Original observation after a cervico-occipital disjunction: Gerhardt syndrome associated with Riegel syndrome - Have L.; Tell L.; Gardie Y.; Vial C.; Rode G. (Annals of Physical and Rehabilitation Medicine, 2011)
Introduction.- Observations of cervico-occipital disjunction are rare. Short-term prognosis is poor. We report the case of a patient presenting cervico-occipital disjunction who achieved a favorable outcome with exceptional laryngeal disorders. Case report.- A 55-year-old man, with no medical history, presented cervicooccipital disjunction caused by a violent deceleration while he was driving a vehicle. He also suffered a heart failure. The initial assessment showed cervicooccipital dislocation with an epidural and prevertebral haematoma, a contusion at the bulbo-medullary junction and a diffuse brain oedema. He was in an intensive care unit for 2 months. He had a tracheotomy and presented severe tetraparesis. The course was favorable and the tracheotomy cannula was removed. The patient was then referred to the rehabilitation unit. Seven days later, the patient developed acute laryngeal dyspnea. The fibroscopy exploration revealed a right Gerhardt syndrome (the vocal cord stayed permanently in a paramedian position) and a left Riegel syndrome (the vocal cord stayed permanently in a median position). Swallowing disorders is also caused by the paralysis of the left side of the tongue. Due to the narrowlaryngeal passage and the major dyspnea, a new tracheotomy was made. The electromyogram showed hyperactivity of the thyro-arythenoidian muscles but no denervation signs in abductor muscles. An injection of botulinic toxin was made in the arythenoidian muscles. The clinical course was favorable: standing ability, gripping ability, orally feeding, no dyspnea, loud and clear voice. Discussion.- The clinical motor recovery achieved by this patient after such serious trauma is exceptional. This case illustrates the importance of carefully monitoring the laryngeal region after a cervical spine injury due to the risk of swallowing and respiratory disorders. Botulinic toxin was an exceptional indication here: cord vocal hyperactivity. In this situation, it functioned as a diagnosis test, a reversible treatment and an alternative to the surgery.
Keywords: toxin; dyspnea; adaptation; human; patient; tracheotomy; muscle; hyperactivity; vocal cord; dysphagia; paralysis; tongue; electromyogram; denervation; disease course; feeding; voice; injury; monitoring; cervical spine injury; risk; injection; respiratory tract disease; diagnosis; surgery; prognosis; larynx disorder; case report; male; medical history; deceleration; heart failure; epidural drug administration; hematoma; contusion; brain; edema; intensive care unit; quadriplegia; cannula; rehabilitation; fiberscope endoscopy; swallowing

Facial and spinal impalement injury: An airway challenge - Gupta B.; Agrawal P.; Soni K.; D'Souza N.; Sinha S. (Indian Journal of Critical Care Medicine, 2011)
Keywords: fentanyl; glycopyrronium; lidocaine; midazolam; nitrous oxide; oxygen; sevoflurane; vecuronium; adult; anesthesia induction; artificial ventilation; body position; bone screw; case report; cervical spine; clinical feature; coughing; extubation; face edema; face injury; fascia; fiberscope endoscopy; foreign body; human; laryngeal nerve; letter; liquorrhea; lung edema; male; mouth cavity; nerve block; nose; odontoid process fracture; operation duration; oral surgery; penetrating trauma; postoperative care; postoperative hemorrhage; premedication; radiography; respiration control; respiratory tract intubation; skull base; spine injury; spine instability; spine stabilization; tracheostomy

Admission asia motor score predicting the need for tracheostomy after cervical spinal cord injury - Menaker J.; Stein D.; Scalea T. (Neurocritical Care, 2011)
Introduction Respiratory compromise and the need for tracheostomy are common after cervical spinal cord injury (CSCI). Recent data suggests the American Spinal Injury Association (ASIA) motor score strongly correlates with the development of organ dysfunction and failure following CSCI. The purpose of the study was to evaluate if ASIA motor score is associated with the need for tracheostomy following CSCI. Methods The trauma registry was used to identify all patients with isolated CSCI over a 3-year period. Patients with an abbreviated injury score > 3 in other body regions were excluded. Medical records were reviewed for demographics, admission ASIA motor score, anatomical level of injury, need for a tracheostomy and length of stay (LOS). Results 128 patients were identified. 74 patients required tracheostomy on mean hospital day 8.5 ( 3.5). Mean ASIA motor was 15.4 ( 19.6). Mean anatomical level of CSCI was 4.6 ( 1.3). Comparing patients with and without tracheostomy, those requiring tracheostomy had significantly lower mean admission ASIA motor score and were more likely to be an AIS A. (Table 1) There was no difference in mean anatomical level of injury. Table 2 demonstrates sensitivities, specificities, PPV and NPV for ASIA motor scores and the need for tracheostomy. Conclusions Tracheostomy after SCI is common. Lower admission ASIA motor score and “complete” injury on admission are significantly associated with the need for tracheostomy. Anatomical level of injury was not associated with tracheostomy after CSCI.
Keywords: tracheostomy; cervical spinal cord injury; society; American Spinal Injury Association impairment scale; human; injury; patient; medical record; length of stay; body regions; register; hospital

Expanding the differential for autonomic dysreflexia: Mucus plugging in a man who is ventilator dependent and with incomplete cervical spinal cord injury. A case report - Feeko K.J.; Formal C.S. (PM and R, 2011)
Patients or Programs: A 43-year-old man with incomplete ventilator-dependent tetraplegia. Program Description: The patient developed bradycardia with lightheadedness, chest discomfort, and hypoxia after routine suctioning. Assessment showed changes consistent with autonomic dysreflexia (AD): diaphoresis, flushing, and elevated systolic/diastolic blood pressure. Interventions, including disrobing the patient, Foley change, digital rectal examination, and application of 2 in. of nitroglycerin paste resulted in no improvement. Elevated peak inspiratory pressures were noted. Auscultation revealed poor air movement in the left lung. Despite removal from the ventilator, there was increased resistance to manual ventilation. Removal of the inner cannula caused a large audible air release from the tracheostomy tube and revealed a large mucus plug adherent to the distal lumen of the cannula. With a new inner cannula, aeration improved and blood pressure normalized. Follow-up chest x-ray film was unremarkable. Setting: A free-standing rehabilitation hospital. Results: AD is common after cervical spinal cord injury and is marked by an increased sympathetic discharge caused by noxious stimuli; treatment is predicated upon removal of this stimulus. Mucus plugging can cause complete airway obstruction, with resultant atelectatic change, or partial obstruction, with lung overdistension. This latter effect is more prevalent with mechanical ventilation, the presence of a tracheostomy, and with ineffective cough, and, therefore, is a potential cause of AD in the tetraplegic population. Discussion: Air trapping due to an obstructing mucus plug that creates a distal high pressure system with lung overinflation has previously been described in the asthmatic and/or chronic obstructive pulmonary population; however, AD due to this phenomenon has not been previously described in the rehabilitation setting. Conclusions: Both hypoxic events and fatal airway obstruction can result after bronchiolar and tracheal mucus plugs. It, therefore, is imperative to recognize mucus plugging as a risk factor for AD in the ventilator-dependent tetraplegia population.
Keywords: glyceryl trinitrate; human; physical medicine; ventilator; mucus; rehabilitation; male; autonomic dysreflexia; case report; cervical spinal cord injury; patient; population; lung; cannula; blood pressure; tracheostomy; stimulus; airway obstruction; quadriplegia; asthma; trachea mucus; risk factor; hyperbarism; thorax radiography; hospital; artificial ventilation; coughing; bradycardia; dizziness; thorax pain; hypoxia; diaphoresis; digital rectal examination; paste; auscultation; air; manual ventilation; tube; aeration; follow up; obstruction; X ray film

Caesarean delivery and exit procedure for the management of a large fetal nasopharyngeal teratoma under combined spinal epidural anaesthesia - Alfoudri H.; Mlechkova L.; Almatrook D. (Regional Anesthesia and Pain Medicine, 2011)
Background: A number of case reports have been published in the litreture describing the use of an EXIT (EX Utero Intrapartum Treatment) procedure during cesarean section (CS). The EXIT procedure involves partial delivery of the fetus where its upper half is exteriorised while the torso remains in the uterus with an intact placenta allowing fetal surgery to be performed. Most EXIT procedures are performed under deep general anaesthesia (GA) which allows uterine relaxation through inhalational agents. However, we report this case of an EXIT procedure performed sucessfully under combined spinal epidural anaesthesia (CSE). Method and Results: A 33 years old pregnant woman presented for an elective CS and an EXIT procedure to manage a large fetal orofacial mass. The procedure was performed under CSE which was achieved with 2.5mls intrathecal 0.5%heavy bupivacaine with 25mcg fentanyl and an epidural catheter sited to allow further topups. a dense neuroaxial blockade was established reaching T4 dermatome. Delivery of the fetal head and thorax was achieved through a Pfannenstiel incision. Intravenous (IV) nitroglycerin was not required as the uterus was sufficienty relaxed. Examination of the baby revealed a large 10×10cm mass protruding from the mouth. The fetal airway was secured with a tracheostomy and a live female was delivered and the CS was completed successfully without need for epidural topups. Conclusions: We suggest that a CSE can be considered for an EXIT procedure in order to avoid the known risks associated with GA in the obstetric population.
Keywords: fentanyl; bupivacaine; glyceryl trinitrate; teratoma; epidural anesthesia; society; regional anesthesia; procedures; uterus; female; case report; human; trunk; pregnant woman; placenta; fetus surgery; general anesthesia; fetus; risk; tracheostomy; inhalational drug administration; population; intrathecal drug administration; baby; epidural catheter; dermatome; thorax; incision; uterus relaxation; examination; airway; epidural drug administration; cesarean section

Dysphagia in cervical spinal cord injury - Shin J.C.; Yoo J.H.; Lee Y.S.; Goo H.R.; Kim D.H. (Spinal Cord, 2011)
Study design:Retrospective chart review of cervical spinal cord injury patients, who underwent videofluoroscopic swallowing study (VFSS).Objectives:To evaluate the swallowing function of cervical spinal cord injury patients, analyze the features of dysphagia and investigate their association with the clinical symptoms and signs.Setting:Spinal Cord Injury Unit, Yonsei Rehabilitation Hospital, Seoul, Korea.Methods:Retrospective study (1 May 2001-31 May 2008) on inpatients with tetraplegia. All enrolled patients underwent VFSS, and their results were correlated with clinical data including symptoms and signs indicative of dysphagia.Results:A total of 121 cervical spinal cord injury patients (106 male and 16 female patients) were included in this study. Ten patients showed evidence of aspiration on VFSS. Statistical correlation to aspiration was found with age, presence of tracheostomy, and symptoms and signs indicating dysphagia. However, out of the 10 patients with evident aspiration, 2 patients did not show any symptoms or signs indicating aspiration.Conclusion: Because of the possibility of silent aspiration, we recommend that physicians treating patients with cervical spinal cord injury should always take the possibility of dysphagia and silent aspiration into consideration, especially in case of previous manifestation of pneumonia, presence of tracheostomy, or presence of signs and symptoms indicating dysphagia. © 2011 International Spinal Cord Society. All rights reserved.
Keywords: adolescent; adult; aged; article; asymptomatic disease; cervical spinal cord injury; child; clinical feature; controlled study; correlation analysis; dysphagia; female; fluoroscopy; groups by age; hospital patient; human; major clinical study; male; priority journal; pulmonary aspiration; retrospective study; risk factor; school child; South Korea; swallowing; tracheostomy; videorecording

Complications of tracheostomy after anterior cervical spine fixation surgery - Romero-Ganuza J.; Gambarrutta C.; Merlo-Gonzalez V.E.; Marin-Ruiz M.A.; Diez De La Lastra-Buigues E.; Oliviero A. (American Journal of Otolaryngology - Head and Neck Medicine and Surgery, 2011)
Purpose: Cervical traumatic spinal cord-injured patients often way require both anterior cervical spine stabilization and tracheostomy in the first few days after the injury. The infectious complication of tracheostomy can interfere with the evolution of the fixation surgery. The aim of our study was to evaluate the safety of tracheostomy performed early after anterior cervical spine stabilization. Materials and methods: We reviewed the clinical records of 28 patients admitted to our hospital intensive care unit. In all cases, percutaneous tracheostomy was performed using the percutaneous dilation technique. Results: The average time interval between the fixation surgery and tracheostomy was 8.25 ± 5.57 days. We had complications in tracheostomy in only 3 cases: minor bleeding occurred in 1 patient and stomal infection, not propagated to the fixation surgery wound, was observed in 2 patients. Two patients died without causal relation to these interventions. Conclusions: The early performance of tracheostomy after cervical spinal fixation surgery is safe, still realized early and nearly this, at least if the tracheostomy is performed by percutaneous method. © 2011 Elsevier Inc.
Keywords: adult; aged; article; bleeding; clinical article; female; human; male; medical record review; methicillin resistant Staphylococcus aureus infection; postoperative complication; priority journal; respiratory failure; retrospective study; spinal cord injury; spine stabilization; stoma infection; surgical infection; tracheostomy; spine fracture

Outcomes after total aortic arch replacement with right axillary artery cannulation and a presewn multibranched graft - Kulik A.; Castner C.F.; Kouchoukos N.T. (Annals of Thoracic Surgery, 2011)
Background: Several techniques are available for aortic arch replacement. We evaluated our experience with total aortic arch replacement using a presewn multibranched graft and right axillary artery cannulation for brain perfusion. Methods: Between 2002 and 2010, 88 patients (mean age, 61.5 ± 14.6 years) underwent total aortic arch replacement by midline sternotomy (27 patients) or bilateral anterior thoracotomy (61 patients). During a brief period of deep hypothermic circulatory arrest (DHCA) (mean duration, 11.0 ± 7.8 minutes), the brachiocephalic arteries were detached from the aorta and clamped. Cerebral perfusion through the right axillary artery was then initiated while the arteries were sequentially attached to the branches of the presewn graft (mean duration: 40.4 ± 9.8 minutes). The ascending aorta and entire arch were replaced in all patients, combined with varying lengths of the descending aorta. Results: The 30-day mortality rate was 5.7%. Stroke occurred in 3.4%, spinal cord ischemic injury in 3.4% (1 paraplegia, 2 paraparesis), and new-onset renal failure requiring dialysis in 3.4% of patients. The 5-year survival rate was 70.7% ± 5.5%. All graft branches remained patent during imaging follow-up (mean duration, 2.6 ± 2.2 years). Six patients required reoperation on the graft or contiguous aorta after the initial repair, but no reoperations were required on the aortic arch or its branches. The 5-year rate of freedom from reoperation was 90.4% ± 4.0%. Conclusions: The use of a presewn multibranched graft and hypothermic brain perfusion through the right axillary artery is a safe method for replacement of the aortic arch, resulting in a low incidence of neurologic complications and favorable durability and patency. © 2011 The Society of Thoracic Surgeons.
Keywords: adult; aged; aortic arch surgery; artery catheterization; artery graft; article; artificial heart pacemaker; artificial ventilation; ascending aorta; axillary artery; blindness; blood transfusion; brachiocephalic trunk; brain perfusion; cerebrospinal fluid drainage; deep hypothermic circulatory arrest; deep vein thrombosis; descending aorta; dialysis; follow up; graft patency; atrial fibrillation; human; kidney failure; lung embolism; major clinical study; neurologic disease; optic nerve injury; outcome assessment; paraplegia; pneumonia; priority journal; reoperation; spinal cord injury; sternotomy; cerebrovascular accident; surgical infection; surgical mortality; survival rate; thoracotomy; tracheostomy; vocal cord paralysis

Severe airway distress following cervical spine operation: Retrospective breakdown of the chain of errors - Paul C.; Ladra A.; Pillai V.; Böttiger B.W.; Spöhr F.; Keller K.; Zarghooni K. (Anaesthesist, 2011)
A 71-year-old female patient received a prothesis due to a cervical disc prolapsed and bleeding into the collar soft tissues occurred postoperatively. Following a computed tomography examination severe peracute respiratory decompensation occurred while administering topical anesthesia to the pharynx in order to perform fiber optic intubation. Endotracheal intubation using conventional laryngoscopy was unsuccessful and the patient required immediate cricothyroidotomy. As an on-site cricothyrotomy set to establish a secure airway was not available the decision was taken to perform surgical cricothyroidotomy. As a conclusion to this life-threatening event in the case of symptoms, such as dyspnea, dysphonia and dysphagia after operations of the cervical spine the airway has to be secured early and according to the local algorithm. © 2011 Springer-Verlag.
Keywords: aged; article; case report; cervical disk hernia; computer assisted tomography; female; human; intervertebral disk hernia; laryngoscopy; postoperative hemorrhage; respiratory distress; spine surgery; topical anesthesia; tracheotomy

