.
Keywords: adult; anamnesis; article; case report; decompression surgery; gastrostomy; human; Klippel Feil syndrome; kyphoscoliosis; laminectomy; lipoma; male; neurologic examination; paralysis; paresthesia; postoperative period; spinal cord disease; spine stabilization; tracheostomy

Cardiac arrest: Recent advances in recognition and management - Zaidi S.; Senthuran S.; Naik M. (CPD Journal Acute Medicine, 2004)
The features of cardiac arrest will be familiar to any reader who has recently undertaken an Advanced Life Support course. Rather than reproducing algorithms which should be readily available in all UK hospitals, this article emphasises the importance of early recognition and prevention, and looks at some of the more recent advances in resuscitation technique.
Keywords: epinephrine; amiodarone; antiarrhythmic agent; antidepressant agent; beta adrenergic receptor blocking agent; digoxin; lidocaine; vasopressin; algorithm; aortic arch syndrome; assisted ventilation; breathing rate; cardiomyopathy; chronic obstructive lung disease; clinical feature; clinical protocol; coronary artery blood flow; death; defibrillator; diastolic blood pressure; drowning; electrolyte disturbance; emergency health service; head injury; health care access; health care organization; health practitioner; heart arrest; heart arrhythmia; heart infarction; heart rate; heart ventricle fibrillation; high risk patient; hospital patient; human; human rights; hypertension; hypothermia; hypovolemia; hypoxia; ischemia; legal aspect; long term care; lung embolism; medical decision making; metabolic acidosis; mortality; myocarditis; neurologic disease; practice guideline; respiratory tract disease; resuscitation; review; risk factor; spinal cord injury; survival rate; systolic blood pressure; temperature; tension; tracheostomy; traffic accident; treatment outcome; tricuspid valve disease; unconsciousness; United Kingdom; vascular resistance

Predictors to dysphagia and recovery after cervical spinal cord injury during acute rehabilitation - Brady S.; Miserendino R.; Statkus D.; Springer T.; Hakel M.; Stambolis V. (Journal of Applied Research, 2004)
The purpose of this retrospective study was to identify factors that predict dysphagia in patients following cervical spinal cord injury and to identify factors that predict dysphagia recovery patterns/outcomes during acute rehabilitation. Data were collected on 131 consecutive patients with a diagnosis of a cervical cervical spinal cord injury over a 27-month period at 2 freestanding rehabilitation hospitals. On admission, 55% (72/131) of the patients were treated for dysphagia. Three significant predictors were identified to the likelihood that the patient would present with dysphagia: the co-occurrence of a brain injury (P=0.003), the presence or history of a tracheotomy tube (P= 0.002), and undergoing a cervical spine surgery (P=0.02). Main dysphagia treatment outcome measures included: aspiration, laryngeal penetration, pharyngeal residue, days of dysphagia treatment provided, and the American Speech-Language-Hearing Association National Outcome Measurement System swallowing level discharge score. Fifty-nine of the 72 patients in the treatment group underwent an instrumental assessment of the swallow. Of these patients, aspiration was present in 39%, laryngeal penetration in 54%, and pharyngeal residue in 66% of the cases. Logistic regression analyses revealed for the outcome of aspiration, the predictor of a tracheotomy tube (P=0.008) was significant. For the outcome of laryngeal penetration, the predictors of a complete spinal cord injury (P=0.01) and the admission American Speech-Language-Hearing Association National Outcome Measurement System swallowing level admission score (P=0.018) were significant. For the outcome of pharyngeal residue, the predictors of an anterior spinal surgery (P=0.011), tracheotomy tube (P=0.004), and admission American Speech-Language-Hearing Association National Outcome Measurement System swallowing level (P=0.032) were significant. Linear regression analyses were completed for the outcome of dysphagia days of treatment and discharge American Speech-Language-Hearing Association National Outcome Measurement System swallowing level and several significant predictors were identified. Results of this study demonstrate that dysphagia does occur following cervical spinal cord injury, several factors may play a role in the patient's recovery, and this patient population can make significant progress with dysphagia treatment during acute rehabilitation.
Keywords: adolescent; adult; aged; american speech language hearing association national outcome measurement system; article; aspiration; brain injury; cervical spinal cord injury; convalescence; dysphagia; female; hospital admission; human; larynx injury; linear regression analysis; logistic regression analysis; male; outcomes research; pharynx; prediction; retrospective study; scoring system; spine surgery; swallowing; tracheotomy

Myotonic dystrophy presenting as new-onset hand weakness and recurrent pneumonia in a patient with paraplegia: A case report - Carver R.T.; Boysel L.C.; Marciniak C.M.; Nussbaum S.B. (Archives of Physical Medicine and Rehabilitation, 2004)
Carver RT, Boysel C, Marciniak CM, Nussbaum SB. Myotonic dystrophy presenting as new-onset hand weakness and recurrent pneumonia in a patient with paraplegia: a case report. Arch Phys Med Rehabil 2004;85:1896-8. We describe a previously independent T11 paraplegic patient who had delayed-onset hand weakness and recurrent pneumonia caused by myotonic dystrophy. A man in his late thirties suffered a thoracic spinal cord injury (SCI) from a gunshot wound at the age of 17 years, with resultant T11 American Spinal Injury Association class A paraplegia. He lived independently until the age of 36 years when he was hospitalized multiple times for pneumonia. During a rehabilitation stay after one of the acute hospitalizations, the patient's hand weakness and diffuse muscular atrophy were noted. Electrodiagnostic testing was performed, which showed myotonic discharges. Genetic testing was consistent with myotonic dystrophy. This case shows the importance of considering causes of weakness that affect the population as a whole when evaluating a patient with SCI who presents with delayed-onset weakness. © 2004 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.
Keywords: etidronic acid; adult; anamnesis; article; case report; clinical feature; death; disease association; electrodiagnosis; gunshot injury; heterotopic ossification; hospitalization; human; male; medical assessment; motor nerve conduction; motor unit potential; muscle strength; muscle weakness; myotonic dystrophy; neurologic examination; paraplegia; physical examination; pneumonia; reflex; sensory nerve conduction; spine injury; tracheostomy

Intubating laryngeal mask airway allows tracheal intubation when the cervical spine is immobilized by a rigid collar - Komatsu R.; Nagata O.; Kamata K.; Yamagata K.; Sessler D.I.; Ozaki M. (British Journal of Anaesthesia, 2004)
Background. 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. Methods. 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. Results. 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. Conclusions. 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 Board of Management and Trustees of the British Journal of Anaesthesia 2004.
Keywords: fentanyl; oxygen; propofol; sevoflurane; vecuronium; adult; aged; anesthesia induction; article; cervical spine; controlled study; endotracheal intubation; female; general anesthesia; human; immobilization; laryngeal mask; major clinical study; male; patient positioning; priority journal; scoring system; spine stabilization; statistical analysis; statistical significance; tracheostomy

Tracheostomy after anterior cervical spine fixation - O'Keeffe T.; Goldman R.K.; Mayberry J.C.; Rehm C.G.; Hart R.A. (Journal of Trauma - Injury, Infection and Critical Care, 2004)
Background: Patients with cervical spine injury may require both anterior cervical spine fusion and tracheostomy, particularly in the setting of associated cervical spinal cord injury (SCI). Despite the close proximity of the two surgical incisions, we postulated that tracheostomy could be safely performed after anterior spine fixation. In addition, we postulated that the severity of motor deficits in patients with cervical spine injury would correlate with the need for tracheostomy. Methods: A retrospective review was undertaken of all adult trauma patients diagnosed with cervical spine fractures or cervical SCI admitted between June 1996 and June 2001 at our university Level I trauma center. Demographic data, severity of neurologic injury based on the classification of the American Spinal Injury Association (ASIA), complications, and use and type of tracheostomy were collected. In the subgroup of patients with unstable cervical spine injury that underwent anterior stabilization and tracheostomy, data regarding timing and technique of these procedures and wound outcomes were also collected. Categorical data were analyzed using χ2 analysis using Yates correction when appropriate, with p < 0.05 considered significant. Results: During this time period, 275 adult survivors were diagnosed with cervical spinal cord or bony injury. Forty-five percent of patients with SCI (27 of 60) and 14% of patients without SCI (30 of 215) underwent tracheostomy (p < 0.001). Moreover, on the basis of the ASIA classification system, 76% of ASIA A and B patients, 38% of ASIA C patients, 23% of ASIA D patients, and 14% of ASIA E patients were treated with tracheostomy (p < 0.001). In the subgroup that underwent both anterior spine fixation and tracheostomy (n = 17), the median time interval from spine fixation to airway placement was 7 days (interquartile range, 6-10 days), with 71% of these tracheostomies performed percutaneously. No patient developed a wound infection or nonunion as a consequence of tracheostomy placement, and there were no deaths because of complications of either procedure. Conclusion: These data support the safety of tracheostomy insertion 6 to 10 days after anterior cervical spine fixation, particularly in the presence of cervical SCI. The presence of severe motor neurologic deficits was strongly associated with the use of tracheostomy in patients with cervical spine injury. Percutaneous tracheostomy, which is our technique of choice, may be advantageous in this setting by virtue of creating only a small wound. The optimal timing and use of tracheostomy in patients with cervical spine injury requires further study.
Keywords: adult; aged; bone injury; cervical spine; cervical spine fracture; classification; clinical article; data analysis; death; demography; female; human; injury; male; patient; postoperative complication; priority journal; retrospective study; review; spine injury; spine stabilization; statistical significance; surgical technique; time; tracheostomy; treatment outcome; wound infection

Increased incidence of emergency airway management after combined anterior-posterior cervical spine surgery - Terao Y.; Matsumoto S.; Yamashita K.; Takada M.; Inadomi C.; Fukusaki M.; Sumikawa K. (Journal of Neurosurgical Anesthesiology, 2004)
Among some kinds of cervical spine surgeries, combined anterior-posterior cervical spine surgery (CAP-CS surgery) requires prolonged operative time and highly invasive procedure. This study was performed to determine whether CAP-CS surgery was associated with increased risk of emergency airway management compared with other cervical spine surgeries (O-CS surgeries). The records of the patients who underwent cervical spine surgery between July 2001 and March 2003 at our institution were reviewed retrospectively, and we determined whether the CAP-CS surgery was associated with an increased risk of emergency airway management in comparison with O-CS surgeries, using the logistic regression analysis. A total of 165 were eligible for inclusion in the study. A total of 127, 20, 11, 5, and 2 patients suffered from cervical myelopathy, traumatic cervical spinal cord injury, atlantoaxial dislocation, cervical spinal tumors, and cervical pyogenic spondylitis, respectively. The operative approaches were CAP-CS surgery, anterior surgery, posterior surgery, and atlantoaxial surgery in 10, 56, 88, and 11 patients, respectively. Thus, the operative approaches were CAP-CS surgery in 10 patients and O-CS surgeries in 155 patients. Postoperative emergency airway management was required in 7 of the 10 patients (70%) who underwent CAP-CS surgery, and 2 of the 155 patients (1%) who underwent O-CS surgeries. The increased risk of postoperative emergency airway management imposed by CAP-CS surgery was 178.5 by an odds ratio, with a 95% confidence interval of 25.6 to 1246. The results show that CAP-CS surgery provides a major risk factor for postoperative emergency airway management.
Keywords: adult; aged; article; atlantoaxial dislocation; cervical myelopathy; cervical spinal cord injury; controlled study; endotracheal intubation; female; first aid; human; incidence; joint surgery; logistic regression analysis; lung clearance; major clinical study; male; medical record; postoperative care; postoperative complication; priority journal; retrospective study; risk assessment; spinal cord tumor; spine surgery; spondylitis; surgical technique; tracheostomy

Weaning of the neurologically impaired patient - Mahanes D.; Lewis R. (Critical Care Nursing Clinics of North America, 2004)
No single method has been found to be superior to the others in weaning patients with neurologic disease or illness. As with other patient populations, it is likely that simply paying attention to the processes of care and ensuring that care is systematic will facilitate weaning. The importance of weaning guidelines, protocols, and algorithms in decreasing ventilator duration and reducing ICU and hospital length of stay has been demonstrated in a number of studies [41-45]. The combination of clinical guidelines or protocols with an advanced practice nurse managing the processes of care has shown benefit for patients with brain and spinal cord injuries [46,47]. All patients receiving mechanical ventilation require attention to general care issues such as nutrition, electrolyte imbalance, mobility, psychologic factors, and prevention of complications. Adequate sleep and management of pain and anxiety contribute significantly to weaning success but may be difficult to assess in patients with a decreased level of consciousness. Data are mixed regarding whether GCS or cough reflex can be used as a predictor of successful extubation. In the absence of clear data predicting successful extubation in patients with impaired neurologic status, a trial extubation can be performed when standard readiness criteria are met, even in patients with a depressed level of consciousness. In those patients in whom extubation is unsuccessful, timely progression to tracheostomy placement is recommended. This requires careful planning and can only be done if good airway management resources are available. In the authors experience, patients with poor cough effort combined with high suction requirements (≥ every 2 hours) or with pooling of oral secretions are likely to fail extubation. For these patients, proceeding directly to tracheostomy without a trial of extubation may be indicated.
Keywords: acute disease; airway dynamics; artificial ventilation; clinical practice; coughing; extubation; Guillain Barre syndrome; hospitalization; human; intensive care unit; length of stay; myasthenia gravis; neurologic disease; neuromuscular disease; nursing; outcomes research; patient; patient care; practice guideline; review; spinal cord injury; validation process

Respiratory capacity course in patients with infantile spinal muscular atrophy - Ioos C.; Leclair-Richard D.; Mrad S.; Barois A.; Estournet-Mathiaud B. (Chest, 2004)
Study objectives: To describe the clinical and respiratory course in infantile spinal muscular atrophy (SMA) type I, type II, and type III, and to evaluate the respiratory needs for these patients, using noninvasive or tracheostomy ventilation. Design: Retrospective cohort study. Methods: We report 33 patients with SMA true type I (onset before age 3 months), 35 patients with SMA intermediate type I (onset between 3 months and 6 months), 100 patients with SMA type II (onset between 6 months and 18 months), 12 patients with SMA type III (onset after age 18 months). We report the clinical symptoms, respiratory course, and respiratory management: respiratory physiotherapy, periodic hyperinsufflation, nasal nocturnal ventilation (NNV), and tracheostomy. Also, we measured the FVC over several years during childhood and adolescence. Results: In patients with SMA true type I, 82% of patients died, one third of whom underwent tracheostomy. In patients with SMA intermediate type I, 43% needed NNV, 57% underwent tracheostomy, and 26% died. In patients with SMA type II, 38% needed NNV, 15% underwent tracheostomy, and 4% died. In patients with SMA type III, respiratory impairment was moderate and began during the second decade of life. Conclusion: This data shows the progressively worsening course of restrictive respiratory insufficiency in patients with SMA, and the importance of early respiratory management to limit pulmonary complications and improve the quality of life for these patients.
Keywords: adolescent; article; artificial ventilation; aspiration pneumonia; atelectasis; breathing exercise; child; clinical feature; controlled study; disease course; dysphagia; gastrostomy; human; infant; intermittent positive pressure ventilation; Kugelberg Welander disease; lung congestion; major clinical study; mortality; nose breathing; priority journal; respiratory failure; retrospective study; tracheostomy; Werdnig Hoffmann disease

Retro-pharyngeal obstruction in association with osteophytes of the cervical spine - Fuerderer S.; Eysel-Gosepath K.; Schröder U.; Delank K.-S.; Eysel P. (Journal of Bone and Joint Surgery - Series B, 2004)
We describe five patients with cervical spondylosis and large anterior osteophytes causing pharyngeal compression. All had dysphagia, two had obstructive sleep apnoea and another two had dyspnoea and strider on inspiration. One, with perforation of the pharynx, required emergency tracheostomy. Only three had pain in the neck or arm. Compression of the retroglottic space was confirmed in all patients by pharyngoscopy and in all the symptoms were relieved by excision of the osteophytes. Three also underwent intervertebral fusion. One had some persistent sleep apnoea. © 2004 British Editorial Society of Bone and Joint Surgery.
Keywords: adult; aged; article; cervical spondylosis; clinical article; computer assisted tomography; decompression surgery; disease association; dyspnea; emergency surgery; female; gastrointestinal endoscopy; glottis; human; inspiratory capacity; male; neck pain; nuclear magnetic resonance imaging; osteophyte; pharynx disease; pharynx examination; priority journal; sleep disordered breathing; spine fusion; spine surgery; stridor; symptom; tracheostomy

Spinal anesthesia in a patient with Down's syndrome [2] - Schmitt H.J. (Canadian Journal of Anesthesia, 2004)
Keywords: bupivacaine; clorazepate; propofol; Ringer lactate solution; adult; anesthesiological procedure; case report; Down syndrome; endotracheal intubation; human; letter; life history; atelectasis; male; oxygen saturation; premedication; priority journal; spinal anesthesia; surgical technique; testis tumor; tracheostomy

Management of paraplegia - Büttner J. (Anasthesiologie und Intensivmedizin, 2004)
In the case of a patient who is awake and communicative the neurologic examination of the senso-motor reflexes provides quick results in order to determine whether partial or total injury of the spinal cord has occurred. With a patient who is unconscious or whose level of consciousness is impaired the spine must be immobilized to prevent potential neural injury until a spinal injury has been excluded by means of a thorough diagnostic procedure in the hospital. To exclude a spinal injury, normal X-rays have to be taken in the lateral and anteroposterior view. A CT scan is mandatory if the spine, especially the lower cervical spine, cannot be visualized by means of a normal X-ray. An acute, total injury of the spinal cord causes immediate flaccid paralysis and loss of all sensation and reflex activity (including autonomic functions) below the level of injury (spinal shock). Patients with an acute, total cervical spinal cord injury show diaphragmatic respiration, bradycardia and hypotension. Patients who are unconscious and/or show signs of respiratory insufficiency require early intubation and assisted ventilation. In the case of emergency intubation, orotracheal intubation with inline manual cervical immobilization is indicated. Cardiovascular resuscitation mainly requires the application of crystalloids and colloids; if hypotension persists, dobutamin must be added. It is debatable whether a high dose of methylprednisolone applied initially during the acute phase gives better results in relation to the spinal cord lesion. Patients who sustain acute traumatic injuries of the cervical spine with associated neurologic deficit may benefit from immediate surgical decompression and stabilization. Patients with a total lesion between the C4 and C6 levels will almost always show hypoventilation. All these patients need an artificial airway for a longer period and, for that reason, a tracheotomy should be performed early on. After days or weeks, the flaccid paralysis changes to spastic paraplegia due to exaggeration of the normal stretch reflexes. Muscle spasms occur and autonomic reflexes return. With the return of the spinal reflexes, precautions must be taken to prevent autonomic dysreflexia, a syndrome characterized by paroxysmal hypertension, bradycardia, sweating, facial flushing and headache. In severe cases cerebral haemorrhage and seizures may occur, precipitated by stimuli such as defecation or bladder distension. In the case of uro-genital procedures, especially cystoscopy, a general anaesthesia with an adequate depth or, better, a spinal anaesthesia has to be performed to prevent the onset of autonomic dysreflexia. Managing patients with paraplegia requires a staff of professional health-care workers familiar with the problems of spinal cord injury. For this reason, patients with spinal cord lesion should be transferred as soon as possible to a centre specialising in this kind of injury.
Keywords: dobutamine; methylprednisolone; anesthesia level; artificial ventilation; assisted ventilation; autonomic dysreflexia; bladder distension; bradycardia; brain hemorrhage; breathing pattern; colloid; computer assisted tomography; crystalloid; cystoscopy; decompression surgery; defecation; diaphragm; emergency treatment; flushing; headache; human; hypertension; hypotension; hypoventilation; intensive care; medical decision making; neurologic examination; paraplegia; patient care; resuscitation; review; spinal cord injury; sweating; treatment planning

Anesthetic implication for brachytherapy for head and neck cancer patients - Sanghavi P.R.; Joshi G.; Patel B.M.; Dave C.R.; Shah R.A. (Journal of Anaesthesiology Clinical Pharmacology, 2004)
This study includes 20 patients of head and neck cancer requiring anesthesia for brachytherapy implant. Our aim of study was to assess the problems associated with anesthetic management of such patients. On preoperative assessment, it was found that 35% of patients were cachexic, 35% patients had associated illness like hypertension, diabetes. 95% of patients had received previous radiotherapy, 10% patients were given chemotherapy and 5% of patients were subjected to surgery during course of their disease. 19 patients were given general anesthesia and one patient was managed under monitored anesthesia. Preoperative tracheostomy was done in six patients. Airway was managed by fiberoptic intubation in one patient Nasogastric tube is must prior to implant Removal of implant also required general anesthesia in ten patients. None of patients had procedure related complications like bleeding, cervical spine injury due to hyperextension of neck and aspiration of blood or secretions in postoperative period. Only two patients (10%) had severe mucosal reaction due to radiation and required treatment Airway management and prevention of aspiration plays the vital role in management of these patients.
Keywords: dexamethasone; diclofenac; halothane; nitrous oxide; oxygen; adult; aged; airway; anesthesia; article; aspiration; bleeding; brachytherapy; cachexia; cancer chemotherapy; cancer surgery; cervical spine injury; clinical article; comorbidity; device removal; diabetes mellitus; female; general anesthesia; head cancer; human; hypertension; intubation; male; mucosa inflammation; nasogastric tube; neck cancer; patient monitoring; preoperative evaluation; tracheotomy

Outcome of Pediatric Patients with Severe Restrictive Lung Disease Following Reconstructive Spine Surgery - Wazeka A.N.; DiMaio M.F.; Boachie-Adjei O. (Spine, 2004)
Study Design. Retrospective chart review. Objectives. To assess outcome and complications in pediatric patients with a vital capacity ≤45% of predicted who underwent reconstructive spine surgery for severe thoracic scoliosis. Summary of Background Data. Despite the known sequelae of untreated spine deformity, pediatric patients with severe restrictive lung disease are frequently not considered good operative candidates for surgical treatment on the basis of their underlying lung disease. Only a few reports have examined surgical treatment in this population Methods. A retrospective chart review was conducted on 21 pediatric patients with restrictive lung disease (average age 11.5 years, range 2-21 years). Eighteen patients completed pulmonary function testing, all with vital capacity ≤45%. The remaining three patients had clinical features of restrictive lung disease but could not perform pulmonary function testing. Eighteen patients underwent combined anterior and posterior spinal fusions. Before surgery, all patients were seen by the pulmonary, cardiology, pediatric, and anesthesia services, as well as neurology and gastroenterology services if indicated. Outcome variables examined were as follows: 1) days on oxygen, 2) need for tracheostomy, 3) days on ventilatory support, 4) mortality rate, 5) pulmonary complications, 6) blood loss, 7) other complications relative to the surgical procedure, and 8) length of stay. Results. For the 21 patients, the preoperative average vital capacity was 32% predicted (range 18-43%). After surgery, the median time on supplemental oxygen was 3 days (range 0-90 days). Only one patient with a vital capacity of 29%, who was successfully extubated on postoperative day 4, developed a deep wound infection, which required incision and drainage, as well as recurrent right lung collapse, and subsequently required a tracheostomy to facilitate ventilator weaning. Four patients were on assisted ventilation before the surgery and continued to require it after surgery. Two additional patients required noninvasive positive pressure ventilation for a short period of time following the surgery. Pneumonia occurred in two patients, and pleural effusion occurred in two patients. Four patients developed postoperative atelectasis. There was one reoperation for implant failure. There were no mortalities or adverse neurologic outcomes. Major thoracic scoliosis measured an average of 82° (range 40-140°) before surgery, with correction to an average of 35° (range 6-75°). Conclusions. Reconstructive spine surgery in pediatric patients with severe restrictive lung disease and significant spinal deformity is well tolerated. Familiarity with different surgical techniques of salvage reconstruction and perioperative multidisciplinary management should be emphasized. Routine preoperative tracheostomy is not indicated.
Keywords: adult; assisted ventilation; atelectasis; bleeding; child; clinical article; female; human; length of stay; lung disease; lung function test; male; mortality; oxygen therapy; pleura effusion; pneumonia; positive end expiratory pressure; postoperative complication; priority journal; restrictive lung disease; review; scoliosis; spine fusion; spine surgery; surgical technique; tracheostomy; vital capacity; wound infection

Cervical spinal cord injury and deglutition disorders - Abel R.; Ruf S.; Spahn B. (Dysphagia, 2004)
The association of cervical spinal cord injury and swallowing disorders is clinically well recognized. This study was performed to determine the clinical significance and the outcome of deglutition disorders observed in the initial treatment of cervical spinal cord injury in our tertiary care spinal cord injury unit. All patients with cervical spinal cord injury admitted to our facility for initial care between January 1997 and December 2000 were included in our study. Prevalence of dysphagia and frequency of pneumonia were determined. An assessment of deglutition at discharge was performed. Dysphagia was diagnosed in 26 of the 73 patients with cervical spinal cord injury. Tracheostomy and duration of orotracheal intubation are associated with dysphagia. The disorder necessitated dietary restrictions in 18 patients. Six of these patients had to be discharged with a percutaneous enterogastric feeding tube; seven had persistent problems not resulting in dietary restrictions. The incidence of late pneumonia was significantly increased with two associated deaths. Dysphagia is a serious complication associated with prolonged requirement for ventilatory support. Patients have to be monitored closely because the incidence of pneumonia is increased. While the situation improves for most patients, a significant number of patients need a percutaneous enterogastric feeding tube as a permanent solution.
Keywords: adult; aged; article; artificial ventilation; cause of death; cervical spinal cord injury; child; controlled study; diet restriction; disease association; dysphagia; endotracheal intubation; enteric feeding; female; hospital discharge; human; incidence; infant; major clinical study; male; patient monitoring; pneumonia; prevalence; priority journal; tracheostomy

Thoraco-abdominal aneurysms of type IV - Stella A.; Paragona O.; Freyrie A.; Faggioli G.; Kapelj S.; Spagnolo C.; Di Nino G.; D'Addato M. (Annali italiani di chirurgia, 2004)
AIM OF THE STUDY: Aims of the study were: 1. to evaluate the results of surgical treatment of type IV thoraco-abdominal aneurysms (TAA), with relationship to other types, 2. to evaluate results obtained with an approach different from the traditional thoraco-phreno laparatomy, with specific attention to postoperative respiratory function. MATERIAL AND METHODS: We have retrospectively compared type IV TAA with all other types of thoraco-abdominal aneurysms electively treated between January 1st, 1994 and May 31st, 2003. Data on perioperative mortality, spinal cord ischemia and renal failure (both temporary and permanent) occurring in the first 30 postoperative days were considered. Protection from spinal cord ischemia was accomplished through liquor drainage and prostaglandin E1 (PGE1) infusion. When the aneurysm extension was limited to the celiac axis an extrapleuric access with removal of XI rib was performed. In this subgroup of patients we have considered postoperative recovery time of respiratory function (intubation time, number of days in intensive care unit, postoperative pulmonary complications) postoperative renal failure, perioperative mortality and morbidity. RESULTS: Seventy-eight TAA have been treated in the period of time of the study. Twenty cases were type IV TAA (25.6%) of which 2 due to chronic dissection. Cumulative postoperative mortality has been 19.2%. The single perioperative death in the group of type IV TAA (5%) occurred in post-operative day 15 for multiple organ failure. No spinal cord ischemia occurred in this group. Temporary renal failure occurred in 3 cases (15%) with one case requiring dialysis. In 10 cases (50%) an extrapleuric access with removal of XI rib was performed, with adequate control of the proximal aorta. Postoperative respiratory failure requiring and intubation time longer than 12 hours occurred in 2 cases (20%). In the remaining 8 cases the mean intubation time was 5.3 hours (range 4-8 hrs). Tracheostomy was not necessary in any case. Mean time of intensive care unit stay was 3.5 days (range 0-15 days). CONCLUSION: The appropriate treatment of type IV TAA leads to low mortality and morbidity with results similar to those of pararenal aneurysms rather than those of other TAA forms. Left extrapleuric access when feasible allows faster recovery of a normal respiratory function.
Keywords: adult; aged; aortic aneurysm; article; classification; female; human; male; methodology; middle aged; retrospective study; vascular surgery

Tracheostomy placement in patients with complete cervical spinal cord injuries: American Spinal Injury Association Grade A - Harrop J.S.; Sharan A.D.; Scheid Jr. E.H.; Vaccaro A.R.; Przybylski G.J. (Journal of Neurosurgery, 2004)
Object. The authors sought to identify variables that predispose patients with acute American Spinal Injury Association (ASIA) Grade A cervical spinal cord injury (SCI) to require tracheostomies for ventilator support or airway protection. Methods. A retrospective analysis was performed of 178 consecutive patients with a cervical ASIA Grade A SCI who were admitted through the Delaware Valley SCI Center at Thomas Jefferson Hospital during a 6-year period. Exclusion criteria included injury occurring more than 48 hours prior to admission, death within 14 days of admission or nontraumatic SCI. Twenty-two patients were excluded based on these criteria. Parameters evaluated in the remaining population (156 patients) included demographics, cervical vertebral ASIA level, tracheostomy placement, pneumonia, premorbid pulmonary disease, smoking history, evidence of direct thoracic/lung trauma, operative intervention, associated appendicular trauma, and preexisting medical comorbidities. The ASIA classification of the 156 patients included in this analysis were C-2 (eight), C-3 (11), C-4 (64), C-5 (36), C-6 (20), C-7 (13), and C-8 (four). Tracheostomies were performed in 107 of these 156 patients. Statistical analysis revealed a significant relationship between tracheostomy and patient age (p = 0.0048), preexisting medical conditions (p = 0.0417), premorbid lung disease (p = 0.0177), higher cervical ASIA level (p < 0.0001), and the presence of pneumonia (p < 0.0001). No patient with a C-8 ASIA A injury required tracheostomy, whereas all C-2 and C-3 ASIA A-injured patients underwent tracheostomies. Patients older than 45 years of age with ASIA A levels between C-4 and C-7 more commonly required tracheostomy (p < 0.005) than patients younger than 45 years of age. Conclusions. Several risk factors were identified that corresponded to the frequent tracheostomy placement in the acute injury phase after complete cervical SCI. Early tracheostomy may be considered in patients with multiple risk factors to reduce duration of stay in the intensive care unit and facilitate ventilatory weaning.
Keywords: adolescent; adult; aged; article; artificial ventilation; cervical spinal cord injury; comorbidity; demography; disease classification; disease predisposition; female; human; intensive care unit; lung disease; lung injury; major clinical study; male; medical society; pneumonia; priority journal; risk factor; smoking; tracheostomy

Diaphragmatic Pacing in Neuromuscular Respiratory Failure - García-Morato J.; De Vito E.L. (Clinical Pulmonary Medicine, 2004)
Electrical activation of the diaphragm is a technology that allows the treatment of selected forms of respiratory failure. The diaphragmatic pacing is carried out by an implanted electrode and receiver with a pocket or tabletop external transmitter. The device electrically stimulates the phrenic nerves to contract the diaphragm rhythmically. The main indication for diaphragm pacing is for ventilator-dependent subjects after high cervical cord injury and patients with central alveolar hypoventilation. The clinical requirements are stable clinical condition and intact phrenic nerves, diaphragms, and lungs. In most patients, a training period is required to provoke a gradual conditioning effect, improving endurance to diaphragmatic fatigue. A cooperative patient, supportive family and friends, and a skilled care team are paramount conditions. Diaphragmatic pacing probably does not lengthen life, but it can increase the quality of life. Tracheostomy is usually required to overcome upper airway obstruction. Poor results are related to inadequate selection of patients, complications related to implantation, system failure, inappropriate pacing schedule, inadequate follow-up, or lack of patient compliance or family support. The long-term results of diaphragm pacing demonstrate its usefulness both in adult and pediatric patients when applied in the correct circumstances.
Keywords: central alveolar hypoventilation; cervical spinal cord injury; diaphragm disease; diaphragmatic pacing; electrode; follow up; human; hypoventilation; motor neuron disease; muscle fatigue; nerve stimulation; patient compliance; patient selection; phrenic nerve; preoperative evaluation; quality of life; respiratory failure; review; tracheostomy; treatment contraindication; treatment indication

Caesarean section in a parturient with type III spinal muscular atrophy and pre-eclampsia - Kitson R.; Williams V.; Howell C. (Anaesthesia, 2004)
Keywords: alfentanil; diclofenac; hydralazine; isoflurane; lidocaine; morphine; nitrous oxide; oxygen; phenylephrine; propofol; steroid; adult; anesthesia induction; case report; cesarean section; collapse; disease classification; female; human; hypertension; Kugelberg Welander disease; kyphoscoliosis; labor; letter; positive end expiratory pressure; postoperative pain; preeclampsia; pregnancy; topical anesthesia; tracheostomy

Review of pediatric patients subjected to tracheotomy in Aragon, La Rioja and Soria, Spain, between 1988 and 2000 - Medrano Marina P.; Ruiz Escusol S.; Galván Manso M.; Muñoz Albillos M.S.; Rebage Moisés V.; López Pisón J. (Acta Pediatrica Espanola, 2003)
Introduction and objective: Advances in medical knowledge and technology, as well as the broadening of ethical criteria in order to improve the life quality of patients with chronic diseases generates new treatment demands, among them, improved respiratory function. The review of pediatric patients tracheotomized in recent years will help us to know the current situation and establish a comparative reference for the future. Patients and methods: The diagnoses in pediatric patients from Aragon, La Rioja and Soria, Spain, tracheotomized between January 1988 and December 2000, were reviewed. Results: Tracheotomy was performed in 17 patients. There were 5 emergency interventions: two cases of acute laryngotracheitis, two children with Down's syndrome (one with chronic lung disease and other with congenital heart disease) and one case of merosin-deficient congenital muscular dystrophy. The operation was elective on 12 occasions: one case of Pierre Robin syndrome, two infants with prenatal involvement of cranial nerves, one case of severe prenatal encephalopathy, one case of encephalopathy as a consequence of near-drowning, one malformation of the craniocervical junction with involvement of the spino-bulbar junction, one case of C1-C2 spinal cord trauma, one case of cervicomediastinal lymphangioma, one metabolic disorder with leukodystrophy and peripheral polyneuropathy, one case of severe mitochondrial encephalopathy, one case of severe infantile mitochondrial myopathy, and a Chiari II malformation. Comments: A neurological disorder at any level of the central nervous system or the neuromuscular junction may be an indication for tracheotomy.
Keywords: merosin; adolescent; Arnold Chiari malformation; assisted ventilation; cervical spinal cord; child; chronic respiratory failure; clinical article; Down syndrome; ethics; female; human; laryngotracheobronchitis; male; muscular dystrophy; neurologic disease; pediatrics; Pierre Robin syndrome; polyneuropathy; quality of life; respiratory function; review; Spain; tracheotomy

Is primary repair of esophageal perforation a safe method of management in case of patients with delayed diagnosis? - Rokicki M.; Rokicki W.; Wallner G. (Polski Przeglad Chirurgiczny, 2003)
Aim of the study was to determine whether primary surgical repair of esophageal perforation is effective when peformed after delayed diagnosis. Material and methods. The study group comprised 10 patients treated during the period between 1994 and 2000 due to esophageal perforation after delayed diagnosis. Perforation was caused by a foreign object in six cases, spontaneous esophageal rupture (Boerhaave's syndrome) in three, and cervical spine fracture on one. Predominant symptoms on admission, included mediastinitis, sepsis and endotoxic shock. Surgical management consisted in a two-layer suture closure of isolated and debrided esophageal edges, removal of fibrin and food residue form the lung, and extensive drainage of the mediastinum and pleural spaces. Eight patients required gastrostomy followed by pyloroplasty, seven received nutritional jejunostomy, while six underwent tracheostomy. Six patients required mechanical ventilation. Results. Six patients presented with postoperative complications, including three requiring reoperation. Remaining patients underwent conservative treatment, which proved successful. All patients survived. Conclusion. Our technique could be adapted individually to each case, enabling complete recovery of all patients who had been admitted to the hospital with delayed diagnosis of esophageal perforation. Moreover, management enabled to preserve the integrity of the esophagus. We believe that the above-mentioned method of treatment is quite safe.
Keywords: adult; aged; article; artificial ventilation; Boerhaave syndrome; cervical spine fracture; clinical article; clinical feature; complication; conservative treatment; debridement; diagnostic error; esophagus perforation; esophagus reconstruction; esophagus surgery; female; foreign body; gastrostomy; human; jejunostomy; male; mediastinitis; parenteral nutrition; postoperative complication; pyloroplasty; reoperation; sepsis; septic shock; surgical technique; survival; suture technique; thoracocentesis; tracheostomy; treatment outcome

Achondroplasia with respiratory failure - Omazić A.; Meštrović J.; Jurinović M.; Stričević L.; Polić B.; Lahman M. (Paediatria Croatica, 2003)
We have documented the case of a 3-year-old girl with achondroplasia, who was hospitalized in our clinic at the age of 14 months with bronchopneumonia and severe hypotonia. Breathing difficulties progressed to complete respiratory failure. She is now mechanically ventilated through a tracheostome. Computed tomography and magnetic resonance imaging showed narrowing of the foramen magnum and vertebrae at the level of the craniocervical junction with subsequent compression of the medulla. A suboccipital craniectomy and laminectomy of the atlas were carried out. Postoperatively the neurologic symptoms were slightly improved, but she had to be further mechanically ventilated. We wish to bring to attention the possibility of respiratory, failure caused by cervicomedullary compression in children with achondroplasia. We emphasize the importance of early diagnosis, the possibility of surgical intervention, and monitoring.
Keywords: achondroplasia; article; artificial ventilation; atlantooccipital joint; first cervical vertebra; breathing disorder; bronchopneumonia; case report; cervical spine; clinical feature; computer assisted tomography; craniectomy; disease association; disease course; disease severity; early diagnosis; female; foramen magnum; general condition improvement; hospitalization; human; laminectomy; monitoring; muscle hypotonia; neurologic disease; nuclear magnetic resonance imaging; postoperative period; preschool child; respiratory failure; spinal cord compression; tracheostomy; treatment outcome

Removal of the tracheostomy tube in the aspirating spinal cord-injured patient - Ross J.; White M. (Spinal Cord, 2003)
Study design: Four related case reports, occurring within a 10-month time frame during 2001. Objectives: Aspiration is commonly reported in the literature as a contraindication to decannulation. We report four examples of successful removal of the tracheostomy tube in the presence of aspiration by an experienced team, utilising a risk management approach. Setting: Victorian Spinal Cord Service (VSCS), Austin Hospital, Melbourne, Australia. Methods: Four individuals in our unit with traumatic spinal cord injury, three quadriplegic and one paraplegic, presented with aspiration identified by a positive modified Evan's blue dye test or constant coughing, gagging and oxygen desaturation during cuff deflation trials. In three of the four cases, the tracheostomy tube had been in situ for a prolonged period and the patients had failed to progress towards decannulation. A decision was made to decannulate these four patients in spite of the presence of traditionally held contraindications for decannulation. The multidisciplinary team carefully compared the inherent risks of premature decannulation against those of prolonged tracheostomisation. Given the risk associated with this procedure, a closely monitored decannulation protocol was instituted. Results: All four patients were successfully decannulated with improved quality of life, eating between 1 and 4 days and communicating immediately after decannulation. None experienced respiratory deterioration. Conclusion: It is possible to safely decannulate aspirating spinal cord injured individuals in some instances, using a risk management approach.
Keywords: adult; aged; article; aspiration pneumonia; case report; coughing; endotracheal tube; female; gastrointestinal symptom; human; male; oxygen saturation; paraplegia; priority journal; quadriplegia; quality of life; risk assessment; risk management; spinal cord injury; teamwork; tracheostomy; treatment contraindication

Clinical Ventilator Adjustments That Improve Speech - Hoit J.D.; Banzett R.B.; Lohmeier H.L.; Hixon T.J.; Brown R. (Chest, 2003)
Study objectives: We sought to improve speech in tracheostomized individuals receiving positive-pressure ventilation. Such individuals often speak with short phrases, long pauses, and have problems with loudness and voice quality. Subjects: We studied 15 adults with spinal cord injuries or neuromuscular diseases receiving long-term ventilation. Interventions: The ventilator was adjusted using lengthened inspiratory time (TI), positive end-expiratory pressure (PEEP), and combinations thereof. Results: When TI was lengthened (by 8 to 35% of the ventilator cycle), speaking time increased by 19% and pause time decreased by 12%. When PEEP was added (5 to 10 cm H 2O), speaking time was 25% longer and obligatory pauses were 21% shorter. When lengthened TI and PEEP were combined (with or without reduced tidal volume), their effects were additive, increasing speaking time by 55% and decreasing pause time by 36%. The combined intervention improved speech timing, loudness, voice quality, and articulation. Individual differences in subject response to the interventions were substantial in some cases. We also tested high PEEP (15 cm H2O) in three subjects and found speech to be essentially identical to that produced with a one-way valve. Conclusions: These simple interventions markedly improve ventilator-supported speech and are safe, at least when used on a short-term basis. High PEEP is a safer alternative than a one-way valve.
Keywords: adult; aged; article; artificial ventilation; clinical article; controlled study; female; human; inspiratory capacity; loudness; male; neuromuscular disease; positive end expiratory pressure; priority journal; speech articulation; speech rehabilitation; speech therapy; spinal cord injury; tidal volume; tracheostomy; ventilator; voice

Spinal fusion in patients with Duchenne's muscular dystrophy and a low forced vital capacity - Marsh A.; Edge G.; Lehovsky J. (European Spine Journal, 2003)
Traditionally, spinal fusion has been denied to patients with scoliosis secondary to Duchenne's muscular dystrophy (DMD) when their forced vital capacity (FVC) is less than 30-40% of predicted values (PFVC). The reasons for this decision are a theoretically increased risk of adverse events from a prolonged anaesthetic and extensive surgery. This paper presents a retrospective analysis of 30 patients with DMD scoliosis who underwent posterior spinal fusion at the Royal National Orthopaedic Hospital. Two subgroups of patients were compared: those with more than 30% PFVC (17 patients) and those with less than 30% PVFC (13 patients). One patient in each group required a temporary tracheotomy and there were nine complications in total. The post-operative stay for patients in each group was similar (24 days in the >30% group, 20 days in the <30% group) and the complication rate was comparable with other published series. We conclude that spinal fusion can be offered to patients with DMD even in the presence of a low FVC.
Keywords: adolescent; adult; article; breathing muscle; child; clinical article; controlled study; Duchenne muscular dystrophy; forced expiratory volume; human; postoperative complication; priority journal; scoliosis; spine fusion; spine surgery; tracheotomy

Ultrasound imaging in the preoperative estimation of the size of tracheostomy tube required in specialised operations in children - Hardee P.S.G.F.; Ng S.Y.; Cashman M. (British Journal of Oral and Maxillofacial Surgery, 2003)
Background: Some children are dependent on a tracheostomy for many years. As they grow, larger tracheostomy tubes may be required. Although tables of sizes of tracheas exist for different age groups, they are estimations of normal and may not be accurate for atypical cases. Chest radiographs and computed tomograms (CT) have been used experimentally to estimate tracheal sizes, but are not in regular use. Method: High-resolution diagnostic ultrasound imaging was used to estimate the internal and external transverse tracheal diameter, and the depth of the trachea from the skin surface. This allowed selection of the correct standard pattern tracheostomy tube, or the construction of a custom-made tube preoperatively. Results: Four children with various abnormalities who were being considered for replacement tracheostomies were scanned. In one, diagnostic ultrasound confirmed that a new larger fenestrated tube could be placed, which subsequently improved vocalisation and respiration. In the other three, the scan showed there was no space to allow a larger tube to be placed. The standard tables were not suitable for any of these patients. Conclusion: High-resolution ultrasound has a role in the non-invasive measurement of the size of the tube needed for specialised operations in children. © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: adolescent; article; atlantoaxial dislocation; breathing; case report; diagnostic imaging; Down syndrome; echography; endotracheal tube; human; male; non invasive measurement; paraplegia; pediatric surgery; preoperative evaluation; preschool child; pterygium; school child; skin surface; spinal cord transsection; standard; surgical technique; trachea; tracheostomy; traffic accident; vocalization

Basilar artery thrombosis in a trauma patient. Case report and review of the literature - De Decker K.; Van Havenbergh T.; D'Archambeau O.; Jorens P.G. (Resuscitation, 2003)
Thrombotic disease of the vertebrobasilar circulation is associated with a poor prognosis. It may occur in trauma patients, especially those with neck injuries and even several months after the initial insult. We report on the case of a young polytrauma patient, victim of a traffic accident, with associated cervical and thoracic spinal injuries resulting in paraplegia. Consciousness was not impaired initially, but during transfer to our hospital he became suddenly unconscious. An occluded basilar artery was found on angiography, but unfortunately we were unable to reopen the vessel with thrombolytic therapy. This case again proves that lesions of the vertebro-basilar system must always be suspected in neck injuries. Even after minor whiplash injuries, fatal basilar thrombosis may occur. A review of all reported cases of traumatic basilar artery thrombosis is given and the use of thrombolytic therapy is discussed. © 2003 Elsevier Ireland Ltd. All rights reserved.
Keywords: acetylsalicylic acid; alteplase; anticonvulsive agent; corticosteroid; dexamethasone; dopamine; heparin; mannitol; steroid; streptokinase; urokinase; warfarin; adult; anamnesis; angiography; anticoagulation; artery thrombosis; article; basilar artery; brain stem infarction; brain surgery; case report; cause of death; cerebellum infarction; cervical spine dislocation; cervical spine fracture; cervical spine injury; consciousness; conservative treatment; fatality; fibrinolytic therapy; head injury; human; intervertebral disk hernia; lung contusion; lung embolism; male; paraplegia; pleura effusion; priority journal; shock; spinal shock; spine fusion; thoracic spine; thorax injury; tracheotomy; traffic accident; unconsciousness; vertebral artery; whiplash injury; actilyse; actosolv

Inpatient chronic assisted ventilatory care: A 15-year experience - Wijkstra P.J.; Avendaño M.A.; Goldstein R.S. (Chest, 2003)
Study objectives: Ventilator users who are unable to leave the acute care setting may be transferred to a unit for chronic assisted ventilatory care (CAVC) with the goal of optimizing their level of function. In this report, we summarize the outcomes of all patients admitted to a CAVC unit between 1986 and 2001. Patients and methods: Fifty patients (24 with neuromuscular disease [NMD], 10 with spinal cord injury, [SCI], 7 with thoracic restriction [TR], 7 with COPD, and 2 with parenchymal restriction [PR]) were reviewed. Thirty-eight patients were transferred to the CAVC unit from intensive care, 5 patients were transferred from inpatient respiratory rehabilitation, 4 patients came from home, and 3 patients came from pediatric long-term care. At the time of CAVC unit admission, all patients were receiving mechanical ventilation via a tracheostomy tube. Results: Ventilator time increased gradually in patients with COPD from 16 h (SD, 5.6) to 22.9 h (SD, 3.0) per day (p < 0.05), and in patients with TR from 18.9 h (SD, 6.1) to 22.9 h (SD, 4.5) [not significant]. Five of the 10 patients with SCI were decannulated. Functional mobility, which decreased in patients with COPD and patients with TR, remained stable in NMD and PR and improved in SCI. Eighteen patients returned home or to an attendant care facility (COPD, n = 1; NMD, n = 10; SCI, n = 5; PR, n = 2); 11 patients died in the CAVC unit (COPD, n = 6; TR, n = 3; NMD, n = 1; SCI, n = 1); and 7 patients were transferred to intensive care, where they died. The average direct cost per patient per diem increased from $252 (Canadian) in 1988 to $335 in 2001. Conclusion: A CAVC unit can provide a safe environment for severely impaired, ventilator-dependent individuals, many of whom (36%) left for a more independent community-based environment. Better outcomes were seen among patients with SCI and NMD than in patients with COPD and TR.
Keywords: adult; aged; article; artificial ventilation; assisted ventilation; biosafety; Canada; cannulation; cause of death; chronic obstructive lung disease; clinical feature; community care; controlled study; devices; disease severity; environmental factor; female; health care cost; health care facility; home care; hospital admission; hospital department; hospital patient; human; intensive care; intensive care unit; long term care; major clinical study; male; medical practice; mobilization; neuromuscular disease; parenchyma; priority journal; spinal cord injury; statistical significance; time; tracheostomy; treatment outcome; tube

Noninvasive interface for transtracheal mechanical ventilation for patients with severe cervical spine deformity - Gonzalez E.L.; Bishop R.G.; Bach J.R. (American Journal of Physical Medicine and Rehabilitation, 2003)
This article describes a custom-molded patient-to-ventilator interface that permits mechanical ventilation via a tracheostomy site for patients for whom tracheostomy tubes can not be used because of severe cervical deformity. The nocturnal delivery of intermittent positive-pressure ventilation resulted in normalization of oxyhemoglobin saturation and end-tidal CO2 and alleviation of symptoms of alveolar hypoventilation. Thermoplastic patient-ventilator tubing interfaces can be constructed to permit ventilatory assistance for patients with tracheostomies who can not use tracheostomy tubes.
Keywords: oxyhemoglobin; adult; article; artificial ventilation; capnometry; case report; cerebral palsy; cervical spine; devices; female; human; hypoventilation; man machine interaction; oxygen saturation; spine malformation; tracheostomy

Emergency surgery in thoracoabdominal aneurysms repair: Clinical outcome - Loddo P.; Degiudici A.; Maxia A.; Pibiri L.; Pisu F.; Ruiu G.; Zanetti P.P. (Giornale Italiano di Chirurgia Vascolare, 2003)
Aim. Surgical treatment of thoracoabdominal aneurysms (TAA) represents a burdensome problem for the vascular surgeon and may become a formable challenge in an emergency procedure. In patients with hemodynamic instability and prolonged low blood pressure, protective measures (cerebral spinal fluid drain-age and/or Bio-pump) against spinal cord, visceral or renal ischemia may be ineffective or impracticable. Methods. We report our experience with 28 emergency-operated patients with TAA out of 117 treated between 1994 and 2001; 23 were men and 5 were women (age range, 33-83 years; mean, 62 years); 57.1% presented with true aneurysms, 42.9% with dissecting aneurysms; 89.2% were hemodynamically unstable; 10.7% were hemodynamically stable. Based on findings from computed tomography scanning with contrast media, the TAA were evaluated by the Crawford classification as 9 type I, 9 type II, 8 type III, and 2 type IV. The surgical technique adopted in the emergency treatment of TAA is described. Results. Overall mortality was 42.8% (12/28); 4 deaths occurred during the operation, 7 within 30 days and 1 within 60 days. Early deaths subdivided by Crawford TAA type were: 2/9 type I, 4/9 type II, 4/8 type III and 1/2 type IV. Out of 24 patients, 4 developed paraplegia/paraparesis (16.6%); spinal cord damage was permanent in 3 out of 4 and bilateral in 3 out of 4 patients. Type H TAA, which was present in 4 patients, of which 2 developed paraplegia/paresis (P/P), was found to be a high risk factor (p=0.02), as was prolonged intra- and postoperative low blood pressure (4 out of 4 patients), (p=0.01). Acute renal failure (ARF) was present in 16.6% of cases (4/24). Dialysis was found to be a risk factor for hospital mortality (p=0.03). Pulmonary insufficiency was present in 33.3% (8/24); 3 patients received tracheostomy, of which 2 died (p=0.04). Postoperative bleeding was present in 20.8% (5/24). Inferior laryngeal nerve palsy was present in 16.6% (4/24). The follow-up period comprised 12-60 months; the 6-year actuarial survival rate of the 16 patients discharged from the hospital was 50%. Conclusion. The literature contains few studies on emergency treatment for TAA; the study data do not distinguish between hemodynamically stable and unstable patients. It is well known that the 2 different classes of patients are not comparable because hemodynamically patients do not differ from those who receive elective surgery. Wider studies are needed to shed light on the pathophysiology and surgical management of TAA, which are still being treated according to the individual surgeon's experience.
Keywords: contrast medium; abdominal aortic aneurysm; acute kidney failure; adult; aged; aneurysm surgery; dissecting aortic aneurysm; article; clinical article; clinical practice; computer assisted tomography; contrast enhancement; disease classification; emergency surgery; experience; female; follow up; hemodialysis; hemodynamic monitoring; high risk patient; human; hypotension; laryngeal nerve; lung insufficiency; male; nerve paralysis; outcomes research; paraplegia; postoperative hemorrhage; risk assessment; risk factor; scoring system; spinal cord lesion; surgeon; surgical mortality; surgical technique; survival rate; thoracic aorta aneurysm; tracheostomy

Long term ventilation in neurogenic respiratory failure - Howard R.S.; Davidson C. (Neurology in Practice, 2003)
Keywords: anterior horn cell disease; artificial ventilation; breathing disorder; breathing muscle; breathing pattern; central nervous system disease; cervical spinal cord injury; clinical feature; coughing; human; intermittent positive pressure ventilation; long term care; lung alveolus hypoventilation; muscle weakness; neuromuscular junction disorder; neuropathy; palliative therapy; pathophysiology; positive end expiratory pressure; priority journal; respiration control; respiratory failure; review; risk factor; sleep disordered breathing; tracheostomy; treatment indication; treatment outcome

Difficult airway in a child with spinal muscular atrophy type I - Arima H.; Sobue K.; Tanaka S.; Morishima T.; Ando H.; Katsuya H. (Paediatric Anaesthesia, 2003)
Spinal muscular atrophy (SMA) type I is a relatively common inherited neuromuscular disease of hypotonic newborns, but is not associated with craniofacial abnormalities. There is nothing in the literature about difficult intubation in patients affected by this disease. We report a case of 34-month-old girl with SMA type I who was scheduled for emergency endoscopic laser treatment of tracheal stenosis caused by granulations. Tracheostomy was performed at 17 months of age and before this, the orotracheal tube was changed periodically without difficulty. For this laser treatment, orotracheal intubation was required. Preoperative physical examination revealed micrognathia and class II malocclusion. Opening her mouth was not difficult. Although difficult orotracheal intubation was predictable, we attempted to intubate her trachea as usual, but could not visualize the epiglottis. We decided to proceed with retrograde intubation, one of the standard techniques employed in a child with a difficult airway, via the tracheostome. A feeding nasogastric catheter was used as a guide catheter, and our strategy was successful. In this study we report a case of difficult airway in a child with SMA type I. The relationship between SMA type I with a tracheostome and difficult airway are discussed.
Keywords: article; case report; craniofacial malformation; endotracheal intubation; epiglottis; female; granulation tissue; human; infantile hypotonia; laser surgery; micrognathia; nasogastric tube; neuromuscular disease; preschool child; priority journal; spinal muscular atrophy; trachea stenosis; tracheotomy

Dysphagia in patients with acute cervical spinal cord injury - Wolf C.; Meiners T.H. (Spinal Cord, 2003)
Study design: Longitudinal observational. Objectives: (a) To establish a reliable and feasible method to indicate the presence and severity of dysphagia and (b) to establish a course of treatment in individuals presenting with cervical spinal cord injury (CSCI). Setting: Spinal Cord Injury Center, Werner Wicker Klinik, Bad Wildungen, Germany. Patients and methods: This is a cross-sectional study of 51 patients consecutively admitted to the Intensive Care Unit of the SCI in-patient service. They were subjected to neurological and fiberoptic endoscopic examination of swallowing (FEES). Data concerning artificial respiration, presence of tracheostomy, oral or non-oral feeding were obtained from the medical charts. Statistics were carried out by a calculation of a nonparametric correlation (Spearman). Results: Five levels of dysphagia could be distinguished. At levels 1 and 2, patients presented with a severe impairment of swallowing, in level 3 aspiration was met by a powerful coughing reflex, level 4 comprised a laryngeal edema and/or a mild aspiration of fluids only and at level 5 laryngeal function was not compromised. On admission, 20 patients with CSCI presented with mild (level 4), eight with moderate (level 3) and 13 with severe dysphagia (levels 1 and 2). In 10 no signs of dysphagia could be detected. After treatment, level 1 was no longer detected, one patient showed level 2, two patients showed level 3, all other patients showed only mild or no signs of dysphagia any longer. Conclusions: Dysphagia of various severities was present in the majority of these patients with CSCI together with respiratory insufficiency. FEES allows for the detection and classification of dysphagia as well as for an evaluation of the therapeutic management. Under interdisciplinary treatment the prognosis of dysphagia is good.
Keywords: adolescent; adult; aged; article; artificial ventilation; aspiration; cervical spinal cord injury; controlled study; coughing; disease severity; dysphagia; fiberscope endoscopy; fluoroscopy; Germany; human; intensive care unit; larynx edema; longitudinal study; major clinical study; neurologic examination; priority journal; prognosis; reliability; respiratory failure; tracheostomy

Psychological management of two cases of self injury on the paediatric intensive care unit - Colville G.A.; Mok Q. (Archives of Disease in Childhood, 2003)
Self injury has not been previously reported in an intensive care setting. Two cases are presented of ventilator dependent children with high spinal cord lesions who exhibited an unusual form of self mutilation, namely lip biting. The key to extinguishing this behaviour was to address the children's psychological needs.
Keywords: anger; article; assisted ventilation; automutilation; behavior therapy; bite; case report; child; clinical feature; fear; female; human; intensive care; play therapy; priority journal; psychosocial withdrawal; social isolation; spinal cord lesion; spine fusion; stress; symptom; tracheostomy; ventilator