Endoscopic image-guided transcervical odontoidectomy: Outcomes of 15 patients with basilar invagination - Dasenbrock H.H.; Clarke M.J.; Ali Bydon M.D.; Sciubba D.M.; Witham T.F.; Gokaslan Z.L.; Wolinsky J.-P. (Neurosurgery, 2011)
BACKGROUND: Ventral decompression with posterior stabilization is the preferred treatment for symptomatic irreducible basilar invagination (BI). Endoscopic image-guided transcervical odontoidectomy (ETO) may allow for decompression with limited morbidity. OBJECTIVE: To describe the peri-operative outcomes of patients undergoing anterior decompression of basilar invagination using ETO. METHODS: 15 patients who had a follow-up of at least 16 months were retrospectively reviewed. Intra-operatively, the vertebral body of C2 was removed and the odontoid was resected in a "top-down" manner using endoscopic visualization and frameless stereotactic navigation. Posterior instrumented stabilization was subsequently performed. RESULTS: The average (±standard deviation) age of the patients was 42.6±24.5 (range 11-72) years. Post-operative complications occurred in 6 patients, including a urinary tract infection (n=2), upper airway swelling (n=2), dysphagia (n=2), gastrostomy tube placement (n=1), and an asymptomatic pseudomeningocele (n=1). No patients required a tracheostomy, had bacterial meningitis, or developed a venous thromboembolic event; only one patient was intubated for more than 48 hours post-operatively. With a mean follow-up of 41.9±14.4 (range 16-59) months, myelopathy improved in all patients and no patient experienced late neurologic deterioration. The mean modified Japanese Orthopedic Association (JOA) score increased from 11.2±4.2 to 15.9±1.4 (P=0.002). Patients with a diagnosis other than rheumatoid arthritis or who had a higher pre-operative JOA score had a significantly better post-operative neurological recovery (P=0.005). CONCLUSION: ETO may be a valid treatment for patients with symptomatic irreducible basilar invagination that avoids some of the morbidity of transoral surgery and leads to long-term improvement in myelopathy.
Keywords: human; patient; invagination; decompression; follow up; morbidity; spinal cord disease; diagnosis; rheumatoid arthritis; vertebra body; odontoid process; frameless stereotactic procedure; postoperative complication; urinary tract infection; upper respiratory tract; surgery; dysphagia; stomach tube; tracheostomy; bacterial meningitis; thromboembolism; deterioration; Japanese (people); swelling

A systematic review of intensive cardiopulmonary management after spinal cord injury - Casha S.; Christie S. (Journal of Neurotrauma, 2011)
Intensive cardiopulmonary management is frequently undertaken in patients with spinal cord injury (SCI), particularly due to the occurrence of neurogenic shock and ventilatory insufficiency and in an attempt to reduce secondary injury. We undertook a systematic review of the literature to examine the evidence that intensive care management improves outcome after SCI and to attempt to define key parameters for cardiopulmonary support/resuscitation. We review the literature in five areas: management of SCI patients in specialized centers, risk in SCI patients of cardiopulmonary complications, parameters for blood pressure and oxygenation/ventilation support following SCI, risk factors for cardiopulmonary insufficiency requiring ICU care after SCI, and preventative strategies to reduce the risks of cardiopulmonary complications in SCI patients. The literature supports that, in light of the significant incidence of cardiorespiratory complications, SCI patients should be managed in a monitored special care unit. There is weak evidence supporting the maintenance of MAP >85 mmHg for a period extending up to 1 week following SCI. © 2011 Mary Ann Liebert, Inc.
Keywords: atropine; dexamethasone; dextran; dihydroergotoxine mesilate; dobutamine; dopamine; hypertensive agent; inotropic agent; methylprednisolone; noradrenalin; apnea; areflexia; artificial ventilation; aspiration pneumonia; atelectasis; bladder function; blood gas analysis; blood transfusion; breathing exercise; breathing rate; cardiopulmonary function; cardiopulmonary hemodynamics; cardiopulmonary insufficiency; cardiovascular risk; colloid; disease association; disease severity; electromyography; fluid therapy; follow up; forced vital capacity; heart arrest; heart arrhythmia; heart atrium pacemaker; hospital admission; hospital care; hospital discharge; hospitalization; human; hypotension; hypoxia; immobilization; injury severity; intensive care; length of stay; life expectancy; atelectasis; lung edema; lung embolism; lung function test; lung infection; lung insufficiency; lung ventilation; mean arterial pressure; morbidity; mortality; muscle strength; neurologic examination; oxygenation; paraplegia; peak expiratory flow; pneumonia; positive end expiratory pressure; prognosis; quadriplegia; reoperation; respiratory failure; respiratory function; respiratory tract disease; resuscitation; retrospective study; review; risk factor; spinal cord injury; spirometry; systematic review; systolic blood pressure; thorax radiography; tidal volume; total lung capacity; tracheobronchial toilet; tracheotomy; treatment outcome; vascular resistance; vital capacity

Pre-Hospital care management of a potential spinal cord injured patient: A systematic review of the literature and evidence-based guidelines - Ahn H.; Singh J.; Nathens A.; MacDonald R.D.; Travers A.; Tallon J.; Fehlings M.G.; Yee A. (Journal of Neurotrauma, 2011)
An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury. © 2011 Mary Ann Liebert, Inc.
Keywords: air medical transport; athlete; autoregulation; cervical spine; clinical assessment; clinical effectiveness; consciousness level; crossover procedure; emergency care; endotracheal intubation; flexor reflex; fluoroscopy; fracture immobilization; fracture treatment; gunshot injury; head immobilization; health care facility; health care personnel; health care quality; health service; hospital care; human; immobilization; injury severity; intracranial pressure; medical education; mortality; multicenter study (topic); nasotracheal intubation; neck pain; neuroimaging; neurologic examination; orthosis; pain assessment; patient assessment; patient care; patient information; patient referral; patient transport; positive end expiratory pressure; pre hospital care; range of motion; respiration control; review; sacrum; spinal cord injury; spine fracture; spine immobilization; splinting; stretcher; supine position; systematic review; thoracolumbar spine; thorax pressure; tracheostomy; transcutaneous carbon dioxide monitoring

Acute management of nutritional demands after spinal cord injury - Thibault-Halman G.; Casha S.; Singer S.; Christie S. (Journal of Neurotrauma, 2011)
A systematic review of the literature was performed to address pertinent clinical questions regarding nutritional management in the setting of acute spinal cord injury (SCI). Specific metabolic challenges are present following spinal cord injury. The acute stage is characterized by a reduction in metabolic activity, as well as a negative nitrogen balance that cannot be corrected, even with aggressive nutritional support. Metabolic demands need to be accurately monitored to avoid overfeeding. Enteral feeding is the optimal route following SCI. When oral feeding is not possible, nasogastric, followed by nasojejunal, then by percutaneous endoscopic gastrostomy, if necessary, is suggested. © 2011 Mary Ann Liebert, Inc.
Keywords: anorexia; aspiration; bacteriuria; calorimetry; decubitus; dysgeusia; dysosmia; dysphagia; energy expenditure; enteric feeding; human; jejunostomy; length of stay; malabsorption; metabolism; nitrogen balance; nose feeding; nutritional assessment; nutritional status; nutritional support; paraplegia; percutaneous endoscopic gastrostomy; pleurisy; pneumonia; quadriplegia; review; septicemia; spinal cord injury; spinal cord transsection; surgical infection; systematic review; total parenteral nutrition; tracheostomy; body weight loss

A clinical description of extubation failure in patients with primary brain injury - Karanjia N.; Nordquist D.; Stevens R.; Nyquist P. (Neurocritical Care, 2011)
Background Patients with acute brain injury but normal lung function are often intubated for airway protection, but extubation often fails. Currently, no clinical data exist that describe the events leading to extubation failure in this population. We examined the extubation failure rate, reintubation rate, and clinical characteristics of patients whose reason for intubation was a primary neurological injury. We then identified the clinical characteristics of those patients with primary brain injury who were reintubated. Methods We conducted a retrospective review of patients admitted to the neurocritical care unit of a tertiary care hospital from January 2002 to March 2007. Results Of 1,265 patients who were intubated because of primary neurological injury of brain, spinal cord, or peripheral nerve, 25 (2%) died before extubation and 767 (61%) were successfully extubated. Tracheostomies were placed in 181 (14%) patients, of which, 77 (6.1%) were completed before a trial of extubation and 104 (8.2%) after extubation failure. A total of 129 (10%) patients were reintubated; 77 (6.1%) were reintubated within 72 h, meeting the definition of extubation failure. The other 52 (4.1%) were intubated after 72 h usually in the setting of pneumonia or decreased mental status. Ninety-nine of the patients reintubated had primary brain injury and resulting encephalopathy. All were successfully reintubated. Most patients intubated as a result of a primary brain injury (981) were successfully extubated. The most common clinical scenario leading to reintubation in these encephalopathic patients was respiratory distress associated with altered mental status [59 patients (59%)]. These patients usually had atelectasis and decreased minute ventilation, independent of fever, pneumonia, aspiration, and increased work of breathing [39 patients (39%)]. Conclusion The extubation failure rate in our neurocritical care unit is low. In patients with encephalopathy and primary brain injury who were reintubated, respiratory distress caused by altered mental status was the most common cause of reintubation. These patients demonstrated signs disrupted ventilation usually with periods of prolonged hypoventilation. Increased work of breathing from lung injury due to pneumonia or aspiration was not the most common cause of reintubation in this population. © Springer Science+Business Media, LLC 2011.
Keywords: aspiration; atelectasis; brain disease; brain injury; breathing rate; clinical evaluation; disease association; extubation; fever; human; intensive care unit; intubation; lung minute volume; major clinical study; mental deficiency; mental health; neurologic disease; outcome assessment; peripheral nerve injury; pneumonia; priority journal; respiratory distress; retreatment; retrospective study; review; spinal cord disease; tracheostomy; treatment failure

Herpes simplex encephalitis following spinal ependymoma resection: Case report and literature review - Raper D.M.S.; Wong A.; McCormick P.C.; Lewis L.D. (Journal of Neuro-Oncology, 2011)
Herpes simplex encephalitis (HSE) is a rare complication of neurosurgical procedures but must be considered in early deterioration of the postoperative patient. This is the first report of HSE following spinal cord tumor resection. A 65-year-old woman had C2-C5 laminectomy for subtotal resection of intramedullary ependymoma. Six days postoperatively she developed fever, vomiting and rapid decline in mental status. Brain MRI revealed enhancement of left insular cortex. Polymerase chain reaction on cerebrospinal fluid (CSF) identified herpes simplex virus type 1 (HSV-1) as the causal agent. Twenty-one days of acyclovir led to improvement. Three subsequent admissions to neurological intensive care unit were required for deterioration in mental status, including pneumonia, hydrocephalus and deep vein thromboses. Ventriculoperitoneal shunt (VPS), tracheotomy, percutaneous intravenous central catheter (PICC) line and percutaneous endoscopic gastrostomy (PEG) were placed. She was discharged to skilled nursing home care. Acyclovir is effective therapy against HSV, though outcomes may be poor even in optimally treated cases. Empiric treatment must be started even in the absence of serologic evidence of HSV infection if suspicion for HSE is high. © 2010 Springer Science+Business Media, LLC.
Keywords: aciclovir; cefepime; dexamethasone; piperacillin plus tazobactam; vancomycin; aged; article; brain ventricle peritoneum shunt; case report; central venous catheterization; cerebrospinal fluid analysis; deep vein thrombosis; ependymoma; female; fever; herpes simplex encephalitis; Human alphaherpesvirus 1; hospital admission; hospital discharge; human; hydrocephalus; intensive care unit; Klebsiella; laminectomy; medical literature; meningitis; mental deterioration; nuclear magnetic resonance imaging; nursing home; percutaneous endoscopic gastrostomy; pneumonia; polymerase chain reaction; postoperative period; Proteus; spine ependymoma; tracheotomy; treatment duration; treatment outcome; urosepsis; virus identification; vomiting

Occipitocervicothoracic stabilization in pediatric patients: Clinical article - Fargen K.M.; Anderson R.C.E.; Harter D.H.; Angevine P.D.; Coon V.C.; Brockmeyer D.L.; Pincus D.W. (Journal of Neurosurgery: Pediatrics, 2011)
Object. Although rarely encountered, pediatric patients with severe cervical spine deformities and instability may occasionally require occipitocervicothoracic instrumentation and fusion. This case series reports the experience of 4 pediatric centers in managing this condition. Occipitocervical fixation is the treatment of choice for craniocervical instability that is symptomatic or threatens neurological function. In children, the most common distal fixation level with modern techniques is C-2. Treated patients maintain a significant amount of neck motion due to the flexibility of the subaxial cervical spine. Distal fixation to the thoracic spine has been reported in adult case series. This procedure is to be avoided due to the morbidity of complete loss of head and neck motion. Unfortunately, in rare cases, the pathological condition or highly aberrant anatomy may require occipitocervical constructs to include the thoracic spine. Methods. The authors identified 13 patients who underwent occipitocervicothoracic fixation. Demographic, radiological, and clinical data were gathered through retrospective review of patient records from 4 institutions. Results. Patients ranged from 1 to 14 years of age. There were 7 girls and 6 boys. Diagnoses included Klippel-Feil, Larsen, Morquio, and VATER syndromes as well as postlaminectomy kyphosis and severe skeletal dysplasia. Four patients were neurologically intact and 9 had myelopathy. Five children were treated with preoperative traction prior to instrumentation; 5 underwent both anterior and posterior spinal reconstruction. Two patients underwent instrumentation beyond the thoracic spine. Allograft was used anteriorly, and autologous rib grafts were used in the majority for posterior arthrodesis. Follow-up ranged from 0 to 43 months. Computed tomography confirmed fusion in 9 patients; the remaining patients were lost to follow-up or had not undergone repeat imaging at the time of writing. Patients with myelopathy either improved or stabilized. One child had mild postoperative unilateral upper-extremity weakness, and a second child died due to a tracheostomy infection. All patients had severe movement restriction as expected. Conclusions. Occipitocervicothoracic stabilization may be employed to stabilize and reconstruct complex pediatric spinal deformities. Neurological function can be maintained or improved. The long-term morbidity of loss of cervical motion remains to be elucidated.
Keywords: adolescent; arm weakness; arthrodesis; article; bone dysplasia; cervical spine; child; clinical article; computer assisted tomography; craniocervical instability; female; follow up; human; infant; Jarcho Levin syndrome; Klippel Feil syndrome; kyphosis; male; morbidity; Morquio syndrome; occipitocervicothoracic fixation; preschool child; priority journal; rib graft; school child; spinal cord disease; spine instability; spine stabilization; syndrome VATER; thoracic spine; tracheostomy; traction therapy

Vascularized free fibula for cervical spine reconstruction following complicated retropharyngeal abscess - Moche J.A.; Chopra K.; Gastman B. (Otolaryngology - Head and Neck Surgery, 2011)
Keywords: antibiotic agent; titanium; adult; anastomosis; article; bone plate; case report; cervical spine injury; computer assisted tomography; contrast enhancement; dysphagia; fibula graft; human; implant; laryngoscopy; leukocyte count; male; neck pain; neurosurgery; osteomyelitis; paresthesia; postoperative period; retropharyngeal abscess; spine surgery; tooth extraction; tracheostomy; treatment outcome; vertebral corpectomy; weakness

Distal embolic brain infarction due to recanalization of asymptomatic vertebral artery occlusion resulting from cervical spine injury: Case report - Nakao Y.; Moridaira H.; Suda K.; Kajino T.; Tojo Y.; Ueda H.; Kokabu T. (Topics in Spinal Cord Injury Rehabilitation, 2011)
Objective: Spinal injuries are frequently associated with vertebral artery occlusion (VAO). Many aspects of the management of VAO remain controversial, including the screening criteria, the diagnostic modality, and the optimal treatment for various lesions. We present a case of brain infarction due to recanalization of the occluded VA following open reduction of cervical spinal dislocation and discuss the management of VAO. Design: A case report. Participants/methods: A 41-yearold man presented with C4-5 distractive-flexion injury manifesting with quadriplegia and anesthesia below the C3 cord level (including phrenic nerve paralysis) and bowel-bladder dysfunction. MR angiography and CT angiography showed left extracranial VA (V2) occlusion and patent contralateral VA. He was observed without antiplatelet and/or anticoagulation therapy and underwent surgery (open reduction and internal fusion of C4/5, and tracheostomy) 8 hours after the injury. Results: After surgery, supraspinal symptoms such as left horizontal nystagmus and left homonymous hemianopsia led to cranial CT and MRI, which showed left-side cerebellar infarction in the posterior inferior cerebellar artery (PICA) territory and rightside posterior cerebral artery (PCA) infarction. MR angiography and CT angiography demonstrated patent bilateral VA (but hypoplastic right VA) and occluded right PCA (P2). He was treated with observation alone without any other ischemic complications. Conclusion: In this case, VA occlusion on the dominant side caused by cervical spinal dislocation led to cerebellar infarction in the PICA territory due to hemodynamic compromise or arterial dissection. Contralateral PCA infarction was caused by artery-to-artery embolization originated from recanalized VA. The management of asymptomatic VAO is controversial with several treatment options available, including observation alone, antiplatelet therapy, anticoagulation therapy, or invasive intervention. Although there are some reports described that management with observation alone seems safe, we should pay serious attention to the VA injury caused by cervical spine trauma.
Keywords: case report; brain infarction; vertebral artery stenosis; recanalization; cervical spine injury; spinal cord; rehabilitation; injury; computed tomographic angiography; cervical spine dislocation; patent; magnetic resonance angiography; anticoagulant therapy; occlusion; cerebellum infarction; open reduction (procedure); surgery; infarction; posterior inferior cerebellar artery; homonymous hemianopia; nystagmus; tracheostomy; male; human; diagnosis; bladder dysfunction; screening; intestine; nerve paralysis; spine injury; quadriplegia; phrenic nerve; artery dissection; anesthesia; artery; artificial embolization; therapy; nuclear magnetic resonance imaging; cerebral artery disease