Stab wounds to the neck with partial transsection of the spinal cord and penetrating injury to the esophagus - Platz A.; Kossmann T.; Payne B.; Trentz O. (Journal of Trauma - Injury, Infection and Critical Care, 2003)
Keywords: methylene blue; abdominal injury; adult; article; body position; case report; clinical feature; colon perforation; esophagus injury; female; hemorrhagic shock; human; intubation; laparotomy; liquorrhea; neck injury; physical examination; priority journal; quadriplegia; resuscitation; spinal cord transsection; stab wound; surgical technique; tracheostomy; treatment outcome

Respiratory management of pediatric patients with spinal cord injuries: Retrospective review of the duPont experience - Padman R.; Alexander M.; Thorogood C.; Porth S. (Neurorehabilitation and Neural Repair, 2003)
Pulmonary complications contribute to morbidity and mortality in spinal cord injuries (SCIs). A retrospective review of 20 years of experience with tracheostomy- and ventilator-dependent SCI children is presented. The authors developed and analyzed a database of 47 children (average age = 11.4 years). Of the patients, 27% had concomitant brain injuries, 690 had prior histories of reactive airway disease, and 2% had thoracic fractures. Injuries were caused by motor vehicle accidents (53%); gunshot wounds (19%); sports-related accidents (19%); and vascular injuries, transverse myelitis, or spinal tumors (8%). Of the injuries, 52% were high level (C1 to C2) and 48% were mid- or low level (C3 to C5). Two groups were analyzed for demographic information. Complications included tracheitis, atelectasis, and pneumonia. Mean tidal volume was 14 cm2/kg (maximum = 22 cm2/kg). Bedside lung function parameters were attempted to assess readiness and the rapidity of weans. T-piece sprints were used to successfully wean 63% of patients. Successfully weaned patients were compared with those not weaned. No deaths or readmissions for late-onset respiratory failure postwean occurred. The authors' clinical impression favors higher tidal volumes and aggressive bronchial hygiene to minimize pulmonary complications and enhance weaning. Successfully weaned patients had fewer complications. A critical pathway for respiratory management of SCI children is presented.
Keywords: adult; article; artificial ventilation; atelectasis; blood vessel injury; child; clinical article; gunshot injury; human; myelitis; pneumonia; respiratory failure; spinal cord injury; spinal cord tumor; sport injury; tidal volume; tracheitis; tracheostomy; traffic accident

Mechanical insufflation/exufflation: Has it come of age? A commentary - Bach J.R. (European Respiratory Journal, 2003)
Keywords: abdominal pressure; abdominal wall musculature; acute respiratory failure; aeration; airway dynamics; amyotrophic lateral sclerosis; artificial ventilation; breathing muscle; bronchus secretion; bulbar paralysis; chronic obstructive lung disease; coughing; diaphragm paralysis; Duchenne muscular dystrophy; editorial; expiratory reserve volume; glottis; human; intercostal muscle; lung clearance; atelectasis; lung volume; medical device; muscle function; muscle weakness; neuromuscular disease; peak expiratory flow; positive end expiratory pressure; priority journal; respiratory tract infection; spinal cord injury; spinal muscular atrophy; trachea stenosis; tracheotomy; Cough-Assist

Dysphagia due to C4-5 spinal cord injury and its mechanism - Report of a case - Ito H. (Otolaryngology - Head and Neck Surgery (Tokyo), 2003)
A 25-year-old man with C4-5 spinal cord injury who underwent anterior cervical fusion had disphagia after the operation. Dysphagia was resulted from pain after the operation, but not from the cranial nerve disorders. The respiratory dysfunction, placement of a naso-tracheal tube, tracheostomy and the placement of a tracheal tube, which resulted in difficulty of expectoration of pooled materials in the hypopharynx and the upper trachea, made his dysphagia more serious. The serious dysphagia consequently required the placement of a tracheal tube. Cutting this vicious circle by the medical management and the physical therapy for respiratory dysfunction, we could succeed in his oral intake. Excluding the factors influencing negatively to dysphagia is important.
Keywords: adult; article; case report; cervical spine; dysphagia; endotracheal intubation; endotracheal tube; human; male; nasotracheal intubation; postoperative pain; respiratory failure; spinal cord injury; spine fusion; tracheostomy

Bilateral vocal cord paralysis caused by cervical spinal osteophytes - Aydin K.; Ulug T.; Simsek T. (British Journal of Radiology, 2002)
Thyroid and cervical surgery, tracheal intubation, trauma and neurodegenerative and neuromuscular diseases may cause bilateral vocal cord paralysis. There are only a few reported cases of bilateral cord paralysis associated with cervical hyperostosis in the English literature. We report the MR and CT findings of a case of bilateral vocal cord paralysis caused by cervical spinal osteophytes compressing the recurrent laryngeal nerves.
Keywords: aged; airway obstruction; anamnesis; anemia; article; case report; cervical spine; computer assisted tomography; disease association; disease severity; electromyography; follow up; hoarseness; human; hyperostosis; laboratory test; laryngoscopy; magnet; male; muscle rigidity; nerve compression; nuclear magnetic resonance imaging; osteophyte; peripheral neuropathy; recurrent laryngeal nerve; stridor; surgical technique; tracheotomy; vocal cord paralysis; Magnetom impact

Major respiratory tract traumas - Petrov D.; Obretenov E.; Kalaidzhiev G.; Plochev M.; Kostadinov D. (Khirurgiia, 2002)
Between 1988 and 2000 a total of 33 patients with traumatic tracheobronchial lesions were diagnosed and treated. The trauma was penetrating in 7 (stab and gun-shot), blunt in 10 (car accidents, compression and falling from heights) and iatrogenic in 16 of them (postintubational--15, after foreign body extraction--1). The main clinical and radiological features were subcutaneous emphysema, hemoptysis, respiratory insufficiency, pneumomediastinum and pneumothorax. The diagnosis was confirmed in all patients by early fiberoptic bronchoscopy. "Watch and see" tactics with massive antibiotics therapy was followed in 4 (12%) patients. A surgical treatment was carried out in 29 (88%) patients as follows: simple repair--19 (58%), left pneumonectomy--2 (6%), tracheal resection and anastomosis "end to end"--2 (6%), tracheostomy--1 (3%), thoracocenthesis and drainage--3 (9%) and cervical mediastinotomy--2 (6%). The operative mortality was 9%. The cause of death in these 3 patients were associated brain and spinal cord injuries. In the rest of patients the early and long-term postoperative results were considered very good.
Keywords: adolescent; adult; aged; article; blunt trauma; bronchoscopy; bronchus; child; human; injury; male; middle aged; penetrating trauma; preschool child; thorax injury; thorax surgery; trachea

Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta - Kouchoukos N.T.; Masetti P.; Rokkas C.K.; Murphy S.F. (Annals of Thoracic Surgery, 2002)
Background. Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch, the descending thoracic, and the thoracoabdominal aorta. The safety and efficacy of this technique when compared with other adjuncts (ie, simple aortic clamping, partial cardiopulmonary bypass, regional hypothermia) is not clearly established. Methods. One hundred and ninety-two patients (age range, 20 to 83 years) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest (mean, 38 minutes). The technique was used when the location and severity of disease precluded placement of clamps on the proximal aorta (31 patients) or (in 161 patients) when extensive thoracic (47) or thoracoabdominal (114) aortic disease was present, and the risk for development of spinal cord ischemic injury was judged to be increased. Lower intercostal and lumbar arteries were attached separately to the aortic graft in 101 of the 161 patients (63%) who had extensive aortic replacement. No other adjuncts for spinal cord protection were used. Results. The 30-day mortality was 6.8% (13 patients). It was 40% (8 of 20) for patients having emergent operations (acute aortic dissection or rupture) and 2.9% (5 of 172) for all others (p < 0.001). The 90-day mortality was 12.5% (24 patients). Paraplegia occurred in 4 and paraparesis in 1 (full recovery) of the 186 operative survivors whose lower limb function could be assessed postoperatively (2.7%). Among the 109 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 36 with Crawford extent I, 0 of 42 with extent II, and 2 of 31 with extent III disease. One patient (extent II) developed paraplegia on the 9th postoperative day after a hypotensive episode. None of the 47 patients with aortic dissection developed paralysis. Among the 186 operative survivors, renal dialysis was required in 4 patients (2.2%), prolonged inotropic support in 18 (10%), reoperation for bleeding in 9 (5%), mechanical ventilation (≥ 48 hours) in 64 (34%), and tracheostomy in 17 (9%). Four patients (2%) sustained a stroke. Conclusions. Hypothermic cardiopulmonary bypass with circulatory arrest provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts. © 2002 by The Society of Thoracic Surgeons.
Keywords: inotropic agent; abdominal aorta; adult; aged; aortic clamping; aortic disease; aortic dissection; aortic graft; aortic reconstruction; aortic rupture; aortic surgery; artery transplantation; artificial ventilation; conference paper; descending aorta; disease severity; emergency surgery; extracorporeal circulation; female; hemodialysis; human; hypotension; induced hypothermia; intermethod comparison; lumbar artery; major clinical study; male; paraplegia; postoperative hemorrhage; priority journal; reoperation; spinal cord injury; spinal cord ischemia; cerebrovascular accident; surgical mortality; surgical technique; thoracic aorta; tracheostomy

Surgical tracheostomy versus percutaneous dilational tracheostomy in patients with anterior cervical spine fixation: Preliminary report - Šustić A.; Krstulović B.; Eškinja N.; Zelić M.; Ledić D.; Turina D. (Spine, 2002)
Study Design. A prospective, randomized study. Objectives. To compare the incidence of perioperative and early postoperative complications of surgical tracheostomy (ST) vs. ultrasound-guided percutaneous dilational tracheostomy (PDT) in patients with anterior cervical spine fixation (ACSF). Summary of Background Data. The patients with ACSF after acute spinal cord injury often require tracheostomy. Surgical tracheostomy is burdened with relatively high incidence of peristomal infections, and, recently, ultrasound-guided PDT is proposed in patients with ACSF. Methods. Sixteen adult patients who underwent tracheostomy after acute spinal cord injury and ACSF were analyzed. The patients were randomly assigned to two groups: eight patients (six males; age range, 24-59 years) who underwent ST and eight patients (seven males; age range, 19-47 years) who underwent ultrasound-guided PDT with dilatational forceps technique. The incidence of peri- and early postoperative complications was followed up, as well as the stoma infections and the duration of the procedure. Results. Not one patient from either group had any major perioperative complication of tracheostomy. In each group, there was one case of prolonged bleeding, which stopped spontaneously inside 24 hours. In two patients (25%) from the ST group, purulent infection of the stoma was verified during subsequent treatment at an intensive care unit. The average time of ST was 21 ± 7 minutes; the average time of ultrasound-guided PDT was 8 ± 6 minutes (P < 0.05). Conclusions. Our preliminary data demonstrate that ultrasound-guided PDT as regards to complications is at least equally safe as ST; at the same time, it is much quicker method, probably with less late infections of the stoma, which could be an important advantage in patients with ACSF.
Keywords: adult; article; cervical spinal cord injury; clinical article; clinical trial; controlled clinical trial; controlled study; echography; female; human; intermethod comparison; male; operation duration; postoperative complication; postoperative hemorrhage; postoperative infection; priority journal; randomized controlled trial; spine stabilization; surgical technique; tracheostomy

Survival of individuals receiving long-term mechanical ventilation - Langmack E.L.; Make B.J. (Respiratory Care Clinics of North America, 2002)
The reports published to date support the concept that LTMV can extend life for patients with respiratory insufficiency, particularly adults and children with neuromuscular and chest wall diseases. The impact of LTMV on survival in patients with obstructive lung diseases, such as COPD and bronchiectasis, is less clear and deserves further study. For all disease states, research is needed to determine the characteristics of patients who are most likely to benefit from LTMV and whether one method of ventilation is superior to another. In addition to survival, other important outcomes, such as patient satisfaction, quality of life, and costs associated with LTMV, should be assessed in future long-term studies.
Keywords: antibiotic agent; corticosteroid; oxygen; riluzole; amyotrophic lateral sclerosis; article; artificial ventilation; bronchiectasis; chronic disease; chronic obstructive lung disease; controlled study; drug efficacy; Duchenne muscular dystrophy; health care cost; human; intermethod comparison; intermittent positive pressure ventilation; interstitial lung disease; lifespan; long term care; medical research; methodology; morbidity; mortality; neuromuscular disease; oxygen therapy; patient care; patient satisfaction; poliomyelitis; quality of life; respiratory failure; risk factor; spinal cord injury; survival; survival rate; thorax deformity; tracheostomy; treatment outcome

Self inflicted neck injury with an electric drill - Barnes D.; Clark F.; Baguley P.; Brady N. (Injury, 2002)
Keywords: adult; air conditioning; airway obstruction; anamnesis; angiography; artery occlusion; article; automutilation; case report; cervical spine fracture; clinical feature; computer assisted tomography; drill; esophagus injury; human; immobilization; infection; male; neck injury; neurologic disease; nuclear magnetic resonance imaging; priority journal; risk factor; spinal cord injury; tracheotomy; vertebral artery

Bilateral vocal fold paralysis and adhesion in anterior spinal artery syndrome - Omori K.; Isshiki N.; Tsuji T.; Yamashita M. (Annals of Otology, Rhinology and Laryngology, 2002)
The purpose of this report is to present a rare case of anterior spinal artery syndrome (ASAS) in which there proved to be a combined lesion of paralysis and adhesion. A 26-year-old woman with a history of ASAS complained of difficulty of tracheal decannulation. In 1988, she was intubated and underwent tracheotomy because of respiratory muscle weakness, and she was decannulated in 1990. In 1998, she had cesarean delivery under general anesthesia, and postdelivery dyspnea necessitated tracheotomy again. On her first visit to us, endoscopic examination revealed bilateral vocal fold immobility at the midline without an apparent web. Direct laryngoscopy under general anesthesia revealed a posterior glottic adhesion and scarring, which were treated by excision of the scar and local steroid injection. The left vocal fold gradually regained mobility, permitting decannulation 3 months after treatment. This complicated vocal fold immobility was found to be due to adhesion and partial paralysis combined.
Keywords: triamcinolone acetonide; adhesion; adult; article; breathing muscle; case report; cesarean section; differential diagnosis; dyspnea; endotracheal intubation; female; general anesthesia; glottis; human; laryngoscopy; muscle weakness; priority journal; scar formation; spinal cord ischemia; tracheotomy; vocal cord paralysis

Continuous noninvasive ventilation for patients with neuromuscular disease and spinal cord injury - Bach J.R. (Seminars in Respiratory and Critical Care Medicine, 2002)
Patients with a variety of neuromuscular diseases including quadraplegia due to high spinal cord lesions can be managed with full-time noninvasive ventilation instead of intermittent positive pressure ventilation (IPPV) via a tracheostomy. This approach is not suitable for patients with severe bulbar involvement. To be successful with full-time noninvasive IPPV, the ventilator user must realize three goals. First, respiratory system compliance should be optimized and maintained by frequent full inflations delivered by stacking breaths from a volume-cycled ventilator or by insufflating air at adequate pressures using a mechanical insufflator-exsufflator. Second, normal levels of alveolar ventilation are sustained using a variety of noninvasive approaches, including nasal, oronasal, or mouthpiece interfaces. Third, patients must be taught to use techniques and devices to enhance cough, particularly the mechanical insufflator-exsufflator. When these goals are met, noninvasive NPPV can offer patients greater comfort, simpler and more convenient ventilator use, and reduced rates of infections, complications, and hospitalizations as compared with tracheostomy IPPV.
Keywords: assisted ventilation; breathing muscle; coughing; devices; intermittent positive pressure ventilation; lung compliance; lung ventilation; neuromuscular disease; priority journal; review; spinal cord injury; tracheostomy; ventilator; BiPAP S/T-D; Cough Assist; Exsufflation Belt; Total Face Mask

Respiratory support in spinal muscular atrophy type I: a survey of physician practices and attitudes. - Hardart M.K.; Burns J.P.; Truog R.D. (Pediatrics, 2002)
OBJECTIVE: To determine whether there is variability in the attitudes and practices of physicians regarding treatment of respiratory failure in children with spinal muscular atrophy type I (SMA type I) and, if so, whether this variation is associated with professional training. METHODS: This was a descriptive, cross-sectional survey mailed to a randomly selected subset of the Child Neurology Society, pediatric members of the Society of Critical Care Medicine and to the membership of the Pediatric Interest Section of the American Academy of Physical Medicine and Rehabilitation. A scenario of a child with SMA type I in respiratory distress was followed by questions that explored practices and attitudes regarding mechanical ventilation. RESULTS: Fifty-seven percent of intensivists (75 of 132), 39% physiatrists (61 of 155), and 34% of neurologists (61 of 155) responded. Specialists differed as to whether they offered and/or recommended respiratory support to patients with SMA type I. Intensivists were less likely to offer and recommend tracheostomy than physiatrists. Intensivists were also significantly less likely than physiatrists to agree with statements supporting the ethical necessity of noninvasive mechanical ventilation (NIMV) and intubation in the setting of an acute respiratory illness, and NIMV and tracheostomy in the setting of chronic respiratory failure. Although parallel differences were found between physiatrists and neurologists regarding their attitudes toward mechanical ventilation, no significant differences were detected between intensivists and neurologists. Finally, physicians who reported that a high percentage of their patients with SMA type I received "comfort care only" also tended to view mechanical ventilation, ie, use of NIMV for chronic respiratory failure, use of intubation for an acute respiratory infection, and use of tracheostomy for chronic respiratory failure as an unreasonable intervention in most circumstances. CONCLUSIONS: We found a wide variation in physician practice regarding the mechanical ventilation of patients with SMA type I. This study suggests a wide variation not only in what is recommended but also in what is actually offered to families of these children. Furthermore, the study suggests that physician training and attitudes affect recommendations regarding mechanical ventilation and ultimately family decision making.
Keywords: article; artificial ventilation; child; clinical practice; cross-sectional study; health personnel attitude; hereditary spinal muscular atrophy; human; medical ethics; respiratory failure; United States; utilization review

Spinal muscular atrophy type 1: Management and outcomes - Bach J.R.; Baird J.S.; Plosky D.; Navado J.; Weaver B. (Pediatric Pulmonology, 2002)
Our objectives were to describe survival, hospitalization, speech, and outcomes related to respirator needs for spinal muscular atrophy type 1 (SMA1) patients, using noninvasive or tracheostomy ventilation. From 65 SMA patients referred to our clinic since 1996, we chose 56 SMA1 patients who developed respiratory failure before age 2 years. Patients either had tracheostomy tubes (group A), or used noninvasive ventilation and assisted coughing; a previously reported extubation protocol (group B) was used as needed. Sixteen patients underwent tracheostomy at 10.8 ± 5.0 months of age, 33 were in group B, and 7 others died without life-support interventions. Compared to group B, group A patients had fewer hospitalizations until age 3 years, but more after age 5, and 15 of 16 lost all spontaneous breathing tolerance posttracheostomy and could not speak. One group A patient died at 16 months of age, and the others were 73.8 ± 57 months of age (the oldest was 19 years old). Two group B patients died at 6 and 13 months, respectively, whereas the other 31 were 41.8 ± 26.0 months (and up to 8.3 years) old. Three of 31 in group B required high-span positive inspiratory pressure plus positive end-expiratory pressure (PIP+PEEP) continuously with minimal tolerance for breathing on their own, and 4 could not communicate verbally. In conclusion, SMA type 1 children can survive beyond 2 years of age when offered tracheostomy or noninvasive respiratory support. The latter is associated with fewer hospitalizations after age 5 years, freedom from daytime ventilator use, and the ability to speak. © 2002 wiley-Liss, Inc.
Keywords: adolescent; adult; article; artificial ventilation; child; hospitalization; human; infant; major clinical study; outcomes research; priority journal; respiratory failure; speech; spinal muscular atrophy; survival; tracheostomy; ventilator

A protocolized approach to pulmonary failure and the role of intermittent prone positioning - Michaels A.J.; Wanek S.M.; Dreifuss B.A.; Gish D.M.; Otero D.; Payne R.; Jensen D.H.; Webber C.C.; Long W.B. (Journal of Trauma - Injury, Infection and Critical Care, 2002)
Introduction: We present a series of adult patients treated under a protocol for severe lung failure (acute respiratory distress syndrome [ARDS]) that uses positive end-expiratory pressure (PEEP) optimization and intermittent prone positioning (IPP) to reduce shunt, improve oxygen (O2) delivery, and reduce Fio2. Methods: Trauma, emergency vascular, and general surgical patients with Pao2/Fio2 (PF) ratio < 200 were entered into a protocol designed to maintain mixed venous saturation (Svo2) > 70% with Fio2 < 0.50. Therapy involved a sequential algorithmic approach that included pulmonary artery oximetry, "best-PEEP" determination, optimization of cardiac function, limitation of Vo2, transfusion to hematocrit of 35%, frequent bronchoscopy, rational diuresis and, if the Fio2 was > 0.50, a trial of IPP with every-6-hour rotations. Unstable spine fractures and pelvic external fixators were the only contraindications to IPP. We collected data prospectively and from the charts and trauma registry. Results: Forty adults were treated by protocol, 29 were injured and 11 had vascular or general surgical primary problems. The patients were 46.3 ± 3.1 years old (the trauma patients were 42.9 ± 3.2, and the vascular/general patients were 62 ± 7.5 years old). Average Injury Severity Score was 25.9 ± 3.7 and the Murray lung injury score was 2.65 ± 0.9. IPP was used in all patients including those with recent tracheostomy, open abdomens, laparotomy, thoracotomy, leg external fixators, central nervous system injury, continuous venovenous hemofiltration and extracorporeal membrane oxygenation cannulae, vasopressor therapy, recent chest wall open reduction and internal fixation, and facial fractures. With the initiation of IPP therapy, the PF ratio increased from 132.1 ± 8.5 to 231.6 ± 14.2 (p < 0.001), the Fio2 was decreased from 65.9 ± 4.0% to 47.0 ± 1.1% (p < 0.001), and the Svo2 increased from 75.3 ± 1.8% to 78.6 ± 1.6% (p = 0.023). PEEP and static compliance were unchanged. The duration of IPP was 85.6 ± 14.9 hours (median, 55 hours; range, 12 to 490 hours). Within 48 hours, all patients were on Fio2 ≤ 0.50. Mortality was 20% (14% for trauma) and none died of ARDS. The only complications of IPP were one case of partial-thickness skin loss from a malpositioned nasogastric tube and a case of transient lingual edema. Conclusion: IPP was independently responsible for an increase in PF ratio and SVO2. We effectively and safely used IPP in our patients with ARDS, including many with issues generally considered to be contraindications. IPP and best-PEEP therapy enabled us to wean all of our patients' Fio2 to ≤ 0.50 within 48 hours of ARDS onset.
Keywords: hypertensive agent; adolescent; adult; adult respiratory distress syndrome; aged; article; blood vessel injury; body position; bronchoscopy; central nervous system disease; clinical article; diuresis; extracorporeal oxygenation; face fracture; female; heart function; hematocrit; hemofiltration; human; injury; laparotomy; lung compliance; lung insufficiency; male; mortality; nasogastric tube; open reduction (procedure); osteosynthesis; oximetry; oxygenation; patient positioning; positive end expiratory pressure; priority journal; spine fracture; surgical patient; thoracotomy; tracheotomy; venous oxygen tension

An exploration of the occurrence of pressure ulcers in a British spinal injuries unit. - Ash D. (Journal of clinical nursing, 2002)
Spinal cord injury (SCI) is associated with increased risk of pressure ulcers, but there are few published data about this in the United Kingdom (UK). This article represents a quantitative exploration of the occurrence of pressure ulcers in a UK spinal injuries unit (SIU). The technique used is a retrospective review of records: details of 144 completed first admissions for SCI between 1998 and 2000 were entered on to a database (SPSS) for analysis. Thirty-two per cent of patients already had pressure ulcers on admission to the SIU, while a total of 56% experienced an ulcer at some stage between injury and discharge from the SIU. Four pressure ulcer risk assessment scales were used (Waterlow, Braden, Norton and SCIPUS-A). These appeared to have moderate predictive power in this population. Pressure ulcers were found to be associated with increased length of hospital stay, density of lesion, surgical stabilization of neck injury before transfer to the SIU, tracheostomy on admission to the SIU and delayed transfer to the SIU after injury. Implications for practice are discussed.
Keywords: adolescent; adult; aged; article; chi square distribution; child; decubitus; female; human; incidence; male; middle aged; retrospective study; risk assessment; risk factor; spinal cord injury; United Kingdom

Myotonia dystrophica and spinal surgery - Colovic V.; Walker R.W.M. (Paediatric Anaesthesia, 2002)
Two cases of patients suffering from the congenital form of myotonia dystrophica under going spinal surgery are presented. Both patients had major complications, including cardiac arrhythmias, postoperative wound infection and more minor complications, such as sedation and opioid sensitivity. However, the most notable complication resulting in long-term morbidity was the deterioration of bulbar muscular function in one of the patients. This resulted in recurrent aspiration pneumonia and the need for a tracheostomy. This serious complication has not previously been reported following surgery.
Keywords: adenosine; atracurium besilate; cefotaxime; fentanyl; midazolam; morphine; propofol; sevoflurane; adolescent; article; aspiration pneumonia; case report; clinical examination; clinical feature; debridement; drug sensitivity; female; heart arrhythmia; human; male; muscle function; myotonic dystrophy; postoperative complication; postoperative infection; priority journal; recurrent disease; sedation; spine fusion; spine surgery; Streptococcus pneumonia; tracheostomy; wound dressing

Impact of respiratory complications on length of stay and hospital costs in acute cervical spine injury - Winslow C.; Bode R.K.; Felton D.; Chen D.; Meyer Jr. P.R. (Chest, 2002)
Context: Respiratory complications are frequent in patients with acute cervical spinal injury (CSI); however, the importance of respiratory complications experienced during the initial hospitalization following injury is unknown. Objective: To determine if respiratory complications experienced during the initial acute-care hospitalization in patients with acute traumatic cervical spinal injury (CSI) are more important determinants of the length of stay (LOS) and total hospital costs than level of injury. Design: A retrospective analysis of an inception cohort for the 5-year period from 1993 to 1997. Setting: The Midwest Regional Spinal Cord Injury Care System, a model system for CSI, at Northwestern Memorial Hospital, a tertiary referral academic medical center. Patients: Four hundred thirteen patients admitted with acute CSI and discharged alive. Patients with concurrent thoracic injuries were excluded. Main outcome measures: Initial acute-care LOS and hospital costs. Results: Both mean LOS and hospital costs increased monotonically with the number of respiratory complications experienced (p < 0.001, between none and one complication, and between one and two complications; p = 0.24 between two and three or more complications). A hierarchical regression analysis showed that four variables - use of mechanical ventilation, occurrence of pneumonia, need for surgery, and use of tracheostomy - explain nearly 60% of the variance in both LOS and hospital costs. Each of these variables, when considered independently, is a better predictor of hospital costs than level of injury. Conclusions: The number of respiratory complications experienced during the initial acute-care hospitalization for CSI is a more important determinant of LOS and hospital costs than level of injury.
Keywords: adult; article; artificial ventilation; cervical spine injury; controlled study; hospital cost; hospitalization; human; intensive care; length of stay; major clinical study; pneumonia; prediction; priority journal; regression analysis; respiratory tract disease; retrospective study; tracheostomy

Summary statement: nonoperative management and critical care of acute spinal cord injury. - Ball P.A.; Nockels R.P. (Spine, 2001)
Keywords: neuroprotective agent; acute disease; emergency treatment; human; intensive care; methodology; note; spinal cord injury; thromboembolism; tracheostomy

Survival of tetraplegic spinal cord injured persons after the first admission of a rehabilitation center and prognosis factors: A multicenter study of 697 subjects in French centers - Lhéritier K.; Ravaud J.F.; Desert J.F.; Pedelucq J.P.; O'Hanna F.; Daures J.P. (Revue d'Epidemiologie et de Sante Publique, 2001)
Background: We surveyed survival and prognosis factors in tetraplegic spinal cord injured persons (TSCI) after their admission to a physical medicine and rehabilitation center. Methods: This multicenter study included 697 individuals, the entire cohort of patients admitted to three of the principal French centers caring for spinal cord injured persons from 1949 to 1997. The data set was drawn from the medical files and included data on the accident and its complications, social and demographic features, and the characteristics of the spinal injury. Survival data were obtained for all subjects from the official registries of their place of birth. Univariate (Kaplan-Meier) and multivariate (Cox regression) analysis was made to study links between these data and survival. Results : Univariate analysis indicated that the principal variables significantly related to survival were : level of the lesion, age at the time of the accident, the cause of the accident, and the presence of a permanent tracheotomy or a depressive syndrome requiring medical care. Multivariate analysis showed that the risk of dying was 82 % lower for persons who did not have a permanent tracheotomy. The risk declined by 92 %, 89 % and 69 % for TSCI aged 20 years or less, 20-39 years and 40-59 years respectively at the time of the accident compared with those aged more than 60 years. This risk was 37 % lower for TSCI without depressive syndrome and 52 % lower for persons injured at levels C6, C7, C8 compared with those injured at levels C2, C3, C4. Conclusion : Multivariate analysis showed that the principal prognosis factors for survival are the presence of a permanent tracheotomy, the age at the time of the accident, the presence of a depressive syndrome and the level of the lesion. No statistical improvement of survival was observed related with time (corresponding to the year of inclusion) but, over the study period, there was an increasing number of spinal cord injured person who survived with high lesions.
Keywords: adult; age; aged; article; depression; female; hospital admission; human; major clinical study; male; multicenter study; prognosis; quadriplegia; rehabilitation center; spinal cord injury; survival; tracheotomy

Management of the patient with spinal cord injury - Walker D.A.J. (Problems in Anesthesia, 2001)
Spinal cord injury can be a devastating condition, and because survival is now probable, continuing disability remains a major problem. Appreciation of some of the mechanisms of secondary injury suggests that both pharmacologic and physiologic interventions may reduce morbidity. The anesthesiologist has a key role in minimizing secondary ischemic insults to the injured spinal cord.
Keywords: suxamethonium; artificial ventilation; Doppler ultrasonography; human; hypertension; intubation; laryngoscopy; magnetic resonance angiography; oxygen therapy; paralytic ileus; patient positioning; physiotherapy; respiratory tract disease; review; spinal cord injury; tracheostomy

An international repatriationof a cervical cord injury patient who was under mechanical ventilation - Kamochi M.; Uchida S.; Munaka M. (Journal of UOEH, 2001)
The patient was a 55-year old Japanese man, who had a traffic accident and suffered cervical cord injury in Thailand. Although he received an emergency operation and intensive care, he had respiratory paralysis and received a tracheostomy. One month after the accident, he still needed to receive mechanical ventilatory support. He and his wife hoped to return to Japan. We were asked to transport the patient from Bangkok to Tokyo. With some help from an assistance company, we could transport the patient safely from Bangkok to Tokyo on a commercial airline under mechanical ventilatory support. We experienced the several regulations and difficulties in performing medical treatment and transportation of a critical patient in a commercial airline.
Keywords: adult; aircraft; article; artificial ventilation; case report; cervical spinal cord injury; human; male; patient transport; Thailand; traffic accident

Fatal stenosis of trachea and main bronchus due to compression by the spine and sternum in three patients with severe motor and intellectual disabilities - Tanaka M.; Watanabe Y.; Fukushima K.; Fujiwara T.; Yagi K.; Ohta S. (No To Hattatsu, 2001)
Three patients with severe motor and intellectual disabilities developed fatal respiratory insufficiencies caused by stenosis of the trachea and main bronchus due to compression by the spine and trachea. The onset of respiratory insufficiency was by 20, 16, and 29 years of age. Chest computed tomography demonstrated deformation and narrowing of the trachea and main bronchus, and shortening of the distance between spine and sternum. Although respiratory insufficiency was temporarily relieved by insertion of a stent into the main bronchus in patient 1, he died at the age of 21 due to proliferation of granulation tissue. Patient 2 died of bleeding from the granulation tissue around the window of tracheotomy at the age of 18 years, and patient 3 died of recurrent pneumonia at the age of 34 years. In conclusion, stenosis of the trachea and bronchus observed in these patients was caused by progressive deformation of the thorax. The stenosis may result in sudden death or recurrent respiratory infections in patients with severe motor and intellectual disabilities.
Keywords: adolescent; adult; article; bleeding; bronchus stenosis; case report; computer assisted tomography; granulation tissue; human; intellectual impairment; motor dysfunction; pneumonia; respiratory failure; respiratory tract infection; spinal cord compression; stent; sternum; sudden death; thorax deformity; trachea stenosis; tracheotomy

Survey of children supported by long-term mechanical ventilation in Switzerland - Kamm M.; Burger R.; Rimenzsberger P.; Knoblauch A.; Jürg Hammer (Swiss Medical Weekly, 2001)
Objective: The aim of the present study was to identify the number of children, from birth to 16 years of age, on long-term mechanical ventilation in Switzerland, and to establish their current location, underlying diagnoses and ventilatory needs. Methods: Postal questionnaires were sent to all chest physicians (pulmonologists), intensive care specialists, neurologists, national health care organisations, rehabilitation services and ventilator suppliers known or thought to be involved in paediatric long-term ventilation in Switzerland. Results: Detailed information was obtained on 32 children from 7 centers. Underlying disorders included congenital central hypoventilation syndrome (CCHS, 41%), neuromuscular disorders (41%), spinal cord injury (6%), craniofacial anomalies (6%) and others (6%). 10 children received positive pressure ventilation by tracheostomy and 19 children by nasal mask. Two children were ventilated by phrenic nerve pacing and one child with the help of a pneumatic belt. Children with CCHS were almost equally divided into nasal mask and tracheostomy users. Ventilation for 16-24 hours a day was necessary in 5 children, exclusively during sleep in 24 children and only episodically in 3 children. All but 2 children were cared for at home. The majority of families received home care support. The most common reasons for readmission into hospital were regular follow-up examinations and respiratory tract infections. The children were mainly admitted to paediatric intensive care units. Conclusions: There are few ventilator-supported children in Switzerland and most of them are cared for at home. Nevertheless, there is a need to establish a system for continuing data collection in this particular patient population to assess outcome and quality of home care support and to follow incidence trends.
Keywords: adolescent; article; artificial ventilation; child; clinical article; health care quality; health survey; home care; hospital admission; human; hypoventilation; infant; neuromuscular disease; newborn; outcomes research; phrenic nerve; preschool child; questionnaire; school child; Switzerland; tracheostomy; treatment indication

Emergency cricothyrotomy: long-term results. - Isaacs Jr. J.H. (The American surgeon, 2001)
In 1996 we reviewed the literature and reported on our own series of emergency cricothyrotomy (EC) patients. The success rate in obtaining an airway was very good. The survival rate was also acceptable. However, there have been no reports of long-term results of EC. We retrospectively reviewed the long-term results in 27 survivors of 65 original EC patients. The average length of follow-up was 37 months (1-77 months). In 13 patients no airway problems were found. The remaining 14 patients had only minor problems such as hoarse voice and mild untreated stenosis. Of these 27 patients, however, only seven were doing well. Five patients had relatively minor problems such as the need for a gastrostomy tube, minor shortness of breath, or minor neurological problems. Fifteen patients had major problems: cervical spine injuries, changes in mental status, need for permanent nursing home care, seizure disorders, or injuries that precluded their working. In most cases these problems were due to the underlying disease process. EC is effective in obtaining an airway with a low incidence of later severe airway problems. However, many of these patients do poorly overall.
Keywords: adult; aged; article; cricoid cartilage; critical illness; dyspnea; emergency treatment; endotracheal intubation; female; health status; hoarseness; human; male; methodology; middle aged; mortality; questionnaire; retrospective study; seizure; survival; trachea stenosis; tracheotomy; treatment outcome

Effect of surgical cricothyrotomy on the unstable cervical spine in a cadaver model of intubation - Gerling M.C.; Davis D.P.; Hamilton R.S.; Morris G.F.; Vilke G.M.; Garfin S.R.; Hayden S.R. (Journal of Emergency Medicine, 2001)
Cricothyrotomy is indicated for patients who require an immediate airway and in whom orotracheal or nasotracheal intubation is unsuccessful or contraindicated. Cricothyrotomy is considered safe with cervical spine (c-spine) injury; however, the amount of c-spine movement that occurs during the procedure has not been determined. In this experimental study, an established cadaver model of c-spine injury was used to quantify movement during cricothyrotomy. A complete C5-6 transection was performed by using an osteotome on 13 fresh-frozen cadavers. Standard open cricothyrotomy was performed on each cadaver, with c-spine images recorded in real time on fluoroscopy, then transferred to video and Kodachrome still images. Outcome measures included movement across the C5-6 site with regard to angulation expressed in degrees of rotation and linear measures of axial distraction and anterior-posterior (AP) displacement expressed as a proportion of C5 body width. Data were analyzed by using descriptive statistics to determine mean change from baseline in each of three planes of movement. Significance was assumed if 95% confidence intervals did not include zero. A significant amount of movement was observed with regard to AP displacement (6.3% of C5 width) and axial distraction (-4.5% of C5 width, indicating narrowing of the intervertebral space). These correspond to 1-2 mm AP displacement and less than 1 mm axial compression. No significant angular displacement was observed. In conclusion, cricothyrotomy results in a small but significant amount of movement across an unstable c-spine injury in a cadaver model. This degree of movement is less than the threshold for clinical significance. Copyright © 2001 Elsevier Science Inc.
Keywords: article; cadaver; cervical spine; emergency treatment; human; human tissue; model; priority journal; spinal cord injury; spine injury; spine stabilization; tracheotomy

Trauma airway management - Langeron O. (Current Opinion in Critical Care, 2000)
Maintenance of a patent and secured airway is essential to the management of trauma, and requires physicians experienced with airway control techniques. Trauma-setting airway control problems can be caused by vital failures, risk of aspiration, potential for cervical spine injury, combative patients, and the obvious risk of difficult tracheal intubation related to the specific injury of the patient. Endotracheal intubation remains the gold standard in airway management for trauma patients, and should be performed via the oral route, with a rapid sequence induction and a manual in-line stabilization maneuver, to circumvent some of the problems previously mentioned. In this paper different techniques to control the airway in trauma patients are discussed, including lighted stylet tracheal intubation, improvement of the laryngoscopic vision, retrograde technique for orotracheal intubation, the laryngeal mask and the intubating laryngeal mask airways, the combitube, and cricothyroidotomy. Airway management in trauma patients requires regular training in these techniques, and knowledge of complementary techniques that allow tracheal intubation or oxygenation to overcome difficult intubation is vitally important. (C) 2000 Lippincott Williams and Wilkins, Inc.
Keywords: oxygen; anesthesia induction; aspiration; cervical spine injury; endotracheal intubation; first aid; human; laryngeal mask; laryngoscopy; lung clearance; oxygenation; patient attitude; review; risk factor; procedures; tracheotomy; traumatology

Sevoflurane mask anesthesia for urgent tracheostomy in an uncooperative trauma patient with a difficult airway - Smith C.E.; Fallon W.F. Jr. (Canadian Journal of Anesthesia, 2000)
Purpose: Proper care of the trauma patient often includes tracheal intubation to insure adequate ventilation and oxygenation, protect the airway from aspiration, and facilitate surgery. Airway management can be particularly complex when there are facial bone fractures, head injury and cervical spine instability. Clinical Features: A 29-yr-old intoxicated woman suffered a motor vehicle accident. Injuries consisted of multiple abrasions to her head, forehead, and face, right temporal lobe hemorrhage, and complex mandibular fractures with displacement. Mouth opening was < 10 mm. Blood pressure was 106/71 mmHg, pulse 109, respirations 18, temperature 37.3°C, SpO2 100%. Chest and pelvic radiographs were normal and the there was increased anterior angulation of C4-C5 on the cervical spine film. Drug screen was positive for cocaine and alcohol. The initial plan was to perform awake tracheostomy with local anesthesia. However, the patient was uncooperative despite sedation and infiltration of local anesthesia. Sevoflurane, 1%, inspired in oxygen 100%, was administered via face mask. The concentration of sevoflurane was gradually increased to 4%, and loss of consciousness occurred within one minute. The patient breathed spontaneously and required gentle chin lift and jaw thrust. A cuffed tracheostomy tube was surgically inserted without complication. Blood gas showed pH 7.40, PCO2 35 mmHg, PO2 396 mmHg, hematocrit 33.6%. Diagnostic peritoneal lavage was negative. Pulmonary aspiration did not occur. Oxygenation and ventilation were maintained throughout the procedure. Conclusion: Continuous mask ventilation with sevoflurane is an appropriate technique when confronted with an uncooperative trauma patient with a difficult airway.
Keywords: sevoflurane; adult; article; breathing; case report; cervical spine injury; clinical feature; consciousness; endotracheal intubation; face fracture; face mask; female; head injury; human; inhalation anesthesia; oxygenation; priority journal; tracheostomy

Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients - Mayberry J.C.; Wu I.C.; Goldman R.K.; Chesnut R.M. (Critical Care Medicine, 2000)
Introduction: The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutanecus tracheostomy. Objective: To determine the necessity of cervical spine clearance and neck extension in trauma patients receiving percutaneous tracheostomy. Design: Prospective analysis of case series from August 1, 1995 to August 31, 1998. Setting: A university-based Level I trauma center. Patients: A total of 88 consecutive trauma patients receiving percutaneous tracheostomy. Patients were divided into two groups based on the radiographic or clinical status of their cervical spine: cleared and noncleared. Results: The overall success and complication rate were 99% (87/88) and 11% (10/88), respectively. There were no procedure-related deaths. The cleared group consisted of 60 patients; three patients in this group who had 'bull' or 'thick' necks did not have full neck extension during percutaneous tracheostomy. The noncleared group consisted of 28 patients, 13 of which had known cervical spine fractures; 27 noncleared patients were maintained in the neutral positron (no extension) during percutaneous tracheostomy, whereas one patient with low suspicion of spinal injury was partially extended. Of the 13 patients with cervical spine fractures, six patients had been stabilized with a halo or operative fixation, and seven patients were stabilized with a cervical collar at the time of percutaneous tracheostomy. The success rate was 100% (60/60) for the cleared group compared with 96% (27/28) for the noncleared group (p > .05). The complication rate was 13% (8/60) for the cleared group compared with 7.1% (2/28) for the noncleared group (p > .05). We had a 100% success rate and no complications in the seven patients with cervical spine injury who were stabilized with a cervical collar. No patient had spinal cord injury caused by percutaneous tracheostomy. Conclusion: Percutaneous tracheostomy can be safely performed in trauma patients without cervical spine clearance and neck extension, including patients with stabilized cervical spine or spinal cord injury.
Keywords: adolescent; adult; aged; article; brace; cervical spine fracture; cervical spine injury; female; human; major clinical study; male; neck injury; priority journal; spine instability; spine stabilization; tracheostomy; treatment outcome

Percutaneous tracheostomy in patients without cervical spine clearance - Scalea T.M. (Critical Care Medicine, 2000)
Keywords: artificial ventilation; body position; cervical spine injury; editorial; health care cost; human; intensive care; postoperative complication; priority journal; spine instability; surgical technique; tracheostomy

Anesthesia for a cervical myelopathy patient with tracheal stenosis - Yamada K.; Nishiyama T.; Hanaoka K. (Japanese Journal of Anesthesiology, 2000)
A 71-year-old male with cervical myelopathy was scheduled for C 3-7 laminectomy. Once he had been rejected of general anesthesia in other hospital because of his tracheal stenosis. The diameter of the narrowest part of his trachea was 5 mm probably resulting from tracheostomy at 2 years of age. His cervical myelopathy seemed to be no problem for anesthesia induction because he had no problems in his neck movement and opening mouth. We evaluated his tracheal stenosis carefully using bronchofiberscopy, chest X-ray, computed tomography and pulmonary function tests. After intravenous fentanyl 100 μg and midazolam 2.5 mg, it was impossible to ventilate the patient. Therefore, tracheal intubation was performed immediately after lidocaine administration into the trachea. During surgery, tracheal tube dilated the narrowed portion. After surgery, the tracheal tube was removed under bronchofiberscopic observation without any problems. Tracheal stenosis was observed by chest X-ray after surgery, but he had no complaints.
Keywords: fentanyl derivative; midazolam; aged; anesthesia induction; article; case report; cervical myelopathy; computer assisted tomography; endotracheal intubation; endotracheal tube; fiberoptic bronchoscopy; general anesthesia; human; laminectomy; lung function test; male; mouth; movement (physiology); neck; thorax radiography; trachea stenosis; tracheostomy

Weaning injured patients with prolonged pulmonary failure from mechanical ventilation in a non-intensive care unit setting - DeBoisblanc M.W.; Goldman R.K.; Mayberry J.C.; Brand D.M.; Pangburn P.D.; Soifer B.E.; Mullins R.J. (Journal of Trauma - Injury, Infection and Critical Care, 2000)
Background: Injured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as safe and effective. One method for accomplishing this mode of ventilation uses a simple bilevel ventilator. Because this ventilator has been successfully used in hospital wards, we postulated that bilevel ventilators could provide sufficient support during weaning from mechanical ventilation of injured patients in a non-ICU setting. Methods: A retrospective review of trauma patients (August 1996-January 1999) undergoing bilevel positive pressure ventilation as the final phase of weaning was conducted. Before ward transfer with bilevel ventilation, conventionally ventilated ICU patients were changed to bilevel ventilation and were required to tolerate this mode for at least 24 hours. All patients had a tracheostomy as a secure airway. Outcomes analyzed included ICU length of stay, hospital length of stay, duration of mechanical ventilation, weaning success, complications, and survival. Results: Fifty-one patients (39 men, 12 women) with a mean age of 53 received more than 24 hours of bilevel positive pressure ventilation. Mean Injury Severity Score was 29, with blunt mechanisms of injury occurring in 90%. Chest or spinal cord injuries that affected pulmonary mechanics were present in 75% of patients. Ventilator-associated pneumonia was treated in 43% of patients. Mean ICU length of stay and hospital length of stay were 21 and 34 days, respectively. Weaning was successful in 89% of patients, whereas 11% were discharged to skilled nursing facilities still receiving bilevel positive pressure ventilation. Two patients died, neither from a pulmonary nor airway complication. Of the remaining 49 patients, 12 were weaned in the ICU and 37 were transferred to the ward with bilevel ventilatory support. The average length of ward ventilation was 6.5 ± 5.4 days (n = 37). Conclusions: Implementation of a program using bilevel ventilation to support the terminal phase of weaning seriously injured patients from mechanical ventilation was successful. After initiating this mode in the ICU, it was satisfactorily continued in standard surgical wards. Because this method enabled the withdrawal of ventilatory support in a non-ICU setting, its major advantage was reducing ICU length of stay.
Keywords: adult; artificial ventilation; conference paper; disease severity; female; hospitalization; human; injury scale; intensive care unit; lung insufficiency; major clinical study; male; multiple trauma; pneumonia; positive end expiratory pressure; priority journal; tracheostomy; treatment outcome; weaning

Forced oscillation technique to detect and monitor tracheal stenosis in a tetraplegic patient - Beraldo P.S.S.; Mateus S.R.M.; Araujo L.M.; Horan T.A. (Spinal Cord, 2000)
Study design: A case report. Objectives: To demonstrate forced oscillation technique's (FOT) utility in a tetraplegic patient with tracheostenosis. Setting: A Rehabilitation Hospital, Brasilia, Brazil. Methods: Serial evaluations of spirometry, bronchoscopy and forced oscillation assessment. Results: A 16-year-old male with C7 spinal cord injury, initially required mechanical ventilation and subsequent tracheostomy over a period of 4 weeks. Five months after the accident the onset of tracheostenosis was diagnosed. Flow-volume data were compatible with a fixed tracheal stenosis. FOT showed an obstructed pattern, manifested by high levels of resonance frequency and impedance. The FOT pattern returned to normal after dilatation. The FOT abnormalities recurred with two subsequent broncoscopicaly confirmed episodes of tracheal restenosis without parallel changes in spirometric parameters. Conclusion: This case suggests a role for FOT in the non invasive detection and follow up of tracheal stenosis. FOT may be particularly useful in tetraplegic patients, in whom the restriction from muscle weakness may make interpretation of forced expiratory flow-volume data problematic.
Keywords: adolescent; article; case report; diagnostic procedure; forced expiratory volume; human; male; muscle weakness; oscillation; patient monitoring; priority journal; quadriplegia; spinal cord injury; trachea obstruction; trachea stenosis

A 67-year-old man with progressive disturbance of gait - Sato K.-I.; Sato S.; Ohta S.; Mori H.; Matsuoka S.; Shirai T.; Kanazaea A.; Mizuno Y. (Brain and Nerve, 2000)
We report a 67-year-old man with progressive disturbance of gait. He was well until the spring of 1993 (62 years of the age), when he noted an onset of unsteady gait. He also noted that he started to have a difficulty in playing tennis, in which he became unable to hit the ball with his racket. He also noted parkinsonian features such as bradykinesia and loss of hand dexterity. He was treated with levodopa, which did not improve his symptoms. His MRI revealed marked atrophy of the cerebellum and the pons. The criss-cross high signal lesion was seen in the center of the pons. The third ventricle was dilated. The putamen was unremarkable. His subsequent course was complicated by easy to fall, difficulty in swallowing with episodes of aspiration pneumonia. He also developed nocturnal apneustic episodes. He was admitted to our hospital on November 15, 1998, when he was 67 years of the age. He had low grade fever and low blood pressure (98/70). He was anemic but not icteric. Tumors were palpated in his jaw, anterior chest, and in the left arm. He was alert but unable to convey his desire because of dyspnea and tracheostomy. His gaze was slightly restricted in the horizontal direction and markedly so in the vertical direction. Motor functions were difficult to evaluate. His clinical course was complicated by atelectasis of the fight lung and pleural effusion. He developed marked edema and oliguria. He developed sudden bradycardia and expired on December 26, 1998. He was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had multiple system atrophy. Majority of the audience agreed with this diagnosis. Post-mortem examination revealed a lung cancer in the right lung(undifferentiated adenocarcinoma) with metastases to the liver, kidneys, lymph nodes, pericardium, pleura, skin, bone marrow, and the brain. Neuropathologic examination revealed marked atrophy of the pons and the cerebellum. The putamen showed brownish discoloration and atrophic changes. The substantia nigra showed marked neuronal loss and gliosis. Oligodendrocytic inclusion bodies (alpha-synuclein positive) were seen in the putamen, globus pallidus, substantia nigra, pontine nucleus, cerebellar white matter, internal capsule, cerebral peduncle, and the spinal cord. These findings are consistent with the pathologic diagnosis of multiple system atrophy. What was interesting to us was the presence of neurofibrillary tangles in the substantia nigra, nucleus ruber, globus pallidus, and subthalamic nucleus. Tuft-shaped astrocytes were also seen. This patient appears to be a rare example of combination of MSA and PSP.
Keywords: aged; anamnesis; article; atelectasis; bradycardia; brain third ventricle; brain ventricle dilatation; case report; clinical examination; gait disorder; human; male; nuclear magnetic resonance imaging; pleura effusion

Patient preference for in-exsufflation for secretion management with spinal cord injury. - Garstang S.V.; Kirshblum S.C.; Wood K.E. (The journal of spinal cord medicine, 2000)
An important aspect of respiratory management in patients with acute spinal cord injury (SCI) is the elimination of secretions. Methods utilized for secretion management in patients with SCI includes endotracheal suctioning and mechanical in-exsufflation (MI-E). Surveyed here is a group of patients with SCI who have had experience with both endotracheal suctioning and MI-E via tracheostomy, to determine patient opinions and experiences regarding the 2 techniques. The survey was administered to 18 patients with traumatic SCI, with an average age of 34. 72% were ASIA A, 22% percent were ASIA B, and 6% were ASIA C, with neurological level of injury ranging from C-1-T-3. Results indicate that patients found MI-E significantly less irritating (p < 0.001), less painful (p < 0.001), less tiring (p = 0.01), and less uncomfortable (p < 0.001) than endotracheal suctioning. In a direct comparison, 89% of patients preferred mechanical in-exsufflation to suctioning. In addition, 89% of patients found MI-E faster, 78% found MI-E more convenient, and 72% found MI-E more effective than suctioning. This study demonstrates that all measured aspects of patient experience are more positive for MI-E than for endotracheal suctioning.
Keywords: adolescent; adult; article; artificial ventilation; female; human; male; middle aged; psychological aspect; spinal cord injury; suction; tracheostomy

Bilateral vocal cord paralysis after anterior cervical discoidectomy and fusion in a case of whiplash cervical spine injury: A case report - Muzumdar D.P.; Deopujari C.E.; Bhojraj S.Y. (Surgical Neurology, 2000)
BACKGROUND: Bilateral vocal cord paralysis is a risk of anterior cervical discoidectomy and fusion. We discuss the mechanism of vocal cord paralysis and the precautions necessary to avoid this catastrophic complication. A rare case of bilateral vocal cord paralysis after anterior cervical discoidectomy and fusion (ACD/F) is reported. CASE DESCRIPTION: The patient, a 37-year-old male, was paraplegic, had bilateral intrinsic hand muscle weakness and sphincter involvement following a whiplash cervical spinal injury. A C5-C6 ACD/F for traumatic C5-C6 disc prolapse was performed. On the third postoperative day, he developed difficulty in coughing and a husky voice. Otolaryngological evaluation revealed bilateral vocal cord paralysis. He later required a tracheostomy that partially alleviated his major symptoms. CONCLUSION: In patients undergoing ACD/F, a mandatory preoperative evaluation of the vocal cords should be performed. An appropriate modification in surgical planning should be made if vocal cord palsy is diagnosed preoperatively to prevent bilateral vocal cord paralysis. Proper and judicious use of Cloward retractors is advocated. (C) 2000 by Elsevier Science Inc.
Keywords: adult; anterior spine fusion; article; case report; cervical spine injury; human; discectomy; male; postoperative complication; treatment outcome; vocal cord paralysis; whiplash injury

Upper airways obstruction - Lloyd E.L. (British Journal of Sports Medicine, 2000)
Keywords: article; blood; cervical spinal cord injury; chin; edema; endotracheal intubation; face injury; head tilting; human; injury; jaw; laryngeal mask; nasopharynx; oropharynx; resuscitation; skull base fracture; procedures; tongue; tracheotomy; upper respiratory tract obstruction; vomiting

Spinal muscular atrophy type 1: A noninvasive respiratory management approach - Bach J.R.; Niranjan V.; Weaver B. (Chest, 2000)
Study objective: To determine whether spinal muscular atrophy (SMA) type 1 can be managed without tracheostomy and to compare extubation outcomes using a respiratory muscle aid protocol vs conventional management. Design: A retrospective cohort study. Methods: Eleven SMA type 1 children were studied during episodes of respiratory failure. Nine children required multiple intubations. Along with standard treatments, these children received manually and mechanically assisted coughing to reverse airway mucus-associated decreases in oxyhemoglobin saturation. Extubation was not attempted until, most importantly, there was no oxygen requirement to maintain oxyhemoglobin saturation greater than 94%. After extubation, all patients received nasal ventilation with positive end-expiratory pressure. Successful extubation was defined by no need to reintubate during the current hospitalization. I Results: Two children have survived for 37 and 66 months and have never been intubated despite requiring 24-h nasal ventilation since 5 and 7 months of age, respectively. One other child underwent tracheostomy for persistent left lung collapse and inadequate home care, another for need for frequent readmission and intubation, and one child was lost to follow-up 3 months after successful extubation. The other six children have been managed at home for 15 to 59 (mean 30.4) months using nocturnal nasal ventilation after an episode of respiratory failure. The nine children were successfully extubated by our protocol 23 of 28 times. The same children managed conventionally were successfully extubated 2 of 20 times when not using this protocol (p < 0.001 by the two-tailed Fisher's Exact t Test). Conclusion: Although intercurrent chest colds may necessitate periods of hospitalization and intubation, tracheostomy can be avoided throughout early childhood for some children with SMA type 1.
Keywords: article; child; child hospitalization; clinical article; endotracheal intubation; extubation; female; follow up; human; male; priority journal; respiratory failure; spinal muscular atrophy; tracheotomy

Education, special needs, and medical exclusions: A good 'IDEA'? - Weiss K.J. (Journal of the American Academy of Psychiatry and the Law, 2000)
Keywords: adoption; child; child welfare; disability; handicapped child; hospitalization; human; law; quadriplegia; review; spinal cord injury; tracheostomy; United States

Endothelin-1 in the brain of patients with galactosialidosis: Its abnormal increase and distribution pattern - Itoh K.; Oyanagi K.; Takahashi H.; Sato T.; Hashizume Y.; Shimmoto M.; Sakuraba H. (Annals of Neurology, 2000)
Endothelin-1 is a peptidic substrate in vitro of lysosomal protective protein/cathepsin A (PPCA) with serine carboxypeptidase activity. Endothelin- 1-specific immunoreactivity has been demonstrated to be markedly increased and distributed abnormally in the neurons and glial cells within autopsied brain regions, including the cerebellum, hippocampal formation, and spinal cord, of patients affected with galactosialidosis, a human PPCA deficiency. The genetic defect of the endothelin-1 degrading activity of PPCA is suggested to cause some of the neurological abnormalities of this disease.
Keywords: cathepsin; endothelin 1; adult; article; ataxia; case report; cause of death; cerebellar ataxia; child; dentate nucleus; face dysmorphia; galactosialidosis; hemangiokeratoma; human; hyperreflexia; immunohistochemistry; male; mental retardation malformation syndrome; muscle atrophy; myoclonus; priority journal; seizure; tracheostomy; visual disorder