Late complications of intrathecal baclofen pump management - Oleson C.V. (Topics in Spinal Cord Injury Rehabilitation, 2011)
Objectives: To explore late complications of intrathecal baclofen (ITB) pump usage, leading to ultimate explantation of the pump; and to explore reasons for elective discontinuation of the pump in subjects with long term ITB use. Design: Retrospective chart review. Participants/methods: 205 charts were screened to identify 67 eligible subjects with ITB pump >8 years and diagnoses of spinal cord injury, anoxic or traumatic brain injury, stroke, multiple sclerosis, or hereditary forms of spastic paraplegia. Independent variables included diagnosis causing spasticity, eventual daily ITB rate, age, years with pump, and living situation. The above factors were examined as a function of complication type and incidence and of rate of voluntary pump. Tests of significance (P & .05) were performed on each of the variables. Results: Complications leading to pump explantation were not associated with daily rates ITB (in mcg), years with pump independent of subject's overall health status, or subject's age. There was a significantly higher number of infections leading to pump removal in persons with SCI relative to other diagnostic groups, especially in SCI subjects with tracheostomy, pressure ulcers, or recurrent urinary tract infections. Independent of diagnostic group, those living in chronic long- term care centers (nursing or group homes) were at significantly higher rates of pump explantation for medical, financial, and social reasons. Conclusion: Complications with ITB such as infections and pump dislodgement/spontaneous explantation were observed more often in persons with urinary tract infections, osteomyelitis and pressure ulcers, and chronic tracheostomy and in those residing in chronic care facilities. In addition to high infection risk, those living in a nursing home face financial and logistical challenges in maintaining the pump, sometimes leading to voluntary discontinuation.
Keywords: baclofen; pump; spinal cord; rehabilitation; intrathecal drug administration; explant; urinary tract infection; decubitus; infection; diagnosis; human; tracheostomy; diagnosis related group; traumatic brain injury; health status; spinal cord injury; spasticity; independent variable; spastic paraplegia; multiple sclerosis; osteomyelitis; cerebrovascular accident; residential home; long term care; nursing; infection risk; nursing home; medical record review

An autopsy case of familial amyotrophic lateral sclerosis with an Arg146Cys mutation in Cu/Zn superoxide dismutase - Hayashi K.; Koide R.; Honma T.; Mochizuki Y.; Kawata A.; Mizutani T. (Neuropathology, 2011)
A 58-year-old man developed hoarseness. He underwent tracheostomy and percutaneous endoscopic gastrostomy at age of 59 because of his severe bulbar palsy and respiratory failure. Three months later, orthostatic hypotension and urination disorder occurred. Generalized muscle weakness and external opthalmoplegia progressed to absent all of his voluntary movement (totally locked-in state). He died of pneumonia at age of 68. He had a family history with ALS (sister and cousin). The brain weighted 1,200 g. The spinal cord and the brainstem showed severe atrophy. Neuron loss of the motor nuclei in the brainstem and the spinal cord, fiber loss of the coritccospinal tract and Betz cell's loss were marked. Furthermore, degeneration extended motor neurons, such as the Clarke's nucleus, posterior columns, spinocerebellar tract, intermediolateral nucleus, globus pallidus, subthalamic nucleus, substantia nigra, and thalamus were observed. This patient had neuronal loss of nucleus of the vagus nerve, solitaly tract nucleus and intermediolateral nucleus, besides the feature of FALS and TLS.
Keywords: superoxide dismutase; Japanese (people); mutation; autopsy; neuropathology; amyotrophic lateral sclerosis; society; brain stem; spinal cord; human; muscle weakness; family history; atrophy; nerve cell; brain; motoneuron nucleus; fiber; pyramidal nerve cell; degeneration; motoneuron; globus pallidus; subthalamic nucleus; substantia nigra; spinocerebellar tract; thalamus; patient; cell loss; male; hoarseness; tracheostomy; bulbar paralysis; percutaneous endoscopic gastrostomy; respiratory failure; orthostatic hypotension; micturition disorder; voluntary movement; pneumonia; vagus nerve

Controlateral cavernous syndrome, brainstem congestion and posterior fossa venous thrombosis with cerebellar hematoma related to a ruptured intracavernous carotid artery aneurysm - Aldea S.; Guedin P.; Roccatagliata L.; Boulin A.; Auliac S.; Dupuy M.; Cerf C.; Gaillard S.; Rodesch G. (Acta Neurochirurgica, 2011)
Intracavernous carotid artery aneurysms (ICCAs) are rarely associated with life-threatening complications. We describe a 55-year-old woman who, after the rupture of an intracavernous carotid artery aneurysm, presented with a contralateral cavernous sinus syndrome and severe posterior fossa and spinal cord symptoms. Following parent artery occlusion, thrombosis of the posterior fossa and spinal cord veins caused a progressive worsening of the neurological status to a "locked-in" state. The patient fully recovered with anticoagulation therapy. Comprehension of the pathophysiological mechanism associated with the rupture of ICCA and early diagnosis of the related symptoms are essential in order to plan a correct treatment that includes the management of the aneurysm rupture and of possible complications related to venous thrombosis. © 2011 Springer-Verlag.
Keywords: anticoagulant agent; fluindione; heparin; abducens nerve paralysis; adult; aneurysm rupture; anticoagulant therapy; article; brain angiography; brain edema; brain hematoma; carotid artery bruit; carotid artery obstruction; carotid cavernous fistula; case report; cavernous sinus thrombosis; clinical feature; computer assisted tomography; confusion; craniectomy; diplopia; disease association; disease exacerbation; disease severity; dysarthria; dysphagia; early diagnosis; exophthalmos; facial nerve paralysis; female; follow up; functional status; gait disorder; Glasgow coma scale; headache; human; internal carotid artery aneurysm; locked in syndrome; magnetic resonance angiography; mydriasis; neuroimaging; nuclear magnetic resonance imaging; paraplegia; posterior fossa; priority journal; tracheostomy

A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: Emerging safety concerns and lessons learned - Carragee E.J.; Hurwitz E.L.; Weiner B.K. (Spine Journal, 2011)
Background context: Increasingly, reports of frequent and occasionally catastrophic complications associated with use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in spinal fusion surgeries are being published. In the original peer review, industry-sponsored publications describing the use of rhBMP-2 in spinal fusion, adverse events of these types and frequency were either not reported at all or not reported to be associated with rhBMP-2 use. Some authors and investigators have suggested that these discrepancies were related to inadequate peer review and editorial oversight. Purpose: To compare the conclusions regarding the safety and related efficacy published in the original rhBMP-2 industry-sponsored trials with subsequently available Food and Drug Administration (FDA) data summaries, follow-up publications, and administrative and organizational databases. Study design: Systematic review. Methods: Results and conclusions from original industry-sponsored rhBMP-2 publications regarding safety and related efficacy were compared with available FDA data summaries, follow-up publications, and administrative and organizational database analyses. Results: There were 13 original industry-sponsored rhBMP-2 publications regarding safety and efficacy, including reports and analyses of 780 patients receiving rhBMP-2 within prospective controlled study protocols. No rhBMP-2-associated adverse events (0%) were reported in any of these studies (99% confidence interval of adverse event rate <0.5%). The study designs of the industry-sponsored rhBMP-2 trials for use in posterolateral fusions and posterior lateral interbody fusion were found to have potential methodological bias against the control group. The reported morbidity of iliac crest donor site pain was also found to have serious potential design bias. Comparative review of FDA documents and subsequent publications revealed originally unpublished adverse events and internal inconsistencies. From this review, we suggest an estimate of adverse events associated with rhBMP-2 use in spine fusion ranging from 10% to 50% depending on approach. Anterior cervical fusion with rhBMP-2 has an estimated 40% greater risk of adverse events with rhBMP-2 in the early postoperative period, including life-threatening events. After anterior interbody lumbar fusion rates of implant displacement, subsidence, infection, urogenital events, and retrograde ejaculation were higher after using rhBMP-2 than controls. Posterior lumbar interbody fusion use was associated with radiculitis, ectopic bone formation, osteolysis, and poorer global outcomes. In posterolateral fusions, the risk of adverse effects associated with rhBMP-2 use was equivalent to or greater than that of iliac crest bone graft harvesting, and 15% to 20% of subjects reported early back pain and leg pain adverse events; higher doses of rhBMP-2 were also associated with a greater apparent risk of new malignancy. Conclusions: Level I and Level II evidence from original FDA summaries, original published data, and subsequent studies suggest possible study design bias in the original trials, as well as a clear increased risk of complications and adverse events to patients receiving rhBMP-2 in spinal fusion. This risk of adverse events associated with rhBMP-2 is 10 to 50 times the original estimates reported in the industry-sponsored peer-reviewed publications. © 2011 Elsevier Inc. All rights reserved.
Keywords: antibiotic agent; antiinflammatory agent; recombinant bone morphogenetic protein 2; anterior cervical discectomy; anterior interbody lumbar fusion; arthrodesis; assisted ventilation; autograft; backache; bladder disease; bone disease; bone graft; bone pain; bone radiography; breathing disorder; cancer risk; carcinogenicity; cervical spine anterior fusion; data base; disease association; drug efficacy; drug megadose; drug safety; dysphagia; ectopic bone formation; food and drug administration; human; iliac crest; iliac crest bone graft; infection; inflammation; leg pain; morbidity; nonhuman; off label drug use; ossification; osteolysis; posterior lateral interbody fusion; posterolateral lumbar interbody fusion; postoperative complication; postoperative pain; postoperative period; priority journal; publication; radiculitis; reoperation; respiratory tract disease; respiratory tract intubation; retrograde ejaculation; review; risk; speech disorder; spinal cord injury; spine surgery; surgeon; swelling; systematic review; tracheotomy; posterior lumbar interbody fusion; treatment outcome; urogenital tract disease; wound complication

Vinorelbine in progressive unresectable low-grade glioma in children - Cappellano A.M.; Bouffet E.; Silva F.; Paiva P.; Alves M.T.D.S.; Cavalheiro S.; Silva N.S. (Journal of Clinical Oncology, 2011)
Background: Low grade glioma represent 30-40% off all childhood brain tumors. Optimal treatment when feasible is surgical resection resulting in cure in the majority of the cases. However, the management of progressive unresectable low-grade glioma (PULGG) remains controversial. There is increasing evidence that chemotherapy can delay or even allow avoidance of radiotherapy and/or surgery in these unresectable tumors. Several protocols have been described. However, short and long term toxicity remains a major issue in this chronic disease. Within this context, we present our experience with single agent vinorelbine, a semi-synthetic vinca alkaloid. Methods:From July 2007 to January 2011, 32 patients with recurrent (10) or newly diagnosed (22) PULGG started treatment with vinorelbine 30 mg/m2 on days 0, 8 and 22 for a total of 18 cycles. Tumor site was hypothalamic/chiasmatic (19), spinal cord (1), cortex (1), cerebellum (1), brainstem (4), multifocal (3) and 2 patients had gliomatosis. Four children had neurofibromatosis and 3 diencephalic syndrome. Twenty- two patients had prior neurosurgical intervention. Response criteria were based on magnetic resonance imaging and physical examination. Results: Twenty- eight patients (median age 7 years 1 month) were evaluable after 4 cycles of vinorelbine, with objective response (OR) in 9 patients, stable disease (SD) in 19. After 8 cycles, 25 patients were evaluable with 9 OR, 15 SD and 1 PD. After 18 cycles, 18 patients were evaluable for response, 5 with OR, 10 SD and 3 PD. Three patients died: one of disease progression, one of atypical pneumonia and one of tracheotomy obstruction. Toxicity was mild and manageable in most cases: Grade I/II gastrointestinal toxicity was observed in 9 patients, grade I/II neurotoxicity in 2 patients and grade IV hematologic toxicity in 3 patients. Conclusions: Our preliminary results suggest that vinorelbine is active in patients with ULGG. This drug offers several advantages including a low toxicity profile associated with excellent quality of life.
Keywords: vinorelbine tartrate; Vinca alkaloid; human; glioma; child; patient; toxicity; surgery; neoplasm; neurotoxicity; quality of life; neurofibromatosis; gliosis; nuclear magnetic resonance imaging; physical examination; disease course; virus pneumonia; tracheotomy; obstruction; cerebellum cortex; spinal cord; childhood; brain tumor; chemotherapy; radiotherapy; chronic disease; brain stem; gastrointestinal toxicity

Long-term ventilation in children: Epidemiology of an epidemic - McDougall C.M.; Adderley R.; Wensley D.F.; Seear M.D. (American Journal of Respiratory and Critical Care Medicine, 2011)
Introduction Children with special healthcare needs, including those benefiting from advanced technologies, represent an increasing segment of the population. Cross-sectional studies have suggested that paediatric long-term ventilation (LTV) has expanded rapidly over the last 20 years. We sought to describe longitudinal trends in LTV in a single regional referral centre which provides all paediatric LTV care for the province of British Columbia (population 4 million). Methods Retrospective data was collected on all patients receiving LTV (medically stable patients ventilated for ≥ 3 months1) at BC Children's Hospital between 1.1.95 and 31.12.09. Data was subdivided into 5-year epochs for statistical analysis (χ2 test). Results 145 children (85 male) commenced LTV during the 15-year period. 28 (19%) were ventilated invasively via tracheostomy (all bilevel) and 117 (81%) received non-invasive ventilation (NIV) (22 CPAP, 95 bilevel). 17 (12%) were ventilated 24 hours/day while 128 (88%) were supported < 24 hours/day. Median age at initiation of LTV was 9.4 (0-23) years but there was a bimodal distribution with peaks in the 1st and 14th years of life. Principal diagnostic categories were: neuromuscular disease (46%), spinal injury (6%), abnormal ventilatory control (13%), craniofacial abnormality/OSA (17%), tracheomalacia (8%) and “other” (10%). 8 (5%) patients died, 27 (19%) discontinued respiratory support after a median of 1.8 (0.2-11.5) years and 38 (26%) transitioned to adult care. Trends in incidence and prevalence of LTV are shown in Figure 1. Using census data2, the calculated incidence rate has increased from 1/106 children/year in 1996 to 14/106 children/year in 2006, with a corresponding increase in prevalence from 6 to 74/106 children. (Figure presented) Incidence of LTV increased significantly across the 3 5-year epochs (Table 1), due to a significant increase in NIV. The number of LTV patients with neuromuscular disease, abnormal ventilatory control and craniofacial problems/OSA increased over time. The number of patients transitioned to adult services has increased significantly. (Table presented) Conclusions The incidence of LTV in children has increased significantly over the last 15 years, with an accompanying 10-fold increase in prevalence. Although some children are able to discontinue respiratory support, a growing number are being transferred to adult care. LTV patients are resource-intensive. Future planning of paediatric hospital and community services, as well as adult services, must take into account the needs of this growing population.
Keywords: recombinant erythropoietin; air conditioning; child; human; epidemiology; epidemic; society; patient; adult; population; prevalence; assisted ventilation; neuromuscular disease; hospital; statistical analysis; cross-sectional study; planning; social welfare; population research; incidence; technology; tracheomalacia; spine injury; diagnosis; tracheostomy; male; Canada; health care need; pediatric hospital

Spinal Muscular Atrophy with Respiratory Distress (SMARD1) - A rare form of Spinal Muscular Atrophy - Ganesan S.; Hussain N.; Gosalakkal J. (European Journal of Paediatric Neurology, 2011)
Spinal muscular atrophy with respiratory distress type 1 (SMARD1) is a form of spinal muscular atrophy characterized by IUGR, often premature birth, foot deformity, and a characteristic pattern of breathing that indicates weakness of the diaphragm. Most patients present at the age of 1 to 6 months with respiratory failure and progressive muscle weakness with predominantly distal lower limb muscle involvement. They may be ventilator dependent and difficult to wean from the ventilator. Early involvement of the diaphragm and predominance of distal muscle weakness clearly distinguishes SMARD1 from Type 1 SMA. SMARD1 is not linked to the SMN1 gene locus on chromosome 5q13 (classic SMA), but is caused by mutations in the IGHMBP2 gene on chromosome 11q13. We present 7 months old infant admitted to PICU at the age of 5 weeks with Bronchiolitis and respiratory failure. She was term IUGR baby initially admitted to SCBU for 2 weeks needing NCPAP and had feeding difficulties. She remained ventilated for 4 weeks with 3 failed extubations and repeated respiratory infections. Her initial investigations for respiratory failure and repeated failed extubations included flexible bronchoscopy, CT scan chest, CF work up, Echo, MRI brain scan which was unremarkable. She had Neurometabolic investigations which were unremarkable. EMG/NCS suggested severe motor axonal neuropathy. Bloods for SMA gene testing was negative. Skin and muscle biopsy were unremarkable. Genetic testing for SMARD (mutations in the IGHMBP2) came back as positive but it was heterozygous on 2 genetic loci on the chromosome. So we tested the parents who were the carriers of the same mutations. It is not been described in the literature before. The child was successfully extubated with tracheostomy in place and currently on non invasive ventilation having multidisciplinary care. Always look for neuromuscular conditions if the child is ventilator dependent. SMARD1 is a rare form of spinal muscular atrophy and diagnosis helped in future management of the child and her family.
Keywords: spinal muscular atrophy; society; neurology; respiratory distress; ventilator; child; respiratory failure; mutation; diaphragm; muscle weakness; gene locus; gene; extubation; muscle biopsy; genetic screening; chromosome; parent; tracheostomy; air conditioning; diagnosis; prematurity; foot malformation; breathing; weakness; patient; weaning; chromosome 5; nuclear magnetic resonance imaging; infant; bronchiolitis; leg muscle; baby; feeding disorder; respiratory tract infection; bronchoscopy; computer assisted tomography; thorax; brain scintiscanning; neuropathy; blood; skin; chromosome 11

Postoperative obstructing laryngeal edema in patients with diffuse idiopathic skeletal hyperostosis of cervical spine-A report of two cases- - Kim Y.-S.; Lee J.J.; Chung Y.H.; Kim E.S.; Chung I.-S. (Korean Journal of Anesthesiology, 2011)
Two cases were reported in which severe postoperative laryngeal edema were developed after the operation of diffuse idiopathic skeletal hyperostosis (DISH) of cervical spine. In the first case, sudden airway obstruction was developed in the general ward 6 hour after uneventful decompression surgery for osteophyte. In the second patient, an elective preoperative tracheostomy was performed before surgery but the tube could not be removed for 2 months because of laryngeal edema and decreased vocal cord mobility. It should be emphasized that this airway problem can develop during the postoperative as well as the preoperative period, especially in the case of anterior cervical spine surgery. © the Korean Society of Anesthesiologists, 2011.
Keywords: heparin; rocuronium; sevoflurane; thiopental; aged; anticoagulant therapy; article; case report; cervical spine; computer assisted tomography; decompression surgery; diffuse idiopathic skeletal hyperostosis; drug withdrawal; dysphagia; elective surgery; human; larynx edema; male; osteophyte; percutaneous coronary intervention; physical examination; postoperative complication; postoperative period; preoperative period; spine disease; spine radiography; tracheostomy; vocal cord

Hereditary adult-onset alexander disease - Beliveau N. (Journal of Hospital Medicine, 2011)
Case Presentation: A 47-year-old white man with a history of alcohol abuse was transferred to our hospital with loss of consciousness and subsequently intubated en route for airway protection. His medical history was unremarkable. On initial presentation, the patient was sedated and comfortable on mechanical ventilation. Vital signs were normal. Physical exam, off sedation, was notable for bilateral conjugate gaze, intact corneal reflexes, minimal movements in extremities but not against gravity, deep tendon reflexes 2+ in both upper and lower extremities, and bilateral positive Babinski's sign. Workup including a complete blood count, complete metabolic panel, drug screen, chest x-ray, pan-culture, echocardiography, and CT head/cervical spine were nonrevealing, except for elevated alcohol level on admission. MRI of the brain stem revealed severe generalized cerebral atrophy extending caudally to the proximal cervical spinal cord on T2 and T2 FLAIR images. Cerebrospinal fluid analysis included protein electrophoresis, acidfast bacilli smear, and culture, Herpes, West Nile virus, toxoplasmosis, syphilis, and Lyme titers were unremarkable. Electroencephalography showed no epileptiform activity. On further investigation, family history was notable for the presence of Alexander disease (AD). A pedigree of his family showed 10 of 20 family members were affected. The diagnosis of AD had been confirmed on autopsy in family members, and typical MRI findings were described in the affected family members. Based on the MRI and an inheritance pattern in the family, the diagnosis of adult-onset Alexander disease was made, and likely progression of thedisease was attributed to his chronic excessive alcohol intake. The patient remained ventilator dependent and subsequently underwent tracheostomy. Discussion: Adult-onset Alexander disease (AOAD) is a subtype of Alexander disease, a rare and often fatal leukodystrophy, characterized pathologically by the accumulation of eosinophilic inclusions in astrocyte cytoplasm (Rosenthal fibers), resulting from nonconservative mutations of chromosome 17q21, which encodes GFAP. It has an autosomal dominant mode of inheritance. Near 450 cases have been reported worldwide since Alexander's initial description in 1949. AOAD has variable features, including bulbar and pseudobulbar signs, spasticity, quadriparesis, and dysautonomia. Atrophy of the medulla and upper cervical spinal cord on MRI is a characteristic finding. Because of the rarity of the disease and the lack of controlled clinical trials, there are no clear recommendations about the diagnosis and treatment of AOAD. Its diagnosis does not require genetic testing and can be established based on clinical and MRI features. Conclusions: The purpose of reporting this case is to increase the general awareness of this rare condition and to provide an up-to-date literature review.
Keywords: alcohol; Alexander disease; adult; hospital; nuclear magnetic resonance imaging; diagnosis; inheritance; cervical spinal cord; patient; blood cell count; echocardiography; spine; brain stem; brain atrophy; cerebrospinal fluid analysis; protein electrophoresis; Bacilli; smear; herpes simplex; West Nile virus; toxoplasmosis; syphilis; electroencephalography; family history; pedigree; autopsy; alcohol consumption; ventilator; tracheostomy; leukodystrophy; astrocyte; cytoplasm; fiber; mutation; autosomal dominant inheritance; spasticity; quadriplegia; dysautonomia; atrophy; controlled clinical trial (topic); genetic screening; male; chromosome 17; consciousness; airway; protection; medical history; artificial ventilation; thorax radiography; Babinski reflex; vital sign; sedation; conjugate; gaze; cornea reflex; gravity; tendon reflex; leg; alcohol abuse

The Isadora syndrome: A case report of cervical, oesophageal and tracheal transection in a go-karting accident - Ahmad M.; Sinha P.; Al-Tamimi Y.Z.; Sylvester D.; Dezso A.; Timothy J. (British Journal of Neurosurgery, 2011)
We report a case of cervical spine, tracheal and oesophageal trauma from a go-karting injury caused by the patient's scarf catching in the vehicle's wheel. We discuss the significance of the pre-hospital and operative management of this potentially life-threatening injury by a multi-specialty surgical team. The importance of health and safety issues in recreational sports is highlighted in view of the increasing incidence of cervical spine trauma over past two decades. © 2011 The Neurosurgical Foundation.
Keywords: adult; article; case report; cervical spine injury; emergency ward; endotracheal tube; esophagus injury; female; Glasgow coma scale; human; isadora syndrome; postoperative period; priority journal; recreation; surgical approach; surgical technique; trachea injury; tracheostomy; tracheotomy

Decannulation: In the ICU or in the ward? Does it really matter? - Milercy O.; López J.; Figueira J.; Manzanares J.; Hernández M. (Critical Care, 2011)
Introduction: The aim of our study was to evaluate the in-hospital mortality of patients who underwent tracheostomy during their ICU admission, and were discharged to different areas of the hospital prior to decannulation. Methods: A prospective observational study of a group of patients who underwent tracheostomy in our ICU from January 2001 to December 2007 and were discharged to different areas of the hospital prior to decannulation. The mortality of patients decannulated or not in the wards was reviewed. Results: Between January 2001 and December 2007, 6,333 patients were admitted to our unit. A total of 1,528 needed mechanical ventilation (MV) for more than 48 hours. Four hundred and fortythree underwent tracheostomy (29% of patients needed prolonged MV). Mean age was 56 years, 66% were male. Mean APACHE II score was 20. The main diagnoses were polytrauma that included head injury (24.2%), other structural neurological diseases (21%), prolonged weaning of several etiologies - sepsis, post-surgical (35%). Tracheostomy was performed with the percutaneous dilatational technique (PDT) in most cases (90%). The most frequent complication was subglottic stenosis presenting in 15 patients. Ninety-two patients (20.77%) died in the ICU and 351 were discharged to different wards. Of these 351, 161 (45.8%) could be decannulated in the ICU and 109 (31%) in the wards. Eighty-one patients (23%) could not be decannulated. The ward mortality in patients decannulated in the ICU was 5.6% (9/161), for those decannulated in the wards was 10% (11/109). In patients not decannulated the mortality reached 37% (30/81). There were no differences of statistical significance in mortality between patients decannulated in the ICU and patients decannulated in the wards (5.6% vs. 10%; OR = 1.9 CI = 0.8 to 4.2). The main diagnoses in the patients who died on the wards were: 31 residual encephalopathy (post-anoxic, post-traumatic, others), fi ve severe chronic respiratory failure, three spinal cord injury, two neuromuscular disease. Conclusions: Mortality was not related to whether decannulation was done in the ICU or on the ward. Although mortality was higher in the group of patients that could not be decannulated in either setting due to their poor neurological or functional status. Several authors suggest tracheostomy in these patients only delays their death without improving overall in-hospital survival due to their poor vital prognosis.
Keywords: ward; emergency medicine; intensive care; human; patient; mortality; tracheostomy; hospital; diagnosis; functional status; death; survival; prognosis; observational study; artificial ventilation; male; multiple trauma; head injury; neurologic disease; weaning; etiology; sepsis; subglottic stenosis; statistical significance; brain disease; chronic respiratory failure; spinal cord injury; neuromuscular disease; APACHE

Swallowing dysfunction after mechanical ventilation in trauma patients - Brown C.V.R.; Hejl K.; Mandaville A.D.; Chaney P.E.; Stevenson G.; Smith C. (Journal of Critical Care, 2011)
Background: Swallowing dysfunction can occur after mechanical ventilation, leading to complications such as aspiration and pneumonia. After mechanical ventilation, authors have recommended evaluating patients with contrast studies or endoscopy to identify patients at risk for swallowing dysfunction and aspiration. The purpose of the study was to determine if a bedside swallowing evaluation (BSE) can identify patients with swallowing dysfunction after mechanical ventilation. Methods: This is a 1-year (2008) prospective study of all adult trauma patients admitted to the intensive care unit requiring mechanical ventilation. Upon separation from mechanical, all patients received a BSE. The BSE used mental status, facial symmetry, swallow reflex, and oral ice chips and water to identify swallowing dysfunction. Patients who passed the BSE were advanced to oral intake per physician orders, whereas patients who failed the BSE were allowed nothing by mouth. Results: A total of 345 patients were included; 54 died before separation from mechanical ventilation and were excluded. The remaining 291 patients underwent BSE after separation from mechanical ventilation, with 143 (49%) passing and 148 (51%) failing. Patients who failed the BSE required mechanical ventilation longer than those who passed (14 ± 13 vs 5 ± 20 days, P = 001). In addition, only 23% of patients extubated within 72 hours failed the BSE, whereas 78% of those intubated more than 72 hours failed the BSE (P < .001). All patients who passed the BSE were discharged from the hospital without a clinical aspiration event. Independent risk factors for failure of BSE included tracheostomy, older age, prolonged mechanical ventilation, delirium tremens, traumatic brain injury, and spine fracture. Three (2%) patients who failed the BSE had a clinical aspiration event despite taking nothing by mouth. Conclusions: A simple BSE can be used to identify patients at risk for swallowing dysfunction after mechanical ventilation. More importantly, BSE can safely clear patients without swallowing dysfunction, avoiding costly and time-consuming contrast studies or endoscopic evaluation. © 2011 Elsevier Inc.
Keywords: adult; age distribution; aged; article; artificial ventilation; bedside swallowing evaluation; clinical evaluation; controlled study; delirium tremens; dysphagia; extubation; female; fluid intake; human; intensive care unit; major clinical study; male; mental health; prospective study; risk factor; spine fracture; swallowing; tracheostomy; traumatic brain injury

One thousand bedside percutaneous tracheostomies in the surgical intensive care unit: Time to change the gold standard - Kornblith L.Z.; Burlew C.C.; Moore E.E.; Haenel J.B.; Kashuk J.L.; Biffl W.L.; Barnett C.C.; Johnson J.L. (Journal of the American College of Surgeons, 2011)
Background: Bedside percutaneous tracheostomy (BPT) is a cost-effective alternative to open tracheostomy. Small series have consistently documented minimal morbidity, but BPT has yet to be embraced as the standard of care. Because this has been our preferred technique in the surgical ICU for more than 20 years, we reviewed our experience to ascertain its safety. We hypothesize that BPT has acceptably minimal morbidity, even in high-risk patients. Study Design Patients undergoing BPT from January 1998 to June 2008 were reviewed. High-risk patients were defined as those with cervical collar or halo, cervical spine injuries, systemic heparinization, positive end-expiratory pressure >10 cm H2O or fraction of inspired oxygen > 50%. Results During the study period, 1,000 patients underwent BPT (74% men; mean ± SEM age 46 ± 0.6 years; 70% trauma). BPT was performed 8.9 ± 0.2 days (mean ± SEM) after admission. Patients remained ventilator dependent for an additional 9.7 ± 0.4 days (mean ± SEM). There were 482 (48%) patients undergoing BPT who were considered high-risk: 1 risk category, 273 patients; 2 risk categories, 139 patients; 3 risk categories, 56 patients; 4 risk categories, 12 patients; 5 risk categories, 2 patients. Complications occurred in 14 (1.4%) patients. Early complications included tracheostomy tube misplacement requiring revision (n = 4), bleeding requiring intervention (n = 2), infection (n = 1), and procedure failure requiring cricothyroidotomy (n = 1). Late complications included persistent stoma requiring operative closure (n = 4) and subglottic stenosis (n = 2). There were 6 complications (1.2%) in normal risk and 8 complications (1.7%) in high-risk patients. There were no deaths related to BPT. Conclusions BPT in the surgical intensive care unit is a safe procedure, even in high-risk patients. We believe BPT is the new gold standard for patients requiring tracheostomy for mechanical ventilation. © 2011 American College of Surgeons.
Keywords: adult; article; bedside percutaneous tracheostomy; bleeding; cervical spine injury; female; heparinization; high risk patient; human; infection; intensive care unit; major clinical study; male; morbidity; positive end expiratory pressure; priority journal; subglottic stenosis; surgical mortality; tracheostomy

Repeated vertebrobasilar thromboembolism in a patient with severe upper cervical instability because of rheumatoid arthritis - Oshima K.; Sakaura H.; Iwasaki M.; Nakura A.; Fujii R.; Yoshikawa H. (Spine Journal, 2011)
Background context: Although many reports have examined upper cervical rheumatoid arthritis (RA) and spinal cord disorders resulting from RA lesions, few cases of thromboembolic events in the vertebrobasilar system associated with RA lesions of the upper cervical spine have been reported. Purpose: We encountered a rare case of repeated vertebrobasilar thromboembolism with severe upper cervical instability resulting from RA. Furthermore, we obtained clinical images of the vertebrobasilar system just before and after the first thromboembolic event. We thus present the case of a patient with RA who recovered without surgery from repeated vertebrobasilar thromboembolism that might have been caused by severe upper cervical instability. Study design: Case report. Methods: A 59-year-old man with a 14-year history of RA experienced nuchal pain because of severe atlantoaxial and vertical subluxations. While awaiting surgery, he developed left Wallenberg syndrome because of occlusion in the left vertebral artery (VA). Five days later, he displayed impaired consciousness and symptoms of right Wallenberg syndrome. Emergency magnetic resonance angiography showed occlusion in the basilar artery. After thrombolytic therapy, he gradually recovered. Results: Because we presumed that the patient's recurrent thrombus formation resulted from kinking of the right VA caused by severe instability of the upper cervical spine, we planned to treat him surgically despite his impaired consciousness and tracheostomy. However, the anesthesiologist would not approve surgery because the patient had high-risk conditions. The cervical spine was thus realigned and immobilized in a halo apparatus for 3 months to achieve stability. Now, more than 5 years after these events, the patient has experienced no more thromboembolic events and his condition has remained stable, without need for surgery. Conclusions: Repeated vertebrobasilar thromboembolism in patients with RA may sometimes be caused by severe upper cervical instability that can be treated without surgery. © 2011 Elsevier Inc.
Keywords: methotrexate; prednisolone; adult; article; atlantoaxial subluxation; case report; cervical spine; cervical spine instability; cervical spine radiography; coil embolization; computer assisted tomography; disease severity; human; intractable pain; magnetic resonance angiography; male; neck pain; priority journal; rheumatoid arthritis; spinal cord disease; thromboembolism; tracheostomy; vertebral artery; vertebral artery stenosis; vertebrobasilar thromboembolism; Wallenberg syndrome

A classification and regression tree to assist clinical decision making in airway management for patients with cervical spinal cord injury - Berney S.C.; Gordon I.R.; Opdam H.I.; Denehy L. (Spinal Cord, 2011)
Study design:This was a prospective observational study.Objectives:To review airway management of patients with acute cervical spinal cord injury (CSCI) who are admitted to the intensive care unit (ICU) and to develop a classification and regression tree (CART) to direct clinical decision making in airway management.Setting:This study was carried out in Australia.Methods:All patients with CSCI who required intubation and mechanical ventilation and who were admitted to ICU in three tertiary hospitals in Melbourne between October 2004 and May 2009 and two other interstate hospitals between December 2004 and December 2005 were included. Airway management was recorded.Results:A total of 114 patients were included. Tracheostomy insertion occurred in 68 patients (59.7%). Using CART analysis, it was found that the variables forced vital capacity, the volume of pulmonary secretion and gas exchange were predictive of airway management on 82.3% occasions with an 8.7% extubation failure rate.Conclusion:A CART can be useful in clinical decision making regarding airway management in CSCI. © 2011 International Spinal Cord Society All rights reserved.
Keywords: adult; article; artificial ventilation; Australia; cervical spinal cord injury; classification and regression tree; clinical classification; clinical decision making; female; forced vital capacity; gas exchange; human; intensive care unit; intubation; lung pressure; major clinical study; male; multicenter study; priority journal; regression analysis; respiration control; tracheostomy

Effect of technique and timing of tracheostomy in patients with acute traumatic spinal cord injury undergoing mechanical ventilation - Ganuza J.R.; Forcada A.G.; Gambarrutta C.; Buigues E.D.D.L.L.; Gonzalez V.E.M.; Fuentes F.P.; Luciani A.A. (Journal of Spinal Cord Medicine, 2011)
Objective: To assess the effect of timing and techniques of tracheostomy on morbidity, mortality, and the burden of resources in patients with acute traumatic spinal cord injuries (SCIs) undergoing mechanical ventilation. Design: Review of a prospectively collected database. Setting: Intensive and intermediate care units of a monographic hospital for the treatment of SCI. Participants: Consecutive patients admitted to the intensive care unit (ICU) during their first inpatient rehabilitation for cervical and thoracic traumatic SCI. A total of 323 patients were included: 297 required mechanical ventilation and 215 underwent tracheostomy. Outcome measures: Demographic data, data relevant to the patients' neurological injuries (level and grade of spinal cord damage), tracheostomy technique and timing, duration of mechanical ventilation, length of stay at ICU, incidence of pneumonia, incidence of perioperative and early postoperative complications, and mortality. Results: Early tracheostomy (<7 days after orotracheal intubation) tracheostomy was performed in 101 patients (47%) and late (≥7 days) in 114 (53%). Surgical tracheostomy was employed in 119 cases (55%) and percutaneous tracheostomy in 96 (45%). There were 61 complications in 53 patients related to all tracheostomy procedures. Two were qualified as serious (tracheoesophageal fistula and mediastinal abscess). Other complications were mild. Bleeding was moderate in one case (late, percutaneous tracheostomy). Postoperative infection rate was low. Mortality of all causes was also low. Conclusion: Early tracheostomy may have favorable effects in patients with acute traumatic SC. Both techniques, percutaneous and surgical tracheostomy, can be performed safely in the ICU. © The Academy for Spinal Cord Injury Professionals, Inc. 2011.
Keywords: adolescent; adult; aged; article; artificial ventilation; bleeding; female; human; intensive care unit; length of stay; major clinical study; male; mediastinum disease; morbidity; mortality; peroperative complication; pneumonia; postoperative complication; postoperative infection; spinal cord injury; tracheoesophageal fistula; tracheostomy; treatment duration