Percutaneous tracheostomy in the severely injured patient: Transition from the operating room to the intensive care unit - Mayberry J.C.; Goldman R.K.; Rehm C.G. (Asian Journal of Surgery, 1999)
This paper describes the authors' experience with percutaneous tracheostomy (PT) in injured patients by transitioning the procedure from the OR to the ICU. One hundred and seven consecutive trauma patients receiving PT at a university-based Level I trauma center from 1 August, 1995 to 31 March, 1999 were retrospectively and prospectively analyzed. The overall success and complication rates were 99% (106/107) and 11% (12/107), respectively, with zero procedure-related deaths. Twenty-seven PTs were performed in the OR before attempting PT in the ICU. The ICU PT complication rate was 9% (6/66) versus 15% (6/35) for OR PTs (p = NS). Ciaglia PT kits were used in 55 patients and Per-fit® PT kits in 52 patients with identical complication rates (11%). Seventy-one patients had no cervical-spine injuries, 30 patients had not been cleaved of c-spine injury, and six patients were stabilized prior to PT. C-spine clearance, neck extension, spine stabilization, and c-spine injury made no difference in success or complication rates (p = NS). No patient had spinal cord injury resulting from PT. It is concluded that PT can be safely performed on trauma patients at the ICU bedside. PT can be performed prior to c-spine clearance and in patients with known spinal injuries as long as spinal cord precautions are maintained. PT is the authors' procedure of choice for severely injured patients requiring tracheostomy.
Keywords: article; devices; human; injury; intensive care; major clinical study; operating room; postoperative complication; spinal cord injury; spine stabilization; tracheostomy; Ciaglia PT kit; Per-fit; Shiley tracheostomy tube

Ultrasonographically guided percutaneous dilatational tracheostomy after anterior cervical spine fixation - Šustić A.; Župan Ž.; Eškinja N.; Dirlić A.; Bajek G. (Acta Anaesthesiologica Scandinavica, 1999)
Patients with anterior cervical spine fixation (ACSF) after acute spinal cord injury often require tracheostomy for prolonged ventilatory support and upper respiratory tract clearance. The authors report two patients with ACSF who underwent a successful ultrasonographically guided percutaneous tracheostomy with dilatation forceps technique. Possible advantages of the ultrasonographically guided method with dilatation forceps in patients with ACSF are discussed.
Keywords: adult; anterior spine fusion; article; artificial ventilation; case report; cervical spine injury; human; lung clearance; male; priority journal; spine stabilization; tracheostomy

False positive perfusion lung scintiscans in tetraplegic patients: A case series - O'Ferrall D.J.M.; Cohn J.R.; Rider-Foster D. (Archives of Physical Medicine and Rehabilitation, 1999)
An accurate diagnosis of pulmonary embolism is essential to prevent excessive morbidity and mortality from either inappropriate therapy or failure to institute anticoagulation. The diagnosis of pulmonary embolism in tetraplegic spinal cord injury patients is complicated by frequent inability to perform the ventilation portion of the ventilation-perfusion scintiscan (V/Q scan) and by controversy regarding classification of defects on perfusion-only scans, as well as by coexisting pulmonary disease, systemic illness, related injuries, and the tendency for tetraplegic patients to have unexplained fever. This report describes three tetraplegic ventilator- dependent patients with hypoxic respiratory failure and normal chest radiographs who had large defects on perfusion-only lung scans. Ventilation scintiscans were not performed because the patients were ventilator-dependent with tracheostomies. Pulmonary angiography findings were normal in all patients, and all three responded to aggressive pulmonary toilet. Even large defects on perfusion-only scans despite normal chest radiographs should not be used to establish a diagnosis of pulmonary embolism in tetraplegic patients, and further diagnostic imaging is warranted.
Keywords: adult; article; case report; controlled study; diagnostic accuracy; diagnostic error; female; human; image analysis; lung embolism; lung scintiscanning; lung ventilation perfusion ratio; male

Predictors of dysphagia after spinal cord injury - Kirshblum S.; Johnston M.V.; Brown J.; O'Connor K.C.; Jarosz P. (Archives of Physical Medicine and Rehabilitation, 1999)
Objective: To quantify the incidence of swallowing deficits (dysphagia) and to identify factors that predict risk for dysphagia in the rehabilitation setting following acute traumatic spinal cord injury. Design: Retrospective case-control study. Setting: Freestanding rehabilitation hospital. Patients: Data were collected on 187 patients with acute traumatic spinal cord injury admitted for rehabilitation over a 4-year period who underwent a swallowing screen, in which 42 underwent a videofluoroscopic swallowing study (VFSS). Main Outcome Measures: VFSS was performed on patients with suspected swallowing problems. Possible antecedents of dysphagia were recorded from the medical record including previous history of spine surgery, surgical approach and technique, tracheostomy and ventilator status, neurologic level of injury, ASIA Impairment Classification, orthosis, etiology of injury, age, and gender. Results: On admission to rehabilitation 22.5% (n = 42) of spinal cord injury patients had symptoms suggesting dysphagia. In 73.8% (n = 31) of these cases, testing confirmed dysphagia (aspiration or requiring a modified diet), while VFSS ruled out dysphagia in 26 2% (n = 11) cases. Logistic regression and other analyses revealed three significant predictors of risk for dysphagia: age (p < 028), tracheostomy and mechanical ventilation (p < .001), and spinal surgery via an anterior cervical approach (p < 016). Other variables analyzed had no relation or at best a alight relation to dysphagia. Tracheostomy at admission was the strongest predictor of dysphagia. The combination of tracheostomy at rehabilitation admission and anterior surgical approach had an extremely high rate of dysphagia (48%). Conclusion: Swallowing abnormalities are present in a significant percentage of patients presenting to rehabilitation with acute traumatic cervical spinal cord injury. Patients with a tracheostomy appear to have a substantially increased risk of development of dysphagia, although other factors are also relevant. Risk of dysphagia should be evaluated to decrease the potential for morbidity related to swallowing abnormalities.
Keywords: adolescent; adult; aged; article; artificial ventilation; dysphagia; female; fluoroscopy; high risk patient; hospital admission; human; incidence; major clinical study; male; prediction; rehabilitation center; spinal cord injury; spine surgery; surgical approach; tracheostomy; videorecording

Continuous epidural anesthesia with a double catheter for sedation for surgery of the vertebral dorsolumbar column - Meggiorin G.; Onali A.; Manduco G.; Coraddu M. (Minerva anestesiologica, 1999)
The case of presented of an obese 42 year-old female patient, undergoing a second spinal cord decompression for a large dorsolumbar fibrous-scar mass, having a small-bore Montgomery tracheal stent (T-tube) on site. Stent replacement with a tracheotomy tube was impossible because of strong accretions hindering stent removal, as well as insertion of a suitable tracheal tube through the external stent branch, because of its very small lumen. So, general anaesthesia was not administered and surgery was performed under continuous epidural block, with light sedation, using two catheters introduced up and down the compression. Surgical and anaesthetic outcomes were optimal and confirm the effectiveness and safety of epidural anaesthesia for dorsolumbar spinal surgery, even in the obese patient. Moreover, with the continuous double-catheter technique it was possible to achieve a good and homogeneous spread of the analgesic solution, with low volume, despite the hard compression and deformation of the epidural space due to the fibrous-scar mass.
Keywords: adult; article; case report; catheterization; decompression surgery; epidural anesthesia; female; human; lumbar vertebra; methodology; obesity; spinal cord compression

Tetraplegia after central venous line via Vena jugularis interna with a following cervical abscess - Fritz K.-W.; Turner E. (Intensiv- und Notfallbehandlung, 1999)
We report on a case of upper tetraplegia caused by an abscess following the insertion of a central venous line (Vena jugularis interna). Bacteria may be applied by non-sterile punction. The cervical myelon was compressed and 2 vertebras (C4, C5), were destructed. The abscess was evacuated. The patient needed 3 weeks ventilatory support (controlled/assisted). A tracheotomy was performed for better suction of the bronchial system. The initial tetraplegia disappeared slowly. Physiotherapy supported the disorder of the muscles. Seven months after the event the patient is able to walk small distances. As we didn't find a report about such a severe case with following particular Restitutio ad integrum it was our desire to present it.
Keywords: adult; article; case report; central venous catheterization; human; internal jugular vein; pelvis abscess; physiotherapy; quadriplegia; spinal cord compression; tracheotomy

External laryngeal trauma analysis of 392 patients - Jewett B.S.; Shockley W.W.; Rutledge R. (Archives of Otolaryngology - Head and Neck Surgery, 1999)
Background: External laryngeal trauma (ELT) is a rare but clinically important injury. Objective: To perform the first population-based, time series analysis of the epidemiology, management, and outcomes of ELT using an 11-state, inpatient sample database containing more than 54 million patients. Patients: Three hundred ninety-two patients with a primary or secondary diagnosis of ELT were identified. Over a 5-year period, the incidence of ELT in this series was 1/137 000. The mean (±SD) age was 37 (±7) years, and the overall mortality rate was 2.04%. Two hundred forty-eight patients required surgical intervention. Results: The average length of stay for 67 patients not requiring surgical intervention for any injury was 3 (±2) days, with no mortality. One hundred eighty patients underwent endoscopy, with 14 requiting tracheotomy alone and 57 requiring tracheotomy plus laryngeal repair. The average length of stay and the morality rate were higher in these latter groups. Overall, 139 patients underwent tracheotomy, with a mortality rate of 5%, while 96 patients underwent laryngeal repair, with a mortality rate of 1%. Surgical treatment was performed in 140 patients with ELT within 24 hours after presentation, while another 60 received treatment within 48 hours. Associated injuries included skull base or intracranial injury (13%), open neck injury (9%), cervical spine injury (8%), and esophageal or pharyngeal injury (3%). Conclusion: External laryngeal trauma is a rare injury, with most patients requiring surgical intervention.
Keywords: adult; article; data base; female; human; larynx injury; larynx surgery; length of stay; major clinical study; male; mortality; prevalence; tracheotomy

Complete upper airway obstruction during awake fibreoptic intubation in patients with unstable cervical spine fractures - McGuire G.; El-Beheiry H. (Canadian Journal of Anaesthesia, 1999)
Purpose: To describe the presentation and management of complete upper airway obstruction with life threatening arterial oxygen desaturation that occurred during attempted awake fibreoptic intubation in two patients presenting with unstable C-spine injury. Clinical Feature: Complete upper airway obstruction occurred during awake fibreoptic intubation of two men (ASA II; 68 and 55 yr old) presenting with unstable C-spine fractures. In both cases, bag and mask ventilation with CPAP failed to relieve the progressive hypoxemia. A surgical airway was established urgently to oxygenate the two patients who were suffering progressive life-threatening oxygen desaturation. One patient had trans-cricothyroid jet ventilation performed through a 16G intravenous cannula prior to an urgent tracheostomy. In the other patient, an emergency tracheostomy was inserted. Interestingly, both patients had been sedated in the Neurosurgical Intensive Care Unit with morphine and benzodiazepines before their scheduled surgeries. The most likely etiology for the complete upper airway obstruction was laryngospasm due to inadequate topicalization of the airway and additional sedation given in the operating room. Neither patients suffered any new neurological deficits following these events. They went on to have uneventful surgeries. Conclusion: This case report suggest that prior to awake fibreoptic intubation oxygenation, adequate topicalization with testing to verify the lack of pharyngeal and laryngeal responses and careful assessment of sedation levels in the operating room are prudent for a safe endoscopic intubation.
Keywords: benzodiazepine; fentanyl; glycopyrronium; lidocaine; midazolam; morphine; adult; aged; article; case report; cervical spine fracture; emergency treatment; endotracheal intubation; human; hypoxemia; intravenous drug administration; larynx spasm; male; oxygenation; positive end expiratory pressure; priority journal; sedation; tracheostomy; treatment outcome; upper respiratory tract obstruction

An unusual case of stridor due to osteophytes of the cervical spine: (Forestier's disease) - Papakostas K.; Thakar A.; Nandapalan V.; O'Sullivan G. (Journal of Laryngology and Otology, 1999)
Stridor is a noisy breathing caused by compromised airway in the larynx and trachea. The causes can either be due to intrinsic or extrinsic compression. Stridor resulting from extrinsic compression due to anterior cervical osteophytes is rare. We report an unusual case of acute stridor due to an osteophytic mass in the cervical vertebrae resulting in a mechanical upper airway obstruction. The underlying pathology was Forestier's disease or diffuse idiopathic skeletal hyperostosis (DISH). Stridor is a rare manifestation of DISH and it certainly represents the most life-threatening one. Only a few cases have been reported in the English literature and are mainly secondary to impaired function of the vocal folds, or postcricoid ulceration and oedema. We present such a case, in that stridor was the result of direct airway obstruction by the osteophytic mass and an emergency tracheostomy had to be performed to establish an airway.
Keywords: aged; airway constriction; ankylosing hyperostosis; article; breathing disorder; case report; cervical spine; compression; emergency surgery; human; larynx disorder; larynx edema; male; osteophyte; spondylosis; stridor; trachea disease; tracheostomy; ulcer; upper respiratory tract obstruction; vocal cord

Current status of long term ventilation of children in the United Kingdom: Questionnaire survey - Jardine E.; O'Toole M.; Paton J.Y.; Wallis C. (British Medical Journal, 1999)
Objectives. To identify the number and current location of children, aged 0 to 16 years, requiring long term ventilation in the United Kingdom, and to establish their underlying diagnoses and ventilatory needs. Design. Postal questionnaires sent to consultant respiratory paediatricians and all lead clinicians of intensive care and special care baby units in the United Kingdom. Subjects. All children in the United Kingdom who, when medically stable, continued to need a mechanical aid for breathing. Results. 141 children requiring long term ventilation were identified from the initial questionnaire. Detailed information was then obtained on 136 children from 30 units. Thirty three children (24%) required continuous positive pressure ventilation by tracheostomy over 24 hours, and 103 received ventilation when asleep by a non-invasive mask (n = 62; 46%), tracheostomy (n = 32; 24%), or negative pressure ventilation (n = 9; 7%). Underlying conditions included neuromuscular disease (n = 62; 46%), congenital central hypoventilation syndrome (n = 18; 13%), spinal injury (n = 16; 12%), craniofacial syndromes (n = 9; 7%), bronchopulmonary dysplasia (n = 6; 4%), and others (n = 25; 18%). 93 children were cared for at home. 43 children remained in hospital because of home circumstances, inadequate funding, or lack of provision of home carers. 96 children were of school age and 43 were attending mainstream school. Conclusions. A significant increase in the number of children requiring long term ventilation in the United Kingdom has occurred over the past decade, contributing factors include improvement technology, developments in paediatric non-invasive ventilatory support, and a change in attitude towards home care. Successful discharge home and return to school is occurring even for severely disabled patients. Funding and home carers are common obstacles to discharge.
Keywords: article; artificial ventilation; child; craniofacial malformation; face mask; female; human; hypoventilation; intensive care; lung disease; major clinical study; male; neuromuscular disease; positive end expiratory pressure; priority journal; questionnaire; spine injury; tracheostomy; United Kingdom

Upper airway obstruction by retropharyngeal hematoma after cervical spine trauma: Report of a case treated with percutaneous dilational tracheostomy - Mazzon D.; Zanatta P.; Curtolo S.; Bernardi V.; Bosco E. (Journal of Neurosurgical Anesthesiology, 1998)
The authors report the case of a patient affected by a cervical spine trauma who developed upper airway obstruction as a result of a retropharyngeal hematoma. An endotracheal intubation with a small-diameter tube was performed, but ventilation and oxygenation were not adequate. An early Percutaneous Dilational Tracheostomy with the Ciaglia technique was then performed. The risk of upper airway obstruction by retropharyngeal hematoma after cervical spine trauma is discussed in this article, as are the feasibility and benefits of using Percutaneous Dilational Tracheostomy in emergency cases of upper airway obstruction.
Keywords: aged; article; case report; cervical spine injury; endotracheal intubation; hematoma; human; lung ventilation; male; priority journal; risk assessment; tracheostomy; upper respiratory tract obstruction

Respiratory problems after high cervical spine injury - Stocker R.; Bürgi U. (Schweizerische Medizinische Wochenschrift, 1998)
Respiratory failure plays a major role in morbidity and mortality after high cervical spine injury. Initially the patients are threatened by acute loss of motor function of the respiratory muscles and the development of neurogenic pulmonary edema. In the further course alterations in the mechanical properties of the respiratory system, changes in lung function, pulmonary infections and airway problems are the main reasons for life threatening respiratory failure. Early surgical stabilization, careful weaning from mechanical ventilation, meticulous search and treatment of infections, aggressive posturing and mobilization and support of impaired mechanical functions by physiotherapy, muscle training, noninvasive respiratory support and in some cases electrophrenic pacing increase survival and independency of quadriplegic patients.
Keywords: artificial ventilation; cervical spine injury; conference paper; human; lung infection; muscle training; physiotherapy; quadriplegia; respiratory failure; tracheotomy

Oxyhemoglobin desaturation and aberrant carbon dioxide homeostasis during electrically stimulated exercise in a ventilator-dependent tetraplegic patient - Nash M.S.; Jacobs P.L.; Klerk K.M.; Green B.A. (Archives of Physical Medicine and Rehabilitation, 1998)
This single-subject case examined oxyhemoglobin saturation and alveolar end-tidal carbon dioxide levels in a ventilator-dependent tetraplegic patient undergoing electrical stimulation cycle ergometry. When exercising with a closed tracheostomy cuff under resting ventilator settings (resting intermittent mandatory ventilation; frequency = 6breaths/min, tidal volume = 83.3mL, minute ventilation =5L/min), his oxyhemoglobin saturation decreased from 100% to 92%, while alveolar end-tidal carbon dioxide increased linearly to 47mmHg. These undesirable changes were corrected under adjusted intermittent mandatory ventilation conditions (frequency = 12breaths/min, tidal volume = 83.3mL, minute ventilation = 10L/min), during which oxyhemoglobin saturation remained above 98% and the alveolar end-tidal carbon dioxide trend resembled that of ventilator-independent tetraplegic individuals undergoing the same exercise. Because the subject's heart rate was higher under adjusted ventilation conditions, these responses may have been caused by augmented venous return resulting from greater abdominothoracic pumping at the higher breathing frequency. These findings support the need to modify ventilator settings in ventilator-dependent tetraplegic persons while undergoing exercise to maintain oxyhemoglobin saturation and carbon dioxide homeostasis.
Keywords: carbon dioxide; oxyhemoglobin; adult; article; artificial ventilation; capnometry; case report; electrostimulation; ergometry; heart rate; human; human tissue; lung ventilation; male; oxygen saturation; quadriplegia; spinal cord injury; treatment indication; treatment outcome; venous return

Spine surgery in Duchenne muscular dystrophy - Chataigner H.; Grelet V.; Onimus M. (Revue de Chirurgie Orthopedique et Reparatrice de l'Appareil Moteur, 1998)
Purpose of the study: The authors present a retrospective review of 27 patients presenting a Duchenne muscular dystrophy and who were operated for spinal deformity, with special reference to functional result and postoperative evolution of vital capacity. Material and methods: Age at surgery averaged-14. Mean scoliotic angulation was 42°. A thoraco-lumbar kyphosis was present in 15 cases (kyphotic index less than 10°). A pelvic obliquity averaging 17°was associated in 19 cases. Mean pre-operative vital capacity was 66 per cent. Preoperative evolution of vital capacity was documented in 18 cases annual rate of decrease was 4.3 per cent. Heart ejection fraction averaged 63 per cent in 23 cases, and was normal in 4 cases. Instrumentation was extented from D3, D4 or D5 to L5 (5 cases) or S1 (22 cases). Spinal fixation was done in all patients by subliminar wiring with Luque rods (5 cases) or Hartshill rectangle (22 cases). Sacral fixation was done with ilio-sacral screws linked to the rectangle by Cotrel Dubousset rods and dominos (15 cases). Results: Mean blood loss was 1750 cc. Postoperatively, 25 patients were extubated on the operative day, 1 patient at D+1, and one patient a tracheostomy after one month. Scoliosis was reduced to 10°after surgery and 13°after 30 months follow-up. Pelvic obliquity was reduced to 4°after surgery and 7°after 30 months. A good spinal balance was present after surgery in 20 patients; at follow-up, a coronal or sagittal imbalance averaging 40 mm was observed in 22 patients. Postoperative evolution of vital capacity was documented in 21 cases. The annual decrease rate was 6.4 per cent. Rate was higher in patients presenting a good preoperative vital capacity (over 70 per cent) and very low in patients presenting a preoperative vital capacity under 40 per cent. 10 patients were deceased at review after a mean 53 months survival, at a mean age of 19. 17 patients were alive with a 50 months follow-up. Discussion: Spinal surgery in Duchenne muscular dystrophy has a low morbidity. It allows to keep sitting position to the child and to preserve quality of life. Surgery should be considered as soon as frontal or sagittal collapse of the spine is observed. However surgery does not result in respiratory improvement nor in life duration lengthening.
Keywords: adult; article; clinical article; Duchenne muscular dystrophy; female; human; male; quality of life; scoliosis; spine malformation; spine surgery; surgical technique; survival; tracheostomy; vital capacity

Esophageal injury secondary to thoracic spinal trauma: The need for early diagnosis and aggressive surgical treatment - Nakai S.; Yoshizawa H.; Kobayashi S.; Miyachi M. (Journal of Trauma - Injury, Infection and Critical Care, 1998)
Keywords: adult; autopsy; case report; conference paper; disseminated intravascular clotting; esophagus fistula; esophagus injury; esophagus perforation; female; human; priority journal; respiratory distress; rib fracture; spine injury; thoracic spine; thorax drainage; tracheotomy; traffic accident; vertebra dislocation

COPD and other diseases in chronically ventilated patients in a prolonged respiratory care unit: A retrospective 20-year survival study - Votto J.; Brancifort J.M.; Scalise P.J.; Wollschlager C.M.; ZuWallack R.L. (Chest, 1998)
Objectives: To evaluate the long-term prognosis of ventilator-dependent patients. Design: Retrospective study. Setting: A prolonged respiratory care unit (PRCU). The PRCU provides comprehensive medical, nursing, and respiratory care to tracheostomized, ventilator-dependent adult patients who had failed all attempts at weaning. Because of their medical complexity, these patients could not be discharged to a lower level of care. Patients: Of the 293 patients admitted to the PRCU over a 20-year period beginning January 1, 1977, 145 had respiratory failure from COPD, 22 from spinal cord disease or trauma, 34 from primary CNS disease, 50 from primary neuromuscular disease, and 16 from chest wall disease. Twenty-six patients were not classifiable into the above categories. Measurements: Demographics, diagnoses, and survival data were reviewed. The survival of patients with COPD was compared with the other diagnosis categories using the Cox proportional hazards model. Results: The median survival for the entire group was 9 months; younger age and female gender were both predictive of longer survival (both, p < 0.001). The median survival of those with COPD (5 months) was significantly shorter than that of patients with spinal cord disease (47 months), neuromuscular disease (17 months), and chest wall disease (27 months) (all, p<0.01). These differences in survival were present even with inclusion of gender and age in the model as covariates. The survival of patients with CNS disease was not significantly different from survival of patients with COPD. Conclusion: Chronically ventilated patients with respiratory failure from COPD have a significantly worse prognosis than patients with respiratory failure from other causes.
Keywords: amyotrophic lateral sclerosis; article; chronic disease; chronic obstructive lung disease; female; human; major clinical study; male; neuromuscular disease; priority journal; prognosis; respiratory failure; survival rate

Ventilation - Burchardi H.; Wöbker G.; Engelhardt W.; Schregel W.; Spiss C.K. (Zentralblatt fur Neurochirurgie, 1997)
Keywords: article; artificial ventilation; brain perfusion; disease severity; intracranial pressure; intubation; spinal cord injury; tracheotomy

Phrenic pacing: The present and future - Thoma H.; Girsch W.; Holle J.; Unger E. (Medizinische Klinik, 1997)
Under certain conditions, phrenic pacing is a rare but most effective and attractive alternative for long-term ventilation. General indications concern diseases of the breathing center, for example Undine's disease (loss of CO2 sensitivity) in infants and high cervical spinal cord lesions in the level of C0 to C3. Despite of the advantage of physiologic respiration mode (no positive air pressure) compared to long-term ventilation, the phrenic pacemaker enables high life quality for the patients due to possibilities of closing of tracheostoma (Vienna system), an optimum in mobility and high cost effectiveness. International research and development in this area concerns 1. nerve transposition of an innervated nerve to a denervating phrenic nerve, 2. additional stimulation of thoracal muscles for inspiration, 3. additional stimulation of expiration, 4. endoscopic operative positioning of the electrodes, 5. development of a pacer with sensor input for an individual respiration rhythm (controlled by the vocal cord) and 6. development of a fully implantable system. Improvements of the present pacemaker system may lead to enlargement of indications, for example use in patients with severe nocturnal arrhythmias in respiration.
Keywords: conference paper; human; pacemaker; phrenic nerve; quality of life; respiration control

Management of concomitant maxillofacial, cervical spine and laryngeal trauma--case reports. - Lim T.C.; Mokal N.J.; Tan W.T. (Annals of the Academy of Medicine, Singapore, 1997)
Three cases are presented to stress important points in the diagnosis and management of concomitant maxillofacial, cervical spine and laryngeal trauma. Emergency tracheostomy to control airway, immediate rigid fixation of maxillofacial fractures, early computed tomographic (CT) scans to evaluate the extent of laryngeal and cervical spine injury and the early repair of laryngeal injury will provide better aesthetic and functional results.
Keywords: adult; article; case report; cervical spine; computer assisted tomography; fracture; human; injury; injury scale; larynx; male; maxillofacial injury; multiple trauma; penetrating trauma; traffic accident

Assessment of the motor pathway to the diaphragm using cortical and cervical magnetic stimulation in the decision-making process of phrenic pacing - Similowski T.; Straus C.; Attali V.; Duguet A.; Jourdain B.; Derenne J.-P. (Chest, 1996)
Background: Phrenic nerve pacing is a recognized substitute to positive pressure ventilation via tracheotomy in patients with high cervical cord lesions or central hypoventilation. Although its indications are infrequent, reliable strategies need to be used in the determinations of patients who may benefit from this treatment; contraindications should be carefully respected. Study objectives: To determine whether modern and noninvasive means to study the motor pathway to the diaphragm, namely cortical magnetic stimulation (CxMS) and cervical magnetic stimulation (CMS), can contribute to the selection of patients who may benefit from phrenic pacing. Design and setting: Prospective study (18 months), on a consecutive basis, of patients referred for possible phrenic pacing to 10-bed ICU associated with a respiratory neurophysiology laboratory. Patients: Seven patients (high cervical cord injury, n=5; central hypoventilation following neurosurgery, n=1; idiopathic acquired central hypoventilation, n=1). Intervention, measurements, and results: Electromyography of the diaphragm and transdiaphragmatic pressure were assessed in response to CxMS and CMS. In three cases, no interruption of the corticodiaphragmatic pathway was evidenced, the decision of pacing was postponed, and the patients eventually recovered a spontaneous breathing activity. In two cases, the diagnosis of irreversible peripheral phrenic dysfunction was reached and pacing was denied. In two cases, complete interruption of the corticodiaphragmatic pathway and integrity of peripheral conduction led to the decision of phrenic pacemaker implantation. Conclusion: CxMS and CMS can be used to refine the assessment of patients proposed for phrenic pacing. CxMS can possibly identify those in whom there is a possibility for eventual recovery, and therefore substantiate a decision to postpone the pacing.
Keywords: adult; aged; article; cervical spinal cord injury; clinical article; decision making; diaphragm; female; human; male; muscle innervation; phrenic nerve; priority journal

Percutaneous dilational tracheostomy after anterior cervical spine fixation - Mazzon D.; Di Stefano E.; Dametto G.; Nizzetto M.; Cippolotti G.; Bosco E.; Conti C.; Giuliani G. (Journal of Neurosurgical Anesthesiology, 1996)
After spinal cord injury, quadriplegic patients generally require tracheostomy for ventilatory support and airway clearance. Early tracheostomy has several advantages over translaryngeal intubation, but in patients who undergo anterior surgical fixation of the spine, it is often delayed until after recovery of the surgical wound. We report the case of a quadriplegic patient who underwent a successful percutaneous dilational tracheostomy with the Ciaglia technique after surgical fixation of the spine. The percutaneous dilational technique minimizes the injury to the adjacent structures of the neck and the risk of stomal infection. Therefore, it should be considered the technique of choice when an early tracheostomy is indicated for quadriplegic patients who have undergone anterior surgical fixation of the cervical spine.
Keywords: adult; article; artificial ventilation; case report; cervical spinal cord injury; human; male; postoperative infection; priority journal; quadriplegia; spine stabilization; surgical technique; tracheostomy