Incidence and clinical predictors for tracheostomy after cervical spinal cord injury: A national trauma databank review - Branco B.C.; Plurad D.; Green D.J.; Inaba K.; Lam L.; Cestero R.; Bukur M.; Demetriades D. (Journal of Trauma - Injury, Infection and Critical Care, 2011)
Background: The purpose of this study was to determine the incidence and identify clinical predictors for the need for tracheostomy after cervical spinal cord injury (CSCI). Methods: The National Trauma Databank version 7.0 (2002-2006) was used to identify all patients who sustained a CSCI. Patients with severe traumatic brain injury (TBI) were excluded. Demographics, clinical data, and outcomes were abstracted. Patients requiring tracheostomy were compared with those who did not require tracheostomy. Logistic regression analysis was used to identify independent predictors for the need of tracheostomy. Results: There were 5,265 eligible patients. Of these, 1,082 (20.6%) required tracheostomy and 4,174 (79.4%) did not. The majority patients were men and blunt trauma predominated. Patients requiring tracheostomy had a higher Injury Severity Score (ISS) (33.5 ± 17.7 vs. 24.4 ± 16.2, p < 0.001) and required intubation more frequently on scene and Emergency Department (ED) (4.2 vs. 1.4%, p < 0.001 and 31.1 vs. 7.9%, p < 0.001, respectively). Patients requiring tracheostomy had higher rates of complete CSCI at C1-C4 (18.2 vs. 8.4%, p < 0.001) and C5-C7 levels (37.8 vs. 16.9%, p < 0.001). Patients requiring tracheostomy had more ventilation days, longer intensive care unit and hospital lengths of stay, but lower mortality. Intubation on scene or ED, complete CSCI at C1-C4 or C5-C7 levels, ISS ≥16, facial fracture, and thoracic trauma were identified as independent predictors for the need of tracheostomy. Conclusion: After CSCI, a fifth of patients will require tracheostomy. Intubation on scene or ED, complete CSCI at C1-C4 or C5-C7 levels, ISS ≥16, facial fracture, and thoracic trauma were independently associated with the need for tracheostomy. Copyright © 2011 by Lippincott Williams &Wilkins.
Keywords: adult; article; artificial ventilation; cervical spinal cord injury; face fracture; female; human; incidence; injury scale; intensive care unit; intubation; major clinical study; male; priority journal; thorax injury; tracheostomy

A second case of Marburg's variant of multiple sclerosis with vasculitis and extensive demyelination - Elenein R.G.A.; Sharer L.R.; Cook S.D.; Pachner A.R.; Michaels J.; Hillen M.E. (Multiple Sclerosis Journal, 2011)
Marburg's variant of multiple sclerosis is a rapidly progressive and malignant form of multiple sclerosis (MS) that usually leads to severe disability or death within weeks to months without remission. Few cases have been described in the literature since the original description by Marburg. The classic pathological findings usually include highly destructive zones of extensive demyelination, necrosis with dense cellular infiltrate, and giant reactive astrocytes. We report a case of a 31-year-old woman with Marburg's variant of MS who, over a period of eight months, became totally disabled, blind, and quadriplegic, with vocal cord paralysis, requiring a tracheostomy. The patient underwent diagnostic stereotactic brain biopsy. Clinical findings, magnetic resonance imaging (MRI), serologic and cerebrospinal fluid (CSF) findings, and neuropathology are discussed. MRI showed extensive white matter involvement in the brain and spinal cord that continuously progressed over time. A diagnostic stereotactic brain biopsy revealed extensive active demyelination with unexpected finding of active vasculitis and fibrinoid necrosis with a vascular inflammatory cell infiltrate, including polymorphonuclear neutrophils and rare eosinophils. Serologic work-up for vasculitis and neuromyelitis optica was unremarkable and the CSF showed only one oligoclonal band (OCB) not present in serum. This is the second case of Marburg's variant of MS that demonstrated both demyelination and vasculitis. In our case these features were demonstrated simultaneously, even though the demyelination was the predominant pathological finding. Since vasculitis is not a feature of classic MS, these findings pose the question as to whether Marburg's variant of MS is a true variant or different entity altogether. © SAGE Publications 2011.
Keywords: adult; article; case report; cerebrospinal fluid analysis; clinical feature; demyelination; disability; female; human; multiple sclerosis; nuclear magnetic resonance imaging; serology; stereotactic biopsy; tracheostomy; vasculitis; vocal cord paralysis

Dysphagia in individuals with tetraplegia: Incidence and risk factors - Shem K.; Castillo K.; Wong S.; Chang J. (Journal of Spinal Cord Medicine, 2011)
Background/objective: Dysphagia following cervical spinal cord injury (SCI) can increase risk for pulmonary complications that may delay the rehabilitative process. The objective of this study was to identify risk factors for dysphagia after cervical SCI. Design: Prospective cohort study. Methods: Individuals with cervical SCI within 31 days of injury underwent a bedside swallow evaluation (BSE) followed by a videofluoroscopy swallow study (VFSS) within 72 hours of the BSE. Subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS. Results: Twenty-nine patients (7 female and 22 male) were enrolled. Of these, 21 (72%) had high cervical tetraplegia (C4 or higher) and 8 (38%) had lower cervical tetraplegia. A tracheostomy was present in 18 (62%) patients; 15 (52%) subjects were on ventilators. Dysphagia was diagnosed in 12 (41%) subjects. Dysphagia was noted in 62% of the subjects with tracheostomy and 53% of the subjects on the ventilator, but only tracheostomy resulted in a statistically significant association with dysphagia (P = 0.047). All three subjects who had nasogastric tubes were diagnosed with dysphagia (P = 0.029). The relationships between dysphagia and gender, high versus low tetraplegia, presence of halo or collar, head injury, and ventilator use were not statistically significant, but age was a significant risk factor (P = 0.028). Conclusions: Dysphagia is present in about 41% of individuals with acute tetraplegia. Only age, tracheostomy, and nasogastric tubes were identified as significant risk factors for dysphagia for individuals with tetraplegia. No relationship between dysphagia and level of SCI, spine surgery, collar, and ventilator use was found to exist. © The Academy for Spinal Cord Injury Professionals, Inc. 2011.
Keywords: adult; article; cervical spine; cervical spine injury; clinical article; cohort analysis; controlled study; disease association; dysphagia; female; fluoroscopy; head injury; human; incidence; male; nasogastric tube; prospective study; quadriplegia; risk factor; spinal cord injury; tracheostomy; ventilator

The acute respiratory management of cervical spinal cord injury in the first 6 weeks after injury: A systematic review - Berney S.; Bragge P.; Granger C.; Opdam H.; Denehy L. (Spinal Cord, 2011)
Study design: Systematic review.Objectives: Identify, evaluate, and synthesize evidence regarding the effectiveness of various treatment strategies for the respiratory management of acute tetraplegia.Setting: Melbourne, Australia.Methods: A search of multiple electronic databases (Medline, Cinahl, EMBASE, Cochrane Library, Web of Science, http://www.guideline.gov and http://www.icord.org/scire) was undertaken accompanied by the reference lists of all relevant articles identified. Methodological quality was assessed using the Newcastle-Ottawa Scale and the PEDro Scale. Descriptive analysis was performed.Results: Twenty-one studies including 1263 patients were identified. The majority of the studies were case series (n=13). A variety of interventions were used for the management of respiratory complications. Mortality (ARR0.4, 95% confidence interval (CI) 0.18, 0.61), the incidence of respiratory complications (ARR0.36, 95% CI (0.08, 0.58)), and requirement for a tracheostomy (ARR0.18, 95% CI (0.05, 0.4)) were significantly reduced by using a respiratory protocol. A clinical pathway reduced duration of mechanical ventilation by 6 days 95% CI (0.56, 12.56), intensive care unit length of stay by 6.8 days 95% CI (0.17-13.77) and costs. Intubation, mechanical ventilation, and tracheostomy are the mainstay of respiratory management for complete injuries above the level of C5.Conclusion: This review showed a clinical pathway with a structured respiratory protocol that includes a combination of treatment techniques provided regularly is effective in reducing respiratory complications and cost. The overall study quality was moderate and further studies using specific interventions that target respiratory complications are associated with specific regions of the cervical spine using more methodologically rigorous designs are required. © 2011 International Spinal Cord Society All rights reserved.
Keywords: artificial ventilation; atelectasis; case study; cervical spinal cord injury; Cinahl; Cochrane Library; descriptive research; Embase; emergency care; hospital cost; human; intensive care unit; intubation; Medline; methodology; mortality; pneumonia; priority journal; quadriplegia; quality control; respiratory failure; respiratory tract infection; review; systematic review; tracheostomy

Cerebellar hemorrhage after spine fixation misdiagnosed as a complication of narcotics use - A case report - Yang K.-H.; Han J.U.; Jung J.-K.; Lee D.I.; Hwang S.-I.; Lim H.K. (Korean Journal of Anesthesiology, 2011)
Cerebellar hemorrhage occurs mainly due to hypertension. Postoperative cerebellar hemorrhage is known to be associated frequently with frontotemporal craniotomy, but quite rare with spine operation. A 56-year-old female received spinal fixation due to continuous leg tingling sensation for since two years ago. Twenty-one hours after operation, she was disoriented and unresponsive to voice. Performed computed tomography showed both cerebellar hemorrhage. An emergency decompressive craniotomy was carried out to remove the hematoma. On the basis of this case, we reported this complications and reviewed related literature. Copyright © the Korean Society of Anesthesiologists, 2011.
Keywords: fentanyl; metoclopramide; ondansetron; adult; aphasia; article; ataxia; case report; cerebellum hemorrhage; computer assisted tomography; consciousness; craniotomy; diagnostic error; disorientation; drug withdrawal; female; hematoma; human; intracranial pressure; lethargy; nausea; patient controlled analgesia; sensory dysfunction; spine stabilization; tracheostomy

Predisposing factors for serum sodium disturbance in patients with severe traumatic brain injury (SBI) - Abrishamkar S.; Safavi M.; Tavakoli P.; Moradi D.; Honarmand A. (Turkish Journal of Medical Sciences, 2010)
Aim: Disturbances in the plasma sodium level in patients with severe brain injury (SBI) is not a rare phenomenon and may cause adverse effects on prognosis and treatment outcomes. The knowledge of the prevalence of risk factors helps in early detection and good management of the serum sodium level disturbance. Materials and methods: This is a prospective clinical trial double blind study. The target population included patients with SBI who had disturbances in their plasma sodium level and were admitted at the ICU of Kashani Hospital Isfahan Iran between January and October 2006. The patients with renal insufficiency diuretic therapy massive transfusion brain death and spinal cord injury were excluded. Gender age the prevalence of hypo- and hypernatremia having tracheal tube or tracheostomy requiring mechanical ventilation support craniotomy type of intracranial pathology positive history of cardiopulmonary disease the mean time after which the disturbance occurs and the mean time needed for the recovery from the disturbance were studied. Results: The prevalence of hypo- and hypernatremia were 60% and 40% respectively. Most of the patients were 21-50- year-old males with craniotomy. The mean time after which the disturbance occurs was 23 days after head trauma and the mean time needed for the recovery from sodium level disturbances was 11.5 days. Conclusion: Hypo- and hypernatremia are common complications of intracranial lesions. Early detection of serum sodium level disturbance is important in these patients and appropriate treatment may actually improve prognosis. © TÜBİTAK.
Keywords: glucose; sodium chloride; sodium ion; adult; aged; arterial oxygen saturation; article; artificial ventilation; blood pressure measurement; body temperature measurement; brain edema; cardiopulmonary insufficiency; central pontine myelinolysis; clinical article; convalescence; craniotomy; disease management; disease predisposition; early diagnosis; electrolyte disturbance; end tidal carbon dioxide tension; endotracheal tube; female; glucose blood level; head injury; human; hypernatremia; hyponatremia; injury severity; intracranial pressure monitoring; male; prevalence; prognosis; prospective study; risk factor; sodium blood level; time; tracheostomy; traumatic brain injury; treatment outcome

Cardiac pacing in patients with a cervical spinal cord injury - Rangappa P.; Jeyadoss J.; Flabouris A.; Clark J.M.; Marshall R. (Spinal Cord, 2010)
Study design: Retrospective medical record review. Objectives: To compare patients, admitted to an intensive care unit (ICU) with an acute cervical spinal cord injury (SCI) and documented motor deficit, who did, with those who did not, require a cardiac pacemaker. Setting: South Australian Tertiary Referral Intensive Care and Spinal Injury Unit. Methods: Retrospective medical record review and data set linkage. Results: From 1995 to 2007, 465 patients sustained a cervical SCI. Of these, 30 (6.5%) were admitted to ICU with a clinically assessable motor deficit and 3 (0.6% of all patients, or 10% of those admitted to ICU) required a cardiac pacemaker. All three patients had a cervical SCI, C5 (American Spinal Injury Association A) tetraplegia, and required invasive mechanical respiratory and inotropic support and a tracheostomy for weaning. Two patients (66%) were discharged alive to rehabilitation. Patients requiring a pacemaker had bradycardic episodes over a longer period (11 vs 4 days, P=0.01), a trend towards a later onset of bradycardia (8 vs 1.5 days, P=0.05) and a longer ICU length of stay (37 vs 10 days, P=0.02). Conclusion: Patients with a cervical SCI requiring a cardiac pacemaker are characterized by a higher level of SCI injury and motor loss, require mechanical respiratory and inotropic support, a tracheostomy to wean, and bradycardic episodes of a later onset and over a longer period of time. These findings suggest that such patients should be managed at hospitals with specialized acute spinal injury, intensive care and cardiac pacemaker services. © 2010 International Spinal Cord Society All rights reserved.
Keywords: atropine; inotropic agent; adult; article; artificial heart pacemaker; artificial ventilation; bradycardia; cervical spinal cord injury; female; heart pacing; human; intensive care unit; length of stay; major clinical study; male; medical record review; oxygen therapy; priority journal; quadriplegia; rehabilitation care; retrospective study; tertiary health care; tracheostomy

Acute airway obstruction associated with the use of bone-morphogenetic protein in cervical spinal fusion - Yaremchuk K.; Toma M.; Somers M. (Laryngoscope, 2010)
Objectives: Bone morphogenetic protein (BMP) used in anterior cervical spinal fusion procedures causes an inflammatory response resulting in upper airway obstruction between postoperative days 4-7. The purpose of this study is to determine the incidence and severity of airway complications associated with use of BMP, the associated clinical outcomes, morbidities and mortalities following its use, and to create a clinical awareness of patients with acute airway obstruction associated with the use of BMP in cervical spinal fusion. Methods: This is a retrospective study of 260 patients who underwent cervical spinal fusion procedures with BMP from 2004-2009 and 520 patients, matched on procedure, who underwent cervical spinal fusion procedures without BMP during the same period at a tertiary care center. The two groups were compared on multiple outcome variables: hospital length of stay (LOS), costs, incidence of airway obstruction, unplanned intubations after surgery, tracheotomies, intensive care unit (ICU) admissions, hoarseness, dyspnea, respiratory failure, dysphasia and dysphagia, readmissions, and need for percutaneous endoscopic gastrostomy (PEG) tubes. All outcome variables that were binary in nature were analyzed using linear logistic regression analyses predicting use of BMP. Deaths up to 90 days post surgery were analyzed with a Cox proportional hazards model. Variables significantly related to BMP use were used as covariates in the above analyses. Results: Patients that underwent cervical procedures with BMP were noted to have significantly longer hospital stays (7.2 ± 11.1 days vs. 4.3 ± 5.2 days, p < 0.001), and greater costs ($129,483 versus $74,974, p < 0.001) than the control group (Table 1). Tracheotomies (Odds Ratio = 3.79, p-value = 0.021), unplanned intubations after surgery (2.81, 0.008), dysphagia (8.94, 0.001), dyspnea (2.43, 0.001), and respiratory failure (3.35, 0.001) were all significantly associated with the BMP group (Table 2 & Figure 1). In addition, hospital readmissions (1.96, 0.040), ICU admissions (3.05, 0.001), and 90 day mortality rates (Hazard Ratio = 2.44, p = 0.047) were significantly worse for the BMP group. Conclusions: Acute airway obstruction in the postoperative period following cervical spine fusion using BMP is a complication of its use. Due to the degree of obstruction and difficulty with intubation postoperatively, a clinical awareness is necessary to effectively manage these patients. Collaborative efforts between the spine surgeon, anesthesia and the otolaryngologist are required for management of the complications that occur after surgery. © 2010 The American Laryngological, Rhinological, and Otological Society, Inc..
Keywords: infuse; recombinant bone morphogenetic protein 2; unclassified drug; airway obstruction; anterior spine fusion; bone graft; case control study; computer assisted tomography; conference paper; controlled study; disease association; disease severity; dysphagia; dysphasia; dyspnea; hoarseness; hospital readmission; hospitalization cost; human; intensive care unit; intubation; length of stay; major clinical study; mortality; outcome assessment; percutaneous endoscopic gastrostomy; postoperative period; prediction; priority journal; respiratory failure; retrospective study; tertiary health care; tracheotomy; treatment outcome; infuse; INFUSE