Direct injury to the cervical spine of a child by a lap-shoulder belt resulting in quadriplegia: Case report - Lynch J.M.; Meza M.P.; Pollack I.F.; Adelson P.D. (Journal of Trauma - Injury, Infection and Critical Care, 1996)
Most pediatric cervical spine injuries from seat-belt restraints result from hyperflexion of the neck without direct injury to the spine from the restraining device. We report what we believe to be the first case of direct injury to the cervical spine by the shoulder component of a lap-shoulder seat belt. This resulted in quadriplegia. The mechanism of injury and recommendations to obviate such injuries are discussed.
Keywords: article; case report; cervical spinal cord injury; clinical feature; female; human; larynx injury; preschool child; priority journal; quadriplegia; seatbelt injury; spine fusion; spine stabilization; tracheostomy; traffic accident; treatment outcome

Massive tongue swelling as a complication after spinal surgery - Miura Y.; Mimatsu K.; Iwata H. (Journal of Spinal Disorders, 1996)
We report four cases of massive tongue swelling after spinal surgery. Swelling resulted from the position of the spine during surgery (flexed thoracic cervical position), fixation of the endotracheal tube, additional surgical gauzes packed around the endotracheal tube, and compression of the base of the tongue. Swelling, which causes obstruction of the airway, is a severe complication after spinal surgery that sometimes requires a tracheotomy. This complication can be avoided by careful positioning of the patient and by fixation of the endotracheal tube before surgery. Once swelling of the tongue occurs, administration of a corticosteroid is effective in preventing constriction of the airway.
Keywords: corticosteroid; adult; airway obstruction; article; case report; edema; endotracheal tube; human; male; patient positioning; postoperative complication; priority journal; spine surgery; tongue disease

The prognosis and the treatment of patients with a C3/4 spinal cord injury - Sannohe A.; Harata S.; Ueyama K.; Ito J.; Sato T.; Tian W.; Ichikawa S. (Spinal Cord, 1996)
Twenty patients with a C3/4 spinal cord injury have been treated in our hospital since 1974. There were 15 new patients. The average follow up period was 68 months, ranging from 7 to 162 months. The 15 new cases were classified as Frankel A in nine cases, B in one, and C in five. Frankel A or B were usually accompanied by either an unstable spinal fracture or by spinal canal stenosis at the C3/4 level. Twelve patients received surgery. At the most recent follow up, eight of the 15 patients (53.3%) had improved according to Frankel's classification. Five, all Frankel A on remission, have died between 2 and 156 months after injury. Seven patients required tracheotomy on account of severe respiratory disturbance.
Keywords: adult; aged; article; cervical spine injury; clinical article; female; follow up; human; injury scale; male; priority journal; prognosis; respiratory failure; tracheotomy; vertebral canal stenosis

Methicillin-resistant Staphylococcus aureus: A four-year experience in a spinal cord injury unit in Spain - Olona-Cabases M.; Ticó-Falguera N.; Ramírez-Garcerán L.; Del Valle-Ortiz O.; Castelló-Verdú T.; García-Fernández L. (Spinal Cord, 1996)
Methicillin-Resistant Staphylococcus aureus (MRSA) infection poses a problem for both acute and long-term-care facilities, Spinal Cord Injury units included. This paper describes the 4-year evolution of MRSA outbreaks in a SCI unit in a university hospital where control measures were implemented from the first case detected. The protocol procedure was as follows: contact isolation, washing with antiseptic soap both those infected and those sharing the same room, contacts study and monitoring of MRSA patients up to the time when three consecutive negative cultures (sampled at time lapses of over 48 h) were obtained, antiseptic soap for the health-care personnel to wash their hands, and cultures of the nares done on the personnel in the event of an outbreak. Twenty-one (3.4%) MRSA positive cases were detected out of 550 admissions registered during the study period (November 1990 through October l994). The evolution occurred in three outbreaks and six isolated MRSA positive patients without secondary cases. 71.5% of the cases were nosocomial. Seven (33%) were colonized and 14 (67%) infected. The 14 patients infected presented 15 infections: nine with urinary tract infections, three surgical wound infections, two tracheostomy wound infections, and one patient with a decubitus ulcer infection. Two of those with urinary tract infections presented with secondary sepsis. No carriers were detected amongst the personnel. Urinary tract colonizations responded to treatment with cotrimoxazol except in two cases in which combined treatment was required (cotrimoxazol plus rifampicin). The patients with a MRSA positive tracheal aspirate were negative after combined treatment. Wounds and cultures of the nares responded favorably to initial treatment. One of the patients with a urinary tract infection and sepsis died, the infection being a contributing cause. The prospective follow-up of the patients with MRSA positive cultures and the precocious implementation of isolation measures allow for the limitation of transmission, even though complete eradication is not possible.
Keywords: amikacin; chloramphenicol; ciprofloxacin; cotrimoxazole; erythromycin; fosfomycin; fusidic acid; gentamicin; lincosamine; meticillin; norfloxacin; rifampicin; tobramycin; unclassified drug; article; bacterial infection; controlled study; drug resistance; human; major clinical study; priority journal; spinal cord injury; Staphylococcus aureus

Anterior extraoral surgery to the upper cervical spine - Laus M.; Pignatti G.; Malaguti M.C.; Alfonso C.; Zappoli F.A.; Giunti A. (Spine, 1996)
Study Design. A series of 10 patients surgically treated with prevascular or retrovascular extraoral retropharyngeal approach to the upper cervical spine is examined. Objectives. In orthopedic surgery, retropharyngeal approach may replace the transoral surgery, obviating the risks of infection and the uncomfortable postoperative course of cases in which median labiomandibular glossotomy was used to accomplish complex bone reconstruction. Summary of the Background Data. The transoral approach is reported in literature as the classical anterior access to the upper cervical spine that provides direct exposure for anterior decompression of the spinal cord. The risks, the surgical limits, and the postoperative difficulties of transmucosal access suggest the use of an anterior extraoral retropharyngeal approach in orthopedic surgery. Methods. The series includes four neoplastic lesions (osteoma, aneurismal bone cyst, giant cell tumor, solitary metastasis), three retropharyngeal ossifications resulting from diffuse idiopathic skeletal hyperostosis, and a single case of os odontoideum, craniocervical malformation, and postlaminectomy kyphosis. Results. At follow-up evaluation, all patients achieved a satisfactory outcome, with good clinical and radiographic results; nasotracheal intubation obviated the need for tracheostomy. The wide surgical exposure allowed reconstruction with iliac strut bone grafts and internal fixation in six patients, avoiding the need of a halo device. The only complications were four instances of transient palsies of the marginal mandibular branch of the facial nerve. Conclusions. In the anterior surgery of the upper cervical spine, the prevascular approach allows a wide surgical exposure, with visualization similar to that obtained with median labiomandibular glossotomy. The retrovascular approach is indicated in selected cases, such as tumor adjacent to the vertebral artery and C1-C2 arthrodesis with bilateral transarticular screws according to Barbour.
Keywords: adolescent; adult; aged; arthrodesis; article; bone graft; bone remodeling; cervical spine; clinical article; facial nerve paralysis; female; human; male; nasotracheal intubation; orthopedic surgery; osteosynthesis; priority journal; spinal cord decompression; spine surgery; surgical technique

Respiratory management, survival, and quality of life for high-level traumatic tetraplegics. - Viroslav J.; Rosenblatt R.; Tomazevic S.M. (Respiratory care clinics of North America, 1996)
Although spinal cord injury is devastating and can compromise the respiratory system, particularly when the cervical cord is injured, aggressive use of noninvasive respiratory muscle aids can reduce the otherwise commonly seen complications of pneumonia, bronchial mucous plugging, atelectasis, and respiratory failure. Accessory muscle function can also usually be improved and the muscles then recruited to help maintain adequate alveolar ventilation during the acute spinal cord injury recovery period. Noninvasive assisted ventilation can be successful for patients with compromised lung function during the acute rehabilitation period as well as on a long-term basis. Removal of an indwelling tracheostomy tube results in improved quality of life from many points of view, a decreased number of local tracheostomy complications, a decreased number of serious respiratory infections, an improved ability to communicate, and an increased ability to use the mouth for functions such as operating computers and wheelchairs.
Keywords: adolescent; adult; breathing mechanics; female; human; devices; intermittent positive pressure ventilation; male; methodology; mortality; pathophysiology; quadriplegia; quality of life; review; spinal cord injury; United States

Reconstructive spine surgery in pediatric patients with major loss in vital capacity - Rawlins B.A.; Winter R.B.; Lonstein J.E.; Denis F.; Kubic P.T.; Wheeler W.B.; Ozolins A.L. (Journal of Pediatric Orthopaedics, 1996)
Thirty-two pediatric patients with severe restrictive lung disease identified with vital capacities <40 of predicted, who had undergone major reconstructive spine surgery, were reviewed. There were 18 boys and 14 girls, the mean age was 13 years (range, 7-17), and the mean vital capacity was 31% of predicted (range, 16-39%). Fifty-four procedures were performed 13 posterior only, one of which was singed, and 19 anterior and posterior procedures, of which 15 were staged and four were sequential. The incidence of pulmonary complications (pneumonia, reintubation, pneumothorax, respiratory arrest, or the need for (tracheostomy) was 19% (six patients), and only three patients required tracheostomy. The surgical and perioperative mortality rate waszero. Patients who had a thoracotomy or a thoracoabdominal approach had a significantly higher number of pulmonary complications. The use of preoperative decreased vital capacity as a measure of inoperability excludes the young patient most in need of surgical intervention. With improved preoperative, intraoperative, and postoperative techniques, careful monitoring, and the cooperation of pediatric pulmonologists and intensivists, reconstructive spine surgery can be performed in the pediatric patient with severe decreased vital capacity with very acceptable morbidity and mortality.
Keywords: adolescent; article; female; human; lung complication; male; priority journal; respiratory function disorder; school child; spine malformation; spine surgery; surgical mortality; vital capacity

Laryngotracheal stenosis after intubation or tracheostomy in patients with neurological disease - Richard I.; Giraud M.; Perrouin-Verbe B.; Hiance D.; Mauduyt De La Greve I.; Mathé J.-F. (Archives of Physical Medicine and Rehabilitation, 1996)
Objective: This retrospective study evaluated the incidence of airway complications in neurological patients following translaryngeal intubation, tracheostomy, or both. Design: The medical records of 315 consecutive patients (200 with traumatic brain injuries, 31 traumatic tetraplegics, and 84 with other neurological disorders) were reviewed. The type of artificial airway, duration of intubation, and use of nocturnal ventilation were recorded. Eighty-six percent of the patients underwent some combination of tracheal tomograms, flow-volume loop analysis, and fiberoptic tracheolaryngoscopy. Stenosis was classified as severe if it required surgery, if it required maintaining the tracheostomy, or was lethal. It was classified as benign if it was successfully treated by medical or local means. Results: Fifty-five percent of the patients were intubated translaryngeally only (mean = 17 days). Three percent underwent tracheostomy only, and 42% underwent tracheostomy after intubation for a mean of 13 days. The overall incidence of airway stenosis was 20%, 1/4 of which was severe. Fifteen percent of these patients died as a result of tracheal complications. The incidence of stenosis was higher following tracheostomy than following intubation only (29% vs 13%, p < .01). The incidence of severe stenosis in intubated-only patients was low (1%) compared with that following tracheostomy (10%, p < .01). No significant relationship was found between the length of intubation or the timing of tracheostomy. Conclusion: Fewer complications are associated with transtracheal intubation than with tracheostomy. The data suggest that longer periods of intubation be used when attempting ventilator weaning before resorting to tracheostomy if weaning fails.
Keywords: adolescent; adult; aged; anesthesia complication; article; brain injury; child; endotracheal intubation; female; human; intensive care; laryngoscopy; larynx stenosis; major clinical study; male; neurologic disease; spinal cord injury; trachea stenosis; tracheostomy; treatment outcome

Home mechanical ventilation: investigation of 34 cases in Taiwan. - Lin M.C.; Huang C.C.; Lan R.S.; Tsai Y.H. (Changgeng yi xue za zhi / Changgeng ji nian yi yuan = Chang Gung medical journal / Chang Gung Memorial Hospital, 1996)
To evaluate the characteristics of and acceptance by persons in Taiwan who currently use positive-pressure mechanical ventilation at home (HMV), a survey was conducted in August 1992 through home care and equipment providers to investigate these patients. The 34 cases enrolled, including 18 males and 16 females, were classified into four groups: (1) lung disease group (LD) (n = 7) including chronic obstructive pulmonary disease and bronchiectasis; (2) neuromuscular group (NM) (n = 14) including diverse neuromuscular diseases; (3) spinal disease group (SP) (n = 7) including spinal cord injuries or tumors and (4) unresponsive stroke group (US) (n = 6). The average age of the SP group was much younger than those of the other three groups. The duration of home ventilation was from 1 to 36 months, with a mean duration of 10.6 +/- 8.7 months. Fifteen cases had received HMV for more than one year. Twenty six (76.5%) of the patients were completely dependent. All of the US patients had to be ventilated all day long in contrast to 71.4% of LD completely dependent. The cost of the US group was higher than that of the other three groups. Two of the LD, five of NM and one US patient had been re-admitted because of pneumonia, tracheostomy wound infection, granulation formation or weaning problems before the study. A follow-up survey was done four months, then one year later. The survival rate was 16.7% for LD group, 50% for NM and US group. Of the SP group, all patients were surviving at the end of this study. Most of the present HMV users were satisfied with their setting. It was concluded that HMV is an acceptable alternative way of therapy for long-term ventilation patients in Taiwan. SP and NM patients are better candidates for HMV. The overall one year survival rate is promising, while SP patients had the best prognosis. Patients who had already used HMV for more than 11 months, regardless of the disease, have a better chance to live another year.
Keywords: adolescent; adult; aged; article; artificial ventilation; child; female; follow up; home care; human; male; middle aged; preschool child

Tracheostomy in the 1990s: Current clinical practice in an urban university teaching hospital - Kasper C.L.; Stubbs C.R.; Barton J.A.; Pierson D.J. (Respiratory Care, 1996)
BACKGROUND: Tracheotomy is a commonly performed procedure in hospitals and may be performed for various reasons by one of several services. Because of the absence of both a defined institution-wide procedure for assessment and recent literature to describe current tracheostomy management, we conducted this retrospective study. METHODS: We reviewed the medical records of all patients for the fiscal year 1992-93 coded as having tracheostomy status prior to admission or having tracheotomy performed during the admission. We attempted to answer (1) Why were tracheotomies performed? (2) Who performed/managed the tracheotomies? (3) What postoperative care was given? RESULTS: Of the 109 patients, 74% were men 13 to 83 years of age. Patients underwent tracheotomy for facial injuries (21%), prolonged ventilation (21%), closed head injuries (20%), other intracranial processes (16%), other head and neck surgery (6%), spinal cord injuries (5%), epiglottitis (3%), and 8% underwent tracheotomy for reasons other than these. Thirty-seven percent were tracked prior to this admission. Of the 93 admissions, 63% had tracheotomy performed during the current admission by General Surgery (27%), Otolaryngology Head and Neck Surgery (46%), Neurosurgery (22%), Oral and Maxillofacial Surgery (2%), Burns-Plastic Surgery (3%). Of the patients with tracheostomies 67% had orders and 85% had progress notes pertaining to tracheostomy management. Of the 147 admissions, 100 (68%) had Respiratory Care notes regarding tracheostomy. CONCLUSION: Because a number of services with various training backgrounds participate in the care of patients with tracheostomy and because variation exists, a multidisciplinary tracheostomy team appears desirable in a hospital such as ours.
Keywords: adolescent; adult; aged; article; assisted ventilation; clinical protocol; face injury; female; head and neck surgery; head injury; human; major clinical study; male; medical practice; tracheostomy; tracheotomy; treatment planning; university hospital

Occurrence of infection in anterior cervical fusion for spinal cord injury after tracheostomy - Northrup B.E.; Vaccaro A.R.; Rosen J.E.; Balderston R.A.; Cotler J.M. (Spine, 1995)
Study Design. This study retrospectively reviewed the outcomes of 11 patients treated for a cervical spine injury with a tracheostomy placed before anterior cervical spine surgery. Objectives. The primary goal was to show that anterior cervical spine surgery in the setting of spinal cord injury is a viable option in patients with previous tracheostomy. Summary of Background Data. Respiratory failure after cervical cord injury commonly requires tracheostomy, possibly increasing the risk of soft tissue or bony infection in patients at high risk for morbidity after surgery. Although numerous studies have explored the risk of infection after tracheostomy or anterior cervical spine surgery, no study has been performed to explore the risk of infection in patients with previous tracheostomy at the time of anterior cervical spine surgery. Methods. A retrospective review of the clinical data of 1800 spinal cord injury patients seen from 1979 to the present at the Regional Spinal Cord Injury Center of the Delaware Valley of Thomas Jefferson University with affiliated institutions of Thomas Jefferson University Hospital and Magee Rehabilitation Hospital was performed. Eleven patients were found who had existing tracheostomy at the time of anterior cervical spine surgery. Clinical follow-up period averaged 28 months with a range of 6-51 months, and radiographic analysis averaged 7 months with a range of 1-51 months. Autogenous lilac crest graft was used in all patients, consisting of an intervertebral graft after a discectomy or a strut graft after a complete corpectomy. Anterior instrumentation was used in more than 50% of the patients. Results. After all patient interviews and review of all radiographs for evidence of infection, no patient was noted to have evidence of a cervical soft tissue or bony infection after surgery. The tracheostomy complications were minor and resolved quickly. Conclusions. The authors concluded that in patients with cervical cord damage resulting from nonpenetrating trauma, tracheostomy was not found to increase the risk of infection in subsequent anterior cervical surgery. Careful preparation of the skin and placement of the second surgical incision lateral to the tracheostomy site is recommended. Anterior cervical spine surgery remains a viable treatment option in this severely injured patient population.
Keywords: adult; article; bone graft; cervical spine; clinical article; high risk population; human; infection; infection risk; discectomy; priority journal; respiratory failure; risk assessment; spinal cord infection; spinal cord injury; spine fusion; spine surgery; tracheostomy

Transoral anterior decompression and fusion of chronic irreducible atlantoaxial dislocation with spinal cord compression - Subin B.; Liu J.-F.; Marshall G.J.; Huang H.-Y.; Ou J.-H.; Xu G.-Z. (Spine, 1995)
Study Design. In this study, 10 patients with chronic irreducible atlantoaxial dislocation were treated by transoral anterior decompression and fusion. Objectives. To examine the benefits of the transoral approach, the patients treated with this procedure were compared with the historical control subjects after 2 years of follow-up. Summary and Background Data. Chronic irreducible atlantoaxial dislocation with cord compression is difficult to treat because the cord is compressed posteriorly by the posterior arch of the atlas as well as anteriorly by the posterior-superior portion of the axial body and nonunited dens. Its irreducibility, as a result of the bony scarring between the dens and the anterior body of the axis, and the locking of the lateral joints of C1-C2, makes reduction more complex. Posterior surgical approaches have been associated with high morbidity and mortality. Methods. Ten patients were diagnosed and followed up by clinical symptoms, radiography, pantopaque myelography, and computed tomography. They were treated surgically by transoral decompression and fusion. During the surgery the nonunited dens as well as callus, granulation, and scar tissue were removed; the cartilage of the articular surfaces of the atlantoaxial joint was excised. Postoperative treatment included skull-cervical biaxial traction, tracheostomy care, nasal feeding, and Minerva cast. Results. The 2- to 6-year follow-up showed that four out of 10 patients recovered completely and returned to work, three recovered to a great degree and ambulated, two partially recovered, and one recovered poorly. Conclusion. Transoral decompression and fusion offered satisfactory results in a series of patients with chronic irreducible atlantoaxial dislocation. None of the patients showed serious complications of stability, even though only one had a secondary posterior fusion. Therefore, anterior decompression associated with subtotal obliteration of the atlantoaxial joints without bone grafts is a feasible therapy for irreducible atlantoaxial dislocation using a multifunctional bed and biaxial traction.
Keywords: adolescent; adult; anterior spine fusion; article; atlantoaxial dislocation; chronic disease; clinical article; controlled study; female; hospital bed; human; intravenous drug administration; male; odontoid process fracture; postoperative care; priority journal; spinal cord compression; spinal cord decompression; spine stabilization; spine surgery; surgical approach; traction therapy; treatment outcome

Respiratory muscle aids for the prevention of pulmonary morbidity and mortality - Bach J.R. (Seminars in Neurology, 1995)
The great majority of individuals with ventilatory failure due to paralytic syndromes can be managed entirely by noninvasive inspiratory and expiratory muscle aids. When the equipment is properly used, individuals may eventually become dependent on noninvasive IPPV 24 hours a day without ever being hospitalized, intubated, tracheostomized, or bronchoscoped. The use of noninvasive respiratory muscle aids eliminates the need for 'crisis' decision making about whether or not to 'go on a respirator. Use of respiratory muscle aids by ALS patients familiarizes them with ventilator dependency before any decision about tracheostomy needs to be made. These methods enhance quality of life in many ways, including permitting the use of GPB for security in the event of ventilator failure. They can also drastically decrease cost and optimize psychosocial functioning. These techniques should become part of the therapeutic armamentarium of every physician who treats patients with generalized neuromuscular disorders who have the potential to develop ventilatory insufficiency, mucus plugging, or both.
Keywords: amyotrophic lateral sclerosis; assisted ventilation; breathing muscle; coughing; Duchenne muscular dystrophy; endotracheal intubation; extubation; feedback system; human; intermittent positive pressure ventilation; lung function test; lung ventilation; multiple sclerosis; muscle weakness; neuromuscular disease; oximetry; poliomyelitis; priority journal; respiratory failure; review; spinal cord injury; spine malformation; tracheostomy

Effectiveness of home ventilation of young children and infants - Wollinsky K.H.; Mindé A.; Schreiber H.; Kluger P.; Mehrkens H.H. (Medizinische Klinik (Munich, Germany : 1983), 1995)
BACKGROUND: The home care ventilation of patients with chronic respiratory insufficiency is a well-established method. In treating infants and newborns a lot of problems arise that deal with indication, prognosis and management. PATIENTS AND METHODS: We investigated 7 newborns and infants with chronic respiratory insufficiency after cervical spine trauma causing "pentaplegia" or due to inherited neuromuscular disorders (spinal muscular atrophy, myopathy) during homecare ventilation. RESULTS AND DISCUSSION: In contrast to experience with adults the management of the children with "pentaplegia" was relatively harmless. All were tracheostomized primarily, but 1 tracheostomy could be closed, because the patient finally achieved to be ventilated only during night-time in the iron lung. The 3 children with neuromuscular diseases were ventilated noninvasively by specially fitted nasal masks. Despite coming to the frontiers of feasibility, and taking into account the psychological stress for patients, relatives, doctors and nurses, satisfactory results were obtained.
Keywords: article; disability; equipment design; female; home care; human; infant; devices; male; mask; neonatal respiratory distress syndrome; newborn; positive end expiratory pressure; preschool child; respiratory failure

Lateral tracheostomy in patients with cervical spinal cord injury - Tran N.V.; Vernick J.; Cotler J.M.; Rabinovici R. (British Journal of Surgery, 1995)
Keywords: article; cervical spinal cord injury; clinical article; human; priority journal; surgical technique; tracheostomy

Noninvasive long-term ventilatory support for individuals with spinal muscular atrophy and functional bulbar musculature - Bach J.R.; Wang T.-G. (Archives of Physical Medicine and Rehabilitation, 1995)
Ten individuals with spinal muscular atrophy (SMA) and chronic ventilatory insufficiency were trained in the use of assisted coughing techniques and received intermittent positive pressure ventilation (IPPV) via oral and/or nasal interfaces for a mean of 5.3 (range = 1 to 17) years. During this time they had significantly fewer respiratory complications than before introduction of noninvasive respiratory muscle aids despite the fact that 6 of the 10 went on to require more than 20 hours per day of ventilator use with less than 2 hours of ventilator-free breathing time (VFBT). All except two noninvasive IPPV users had vital capacities (VCs) less than 13% of predicted normal. They could, however, communicate verbally and take nutrition by mouth. All of the patients remained in the community. Five patients were gainfully employed and four were in school. We conclude that noninvasive respiratory muscle aids including noninvasive IPPV and assisted coughing techniques are effective and practical alternatives to tracheostomy for SMA patients with ventilatory failure but functional bulbar musculature.
Keywords: adolescent; article; assisted ventilation; breathing muscle; child; chronic disease; clinical article; clinical trial; human; intermittent positive pressure ventilation; long term care; neurologic disease; oropharynx; respiratory failure; spinal muscular atrophy; vital capacity

Ethical considerations in the management of individuals with severe neuromuscular disorders - Bach J.R.; Barnett V. (American Journal of Physical Medicine and Rehabilitation, 1995)
There have been many recent advances in improving the quality of life and prolonging life for individuals with advanced neuromuscular disease. These include the use of physical medicine techniques to balance extremity muscle strength and improve range of motion and noninvasive techniques to provide inspiratory and expiratory muscle assistance to prolong life without resort to tracheostomy. Such advances help eliminate the 'crisis' decision making about 'going on a respirator' and sophisticated assistive equipment and robotic aids. Physicians and society in general use quality of life issues inappropriately derived by questioning physically able individuals to justify withholding or implementing life-sustaining therapeutic interventions for these individuals. Informed decisions about ethically and financially complex matters such as long-term ventilator use should be made by examining the life satisfaction of competent individuals who have already chosen these options. The great majority of severely disabled ventilator-assisted individuals with neuromuscular disease are satisfied with their lives despite the inability to achieve many of the 'usual' goals associated with quality of life in the physically able population. Their principle life satisfaction derives from social relationships, the reorganization of goals and from their immediate environment. Although the Americans with Disabilities Act is seen as an important step to prevent discrimination against disabled individuals, it does little or nothing for the self-directed disabled individual who is not informed by his/her physicians regarding potentially vital therapeutic options nor does it help those who are warehoused in institutions because of lack of a national personal assistance services policy. This is ironic because the provision of personal assistance services for the home care of ventilator-assisted individuals can greatly reduce cost as well as enhance quality of life. The institutional control of chronic care, whether in an institution itself, or in the community with personal assistance services managed by nursing organizations rather than by the self-directed client himself, impersonalizes and dehumanizes care in the name of safety. It reduces the client's sense of personal control and self-efficacy and suggests inadequacy in coping except in the most restrictive environment. Physical medicine and rehabilitation specialists who train their patients in how to manage and take responsibility for their care need to play a more active role in advocating for the procurement of the services needed to permit them to return to the community.
Keywords: artificial ventilation; cost control; disability; Duchenne muscular dystrophy; health care cost; life satisfaction; medical ethics; neuromuscular disease; patient right; poliomyelitis; quality of life; rehabilitation medicine; respiratory failure; review; spinal cord injury

Respiratory dysfunction associated with traumatic injury to the central nervous system - Slack R.S.; Shucart W. (Clinics in Chest Medicine, 1994)
Pulmonary dysfunction is a common complication of head trauma and spinal cord injury. Abnormal breathing patterns reflect the influence of altered neural integration. Early arterial hypoxemia can result from ventilation- perfusion mismatching, microatelectasis, aspiration, fat embolism, or the development of the adult respiratory distress syndrome. Significant changes in lung volumes, ventilation, and gas exchange can occur in spinal cord injury as a result of the loss of diaphramatic or intercostal muscle function. Recruitment of accessory respiratory muscles plays an important role in stabilizing the rib cage and improving expiratory function. Strength training improves expiratory muscle function in quadriplegics and should be continued indefinitely. Most importantly, survival of patients with CNS injuries improves with meticulous and vigorous pulmonary hygiene. The pulmonary hygiene program should include regular changes in the patient's position, assisted coughing and deep breathing exercises, incentive spirometer, bronchodilators, fiberoptic bronchoscopy when indicated, and frequent monitoring of pulmonary mechanics. Long-term survival of the patient with head trauma or spinal cord injury is correlated to successful weaning from mechanical ventilation. Various forms of mechanical ventilator support can be adopted for the patient's ventilatory needs and many patients will achieve some degree of freedom from mechanical ventilation. Newer ventilatory assist devices that do not require tracheostomy should be considered.
Keywords: bacterial pneumonia; brain injury; breathing pattern; bronchus secretion; cervical spinal cord injury; Cheyne Stokes breathing; endotracheal intubation; human; hyperventilation; hypoxemia; lung edema; lung embolism; lung mechanics; mucus secretion; patient positioning; positive end expiratory pressure; priority journal; respiration control; respiratory failure; review; spinal cord injury; suction drainage; tracheobronchial toilet; traffic accident

Options for mechanical ventilation in neuromuscular diseases - Unterborn J.N.; Hill N.S. (Clinics in Chest Medicine, 1994)
A variety of mechanical devices may be used to provide assistance when ventilation and cough are severely impaired by progressive respiratory weakness caused by neuromuscular disease. Traditionally, positive pressure ventilation via a tracheostomy has been used, but if upper airway function is adequate, a variety of noninvasive devices also may be considered. Although positive pressure ventilation is the preferred noninvasive mode for assisting ventilation, other modes may be selected depending on patient needs, preferences, and physical characteristics.
Keywords: amyotrophic lateral sclerosis; article; artificial ventilation; assisted ventilation; breathing mechanics; follow up; Guillain Barre syndrome; human; medical decision making; multiple sclerosis; muscular dystrophy; myasthenia gravis; neuromuscular disease; Parkinson disease; patient monitoring; positive end expiratory pressure; priority journal; respiratory failure; spinal cord injury; cerebrovascular accident; ventilator

The prevention of spread of methicillin resistant Staphylococcus aureus in a spinal injuries centre - Pick F.C.M.; Rose M.; Wang D.; Gardner B.P.; Gillett A.P. (Paraplegia, 1994)
The National Spinal Injuries Centre (NSIC) is a tertiary referral centre. It accepts most of its patients from other hospitals in the UK and overseas. The severity of injury, the presence of a tracheostomy, urinary catheter and pressure sores predisposes this group of patients to colonisation or infection with Methicillin resistant Staphylococcus aureus (MRSA). The NSIC uses simple but strict protocols for hygiene, screening for MRSA, and source isolation of known or suspected MRSA carriers in single room accommodation to control the spread of MRSA in the centre. A retrospective search of microbiology and patient records revealed that in 4 years there had been 24 admissions with MRSA, with a total of 1421 isolation days. There was only one outbreak of MRSA. This involved three patients. Hygiene, screening of potential MRSA carriers together with single room isolation can limit the spread of MRSA.
Keywords: meticillin; article; bladder catheterization; clinical article; decubitus; female; hospital hygiene; human; infection control; length of stay; male; medical record; microbiology; patient referral; penicillin resistance; priority journal; spine injury; Staphylococcus aureus; Staphylococcus infection; tracheostomy; United Kingdom

Mechanical ventilation in acute cervical spinal cord injuries - Romero Ganuza J.; La Banda Brusi F.; Garcia Leoni M.E.; Gambarruta de Shore C.; Espinosa Ramirez S.; Cortes Bermejo S.; Mazaira Alvarez J. (Medicina Intensiva, 1994)
Objective. To analyse respiratory care required by patients with acute cervical spinal cord injuries. Methods. We have retrospectively studied all the patients admitted to the ICU of the Hospital Nacional de Paraplejicos de Toledo with traumatic cervical spinal cord injury during 2.5 years. From the whole group, 183 patients required to be transferred to the ICU and 131 needed mechanical ventilation. Results. Mechanical ventilation lasts a long time, and this causes long ICU stays: the higher is the level of the injury, the longer is the stay. There is a high rate of respiratory complications (71.6%), and tracheostomies (91.6%); and a low mortality (5.5%). Conclusions. Every cervical spinal cord injury must be initially admitted to the ICU. If mechanical ventilation is required it must be assumed to be prolonged and so will be the stay; there is a relation between the level of the injury and the necessity of mechanical ventilation. Mode of ventilation and weaning must be individualized. Tracheostomy necessity is related to the level of the injury. There is a low mortality according to a low APACHE II score and a low rate of associated lesions in our series. It is desirable to transfer this type of patients to a unit specialized in spinal cord injuries when the situation of the patient allows it.
Keywords: adolescent; adult; article; artificial ventilation; cervical spinal cord injury; child; female; human; infant; length of stay; major clinical study; male; mortality; newborn; preschool child; quadriplegia; respiratory tract disease; retrospective study; school child; tracheostomy

Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury - Esclarin A.; Bravo P.; Arroyo O.; Mazaira J.; Garrido H.; Alcaraz M.A. (Paraplegia, 1994)
We have made a retrospective comparative study of patients with spinal cord injury, nine with a diaphragmatic pacemaker and 13 with mechanical ventilation. Clinical outcome, cost and subjective satisfaction with both modalities have been evaluated. The functional status was the same with both types of treatment. Proper management of an electric wheelchair and optimal phonation were attained, respectively, in 100% and 89% of pacers and in 77% and 77% of mechanically ventilated. The rate of hospital discharge and satisfaction with the treatment were significantly better for pacers. The time devoted to ventilatory assistance and cost were also more favourable in this group.
Keywords: adolescent; adult; article; artificial ventilation; clinical article; controlled study; cost benefit analysis; female; hospital discharge; human; intermethod comparison; male; pacemaker; patient satisfaction; phonation; priority journal; school child; spinal cord injury; tracheostomy; wheelchair

Respiratory complications after cervical spinal cord injury - Lemons V.R.; Wagner Jr. F.C. (Spine, 1994)
Study Design. Sixty-five consecutive cases of acute cervical spinal cord injuries were reviewed retrospectively for respiratory complications. Objectives. The objectives were to identify factors that may contribute to respiratory dysfunction and to evaluate therapeutic measures designed to reduce respiratory complications. Summary of Background Data. Respiratory complications continue to be a major cause of morbidity and mortality after cervical spinal cord injury with a reported incidence from 36 to 83%. Methods. Multiple factors were evaluated which could potentially influence the incidence or severity of respiratory complications. These included age, pre-existing cardiac or pulmonary disease, accompanying major injuries and the severity of the spinal cord injury. The effects of various therapeutic measures were also assessed including the benefit of rotating beds, early fracture stabilization and patient mobilization. Results. Respiratory complications occurred in 62% of these patients and were transient in nature, variable in severity and duration, strongly associated with the severity of spinal cord injury, and only marginally affected by therapeutic interventions. Conclusions. The characteristics of respiratory dysfunction following cervical spinal cord injury correspond to those of spinal shock.
Keywords: adolescent; adult; aged; artificial ventilation; atelectasis; cervical spinal cord injury; conference paper; fiberoptic bronchoscopy; human; incidence; intubation; lung embolism; major clinical study; pneumonia; priority journal; respiratory failure; respiratory tract disease; retrospective study; tracheostomy

Tuberculosis of the cervical spine - Bahadori R.S.; Arjmand E.M.; Goldberg A.N. (Otolaryngology - Head and Neck Surgery, 1994)
Keywords: ceftriaxone; clindamycin; isoniazid; pyrazinamide; rifampicin; adult; article; bone graft; case report; cervical spine dislocation; human; human tissue; lymphadenopathy; male; Mycobacterium tuberculosis; retropharyngeal abscess; tracheotomy; traction therapy; trismus; tuberculous spondylitis

Survival of individuals with spinal muscular atrophy on ventilatory support - Wang T.-G.; Bach J.R.; Avilla C.; Alba A.S.; Yang G.-F.W. (American Journal of Physical Medicine and Rehabilitation, 1994)
Six ventilator-assisted individuals (VAIs) with spinal muscular atrophy (SMA) are described. All six survived by using intermittent positive pressure ventilation via an indwelling tracheostomy for a mean of 11.7 ± 17.7 yr despite frequent episodes of mucus plugging and pneumonia. Four of the VAIs also received all nutrition via indwelling gastrostomy tubes because of severe bulbar muscle weakness. Four VAIs used tracheostomy intermittent positive pressure ventilation with their tracheostomy cuffs deflated and could communicate verbally. Five of the six VAIs remained institutionalized from the onset of ventilatory use. Two SMA VAIs survived for 15 and 4 yr, respectively, despite need for ventilatory support since early infancy. All four SMA VAIs who could communicate remained socially active and one, gainfully employed. We conclude that for patients with advanced SMA markedly prolonged survival is possible with ventilatory assistance despite severe respiratory and bulbar muscle dysfunction.
Keywords: adolescent; adult; article; artificial ventilation; child; chronic disease; clinical article; clinical trial; female; human; interpersonal communication; male; neuromuscular disease; pneumonia; positive end expiratory pressure; respiratory failure; social adaptation; spinal muscular atrophy; survival time; tracheostomy; vital capacity

The tracheostomy tube. - Kirschner K.L.; Smith J.; Donnelley S. (The Hastings Center report, 1994)
Keywords: adolescent; article; case report; decision making; doctor patient relation; emergency; human; living will; male; medical staff; professional-patient relationship; psychological aspect; respiratory failure; spinal cord injury; tracheostomy; treatment refusal; treatment withdrawal

Problems of long term hospitalised spinal cord injury patients in university hospitals - Arima T.; Noguchi T.; Mochida J.; Toh E.; Konagai A.; Nishimura K. (Paraplegia, 1994)
Of the 215 cervical spinal cord injury (CSCI) patients treated in Tokai University Hospital over the last 17 years, 42 who were hospitalised for more than 90 days were selected as the subjects for this survey. They were divided into two groups: group A: patients hospitalised for 180 days or more; and group B: patients hospitalised for more than 90 but less than 180 days. The aspects surveyed were: the number of days of hospitalisation, type of injury, level of spinal cord injury, extent of spinal cord paralysis, assessment based on Frankel's classifications, whether a tracheotomy was performed or not, surgical treatment, complications, and the clinical course after discharge. The most common injury for the 13 patients in group A (average stay 281 days) was a fracture-dislocation, followed next by those with a burst fracture. The majority of the 28 patients in group B (average stay was 117 days) had a central type of spinal cord injury. Characteristics observed in group A in particular were: higher segment injuries to the cervical spinal cord, complete paralysis, respiratory complications such as pneumonia, tracheotomy, or a waiting time of at least 6 months before discharge, in cases where a transfer to a rehabilitation hospital was possible. The major problems of treating CSCI patients in university hospitals are that severe cases, which are concentrated in university hospitals, are forced to occupy private rooms for long term treatment, and there is a difficulty in transferring these patients to rehabilitation hospitals. The following measures are desirable to improve the situation: construction of facilities specialising in the treatment of spinal cord injuries, and other assertive measures to be taken at national and prefectural levels.
Keywords: adult; article; cervical spinal cord injury; cervical spine dislocation; clinical article; female; hospital discharge; hospitalization; human; Japan; long term care; male; pneumonia; priority journal; spinal cord injury; tracheotomy; university hospital

Airway control in trauma patients with cervical spine fractures. - Lord S.A.; Boswell W.C.; Williams J.S.; Odom J.W.; Boyd C.R. (Prehospital and disaster medicine : the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation, 1994)
INTRODUCTION: Proper airway control in trauma patients who have sustained cervical spine fracture remains controversial. PURPOSE: This study was undertaken to survey the preferred methods of airway management in cervical spine fracture (CSF) patients, to evaluate the experience of handling such patients at a level-I trauma center, and to contrast the findings with recommendations of the American College of Surgeons Committee on Trauma. HYPOTHESIS: The methods used for control of the airway in patients with fractures of their cervical spine support the recommendation of the American College of Surgeons (ACS) Committee on Trauma. METHODS: The study consisted of two parts: 1) a survey; and 2) a retrospective study. Survey questionnaires were sent to 199 members of the Eastern Association for the Surgery of Trauma and to 161 anesthesiology training programs throughout the United States. Three resuscitation scenarios were posed: 1) Elective airway--CSF--breathing spontaneously, stable vital signs; 2) Urgent airway--CSF--breathing spontaneously, unstable vital signs; and 3) Emergent airway--CSF--apneic, unstable. In addition, a three-year retrospective study was conducted at a level-I trauma center to determine the method of airway control in patients with cervical spine fractures. RESULTS: Responses to the questionnaires were received from 101 trauma surgeons (TS) and 58 anesthesiologists (ANESTH). Respondents indicated their preference of airway methods: Elective airway: Nasotracheal intubation: TS 69%, ANESTH 53%. Orotracheal intubation: TS and ANESTH 27%. Surgical airway: TS 4%. Intubation with fiberoptic bronchoscope (FOB): ANESTH 20%. Urgent airway: Nasotracheal intubation: TS 48%, ANESTH 38%. Orotracheal intubation: TS 47%, ANESTH 45%. Surgical airway: TS 4%. FOB: ANESTH 16%. Emergent airway: Orotracheal intubation: TS 81%, ANESTH 78%. Surgical Airway: TS 19%, ANESTH 7%. FOB: ANESTH 15%. The retrospective review at the trauma center indicated that 102 patients with CSF were admitted; 62 required intubation: four (6%) on the scene, seven (11%) en route, five (8%) in the emergency department, 42 (67%) in the operating room, and four (6%) on the general surgery floor. Airway control methods used were nasotracheal: 14 (22%); orotracheal: 27 (43%); FOB: 17 (27%); tracheostomy: one (2%); unknown: three (4%). No progression of the neurological status resulted from intubation. CONCLUSION: The choice of airway control in the trauma patient with CSF differs between anesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The recommendations of the American College of Surgeons Committee on Trauma for airway control with suspected cervical spine injury are useful. The technique utilized is dependent upon the judgment and experience of the intubator.
Keywords: anesthesiology; article; cervical spine; clinical practice; decision tree; emergency health service; endotracheal intubation; human; injury; methodology; questionnaire; respiratory failure; retrospective study; spine fracture; tracheostomy; traumatology

Comparison between conventional cap and one-way valve in the decannulation of patients with long-term tracheostomies - Hai Minh Le; Aten J.L.; Chiang J.T.; Light R.W. (Respiratory Care, 1993)
The purpose of this study was to compare success with the conventional method of capping, or 'plugging,' the tracheostomy tube to success with that of using a one-way-airflow valve, in the decannulation of patients with long- term tracheostomies. MATERIALS AND METHODS: To be eligible for the study, the patient had to have had a tracheostomy for at least 30 days and be deemed by his primary care physician to be a candidate for decannulation. Patients who were on mechanical ventilation and patients with sleep apnea syndrome, severe aspiration, or clinically apparent upper-airway obstruction were excluded from the study. Twelve patients who were deemed ready for the decannulation protocol were randomly assigned either to cap or one-way valve. The times of occlusion were increased by 1-hour increments/day up to 6 hours and then by 2-hour increments/day up to 24 hours. RESULTS: Ten patients were successfully decannulated; 5 in each group. The median time for decannulation was 18 days with the one-way valve and 23 days with standard capping. We noted no significant difference in the proportion successfully decannulated or time to decannulation between the two groups (p > 0.05). However, patients with the one-way valve appeared to be more comfortable. Pulmonary function testing results varied among and within patients because the patients were unable to cooperate or had uncuffed tubes in place. CONCLUSIONS: In this small group of patients, neither method appeared to be superior, although subjective observation suggested that patients appeared to be more comfortable with the one-way valve. Pulmonary function testing was not useful in predicting successful decannulation.
Keywords: adult; aged; airflow; article; cannulation; cerebrovascular accident; clinical article; clinical trial; controlled study; head injury; human; lung function test; mouth carcinoma; randomized controlled trial; respiratory care; respiratory failure; spinal cord injury; tracheostomy

Transoral-transpharyngeal approach to the upper cervical vertebrae - Shaha A.R.; Johnson R.; Miller J.; Milhorat T. (American Journal of Surgery, 1993)
The classical operative approaches to the cervical spine include the posterior one and the anterior exposure along the sternomastoid muscle. However, neither of these are helpful in exposing the upper cervical vertebrae, especially the odontoid process, atlas, and axis. We have used the transoral-transpharyngeal exposure for lesions of the odontoid process and upper (first to third) cervical vertebrae in six patients. The pathologic processes included rheumatoid disease and fracture of the cervical vertebrae, suspected tumor with compression of the spinal cord, basilar invagination, and compression of the medulla. In all six patients, the exposure was excellent, and postoperative morbidity was minimal. Tracheostomy was performed routinely in all these patients. In five patients, vertebral stabilization was performed as a secondary procedure a few days after the initial anterior decompressive surgery. The transoral-transpharyngeal approach appears to be relatively easy. It is associated with minimal complications and provides excellent exposure of the odontoid and upper cervical vertebrae for a microneurosurgical approach. Modifications of this approach include incision of the soft palate, excision of a portion of the hard palate, and, occasionally, transmandibular median labio-mandibulo- glossotomy (Trotter's) approach. Although the technique was described initially approximately 35 years ago, this neglected anatomic approach will facilitate cooperative efforts between head and neck surgeons and neurosurgeons.
Keywords: adult; aged; cervical spine; clinical article; clinical trial; conference paper; controlled clinical trial; controlled study; human; mouth cavity; priority journal; spinal cord compression; spinal cord decompression; surgical anatomy; surgical approach; surgical technique

A methodology to evaluate motion of the unstable spine during intubation techniques - Donaldson III W.F.; Towers J.D.; Doctor A.; Brand A.; Donaldson V.P. (Spine, 1993)
Airway management in patients with an unstable cervical spine remains a challenge. A video fluoroscopic technique that transfers the image to a floppy disk for direct measurement is described. This technique enabled standardized, direct measurement of the cervical spine during airway maneuvers before and after a C5-6 posterior instability was surgically created in five cadaveric specimens. Unsupported direct oral techniques often can cause more motion than do indirect nasal techniques, and chin lift/jaw thrust and cricoid pressure can cause as much motion as do some of the intubation techniques.
Keywords: cervical spine; conference paper; endotracheal intubation; fluoroscopy; human; human experiment; image intensifier; motion; nasotracheal intubation; priority journal; respiratory tract intubation; spine instability; tracheostomy

Multichannel stimulation of phrenic nerves by epineural electrodes. Clinical experience and future developments - Mayr W.; Bijak M.; Girsch W.; Holle J.; Lanmuller H.; Thoma H.; Zrunek M. (ASAIO Journal, 1993)
Between 1983 and 1992, 23 patients with complete ventilatory insufficiency of differing etiologies were treated with an eight channel implant (Medimplant Inc., Vienna) for fatigue free stimulation of both phrenic nerves. Data for 15 patients with high spinal cord lesions (ages: 9-51 years) are summarized: 1) level of lesion: C0, 3 patients; C1/C2, 4; C2/C3, 8; 2) time between incident and implantation: 3-14 months; 3) diaphragm training: 1-22 months; 4) chronic pacing: 5-83 months; 5) tracheostomy closed: 7 patients; 6) living permanently at home: 13 patients; 7) respiratory rate per minute: 12-17; 8) duration of inspiration: 1.0-1.3 sec; 9) tidal volume: 7- 20 ml/kg body weight; 10) volume per minute: 121-198 ml/kg body weight; 11) pH: 7.39-7.42; 12) pCO2: 22.9-38.6 mmHg; 13) pO2: 81.2-104.5 mmHg; and 14) died by December 1992, 4 patients. All currently available implants for phrenic pacing need an external power supply and radio control. The authors have developed and tested the first fully implantable device. Features of this implant include an electronic circuit based on the microcontroller MC68HC705C8; surface mounted technology (SMD); eight channels; constant current source adjustable to 5 mA in 256 steps, impulse duration: 100-1000 μsec, stimulation frequency: 1-33 Hz; and minimum lifetime: 3 years. The implant is programmed via bidirectional radio transmission using an IBM compatible computer. The dimensions, including battery, eight electrode connectors, and antenna, are 67 x 48 x 13 mm. The implant weighs 58 g. This new device may improve patients' safety and quality of life in the near future.
Keywords: adolescent; adult; article; breathing rate; carbon dioxide tension; child; clinical article; devices; electrode; female; home; human; implant; lung minute volume; male; multichannel recorder; nerve stimulation; oxygen tension; pH; phrenic nerve; respiratory function disorder; sleep disordered breathing; spinal cord lesion; tidal volume; tracheostomy

The Swedish modification of the tracheostomy tube to permit speech - Andersson G. (Paraplegia, 1993)
Over the last 20 years the Respiratory Unit at Danderyd Hospital, Sweden has treated and rehabilitated more than 90 patients on domiciliary ventilation, the majority of whom require night-time ventilation. Sixteen patients (11 men and 5 women) with high spinal cord lesions have been treated. Of these 16 patients, 9 are using diaphragmatic pacing. Every patient has a customised tube. If the patient can use diaphragmatic pacing the tube, as a rule, is single fenestrated. In patients using the ventilator full time, the tube is made to fit snugly in the trachea. When such a tube fits 'as a bullet in its tube' there is no need for a cuff. The patient has adequate ventilation and the small leak around the tube also permits good speech function. Sometimes a PEEP-valve is used to get a better voice.
Keywords: article; assisted ventilation; clinical article; diaphragm; female; fenestration; human; male; positive end expiratory pressure; speech articulation; spinal cord lesion; Sweden; trachea; tracheostomy; voice

Inappropriate weaning and late onset ventilatory failure of individuals with traumatic spinal cord injury - Bach J.R. (Paraplegia, 1993)
Eight traumatic spinal cord injured (SCI) individuals are described. Four tetraplegic patients who were weaned from initial ventilator use despite severe restrictive pulmonary syndromes experienced multiple pulmonary complications, episodes of acute respiratory failure, and 3 of the 4 required long term ventilatory support within 2 years of initial weaning. Three other SCI individuals developed chronic late-onset ventilatory failure 17, 25, and 29 years postinjury. One other tetraplegic patient was mechanically ventilated for 8.2 years postinjury despite complete recovery of autonomous ventilatory function years earlier. Of the 6 patients requiring long term ventilatory support, 4 were managed by noninvasive techniques of intermittent positive pressure ventilation (IPPV), one by negative pressure body ventilators, and one by tracheostomy IPPV. At least one and possibly as many as 5 patients were spared bronchoscopy and/or pulmonary complications by using mechanical insufflation-exsufflation (MI-E). We conclude that patients who are weaned despite having significant restrictive pulmonary syndromes are at risk for ventilatory decompensation weeks to decades after weaning. Ongoing clinical assessment, evaluation of respiratory muscle function and, at times, nocturnal blood gas analyses are warranted in the follow up of traumatic SCI individuals.
Keywords: acute respiratory failure; adult; aeration; aged; article; artificial ventilation; blood gas analysis; breathing muscle; bronchoscopy; case report; clinical feature; female; human; intermittent positive pressure ventilation; lung insufficiency; male; muscle function; quadriplegia; respiratory function; spinal cord injury; tracheostomy; weaning

Complete cricotracheal separation and third cervical spinal cord transection following blunt neck trauma: A case report of one survivor - Chen F.H.; Fetzer J.D. (Journal of Trauma, 1993)
We report the case of a patient who sustained a scissors-type blunt neck trauma and survived the following injuries: comminuted cricoid fracture, complete cricotracheal separation, interruption of the recurrent laryngeal nerves bilaterally, multiple cervical vertebral fractures, and a third cervical cord transection. He was rendered apneic instantly at the accident site and was immediately resuscitated by coworkers by mouth-to-mouth resuscitation. Attempts at endotracheal intubation to establish an initial airway caused acute airway occlusion and an emergency tracheostomy was then succesfully performed. He was treated by immediate stabilization of the cervical spine, emergency neck exploration, and early primary repair of the airway injury. Any patient with cervial airway injury should be assumed to have cervical spine injury and should have neck immobilization from the beginning of resuscitation.
Keywords: adult; article; blunt trauma; case report; cervical spinal cord injury; clinical feature; human; larynx injury; male; neck injury; nerve injury; priority journal; recurrent laryngeal nerve; resuscitation; spine stabilization; tracheostomy; treatment planning

Rigid spine syndrome and nocturnal alveolar hypoventilation. - Kawata A.; Suga M.; Miyamoto K.; Hirose K.; Tanabe H. (Internal medicine (Tokyo, Japan), 1993)
A 17-year-old Japanese woman with rigid spine syndrome (RSS) presented with respiratory failure leading to CO2 narcosis. The clinical symptoms were drowsiness, asterixis and cardiac arrhythmias. Tracheostomy and temporary ventilatory support abolished these symptoms. However, polygraphic sleep studies without a ventilator revealed Cheyne-Stokes respiration and profound arterial oxygen desaturation during rapid eye movement sleep. Nocturnal ventilatory support improved not only nocturnal hypoxemia, but daytime blood gas values during spontaneous breathing. These findings indicate that the onset of respiratory failure is preceded by severe nocturnal hypoxemia and that the evaluation and control of nocturnal respiratory insufficiency is essential for RSS patients.
Keywords: oxygen; adolescent; article; artificial ventilation; blood; breathing muscle; case report; Cheyne Stokes breathing; electroencephalography; female; human; hypoxemia; pathophysiology; physiology; REM sleep; respiratory failure; sleep disordered breathing; spine disease; syndrome

Longitudinal study of spinal deformity in Duchenne muscular dystrophy - Oda T.; Shimizu N.; Yonenobu K.; Ono K.; Nabeshima T.; Kyoh S. (Journal of Pediatric Orthopaedics, 1993)
To investigate the natural course of the spinal deformity in Duchenne muscular dystrophy (DMD) and its clinical relevance, longitudinal series of spinal radiographs and medical records of 46 patients with DMD were reviewed. The natural course of the deformity was classified into three types; type 1 (n = 21), unremittent progression of scoliosis with kyphosis; type 2 (n = 18), transition from kyphosis to lordosis before age 15 years; and type 3 (n = 7), less deformity without prominent longitudinal changes. Age at loss of ambulatory ability was not a predictor of type. Neither was the age at which the Cobb angle was 30° correlated with the rate of subsequent progression. Because the spinal deformity always progresses, we consider spinal surgery justifiable in type 1, when a certain strict indication exists, such as spinal deformity >30° and age <15 years in patients with >35% predicted value of vital capacity. In type 2, operation may be necessary in patients in whom Cobb angle will progress unremittently. There is no surgical indication for patients with type 3.
Keywords: adolescent; age; article; child; clinical article; disease course; Duchenne muscular dystrophy; forced expiratory volume; human; kyphosis; lordosis; lung function; male; measurement; prognosis; scoliosis; spine malformation; spine radiography; spine surgery; tracheotomy

Late post-tracheostomy airway complications in patients with central nervous system injuries - Kas J.; Baranyai L.; Lantos A.; Kertész G.; Fehér M.; Vass M. (Orvosi hetilap, 1993)
At decannulation or often weeks later some of the patients undergone long-term mechanical ventilation through tracheostoma reveal symptoms of airway stenosis. Posttracheostomy airway complications detected during the rehabilitation of 34 patients with central nervous system injury are presented. Endoscopic examinations (total 130) were performed with Olympus BF B3 and OES 20-type fiberscopes and Friedel-type rigid bronchoscopes under local or general anaesthesia. Stridor (20 cases) and possible decannulation (10 cases) were the main indications of the first endoscopic examinations. Stridor was caused by tracheal (12 cases) and laryngeal (8 cases) stenosis. With six patients decannulation was possible after the first endoscopy. Removal of granulomas and sutures was successful in 8 cases. Rigid bronchoscopic dilatations were temporarily successful in 7 cases, but in five of them it had to be repeated on emergency. Further therapeutic interventions were: recannulation (3 cases), retracheostomy (4 cases), implantation of silicon T-endoprothesis (5 cases), tracheal resection (4 cases). Three patients are discussed in details. Eliminating airway complications largely contributed to rehabilitation of the nervous and musculoskeletal system, improved the quality of life, and in acute cases it was a life-saving measure. In order to prevent the development of late airway complications or detect them in time, it is recommended to have an endoscopic protocol following every tracheostomy: 1. at the time of decannulation 2. at closing the trachea and 3. 2-3 months after decannulation.
Keywords: adolescent; adult; airway obstruction; article; brain injury; bronchoscopy; case report; female; fiber optics; investigative procedures; human; laryngoscopy; larynx stenosis; male; multiple trauma; spinal cord injury; trachea stenosis; tracheostomy; traffic accident

Rigid spine syndrome presenting with respiratory failure--report of one case. - Lin S.J.; Wang P.J.; Lin M.Y.; Shen Y.Z. (Zhonghua Minguo xiao er ke yi xue hui za zhi [Journal]. Zhonghua Minguo xiao er ke yi xue hui, 1993)
A case of rigid spine syndrome presenting with respiratory failure was reported. A seven-year-old girl had had dyspnea and orthopnea for one month. Symptoms had aggravated gradually and she was in a state of respiratory failure on arrival at our hospital. There was no evidence of active lung lesions and response to mechanical ventilation was good. Physical examination revealed an extremely thin girl with marked flexion limitation of neck and severe wasting of sternocleidomastoid and intercostal muscles. Serum creatine phosphokinase was moderately elevated (801 IU/L). Muscle biopsy specimen obtained from the right quadriceps femoris revealed increased perimyseal connective tissue and marked Type II fiber atrophy. Electromyography of left paraspinal muscles demonstrated small amplitude, short duration motor unit potentials. She received tracheostomy and a home-care ventilator use during sleep. Ventilatory insufficiency, though rare, should be anticipated in patients with rigid spine syndrome, and timely ventilatory support should be given.
Keywords: article; case report; child; female; human; muscle disease; respiratory failure; spine disease; syndrome