Early and late results of descending thoracic and thoracoabdominal aortic aneurysm open repair with deep hypothermia and circulatory arrest - Fehrenbacher J.W.; Siderys H.; Terry C.; Kuhn J.; Corvera J.S. (Journal of Thoracic and Cardiovascular Surgery, 2010)
Objective: Open repair of descending thoracic aortic and thoracoabdominal aortic aneurysms may carry low morbidity and mortality, depending on experience of the surgeon and operative technique used. Although thoracic endovascular aortic repair is less invasive, its limitations include anatomy and pathology of the aorta, proximity of major branches, and significant complication and reintervention rates. We retrospectively reviewed a 2-surgeon experience (J.W.F. and J.S.C.) with deep hypothermic circulatory arrest to repair descending thoracic aortic and thoracoabdominal aortic aneurysms. Methods: All patients (n = 343) who underwent surgical replacement of descending thoracic aortic or thoracoabdominal aortic aneurysm with deep hypothermic circulatory arrest from 1995 to 2009 were included. Segmental arteries between T8 and the celiac artery were aggressively reimplanted as indicated. Visceral and renal artery bypasses were performed for significant stenosis. Concomitant coronary artery bypass grafting was performed if targets were anterior or lateral wall vessels. Lumbar drains were not routinely used but placed postoperatively on clinical evidence of spinal cord ischemia. Results: Of 343 patients, 98 had descending thoracic aortic aneurysms, 69 had Crawford type I thoracoabdominal aortic aneurysms, 111 had type II, 32 had type III, and 33 had type IV. Emergency or urgent operations comprised 13% of repairs. Hospital mortalities were 5.0% for all cases, 3.7% for elective cases, and 13.3% for urgent or emergency cases. Overall incidences were 4.4% for stroke, 3.2% for paraplegia or paraparesis, 1.5% for renal failure requiring dialysis, and 3.5% for tracheostomy. The 1-, 3-, 5-, and 10-year survival rates were 90%, 79%, 69%, and 54%, respectively. Conclusions: Surgical repair of descending thoracic aortic and thoracoabdominal aortic aneurysms with deep hypothermic circulatory arrest carries low operative morbidity and mortality and excellent early and late survival rates. These results can be used as a benchmark for future techniques and technologies. Copyright © 2010 by The American Association for Thoracic Surgery.
Keywords: abdominal aortic aneurysm; adult; aged; conference paper; coronary artery bypass graft; deep hypothermic circulatory arrest; descending aortic surgery; dialysis; female; human; kidney failure; major clinical study; male; morbidity; paraplegia; postoperative period; priority journal; spinal cord ischemia; stenosis; cerebrovascular accident; surgical mortality; surgical technique; survival; thoracic aorta aneurysm; tracheostomy

Extubation failure in patients with primary brain injury - Karanjia N.; Nordquist D.; Stevens R.; Nyquist P. (Critical Care Medicine, 2010)
Introduction: Patients with acute brain injury but normal lung function are often intubated for airway protection. Extubation often fails. Currently, no clinical data exist that describe the events leading to extubation failure and reintubation in this population. Hypothesis: Our objective was to identify the clinical characteristics of patients for whom extubation failed whose primary reason for intubation was a primary brain injury independent of mechanical lung injury. We also identified the extubation failure rate, reintubation rate, and clinical characteristics of these patients. Our primary hyopthesis was that causes other than aspiration and or pneumonia would be the main reason for reintubation. Methods: Retrospective review of electronic databases supplemented by chart review from January 2002 to March 2007. Results: Patients admitted to the neurocritical care unit who were intubated because of primary neurological injury of brain, spinal cord, or peripheral nerve numbered 1265. Of these, 25 (2%) died before extubation and 767 (61%) were extubated. The number of patients extubated to comfort care was 292 (23%). Tracheostomies were placed in 181 (14%) patients, of which, 77 (5.9%) were attempted before extubation. A total of 129 (10%) patients were reintubated; 77 (5.9% ) met the clinical definition of extubation failure. Ninety-nine of the patients reintubated had encephalopathy that resulted from primary brain injury. Of these, 12 (12%) had a documented pneumonia, six (6%) aspirated, six (6%) experienced stridor, and 17 (17%) experienced a medical emergency. The most common clinical scenario leading to reintubation was respiratory distress with altered mental status [59 patients (59%)]; these patients usually suffered from atelectasis and decreased minute ventilation, independent of fever, pneumonia, aspiration, and increased work of breathing [39 patients (39%)]. Conclusions: The extubation failure rate in our neurocritical care unit is low. In patients with primary brain injury who were intubated, atelectasis and decreased minute ventilation were the most common causes for reintubation. Aspiration and pneumonia were not the most common reason for reintubation.
Keywords: society; patient; extubation; brain injury; intensive care; pneumonia; atelectasis; lung minute volume; aspiration; lung function test; lung function; airway; protection; clinical study; population; hypothesis; intubation; lung injury; data base; medical record review; injury; spinal cord; peripheral nerve; tracheostomy; brain disease; stridor; emergency; respiratory distress; mental health; fever; aspiration pneumonia; brain

[Preferable surgical approaches to the aortic root-arch in patients with functioning tracheostomy]. - Nakayama T.; Kanou M.; Isshiki S.; Sasaki H.; Tominaga T.; Ishitoya H.; Kurobe H.; Kitagawa T.; Hiratani K.; Hori T. (Kyobu geka. The Japanese journal of thoracic surgery, 2010)
Preferable surgical approaches to aortic diseases occurring between the aortic root and the arch in patients with functioning tracheotomy or permanent tracheostomy are described for securing adequate exposure and avoiding postoperative mediastinitis. Case 1: A 41-year-old man with Marfan syndrome presented with chronic type A thrombosed aortic dissection and severe aortic valve regurgitation. He had had a functional tracheostomy for managing respiratory function due to traumatic spinal cord damage. The heart and the ascending aorta were shifted to the right side of the chest and showed a significant counterclockwise rotation. Therefore, the reverse L-figure approach of a right-sided 3rd intercostal anterior thoracostomy and lower midline sternotomy was performed for Bentall operation. Case 2: A 76-year-old woman presented with thoracic aortic aneurysm of 11 cm in diameter. She had had a permanent tracheostomy with total laryngectomy. Therefore, cram shell approach was performed for total arch replacement. The 2 cases had no postoperative mediastinitis. These approaches are recommended for aortic diseases occurring in the ascending aorta or the aortic arch in patients with functioning tracheotomy.
Keywords: adult; aged; aorta; aortic disease; article; cardiovascular surgery; case report; female; human; male; methodology; thoracic aorta; tracheostomy

Use of ECMO for resection of post-traumatic ruptured lung abscess with empyema - Brenner M.; O'Connor J.V.; Scalea T.M. (Annals of Thoracic Surgery, 2010)
We report a patient who sustained multiple injuries from a motorcycle collision. He had a protracted intensive care course complicated by ventilator-associated pneumonia and empyema resulting from a ruptured lung abscess. He successfully underwent a thoracotomy, lung resection, decortication, and pleurectomy on veno-venous extracorporeal membrane oxygenation. © 2010 The Society of Thoracic Surgeons.
Keywords: antiinfective agent; nitric oxide; vasoactive agent; abnormal respiratory sound; adult; airway pressure; antimicrobial therapy; arterial gas; article; assisted ventilation; case report; crystalloid; decortication; disease severity; dyspnea; endotracheal intubation; endotracheal tube; extracorporeal oxygenation; flail chest; hematothorax; human; intensive care; Klebsiella pneumoniae infection; leukocytosis; lung abscess; lung infiltrate; lung resection; lung ventilation; male; multiple trauma; oxygen tension; physical examination; pleura; pleura empyema; pleurectomy; pneumomediastinum; preoperative evaluation; priority journal; respiratory distress; respiratory failure; spinal cord decompression; spinal cord injury; spine fracture; spiral computer assisted tomography; thoracotomy; thorax drainage; thorax pain; thorax radiography; tracheostomy; traffic accident; transesophageal echocardiography; ventilator associated pneumonia; vertebra body

[Respiratory failure from upper airway collapse following anterior cervical spine surgery]. - Benatar-Haserfaty J.; Claros E. (Revista española de anestesiología y reanimación, 2010)
OBJETIVES: To determine the frequencies of variables that might predispose to upper airway collapse in a series of patients undergoing anterior cervical spine surgery. Retrospective review of the medical records of 204 patients who underwent anterior cervical spine neurosurgery between 2003 and 2009. We gathered information on perioperative variables that might be related to upper airway collapse, on whether intensive care unit admission was planned or not, and on the moment when obstruction developed. Partial obstruction occurred in 7 cases (3.4%); 4 (1.9%) resolved with tracheal intubation and 3 (1.5%) required emergency tracheostomy. None of the variables were significantly associated with the development of postoperative upper airway obstruction in these patients. Upper airway obstruction after anterior cervical spine surgery is an unforeseen event and the emergency assessment of the airway may not coincide with the assessment of the anesthetist during the preanesthetic visit. This event may constitute an emergency for which preparation times and resources may differ from those available when this complication is foreseen. The problem for the anesthetist is not the impossibility of tracheal intubation but rather the difficulty of ventilating through a facial mask or supraglottic device, possibly with life-threatening consequences.
Keywords: corticosteroid; nonsteroid antiinflammatory agent; adult; airway obstruction; article; artificial ventilation; cervical spine; disease predisposition; emergency; female; human; intensive care; male; methodology; middle aged; neurosurgery; postoperative complication; respiratory failure; retrospective study; risk factor; tracheostomy

Intensity modulated radiation therapy (IMRT) after supraglottic laryngectomy: Radiotherapy to the neck with sparing of the larynx and constrictors - Holland J.M.; Gagnon P.J.; Rhodes S.M.; Schindler J.S. (International Journal of Radiation Oncology Biology Physics, 2010)
Purpose/Objective(s): Radiotherapy after supraglottic laryngectomy is morbid with reported increased long-term swallowing difficulties, incidence of aspiration pneumonia and long-term tracheotomy dependence. Patients with high-risk nodal disease and negative laryngeal margins still require regional radiotherapy. We evaluated IMRT as a means of delivering radiotherapy to the neck while sparing the remaining larynx and structures involved in swallowing (base of tongue, pharyngeal constrictors). Materials/Methods: We utilized IMRT planning using Eclipse (Varian Medical Systems) software seeking to provide 95% coverage of our expanded (2 mm medially, 3 mm elsewhere) planning target volumes (PTVs) of a sample patient after supraglottic laryngectomy and bilateral neck dissection. We developed independent IMRT plans for three scenarios of postoperative regional radiotherapy: 1) High dose (63 Gy) to one side of the neck (levels retropharynx, Ib, II, III, IV, V) and no dose prescribed to the other side; 2) High dose to one side of the neck (63 Gy) and low dose (56 Gy) to the other side (levels retropharynx, II, III, IV and V); and 3) High dose (63 Gy) to both sides of the neck (levels retropharynx, Ib, II, III, IV and V). IMRT plans to both sides of the neck utilized 9 fields with carriage shifts for each field resulting in a total of 18 fields, while the ipsilateral neck only plan utilized 7 fields of which two contained carriage shifts. We sought to limit radiotherapy to the following organs at risk: pharyngeal constrictors, base of tongue, remaining larynx (true vocal cords, right arytenoid, left arytenoid, interarytenoid tissue), oral cavity, parotids, and spinal cord. Results: Using IMRT, adequate coverage of the PTVs was achieved while limiting dose to organs at risk. In scenario < 1, mean doses were 3124 cGy to the constrictors, 2576 cGy to the larynx and 3592 cGy to the base of tongue. In scenario < 2, mean doses were 4044 cGy to the constrictors, 2975 cGy to the larynx and 4272 cGy to the base of tongue. In scenario < 3 with high dose radiation to both sides of the neck, mean doses were 4414 cGy to the constrictors, 3718 cGy to the larynx and 5218 cGy to the base of tongue. Conclusions: IMRT can be used after supraglottic laryngectomy to treat high risk nodal disease while limiting potentially morbid radiotherapy to the remaining larynx, pharyngeal constrictors and base of tongue.
Keywords: larynx; neck; intensity modulated radiation therapy; radiotherapy; laryngectomy; oncology; society; tongue; drug megadose; risk; swallowing; patient; planning; aspiration pneumonia; tracheotomy; software; neck dissection; low drug dose; vocal cord; tissues; mouth cavity; spinal cord; radiation dose

International survey of physician recommendation for tracheostomy for children with Spinal Muscular Atrophy Type I - Benson R.C.; Hardy K.; Gildengorin G.; Hsia D. (Chest, 2010)
PURPOSE: The ethics of invasive mechanical ventilation for children with the progressive neuromuscular disease Spinal Muscular Atrophy Type I (SMA I) is highly debated. We conducted this international survey to identify regional factors and physician characteristics associated with recommendation for tracheostomy and ventilation for SMA I. METHODS: A cross-sectional international online survey was distributed to 1736 pediatric pulmonologists and intensivists from online membership directories of ATS, ACCP, and ERS. Questions explored physician demographics, attitudes and experience with SMA and end-of-life care, knowledge of consensus guidelines, and recommendations for respiratory care of SMA I. Predictor variables were analyzed with Chi-square testing and entered into a logistic regression model. RESULTS: 363 (21%) physicians completed the survey; 84% were pediatric pulmonologists and 16% pediatric intensivists. 70% of respondents were from the U.S. Physicians averaged 16 years of experience in their field of practice. 50% of physicians were aware of SMA consensus guidelines. 60% agreed invasive ventilation is acceptable for SMA I patients with chronic respiratory failure. In univariate analysis, physicians from Commonwealth countries (U.K., Canada, Australia, etc.) were significantly less likely to recommend tracheostomy/ventilation than U.S. physicians (7% vs. 25%, p = 0.011). Logistic regression modeling identified years of experience, agreement with a pro-life statement, and recommendation for noninvasive ventilation as predictive of recommendation for long-term invasive ventilation for SMA I. CONCLUSION: In the largest international survey on this topic, we identified regional differences in physician recommendation for tracheostomy/mechanical ventilation for SMA I. We found that only half of physicians caring for children with SMA I were aware of consensus guidelines. Logistic regression modeling identified physician experience and attitudes as predictive of recommendation of long-term invasive ventilation. CLINICAL IMPLICATIONS: Key goals for SMA I include improving awareness of treatment options, reducing variability of care, reducing costly invasive interventions, and minimizing suffering of patients and families. Our data demonstrate a need for increased awareness of consensus guidelines and will hopefully serve to stimulate physician dialogue to further these goals.
Keywords: physician; spinal muscular atrophy; child; tracheostomy; air conditioning; consensus; logistic regression analysis; model; United States; patient; respiratory care; univariate analysis; predictor variable; neuromuscular disease; artificial ventilation; ethics; Canada; Australia; chronic respiratory failure; directory; terminal care

Acute airway obstruction in cervical spinal procedures with bone morphogenetic proteins - Yaremchuk K.L.; Toma M.S.; Somers M.L.; Peterson E. (Laryngoscope, 2010)
Objectives: Bone morphogenetic proteins (BMP) used in anterior cervical spinal procedures causes an inflammatory response resulting in upper-airway obstruction between postoperative days 2 to 7. The purpose of this study is to determine the incidence and severity of complications associated with use of BMP. Study Design: Retrospective cohort study. Methods: This is a retrospective study of 260 patients who underwent cervical spinal procedures with BMP from 2004 to 2009 and a control group of 515 patients who underwent cervical spinal procedures without BMP during the same period at a tertiary care institution. The two groups were compared on hospital length of stay (LOS), hospital charges, incidence of airway obstruction, unplanned intubations after surgery, tracheotomies, intensive care unit (ICU) admissions, hoarseness, dyspnea, respiratory failure, dysphasia, dysphagia, readmissions, and need for percutaneous endoscopic gastrostomy (PEG) tubes. Results: Patients who underwent cervical spine procedures with BMP were noted to have significantly longer hospital stays (P = .001) and higher hospital charges (P = .001) than the control group. Tracheotomies (P = .024), unplanned intubations after surgery (P = .003), dysphagia (P = .001), dyspnea (P = .001), respiratory failure (P = .001), hospital readmissions (P = .040), ICU admissions (P = .001), and 90-day mortality rates (P = .047) were increased for the BMP group. Conclusions: The use of BMP in anterior cervical spinal procedures results in acute airway obstruction due to an extensive soft-tissue inflammatory reaction that is most likely to occur 2 to 7 days after surgery. The increased incidence of unplanned intubations and tracheotomies demonstrates the risk associated with BMP in cervical spinal procedures. © 2010 The American Laryngological, Rhinological and Otological Society, Inc.
Keywords: recombinant bone morphogenetic protein 2; acute airway obstruction; airway obstruction; anterior spine fusion; article; cervical spine; controlled study; dysphagia; dysphasia; dyspnea; hoarseness; hospital charge; hospital readmission; hospitalization; human; intensive care unit; intubation; length of stay; major clinical study; percutaneous endoscopic gastrostomy; priority journal; respiratory failure; retrospective study; tertiary health care; tracheotomy; INFUSE

Mechanical insufflation exsufflation: Practice patterns among respiratory therapists in ontario, canada - Prevost S.; Brooks D.; Bédard M.; Biman B.; Bwititi P.T. (Canadian Respiratory Journal, 2010)
Background: The mechanical insufflator exsufflator (MIE) is effective in assisting cough and in helping to avoid unplanned hospitalizations, tracheostomy and long-term ventilation in patients with neuromuscular disease or spinal cord injury. In spite of this, the availability and usage of the device in Canada is not known. Objective: To investigate practice patterns and availability of the MIE in Ontario hospitals. METHODS: A cross-sectional, self-administered mail survey was sent to a random sample of 400 respiratory therapists practicing within 96 Ontario hospitals. RESULT S: A total of 114 (28%) completed surveys were returned from 62 (65%) hospitals. Twenty hospitals (32%) had a MIE. Predominantly the respiratory therapist was the health care provider using the MIE. The device was most commonly used in the intensive care unit and medical/ surgical units in patients with neuromuscular diseases or spinal cord injuries. Optimal pressure spans of 35 cmH2O to 40 cmH2O were used by 54% of respondents. Fourteen of the 20 hospitals with a MIE had policies or guidelines in place and 4 of those hospitals had established staff competencies. Measurements of peak cough flow, maximal inspiratory/expiratory pressure and vital capacity were reported to be infrequently performed. CONCLUSIONS: This study demonstrated the MIE device is not widely available in Ontario hospitals and there are variations in how the devices are applied possibly resulting in suboptimal therapy. A comprehensive educational program on MIE devices that incorporates best practices and a practical component is recommended for current providers as well as for inclusion in student curriculum.
Keywords: Canada; respiratory therapist; human; breathing; aeration; hospital; devices; spinal cord injury; coughing; neuromuscular disease; patient; curriculum; student; therapy; vital capacity; policy; intensive care unit; air conditioning; health care personnel; random sample; tracheostomy; hospitalization