Anterior surgery of the upper part of the cervical spine by prevascular extraoral approach. - Laus M.; Alfonso C.; Laguardia A.M.; Giunti A. (La Chirurgia degli organi di movimento, 1993)
Anterior surgery of the upper part of the cervical spine, that is, proximal to C3, may be performed by transoral approach, possibly enlarged by glossomandibulotomy, by a retrovascular extraoral approach, or by a prevascular extraoral approach. The authors describe the surgical method of prevascular extraoral approach that allowed them to effectively treat osteoma localized at C2 and C3, post-laminectomy instability at C3 and C4, solitary metastasis at C3. As compared to transoral surgery the prevascular extraoral approach has the advantage of avoiding the risk of infection from germs in the oral cavity and of allowing for easier postoperative management, avoiding tracheotomy and/or prolonged dysphagia. As compared to a retrovascular approach the prevascular approach obtains a truly anterior exposure instead of an anterolateral one. Prevascular extraoral approach should thus be used whenever possible. Transoral surgery is indicated for decompression, of the brainstem and a bilateral retrovascular approach may be used to perform anterolateral fusion at C1-C2.
Keywords: aged; article; case report; cervical spine; female; human; male; metastasis; middle aged; osteoma; spinal cord tumor; squamous cell carcinoma; procedures; vascularization

Tracheostomy in spinal cord injured: Frequency and follow up - Biering-Sorensen M.; Biering-Sorensen F. (Paraplegia, 1992)
Among 600 traumatic spinal cord injured (SCI) patients admitted during a 20 year period, 67 had a tracheostomy performed (11.2%). Of these 67 patients 46 had a cervical SCI. A concomitant thoracic trauma had occurred significantly more often in the group with thoracic or lumbar SCI than in those with a cervical SCI. The period from injury to tracheostomy was 0-48 days (median 4.4 days), and from tracheostomy to decannulation 3-167 days (median 31 days). At follow up 20 (30%) had died, primarily because of respiratory problems. Of the remaining 47 patients, 43 (91%) responded to a follow up questionnaire 3.5-21.7 years (median 10.4 years) after the injury. In the follow up 53% reported never to have had any inconvenience or trouble related to the tracheosotmy. The majord inconvenience among the others had been of cosmetic tracheostomy. The major inconvenience among the others had been of cosmetic origin (28%), and 3 had had a surgical revision for this reason. At the time of follow up 9 patients (21%) still had certain complaints, primarily described as difficulty in swallowing. Minitracheostomy might in the future reduce reduce the number of these complications.
Keywords: adolescent; adult; aged; article; breathing disorder; child; controlled study; human; major clinical study; spinal cord injury; tracheostomy

Ventilatory support at home in children with spinal muscular atrophies (SMA) - Barois A.; Estournet-Mathiaud B. (European Respiratory Review, 1992)
Early management of children diagnosed as having spinal muscular atrophies (SMA) is important since development of the lung may be affected in children who have paralysis of respiratory muscles. We report our experience of ventilatory support at home in more than 100 children with SMA. In each case, we explain the operating conditions. Oral positive pressure breathing with periodic hyperinsufflation is always used as early as possible if there are no severe swallowing disorders. Nasal ventilation has been used in nine patients under two yrs of age, in 14 older children and in two adults. Endotracheal ventilation by tracheostomy was used 24 times; three children subsequently died. Earlier management of such children, as soon as diagnosis is performed, gives a better quality of life for babies in the acute forms and a good sociological integration to adult life for the others.
Keywords: assisted ventilation; breathing muscle; child; chronic respiratory failure; conference paper; home care; human; lung development; quality of life; spinal muscular atrophy; tracheostomy

Pulmonary issues in quadriplegia - Sortor S. (European Respiratory Review, 1992)
Pulmonary concerns in quadriplegia caused by neuromuscular disorders and traumatic injury have been reviewed. Whatever the cause of the quadriplegia the initial approach to the patient is extensive evaluation. This includes physical assessment, pulmonary function testing, measurement of 'mechanical' inspiratory capacity, arterial blood gas or saturation measurement and sometimes monitoring of ventilation during sleep. After evaluation an appropriate treatment programme is commenced and the ventilation system selected. Since 1984 sixty two ventilator dependent quadriplegic patients have been treated in the Spinal Cord Injury Dallas Rehabilitation Unit. Fifty eight patients were discharged to home, four remained hospitalized. Fifty two were placed on non-tracheostomy forms of ventilation by discharge. The aetiology of the quadriplegia was 40 neuromuscular disorders (20 polio, 3 amyotrophic lateral sclerosis (ALS), 2 spina bifida, 9 muscular dystrophy, 6 spinal muscular atrophy (SMA) and 22 traumatic injuries. Seven deaths have been reported. One child with SMA discontinued support after 3 months. Treatment focused on prevention of abnormal lung and chest wall growth, chest wall rigidity and atelectasis. Assisted coughing is freely used to prevent secretion retention and pneumonia. The overall goal is to minimize disability and return patients to the community.
Keywords: assisted ventilation; conference paper; human; lung complication; neuromuscular disease; quadriplegia; respiratory failure; spinal cord injury

Excessive atlanto-occipital flexion as a cause of complete airway obstruction following anterior cervical spine fusion - Szabo M.D.; Crosby G. (Journal of Clinical Anesthesia, 1992)
This report describes complete airway obstruction following anterior cervical fusion caused by extreme, fixed flexion of the neck in a halo device. The causes and treatment of such an airway complication are reviewed.
Keywords: adult; airway obstruction; anterior spine fusion; article; atlantooccipital joint; case report; cervical spine; endotracheal intubation; extubation; head position; human; joint laxity; male; orthopedic equipment; spine instability; tracheostomy

Hypoventilation and apnea in children during mechanically assisted ventilation - Gilgoff I.S.; Peng R.-C.; Keens T.G. (Chest, 1992)
Uncuffed tracheostomy tubes are used for long-term mechanical ventilation in children. However, upper airway mechanics differ between sleep and wakefulness; this may affect air leak around tracheostomies. We studied 19 children with high cervical spinal cord injury on portable positive pressure ventilators, age range birth to 19 years. Ventilator settings were adjusted while awake to achieve PaCO2 <45 mm Hg and PO2 >90 mm Hg. Clinically several children with uncuffed tracheostomies became unstable at night with seizures and sleep disruption. Nine of 11 children on volume controlled systems were found to be inadequately ventilated during sleep. Substitution with a cuffed tracheostomy allowed adequate ventilation both awake and asleep, suggesting that inadequate ventilation during sleep was due to an uncompensated leak around the uncuffed tracheostomy. To avoid cuffed tracheostomies, eight children received pressure controlled ventilation. Gas exchange was adequate throughout the day and night. We conclude that children receiving volume controlled mechanical ventilation via uncuffed tracheostomy tubes can exhibit hypoventilation due to uncompensated air leak. Pressure controlled ventilation improves adequacy of gas exchange during sleep and wakefulness.
Keywords: carbon dioxide; oxygen; adolescent; adult; apnea; arterial gas; article; artificial ventilation; assisted ventilation; child; child care; clinical article; controlled study; cuff; endotracheal tube; female; human; hypoventilation; infant; lung gas exchange; male; newborn; priority journal; respiratory care; sleep; tracheostomy; wakefulness

Paraplegia after spinal anaesthesia - Bessac B.; Levy R.; Chauvin M. (Annales Francaises d'Anesthesie et de Reanimation, 1992)
A case of paraplegia occurring after a spinal anaesthetic is reported. The 79-year-old man was admitted for a fractured neck of femur. Twenty years previously, he had had pharyngeal surgery and a tracheostomy. He had also undergone a prostatectomy for prostate cancer, and had been on oestrogen therapy for two years. He complained of dyspnoea at rest and his chest film showed diffuse pulmonary opacities. In order to avoid possible intubation and respiratory complications, spinal anaesthesia was performed without any problems in the L4 space. After the surgery, the patient recovered all his motor and sensory functions in the lower limbs. On the second postoperative day, he suffered from a motor paralysis of the right leg, which spread to the left leg on the fourth day. NMR imaging showed several vertebral metastases, together with anterior and lateral epidural invasion responsible for cord compression. Treatment with tetracosactide was begun, but the patient died six weeks later in his home, not having recovered any neurological function at all in his lower limbs. In fact, it was only after the procedure that the anaesthetist was informed that, at the time the prostate cancer had been diagnosed, vertebral body metastases, of which the patient had not been informed, were already present. The part played by the spinal anaesthetic in the occurrence of the paraplegia is not clear. It is a reminder that such a technique should be used with extreme care in patients having a neoplasm with often a very high incidence of vertebral metastases.
Keywords: bupivacaine; aged; article; case report; cervical spine fracture; human; intrathecal drug administration; male; paraplegia; spinal anesthesia

Percutaneous tracheostomy after trauma and critical illness - Ivatury R.; Siegel J.H.; Stahl W.M.; Simon R.; Scorpio R.; Gens D.R. (Journal of Trauma, 1992)
A method of percutaneous tracheostomy (PT) using a tracheostome, which permits insertion of a full-sized cuffed tracheostomy tube, was evaluated in 61 critically ill or injured patients (89% had trauma). Of the 54 trauma patients, 65% had brain injuries, 14% had injuries to the cervical spinal cord, 33% had face or jaw injuries, and 15% had lung injuries. The indications for PT were coma (46%), acute airway obstruction (5%), face or jaw injury (20%), pneumonitis (39%), adult respiratory distress syndrome (12%), and sepsis (21%). Tracheostomy was done in 51% of all cases specifically for managing pulmonary secretions, in 37% for prolonged intubation, and in 25% for neurologic lesions. The tracheostomy was done as an emergency in 5%, as urgent in 28%, and electively in 77%. Percutaneous tracheostomy was successful in 90% of the cases, and in 8% it was converted to a surgical tracheostomy after an initial percutaneous attempt. In 46% it was performed at the bedside, in 46% in the operating room, and in 7% in the emergency suite. A full-sized tracheostomy tube (6 to 8) was used in all cases and was considered optimal or larger than needed in 87% of cases. With three exceptions the complications of PT were minor, but 30% of the patients died of their primary disease. In one case death occurred because of bronchospasm and cardiac arrest during the PT, but appeared to be independent of the type of tracheostomy. Healing after in-hospital removal (37%) was excellent in 95% of cases and 97% of physicians indicated that they would use the device again.
Keywords: adult; adult respiratory distress syndrome; airway obstruction; article; brain injury; cannula; cervical spinal cord injury; coma; critical illness; emergency treatment; face injury; female; healing; human; injury; intubation; jaw fracture; lung injury; major clinical study; male; mortality; pneumonia; priority journal; sepsis; surgical technique; tracheostomy

Anterior surgery of the upper cervical spine. - Louis R. (La Chirurgia degli organi di movimento, 1992)
The authors report the results obtained in a series of more than 80 cases submitted to 76 operations of the upper cervical spine by transoral approach with a minimum follow-up of two years. The cases include: 15 unstable fractures or non-union of the odontoid processes; 28 cases of post-traumatic instability of C1-C2 level without fracture of the odontoid process; 13 cases of rheumatoid arthritis with instability at C1-C2; 14 cases of severe anomalies of the craniovertebral junction, often associated with basilar impression and spinal cord compression, of which 7 cases presented with tetraparesis; 6 malignant tumors. The method used involves an anterior transoral approach, more often without tracheotomy, and with exposure of the anterior aspect of the atlas and of the odontoid process by means of a midline incision of the posterior wall of the pharynx. When spinal cord lesion was present, decompression and reconstruction by bone grafts taken from the iliac crest were performed. In nearly all of the cases osteosynthesis with an anterior plate was used. Complications were mild. There were two cases of infection, observed at the onset of our experience, which were resolved after removal of the instrumentation. There was loosening of a screw in three cases; this was eliminated through the digestive tube with no consequences. There were no early intra- or postoperative deaths. Consolidation was obtained in most of the patients, and only in three cases did we observe a loss of postoperative reduction. Among patients affected with tetraparesis we observed many cases of neurological recovery.(ABSTRACT TRUNCATED AT 250 WORDS)
Keywords: article; cervical spine; congenital malformation; dislocation; female; human; injury; male; methodology; odontoid process; osteosynthesis; postoperative complication; radiography; spinal cord tumor; spine fracture; spine fusion

A case of rigid spine syndrome associated with severe respiratory failure - Nakagawa M.; Kubota R.; Nakamura A.; Fujiyama J.; Suehara M. (Clinical Neurology, 1991)
Keywords: adult; article; case report; human; male; myopathy; respiratory failure; rigid spine syndrome; tracheotomy

Alternative methods of ventilatory support for the patient with ventilatory failure due to spinal cord injury. - Bach J.R. (The Journal of the American Paraplegia Society, 1991)
Ventilatory insufficiency and impaired airway secretion clearance are common complications of spinal cord injury (SCI) and can lead to respiratory failure which is the leading cause of death in both the acute and chronic stages. Standard invasive management options such as intubation, tracheostomy and electrophrenic respiration have been reviewed. The review findings are consistent with our clinical experience in that these invasive options appear to entail unacceptably high morbidity and risks of mortality. A number of detailed parameters are suggested for evaluating the respiratory functioning of the individual in order to determine the most acceptable and successful noninvasive systems for both ventilatory support and evacuation of airway secretions. They are physiological substitutes for the action of the inspiratory and expiratory muscles. These techniques are described in detail. We conclude that noninvasive techniques can safely and effectively obviate the need for intubation, tracheostomy and electrophrenic pacemakers in appropriate individuals with SCI.
Keywords: artificial ventilation; endotracheal intubation; human; intermittent positive pressure ventilation; methodology; psychological aspect; quality of life; respiratory failure; review; spinal cord injury

New approaches in the rehabilitation of the traumatic high level quadriplegic - Bach J.R. (American Journal of Physical Medicine and Rehabilitation, 1991)
The use of noninvasive alternatives to tracheostomy for ventilatory support have been described in the patient management of various neuromuscular disorders. The use of these techniques for patients with traumatic high level quadriplegia, however, is hampered by the resort to tracheostomy in the acute hospital setting. Twenty traumatic high level quadriplegic patients on intermittent positive pressure ventilation (IPPV) via tracheostomy with little or no ability for unassisted breathing were converted to noninvasive ventilatory support methods and had their tracheostomy sites closed. Four additional patients were ventilated by noninvasive methods without tracheostomy. These methods included the use of body ventilators and the noninvasive intermittent positive airway pressure alternatives of IPPV via the mouth, nose, or custom acrylic strapless oral-nasal interface (SONI). Overnight end-tidal pCO2 studies and monitoring of oxyhemoglobin saturation (SaO2) were used to adjust ventilator volumes and to document effective ventilation during sleep. No significant complications have resulted from the use of these methods over a period of 45 patient-years. Elimination of the tracheostomy permitted significant free time by glossopharyngeal breathing for four patients, two of whom had no measurable vital capacity. We conclude that noninvasive ventilatory support alternatives can be effective and deserve further study in this patient population.
Keywords: adolescent; adult; aged; clinical article; human; intermittent positive pressure ventilation; priority journal; quadriplegia; review; spinal cord injury; tracheostomy

Noninvasive options for ventilatory support of the traumatic high level quadriplegic patient - Bach J.R.; Alba A.S. (Chest, 1990)
The ventilation of 25 ventilator-dependent traumatic quadriplegic patients was supported by noninvasive means of ventilatory assistance. Twenty-four of the 25 were initially managed by endotracheal intubation, and 23 of these went on to tracheostomy intermittent positive pressure ventilation before being converted to NVA. Seventeen of the 23 patients had their tracheostomies closed. This included three patients with no significant free time except with the use of glossopharyngeal breathing. Seven of the 25 patients who used NVA for at least one year with no significant free time have employed NVA for a mean of 7.4±7.4 years (1 to 22 years). Mouth IPPV was the most common form of NVA used both during the daytime and overnight. The wrap ventilators, intermittent abdominal pressure ventilator, and GPB were also employed for long-term respiratory support. It was concluded that, in general, because of their youth, intact mental status and bulbar musculature, and absence of obstructive lung disease, patients with traumatic high level spinal cord injury are candidates to benefit from these techniques.
Keywords: adult; article; assisted ventilation; endotracheal intubation; female; human; injury; major clinical study; male; methodology; priority journal; quadriplegia; tracheostomy

Patient in intensive care unit with traumatic medullar lesions. Evolution and complications - Castellote Olivito J.M.; Leon Valles M.; Cepero Moreno E.; Toribio Clemente L.J.; Trujillano Cabello J.; Campos Gutierrez E. (Rehabilitacion, 1990)
Keywords: adult; article; artificial ventilation; clinical article; female; human; intensive care unit; lung complication; male; shock; spinal cord injury; tracheostomy

Elective hypothermic cardiopulmonary bypass and circulatory arrest for spinal cord protection during operations on the thoracoabdominal aorta - Kouchoukos N.T.; Wareing T.H.; Izumoto H.; Klausing W.; Abboud N. (Journal of Thoracic and Cardiovascular Surgery, 1990)
Resection of aneurysms of the entire descending thoracic aorta and segments of the abdominal aorta is associated with a substantial incidence of spinal cord ischemic injury, particularly in patients with aortic dissection. Since hypothermia has a protective effect on spinal cord function, we evaluated a technique of total cardiopulmonary bypass with periods of hypothermic circulatory arrest and low flow (rectal/bladder temperatures of 15° to 19°C) in five patients requiring replacement of the entire descending thoracic and the upper abdominal aorta and judged to be at high risk for the development of spinal cord injury. All patent lower intercostal and lumbar arteries were preserved or reimplanted during the hypothermic interval. There was one hospital death. None of the four survivors had a new spinal neurologic deficit, renal or cardiac dysfunction, or required reoperation for bleeding. Transfusion of blood was not excessive. Severe pulmonary dysfunction necessitating tracheostomy occurred in one patient and contributed to his death 7 weeks postoperatively. The remaining three patients are well 8 to 36 months postoperatively. This initial experience suggests that hypothermic perfusion and circulatory arrest can be safely implemented in selected patients who require extensive aortic resections and who are at substantial risk for the development of spinal cord injury. Further evaluation of this technique is warranted.
Keywords: abdominal aorta; adult; aged; aortic surgery; article; cardiopulmonary bypass; clinical article; human; hypothermia; priority journal; spinal cord; thoracic aorta

Oral intubation in the multiply injured patient: The risk of exacerbating spinal cord damage - Rhee K.J.; Green W.; Holcroft J.W.; Mangili J.A.A. (Annals of Emergency Medicine, 1990)
The use of oral intubation during the resuscitation of seriously injured patients has been discouraged because of the fear that this technique may lead to cervical cord damage. We report a retrospective study of the 18-month experience of an emergeny department in which oral intubation was the usual method of airway control for victims of blunt trauma. There were 237 injured patients intubated in the ED; 21 patients (8.9%) had cervical cord or bone injury. There were no patients in whom a neurologic loss followed an airway maneuver. Oral intubation was the definitive airway maneuver in 213 patients. There was no statistically significant difference in the type of definitive airway maneuver used (eg, oral intubation, nasal intubation, or cricothyrotomy-tracheotomy) between patients with cervical injuries and patients without such injuries. The risk of spinal cord injury secondary to oral intubation in the seriously injured patient was low in our population. Selection of the method for definitive airway control should be based primarily on the operator's skills and experience rather than the fear of inflicting cervical cord damage.
Keywords: adult; conference paper; human; intubation; major clinical study; multiple trauma; priority journal; resuscitation; spinal cord injury

A rare and severe complication of meningeal hemorrhage: spinal arachnoiditis with paraplegia - Jourdan C.; Artru F.; Convert J.; Ottolese C.; Chiara Y.; Naous H.; Tixier S.; Terrier A. (Agressologie: revue internationale de physio-biologie et de pharmacologie appliquées aux effets de l'agression, 1990)
This observation relates a case of spinal arachnoiditis with paraplegia, for a 56 year old patient hospitalized for a S.A.H. by a ruptured aneurysm of the P.I.C.A. This patient present some complications, requiring a prolonged ventilatory support with a tracheostomy, a ventricular shunt for hydrocephalus. The treatment is only surgical, and the corticosteroids delay the evolution, but without successful outcome.
Keywords: arachnoiditis; article; case report; female; human; laminectomy; middle aged; paraplegia; subarachnoid hemorrhage; vertebra

Prehospital cricothyrotomy: An investigation of indications, technique, complications, and patient outcome - Spaite D.W.; Joseph M. (Annals of Emergency Medicine, 1990)
The records of all patients who presented to a Level 1 trauma center during a two-year period for whom a prehospital cricothyrotomy was attempted or ordered were reviewed. Twenty patients met the study criteria. The average age was 37 years (range, 11 to 65 years). Indications for prehospital cricothyrotomy were massive facial trauma (eight), failed oral intubation (seven), and suspected cervical-spine injury (one). Cricothyrotomy was attempted in 16 patients (80%), with the remaining four having the procedure ordered but not attempted. A successful airway was achieved in 14 patients (88%). Horizontal incisions were used in all cases and were anatomically correct in 15 of 16 attempts (94%). The overall immediate complication rate was 31%. Two patients (12%) sustained major complications (failure to obtain an airway). No hemorrhagic complications occurred, but 16 of the 20 were in cardiac arrest in the field. Long-term complications were not evaluated. All patients sustained major injuries (mean Injury Severity Score, 53.7), except one patient who suffered airway obstruction from food. Three patients (15%) survived; two of the three suffered permanent, severe brain dysfunction. These preliminary findings demonstrate that prehospital cricothyrotomy is being used chiefly in massively injured patients who are already beyond recovery. It is thus difficult to assess whether the procedure is either safe or effective. There is a need for further investigation to determine whether prehospital cricothyrotomy has any beneficial effect on outcome and, if so, in what setting.
Keywords: adolescent; adult; article; bleeding; cervical spine injury; female; heart arrest; human; major clinical study; male; methodology; organization and management; outpatient; priority journal; school child; tracheotomy

Spinal unit long term inpatient management of patients with severe neurological deficit - Griffiths E.R. (Paraplegia, 1989)
Patients with the 'locked-in syndrome' are now being presented to spinal units for long term care. This is becoming a problem in spinal cord injury units, which have developed to accept spinal cord injury in the acute stage, to manage problems resulting from this, and to conduct a rehabilitation programme. A case history is presented of a patient with Guillain-Barre's recurrent syndrome, already 3 years an inpatient in a spinal unit and with minimal recovery. Problems in care are described in a patient with total bulbar palsy, paralysis of the intercostal and of the diaphragm includes inability to swallow due to bulbar paralysis with nutrition delivered by jejunostomy. The presence of a tracheostomy, as well as the bulbar and laryngeal palsy, render vocal communication impossible. Total care has been provided in a spinal unit for the past 3 years, with no complications during his management. Given continuation of expert care, life expectancy may be that of many years. Is a spinal cord injury unit the proper place for long term management of cases of this nature and many similar cases described as having the 'locked-in syndrome'?
Keywords: adult; case report; Guillain Barre syndrome; human; jejunostomy; locked in syndrome; male

Minitracheotomy in the early respiratory management of patients with spinal injuries - Gupta A.; McClelland M.R.; Evans A.; El Masri W.S. (Paraplegia, 1989)
Minitracheotomy is a new technique of tracheal suction by the introduction under local anaesthetic of a small bore tube into the trachea through the cricothyroid membrane. The use of minitracheotomy in the early management of respiratory problems in patients with spinal injuries is described with a few illustrative cases. This technique is an adjunct to good physiotherapy in clearing secretions from the trachea. Its advantages and disadvantages are discussed.
Keywords: adult; human; major clinical study; methodology; spinal cord injury; tracheotomy

Diaphragm pacing - Moxham J.; Potter D. (Thorax, 1988)
Keywords: artificial ventilation; editorial; human; hypoventilation; methodology; phrenic nerve pacing; priority journal; spinal cord injury; therapy; tracheotomy

CT digital radiography: Alternative technique for airway evaluation in physically disabled patients - Mandell G.A.; Harcke H.T.; Padman R.; Brunson G.; Delengowski R. (Pediatric Radiology, 1987)
Evaluation of the airway for the presence of granulation tissue prior to removal of a tracheostomy is essential to prevent sudden respiratory decompensation secondary to obstruction. Airway examination in a brain and/or spinal cord injured patient is especially difficult under fluoroscopy. The patient's lack of mobility results in poor visualization of the trachea, secondry to the overlying dense osseous components of the shoulders and thoracic cage. A CT localization view (digital view), which allows manipulation and magnification of the digital data in order to see the hidden airway and detect associated obstructing lesions, is proffered as an alternative technique to high KV, magnifiction technique. Thirteen examinations were performed satisfactorily in eleven patients examined by this technique with little expenditure of time, physical exertion, and irradiation. The sensitivity, specificty and accuracy of digital airway examination were 100%, 67% and 92% respectively with bronchoscopy used as the standard.
Keywords: bronchoscopy; bronchus patency; case report; clinical article; computer analysis; computer assisted tomography; diagnosis; human; methodology; respiratory system; trachea granuloma; tracheostomy

Diaphragm paralysis causing ventilatory failure in an adult with the rigid spine syndrome - Efthimiou J.; McLelland J.; Round J.; Gribbin H.R.; Loh L.; Spiro S.G. (American Review of Respiratory Disease, 1987)
A syndrome consisting of a rigid spine and myopathy predominantly affecting proximal limb muscles has been previously described in children, and as with most neuromuscular disorders, the respiratory muscles appear to be affected only at an advanced stage in the disease. We describe an adult male with this syndrome who presented with ventilatory failure caused by severe respiratory muscle weakness and who demonstrated profound nocturnal arterial oxygen desaturation, particularly during rapid eye movement sleep. Treatment with negative pressure ventilation initially resulted in only modest improvements in symptoms, blood gas tensions, and nocturnal desaturation. The cause of this only partial improvement was upper airway obstruction provoked by the mode of ventilatory support used. After tracheostomy there was a dramatic and sustained improvement in symptoms and blood gas tensions and complete abolition of nocturnal arterial oxygen desaturation. This is the first report of an adult with the rigid spine syndrome presenting with ventilatory failure and cor pulmonale due to severe respiratory muscle weakness.
Keywords: adult; case report; diaphragm paralysis; human; male; myopathy; respiratory failure; spine disease; tracheostomy

The choice to end life as a ventilator-dependent quadriplegic - Maynard F.M.; Muth A.S. (Archives of Physical Medicine and Rehabilitation, 1987)
A 17-year-old male sustained a C5/6 fracture dislocation and complete C5 quadriplegia in a diving accident. Three days later sensory and motor function deteriorated and he required mechanical ventilation. Surgical exploration found no cause and a fusion was done. Neurologic function stabilized after three weeks with a C1 sensory level, no neck movement, and slight weakness of the tongue. Patient and family were followed closely by the spinal cord injury rehabilitation team from onset of injury. The patient was transferred to the ventilator-dependent pediatric rehabilitation program after ten weeks. Bowel, bladder, skin, and nutritional management were stabilized and taught to his parents who remained with him constantly. Communication was achieved with a 'talking tracheostomy'. He learned to use 'Sip-n-Puff' control for driving an electric wheelchair and for Morse code input to a computer. He was passive but cooperative during hospitalization. Eight months after injury he was discharged to his home, which had been modified to meet his needs. A computer word processor, environmental control unit, and modified van were obtained; nursing care was provided around the clock. The patient enrolled in a community college course. Soon after discharge he contacted an attorney to explore legal actions for ending his life, which he considered intolerable. After obtaining medical and psychiatric reports, a court order was issued, which established his legal competence and directed people taking care of him to follow his directions. A few weeks later, 25 months after his injury, he privately said goodbye to his family, asked to be disconnected from the ventilator, and died. Medical and legal issues raised by this case are discussed.
Keywords: adolescent; artificial ventilation; case report; ethics; euthanasia; human; interpersonal communication; law; legal aspect; male; priority journal; psychological aspect; quadriplegia

Spinal epidural abscess--report of 5 cases - Tsuji N.; Igarashi S.; Koyama T. (No shinkei geka. Neurological surgery, 1987)
We reported 5 patients with spinal epidural abscess. They were two men and three women. Their ages ranged from 48 to 56 years (mean, 53 years). In three out of 5 cases, the etiology was thought to be infection after lumbar discography, tracheostomy and lumber surgery. In the other two cases the etiology could not be determined. The abscess was located at cervical, thoracic and lumbar levels in 2, 1 and 2 cases, respectively. The interval between initial symptoms and operation was from 1 to 3 months. Purulent epidural collection was found in four cases at operation. Irrigation and drainage were sufficiently performed postoperatively in 4 cases. Antibiotic therapy had been continued for at least 8 weeks in every case. As demonstrated in the case 2, CT scan was very useful in determining the extension of the abscess and degree of the cord compression by the abscess. Also in the case 2, the epidural abscess extending from cervical canal to extracanalicular space was completely drained by applying draining tubes without laminectomy. The present results indicate that emergency laminectomy is not always necessary for the treatment of epidural abscess, especially in subacute or chronic cases.
Keywords: abscess; article; case report; computer assisted tomography; epidural space; female; human; laminectomy; male; middle aged; radiography; spine disease; wound drainage