Safety of percutaneous tracheostomy in trauma patients - Becker S.A.; Maldonado I. (Intensive Care Medicine, 2010)
INTRODUCTION. Percutaneous tracheostomy is a common procedure in many Trauma Intensive Care units. Concerns about the safety of percutaneous tracheostomy in patients without cervical spine clearance or with cervical spine injury limited its adoption for some surgeons. Most experts recommend the use of fiberoptic bronchoscopy during percutaneous tracheostomy. OBJECTIVES. To determine the safety of performing percutaneous tracheostomy in trauma patients with either no cervical spine clearance status or with cervical spine injury. METHODS.: From 1/1/2001 to 12/31/2007we retrospectively evaluated the medical records of all patients with blunt trauma who required tracheostomy in a Level II Trauma Center. Data was gathered from a trauma registry database and medical records. Patients were divided in two groups, Open Tracheostomy (OT) and Percutaneous Tracheostomy (PT). Patient age, Injury Severity Score (ISS), type of tracheostomy insertion method, cervical spine clearance status prior to tracheostomy, presence of cervical spine injury, use of bronchoscopy assistance in percutaneous tracheostomy, and immediate complications post tracheostomy were recorded for each patient. The results: The total number of tracheotomies during the study period was 220 of which 125 (56%) were PT and 95(44%) were OT. Both groups were similar in age, sex and ISS distribution. Of theOTgroup, 60 (63%) were done in patients with no cervical spine clearance or cervical spine injury. No immediate complications were reported in the OTgroup. The PT group had 63 cases (50.4%) done with no pre-operative cervical spine clearance or positive for cervical spine injury. The PT group underwent the procedure without bronchoscopy assistance in 95% of the cases. Two cases (1.5%) in the PT group were reported with postoperative bleeding from the insertion site that did not required intervention. Both cases were PT done without bronchoscopy assistance and did not have pre-operative cervical spine clearance. No other immediate complications were reported. RESULTS. The results of this study suggest that PT is safe in trauma patients without preoperative cervical spine clearance or with cervical injuries as compared with theOTgroup. Most of the PT cases were done without bronchoscopy assistance (95%). CONCLUSIONS. Percutaneous tracheostomy without bronchoscopic guidance is safe and efficacious in trauma patients even if cervical spine injury has not been excluded.
Keywords: society; tracheostomy; patient; injury; safety; intensive care; cervical spine; cervical spine injury; bronchoscopy; medical record; surgeon; blunt trauma; emergency health service; register; data base; injury scale; intensive care unit; tracheotomy; postoperative hemorrhage; fiberoptic bronchoscopy

Early tracheostomy advantages in neurointensive care, our 6 years experiences - Prochazka J. (Intensive Care Medicine, 2010)
INTRODUCTION. Tracheostomy is among the most commonly performed surgical interventions in ICU in patients requiring ventilatory support. The best appropriate method of this procedure and the issue of timing of the tracheostomy are permanently debated. METHODS. Our ICU performed 351 tracheostomies in total between January 2004 and December 2009; out of this number we assessed 293 tracheostomies in patients with neurological or neurosurgical diseases, 178 males and 115 females, aged 15 to 89, averege age 56.9 years. These interventions were performed using standard surgical approach with trachea fixation to the skin using suture. RESULTS. The most common diagnosis in our study were brain injuries (29%), followed by subarachnoidal hemorrhage (21%), hemorrhage stroke (18%), brain tumours (11%), ischemic stroke (10%), spinal injuries (6%) and other diagnoses in 5% patients. The average duration of the ventilatory support to tracheostomy was 4 days (rating from 1 to 20). The duration of the procedure averaged 20.5 min (10-75 min). A surgical manipulation with tyreoid gland was necessary in 49% procedures. Majority of the tracheostomed patients were afterward transported into their regional hospitals (42%), 27% patients died in our ICU, 12% patients were transferred in other department within our hospital, 11% patients were decannulated in our hospital after stabilisation of their health condition,7%were transferred in nursing home or long-term medical care department and1%in spinal care department. The most common complication we met was bleeding (usually from tyroid gland's bed, in 4.8% procedures), discission of the tracheal ring during tracheal fixation to skin (3.4%) and endotracheal tube cuff perforation (2%). One patient suffered cardiac arrest with successful resuscitation during procedure. CONCLUSIONS. Performing an early tracheostomy (within 7 days of intubation) helps to decrease the level of sedation needed for tracheal tube tolerance, makes weaning from ventilatory support easier, improves pulmonary toilet, and in emergency transport conditions enables easier handling in contrast with intubated patients. Regarding neurointensive patients, at our department we definitely prefer early tracheostomy. Employing the surgical technique with tracheal fixation to the skin facilitates coping with possible periprocedural complications.
Keywords: tracheostomy; intensive care; society; patient; hospital; skin; diagnosis; bleeding; endotracheal tube; cuff; heart arrest; resuscitation; intubation; sedation; perforation; weaning; emergency; surgical technique; coping behavior; surgery; male; female; surgical approach; suture; brain injury; subarachnoid hemorrhage; cerebrovascular accident; brain ischemia; spine injury; brain; health; nursing home; medical care; trachea

Spinal cord infarction following cricotracheal resection - Windfuhr J.P.; Dülks A. (International Journal of Pediatric Otorhinolaryngology, 2010)
We report a case of an 18-year-old female who was referred to our institution after incurring a permanent quadriplegia resulting from spinal cord infarction following cricotracheal resection. Methods were case report and review of the literature. A tracheal stenosis had resulted from long-term intubation after premature birth, followed by tracheotomy after 1 year, surgical revision at 4 years of age and a spontaneous closure at the age of 6 after decannulation. At the age of 18, a cricotracheal resection was performed at another institution. At the termination of the procedure, a chin-to-chest suture was placed to prevent unintentional hyperextension of the neck. She was extubated on the third postoperative day, however, serious dyspnea required repeated re-intubation for 2 days thereafter. She developed paraplegia on the sixth postoperative day, prompting an MRI to be performed, which identified spinal cord edema. Intravenous administration of steroids in high doses was ineffective and unfortunately the patient has remained severely impaired since then. Permanent quadriplegia is a complication of cricotracheal resection with chin-to-chest sutures and should be included in the informed consent process. Therefore, a daily postoperative neurological examination should be performed in these patients. Immediate MRI should be performed if any abnormal findings are seen to verify the diagnosis. Quadriplegia in this setting likely resulted from compromised blood supply with concomitant edema, however, the exact cause of injury remains unclear: despite having chin-to-chest sutures, the patient's head remained in neutral position and was not in hyperflexion. Such an injury is likely more susceptible to steroid therapy if diagnosed as early as possible. © 2010 Elsevier Ireland Ltd.
Keywords: steroid; adult; article; case report; cricoid cartilage; drug megadose; dyspnea; early diagnosis; endotracheal intubation; extubation; female; human; long term care; neurologic examination; nuclear magnetic resonance imaging; paraplegia; postoperative complication; priority journal; quadriplegia; spinal cord disease; spinal cord infarction; surgical technique; trachea resection; trachea stenosis; tracheotomy

Successful pregnancy and delivery in a C1 ASIA a spinal cord injured woman: The role of coordinated care between PM&R and obstetrics services: A case report - Lin C.Y.; McKenna S.; Shem K.L. (PM and R, 2010)
Patients or Programs: 20-year-old pregnant woman with a C1 ASIA A SCI. Program Description: 20-year-old woman involved in a motor vehicle accident who sustained a C1 ASIA A SCI, right BKA, and sacral and bilateral pubic rami fractures. Patient became pregnant through normal conception 2 years after the injury. The patient is ventilator dependent on room air with a tracheostomy, has nutritional support via PEG feeds, neurogenic bowel and bladder with suprapubic catheter. Patient was followed up closely throughout the pregnancy by coordinated care between the PM&R and High Risk Pregnancy Clinics. Pregnancy was complicated by gestational diabetes mellitus type A1. Setting: Tertiary care hospital. Results: At 33 weeks' routine follow-up, the patient was found to be in preterm labor with contractions every 1-2 minutes. Patient was admitted to L&D Service. Rehabilitation service critical care staff was seconded to the L&D service. The patient was administered magnesium sulfate for tocolysis, however, this was discontinued when she developed mild hypoxia. The decision was made to proceed with labor augmentation with Pitocin when patient could not be weaned from oxygen supplementation. Patient received an epidural to decrease risk of autonomic dysreflexia. During her labor, patient had blood pressures to 140/100 and received IV hydralazine. The patient had a forceps-assisted delivery of a male infant in vertex presentation with Apgars of 6 at 1 minute and 8 at 5 minutes, birth weight 1622 g. Discussion: This is the first case, to our knowledge, documenting successful normal spontaneous vaginal delivery to a woman with C1 ASIA A SCI. Common complications in pregnant women with SCI include changes in ventilator needs, autonomic dysreflexia, urinary tract infections, incontinence, pressure ulcers, thrombosis, spasticity, and preterm labor. Conclusions: Coordinated care between rehabilitation and obstetrics physicians, nursing, and respiratory care can minimize complications and ensure successful pregnancies and spontaneous vaginal deliveries in patients with high cervical complete SCI.
Keywords: hydralazine; magnesium sulfate; oxytocin; oxygen; obstetrics; female; human; rehabilitation; pregnancy; physical medicine; spinal cord; case report; patient; pregnant woman; hospital; autonomic dysreflexia; ventilator; premature labor; vaginal delivery; blood pressure; forceps; boy; male; birth weight; incontinence; decubitus; thrombosis; spasticity; physician; nursing; respiratory care; traffic accident; fracture; injury; ambient air; tracheostomy; nutritional support; bladder; suprapubic catheter; high risk pregnancy; pregnancy diabetes mellitus; neurogenic bowel; follow up; rehabilitation center; intensive care; tocolysis; tertiary health care; hypoxia; supplementation; epidural drug administration; risk; urinary tract infection

A particular evolution of Currarino syndrome - Simon L.G.; Constantinescu A.; Maftei A.G.; Popescu C.D. (European Journal of Neurology, 2010)
Introduction: Currarino syndrome (autosomal dominant genetic trait with a mutation in the HLXB9 homeobox gene) is a rare embryological complex of congenital caudal anomalies, including anorectal malformations, sacral bone defects and presacral tumoral mass (meningocele or teratoma). Objective:We present the case of Currarino syndrome with particular aspects in evolution. Case report: A caucasian female, 30 years old, presenting with sudden onset of intracranial hypertension, without any previous signs. Positive family history, but with incomplete investigations: one son with spina biphida, one sister with flaccid paraparesis postpartum, and a niece with congenital megacolon and anal stenosis. The neurological status at the admission in the Emergency Department was severe, with coma, seizures, respiratory failure requiring tracheostomy and mechanical ventilation, right peripheral facial paresis and flaccid paraplegia. The cerebral MRI excluded space occupying processes or vascular disease, but confirmed a diffuse cerebral oedema. The lumbosacral MRI confirmed the sacral splitting under S-2, an anterior sacral meningocele, a dermoid cyst and tethered spinal cord. The appearance of spontaneous meningocele fistula, complicated with meningomyelitis and meningoencephalitis explained the inaugural coma. The patient underwent surgical intervention consisting of aspiration and ligation of the anterior meningocele and tethered spinal cord releasing. Discussions:We report a good post-surgery evolution of the cerebral complication, but persistence of a transverse L-2 myelitis after 3 years. Conclusions: Tardive complications in a patient completely asymptomatic until the acute onset of the cerebral manifestations represent particular aspects in the evolution of a congential disease like the Currarino syndrome.
Keywords: health care organization; meningocele; nuclear magnetic resonance imaging; surgery; coma; teratoma; tethered cord syndrome; patient; paraplegia; respiratory failure; artificial ventilation; facial nerve paralysis; vascular disease; tracheostomy; fistula; meningoencephalitis; edema; aspiration; ligation; myelitis; autosomal dominant inheritance; genetic trait; mutation; homeobox; anorectal malformation; bone defect; Caucasian; female; case report; intracranial hypertension; family history; Hirschsprung disease; stenosis; emergency ward; seizure; sacrum

Reconstruction of a nasopharyngeal defect from cervical spine osteoradionecrosis - Kakarala K.; Richmon J.D.; Durand M.L.; Borges L.F.; Deschler D.G. (Skull Base, 2010)
Osteoradionecrosis of the cervical spine is a rare complication of radiation treatment of head and neck tumors that requires a multidisciplinary approach to management and reconstruction. The case of a 57-year-old man with osteoradionecrosis of the cervical spine secondary to radiation for metastatic hepatocellular carcinoma is presented. Operative debridement of the necrotic bone was performed and the nasopharyngeal soft tissue defect was reconstructed with a radial forearm free flap. The management and reconstruction options for osteoradionecrosis of the cervical spine are discussed. Copyright © 2010 by ThiemeMedical Publishers, Inc.
Keywords: amoxicillin plus clavulanic acid; fluconazole; sultamicillin; adult; anamnesis; article; bone necrosis; bone remodeling; cancer radiotherapy; cancer surgery; case report; cervical spine osteoradionecrosis; computer assisted tomography; debridement; free tissue graft; human; hyperbaric oxygen therapy; liver cell carcinoma; male; nasopharynx; nuclear magnetic resonance imaging; oropharynx; pharynx disease; priority journal; radial forearm flap; soft tissue defect; tissue culture; tracheostomy; ulcer

Multidisciplinary approach to prevent spinal cord ischemia after thoracic endovascular aneurysm repair for distal descending aorta - Matsuda H.; Ogino H.; Fukuda T.; Iritani O.; Sato S.; Iba Y.; Tanaka H.; Sasaki H.; Minatoya K.; Kobayashi J.; Yagihara T. (Annals of Thoracic Surgery, 2010)
Background: This article discusses the multidisciplinary approach to prevent spinal cord ischemia (SCI) with reference to the incidence of SCI after thoracic endovascular aneurysm repair (TEVAR) associated with closure of the intercostal-lumbar artery that supplies the Adamkiewicz artery (ICA-AKA). Methods: We reviewed 60 patients [49 men, 57 to 89 years old] who underwent TEVAR (TAG [W. L. Gore & Associates, Flagstaff, AZ] 42; the Matsui-Kitamura (Kanazawa, Japan) 10; Talent [Medtronic Inc, Santa Rosa, CA] 5; TAG and Talent 3) for part of or the entire distal descending aorta between T7 and L2. These patients had frequently undergone aortic surgeries: ascending aorta (4), aortic arch (25), descending aorta (4), thoracoabdominal aorta (3), and abdominal aorta (19). The multidisciplinary approach consists of identification of the ICA-AKA by magnetic resonance angiography or computed tomographic angiography to avoid unnecessary coverage of the ICA-AKA, in combination with monitoring of motor evoked potentials, augmentation of mean arterial pressure (> 80 mm Hg), and cerebrospinal fluid drainage. Results: Spinal cord ischemia occurred in 4 patients and patent ICA-AKAs were covered in 3 of them. The overall incidence of SCI was 6.7% and 9.4% in the group of 32 patients whose patent ICA-AKAs were covered by TEVAR. After treatment for SCI, 3 patients regained full ambulatory ability. Significant risk factors were identified as the artificial graft at the proximal landing zone, the number of covered zones (>8), the length of aortic coverage (>250 or >300 mm), and the length of the uncovered distal aorta (<60 mm). Conclusions: A multidisciplinary approach is essential to prevent SCI after TEVAR for the distal descending aorta. This approach includes the preservation of patent ICA-AKAs after their identification, early diagnosis of SCI during TEVAR by monitoring motor evoked potentials, and prophylaxis and treatment of SCI by increasing mean arterial pressure to at least 80 mm Hg and performing cerebrospinal fluid drainage. © 2010 The Society of Thoracic Surgeons.
Keywords: methylprednisolone; naloxone; abdominal aorta; abdominal aortic aneurysm; adult; aged; aneurysm surgery; aortic aneurysm; aortic arch; aortic graft; aortic surgery; aortic arch surgery; artery injury; artery thrombosis; article; ascending aorta; bleeding; cerebrospinal fluid drainage; computed tomographic angiography; descending aorta; drug withdrawal; motor evoked potential; female; gender; groups by age; human; iliac artery; internal iliac artery; lumbar artery; magnetic resonance angiography; major clinical study; male; mean arterial pressure; operation duration; patient mobility; peroperative complication; pneumonia; priority journal; prophylaxis; spinal cord ischemia; surgical patient; surgical risk; tracheostomy

Endoscopic endonasal resection of the odontoid process-clinical outcomes - Tormenti M.J.; Madhok R.; Carrau R.; Snyderman C.H.; Kassam A.B.; Gardner P.A. (Journal of Neurosurgery, 2010)
Introduction: The treatment of odontoid disease from a ventral approach has traditionally consisted of a transoral approach. More recently, an endoscopic endonasal approach has been used to access this region for decompression of the cervicomedullary junction. Methods: A retrospective review was conducted for all patients from 1997-2008 who underwent a completely endoscopic endonasal odontoidectomy for decompression of the cervicomedullary junction. Each patient's clinical outcome was assessed using the Neck Disability Index (NDI) and Nurick cervical myelopathy scale. Results: Twenty-four patients underwent a completely endoscopic endonasal resection of the odontoid. The most common pathology treated was rheumatoid pannus disease. The mean patient age was 63.4 years. No patient suffered worsening of their preoperative neurologic status, and all patients having either improvement or stabilization of their neurologic status. Twenty-one of the 24 patients had an additional posterior fusion. No patients required a tracheostomy related to the surgical procedure or suffered a surgical site infection. Nurick and NDI data were available for 12 patients who had a mean follow-up of 28.6 months (range 3-57). The mean Nurick score postoperatively was 0.9, and no patient received a score of 5. The mean NDI score was 9.1 (range 0-32). Nine of 12 patients had an NDI score of less than 15. Conclusions: A completely endoscopic endonasal approach can be performed for odontoid disease with good outcomes and low morbidity. In objective follow-up evaluation, the majority of patients returned to an excellent quality of life with no or minimal disability.
Keywords: odontoid process; surgery; surgeon; patient; follow up; decompression; disability; quality of life; neck; pathology; pannus; tracheostomy; surgical technique; infection; morbidity; cervical myelopathy

Oral dantrolene and severe respiratory failure in a patient with chronic spinal cord injury - Javed M.; Bogdanov A. (Anaesthesia, 2010)
Oral dantrolene is used widely for the treatment of spasticity in patients with spinal cord injury. A 60-year-old patient in the rehabilitation phase following cervical spine injury presented with generalised weakness and deteriorating respiratory function, requiring intensive care admission, tracheal intubation and ventilation. He had bilateral basal lung collapse and a raised diaphragm and was on high-dose oral dantrolene. The cessation of dantrolene resulted in a dramatic recovery of respiratory function within two days. High-dose oral dantrolene can cause severe respiratory insufficiency and may present difficulties in the differential diagnosis of respiratory failure in patients with high cervical spinal cord injuries. © 2010 The Association of Anaesthetists of Great Britain and Ireland.
Keywords: antibiotic agent; dantrolene; adult; airway pressure; arterial gas; article; breathing rate; case report; cervical spine injury; chronic disease; computed tomographic angiography; computer assisted tomography; differential diagnosis; disease severity; drug dose increase; drug dose reduction; drug megadose; drug withdrawal; endotracheal intubation; evening dosage; facial expression; fatigue; hospital admission; human; hypercapnia; hypoxia; intensive care; intermittent positive pressure ventilation; intubation; leg spasm; leg spasm; atelectasis; male; muscle spasm; physiotherapy; positive end expiratory pressure; rehabilitation care; respiratory acidosis; respiratory failure; respiratory function; single drug dose; thorax radiography; tracheostomy; weakness

Safety of percutaneous tracheostomy in trauma patients - Maldonado I.M.; Becker S.B. (Critical Care, 2010)
Introduction: Percutaneous tracheostomy is a common procedure in many trauma ICUs. A concern about the safety of performing percutaneous tracheostomy in patients with no cervical spine clearance or cervical spine injury has limited its adoption for some surgeons. Most experts recommend the use of fiberoptic bronchoscopy during the insertion of percutaneous tracheostomy. Methods:: From January 2001 to December 2007 we retrospectively evaluated the medical records of all patients with blunt trauma who required tracheostomy in a level II trauma center. Data were gathered from a trauma registry database and medical records. Patients were divided in two groups, open tracheostomy (OT) and percutaneous tracheostomy (PT). Patient age, Injury Severity Score (ISS), type of tracheostomy insertion method, cervical spine clearance status prior to tracheostomy, presence of cervical spine injury, use of bronchoscopy assistance in percutaneous tracheostomy, and immediate complications post tracheostomy were recorded for each patient. Results: The total number of tracheotomies during the study period was 220, of which 125 (56%) were PT and 95(44%) were OT. Both groups were similar in age, sex and ISS distribution. Of the OT group, 60 (63%) were done in patients with no cervical spine clearance or cervical spine injury. There were no immediate complications reported in the OT group. The PT group had 63 cases (50.4%) done with no preoperative cervical spine clearance or positive for cervical spine injury. The PT group underwent the procedure without bronchoscopy assistance in 95% of the cases. Two cases (1.5%) in the PT group were reported with postoperative bleeding from the tracheostomy site that did not required intervention. Both cases were PT done without bronchoscopy assistance and did not have preoperative cervical spine clearance. No other immediate complications were reported. Conclusions: The results of this study suggest that PT is safe in trauma patients without preoperative cervical spine clearance or with cervical injuries as compared with the OT group. Most of the PT cases were done without bronchoscopy assistance (95%). This finding suggests the need for further study to clarify the role of bronchoscopy assistance in PT.
Keywords: tracheostomy; intensive care; patient; injury; safety; emergency medicine; cervical spine; bronchoscopy; cervical spine injury; medical record; blunt trauma; emergency health service; register; data base; injury scale; surgeon; tracheotomy; postoperative hemorrhage; fiberoptic bronchoscopy

Anaesthetic aspects of implanting diaphragmatic pacing in patients with spinal cord injury - Story D.A.; Mariampillai E.; Nikfarjam M.; Howard M.; Nunn A.; Onders R. (Anaesthesia and Intensive Care, 2010)
Some patients with high cervical spinal cord injury are largely or completely dependent on mechanical ventilator support. Diaphragmatic phrenic nerve pacing is a new technique that offers some patients greater independence from mechanical ventilation. In selected patients, electrodes are placed on the abdominal side of the diaphragm via laparoscopy. An external pacing box provides the pacing stimulus. We report our experience with four patients with spinal cord injury in a pilot project, presenting for laparoscopic insertion of diaphragmatic phrenic nerve pacing leads inserted. The surgery took about two hours and diaphragmatic mapping precluded muscle relaxants. We used desflurane with remifentanil for maintenance. Apart from transferring the patients to and from their usual ventilators, other anaesthesia issues were difficult venous and arterial access for lines and long-term tracheostomies with no cuff or cuffs filled with water. While hypotension was a frequent problem, one patient also developed intraoperative hypertension secondary to autonomic dysreflexia. Preoperative testing predicted pacing outcome with three of the four patients having successful pacing with tidal volumes of up to 10 ml/kg at the end of surgery. This initial Australian experience may lead to greater use of the technique.
Keywords: desflurane; muscle relaxant agent; phentolamine; remifentanil; water; adult; article; autonomic dysreflexia; case report; diaphragmatic phrenic nerve pacing; electrode; human; hypertension; hypotension; laparoscopy; male; preoperative evaluation; spinal cord injury; surgical technique; tidal volume; tracheostomy; vascular access; ventilator

Video-assisted anterior transcervical approach for the reduction of irreducible atlantoaxial dislocation - Liu T.; Li F.; Xiong W.; Du X.; Fang Z.; Shang H.; Chen A. (Spine, 2010)
Study Design. Technique note. Objective. To describe a modified minimally invasive approach for the treatment of irreducible atlantoaxial dislocation (IAAD). Summary of the Background Data. Currently, the most frequently used route for the treatment of symptomatic IAAD is transoral-transpharyngeal approach. Although it provides the most direct route to the atlantoaxial joint, potential problems may arise because of traverse oral cavity, such as the potential risks of infection, postoperative disturbances of breathing, and swallowing. The aim of this study was to describe a less-invasive approach for IAAD. Methods. Four consecutive patients with IAAD underwent the combined video-assisted atlantoaxial transcervical release (VAAT) procedure and posterior occipital-cervical fusion or C1-C2 screw fixation at Tongji Hospital. Clinical characteristics, images data, operative variables, and follow-up data were recorded. Results. Four cases presented with signs and symptoms of spinal cord dysfunction caused by IAAD underwent 1-stage anterior release, reduction, and posterior fixation. Three cases received C1-C2 screw fixation, and 1 case with occipitocervical fixation. Postoperative imaging studies showed that complete decompression was achieved in all the cases. No systemic infections, cerebrospinal fluid leaks, or adverse neurologic sequelae were found. None of the patients required prolonged intubation, tracheostomy, or enteral tube feeding. All patients started to oral intake after anesthesia. Neurologic status in 1 case remained at baseline whereas it improved in the others. The mean follow-up period was 9 months (6∼12 months). All cases achieved solid fusion, without implants failure. Conclusion. Our initial experience showed that the VAAT procedure for IAAD is a safe supplement and alternative to conventional and transcervical procedures. © 2010, Lippincott Williams & Wilkins.
Keywords: adolescent; adult; anesthetic recovery; article; atlantoaxial dislocation; atlantoaxial joint; case report; cerebrospinal fluid otorrhea; endoscopic surgery; enteric feeding; female; follow up; food intake; fracture fixation; fracture nonunion; human; intubation; invasive procedure; irreducible atlantoaxial dislocation; male; minimally invasive surgery; neck pain; neurological complication; odontoid process fracture; pedicle screw; posterior occipital cervical fusion; postoperative period; priority journal; shoulder pain; spinal cord decompression; spinal cord disease; spine fusion; spine radiography; spine surgery; surgical approach; tracheostomy; feeding tube; video assisted atlantoaxial transcervical release

Failed videolaryngoscope intubation in a patient with diffuse idiopathic skeletal hyperostosis and spinal cord injury - Thompson C.; Moga R.; Crosby E.T. (Canadian Journal of Anesthesia, 2010)
Purpose: A case of difficult intubation in a patient with cervical spinal cord injury with diffuse idiopathic skeletal hyperostosis (DISH) is described. The trachea could not be intubated with a videolaryngoscope, and successful intubation was achieved with a laryngeal mask airway device (LMAD) and a fibreoptic bronchoscope (FOB). Clinical features: A 65-yr-old male developed sudden tetraplegia after a fall. Initial attempts at securing his airway were unsuccessful with a videolaryngoscope, but success was achieved with a LMAD and a FOB. Diagnostic imaging revealed no cervical spine fracture but demonstrated severe airway distortion from DISH and a spinal cord contusion accounting for his tetraplegia. Subcutaneous neck emphysema likely secondary to difficult intubation was also identified, but it did not result in additional morbidity. Conclusions: Although often considered to be a benign entity, DISH can predispose patients to catastrophic cervical injury and difficult airway management. Careful review of plain radiographs in the spinal cord injury patient may assist with appropriate selection of airway interventions. The videolaryngoscope is useful for difficult airways, but its effectiveness may be compromised with an anteriorly displaced airway in combination with restricted cervical movement and limited oropharyngeal airspace. © 2010 Canadian Anesthesiologists' Society.
Keywords: aged; airway obstruction; article; artificial ventilation; bronchoscope; case report; diagnostic imaging; digestive tract intubation; emphysema; endotracheal intubation; falling; fiberoscope; Glasgow coma scale; human; hyperostosis; laminoplasty; laryngeal mask; laryngoscope; male; nuclear magnetic resonance imaging; priority journal; quadriplegia; spinal cord decompression; spinal cord injury; tracheostomy

Unusually difficult nasogastric tube insertion - Gupta B.; Soni K.D.; D'Souza N.; Das S. (Journal of Neurosurgical Anesthesiology, 2010)
Keywords: adult; airway obstruction; bone graft; bone plate; case report; cervical spine fracture; dysphagia; endotracheal intubation; esophagus perforation; human; infection; laryngoscopy; letter; male; nasogastric tube; priority journal; quadriplegia; repeat procedure; spinal cord compression; spine surgery; trachea obstruction; tracheostomy; traffic accident

An autopsied case of Parkinson's disease with severe hallucination and delusion - Noritaka Y.; Hisayoshi N.; Nozomi H.; Tomonobu N.; Satoko S.; Kazuhiro H.; Nobuyuki M.; Mayuki K.; Makoto I.; Maya M.; Mari Y.; Yoshio H. (Neuropathology, 2010)
44 years-old man was aware of uselessness of left hand and gait disturbance. He had cogwheel rigidity and postural instability. Antiparkinsonian drugs worked well, so he was diagnosed as Parkinson disease. 10 years later, severe hallucination and delusion appeared. Because of deterioration of his ADL, it was unavoidable to perform gastrostomy and tracheotomy. Paralytic ileus occurred repeatedly. After end, he showed emaciation, and died of severe infection at age of 60.The brain weight was 1160g. Mild atrophy of frontal lobe was noticed. Microscopically, neuronal loss with astrogliosis was present in the substantia nigra, locus ceruleus and dorsal motor nucleus of the vagus, and in which numerous Lewy bodies were detected. But Lewy bodies were sparse in the limbic system and other cerebral cortex. Mild NFT, coiled body and argyrophilic threads in the cerebrum, and vacuolar myelopathy were found. From the appearance of Lewy bodies and α-synuclein positive structures, we regarded this case as brain stem type (Mackeith) and stage 4 (Braak). Severe hallucination and delusion weren't linked to the distribution of Lewy bodies in the cerebrum.
Keywords: synuclein; antiparkinson agent; hallucination; neuropathology; delusion; society; Japanese (people); Parkinson disease; Lewy body; brain; atrophy; frontal lobe; astrocytosis; substantia nigra; locus ceruleus; motoneuron nucleus; vagus nerve; limbic system; brain cortex; coiled body; spinal cord disease; brain stem; male; hand; gait; deterioration; gastrostomy; tracheotomy; paralytic ileus; body weight loss; infection; brain weight; rigidity

Acute management of traumatic spinal cord injury in a Greek and a Swedish region: A prospective, population-based study - Divanoglou A.; Seiger Å.; Levi R. (Spinal Cord, 2010)
Study design:Prospective, population-based study. This paper is part of the Stockholm Thessaloniki Acute Traumatic Spinal Cord Injury Study (STATSCIS).Objectives:To characterize patient populations and to compare acute management after traumatic spinal cord injury (TSCI).Settings:The Greater Thessaloniki region in Greece and the Greater Stockholm region in Sweden.Methods:Inception cohorts with acute TSCI that were hospitalized during the study period, that is September 2006 to October 2007, were identified. Overall, 81 out of 87 cases consented to inclusion in Thessaloniki and 47 out of 49 in Stockholm. Data from Thessaloniki were collected through physical examinations, medical record reviews and communication with TSCI cases and medical teams. Data from Stockholm were retrieved from the Nordic Spinal Cord Injury Registry.Results:There were no significant differences between study groups with regard to core clinical characteristics. In contrast, there were significant differences in (1) transfer logistics from the scene of trauma to a tertiary-level hospital (number of intermediate admissions, modes of transportation and duration of transfer) and (2) acute key therapeutic interventions, that is, the use of mechanical ventilation (49% in Thessaloniki versus 20% in Stockholm), and performance of tracheostomy (36% in Thessaloniki versus 15% in Stockholm); spinal surgery was performed significantly more often and earlier in Stockholm than in Thessaloniki.Conclusions:Despite largely similar core clinical characteristics, Stockholm and Thessaloniki cases underwent significantly different acute management, most probably to be attributed to adaptations to the differing regional approaches of care one following a systematic approach of SCI care and the other not. © 2010 International Spinal Cord Society All rights reserved.
Keywords: anticoagulant agent; corticosteroid; article; artificial ventilation; clinical trial; controlled clinical trial; controlled study; Greece; hospital admission; human; major clinical study; patient transport; priority journal; spinal cord injury; spinal cord lesion; spine surgery; Sweden; tertiary health care; tracheostomy

Medical conditions and outcomes at 1 year after acute traumatic spinal cord injury in a Greek and a Swedish region: A prospective, population-based study - Divanoglou A.; Westgren N.; Bjelak S.; Levi R. (Spinal Cord, 2010)
Study design:Prospective, population-based study. This paper is part of the Stockholm Thessaloniki Acute Traumatic Spinal Cord Injury Study (STATSCIS). Objectives:To evaluate and compare outcomes, length of stay (LOS), associated conditions and medical complications at 1-year post-trauma. Settings:The Greater Thessaloniki region, Greece, and the Greater Stockholm region, Sweden. While Stockholm follows a SCI system of care, Thessaloniki follows a fragmented non-system approach. Subjects:Out of the 87 cases in Thessaloniki and the 49 cases in Stockholm who comprised the study population of STATSCIS, 75 and 42 cases respectively were successfully followed-up during the first year post-trauma. Results:Significantly superior outcomes (that is, survival with neurological recovery, functional ability and discharge to home) and shorter LOS for initially motor complete cases occurred in Stockholm. Management routines known to increase long-term morbidity, for example, long-term tracheostomy and indwelling urethral catheters were significantly more common in Thessaloniki. Major medical complications, that is, multiple pressure ulcers, heterotopic ossification and bacteremia/sepsis were more frequent in Thessaloniki. Conclusions:Our findings show how two rather similar cohorts of TSCI manifest large discrepancies in terms of 1-year outcomes and complications, depending on the type of management they receive. As the major difference between regions was the presence or absence of a SCI system of care, rather than differences in availability of modern medicine, the mere presence of the latter does not seem to be sufficient to guarantee adequate outcomes. This study provides strong evidence as to the urgent need of implementing a SCI system of care in Greece. © 2010 International Spinal Cord Society All rights reserved.
Keywords: article; bacteremia; bladder emptying; controlled study; decubitus; follow up; functional status; Greece; health care delivery; heterotopic ossification; hospital discharge; human; length of stay; major clinical study; morbidity; outcome assessment; population research; practice guideline; priority journal; respiratory tract infection; sepsis; spinal cord injury; survival; Sweden; tracheostomy; urinary tract infection

Anterior Spinal Cord Syndrome After Initiation of Treatment with Atenolol - Schneider G.S. (Journal of Emergency Medicine, 2010)
Anterior spinal cord syndrome is a rare condition with a variety of precipitating factors. Patients typically complain of weakness or paralysis of the extremities, often accompanied by pain, but frequently without a history of trauma. A 48-year-old man presented to the emergency department complaining of neck pain and inability to move his legs in the absence of trauma. Several hours prior he had seen his private physician and was given a dose of atenolol for elevated blood pressure. He had not previously been on medications for hypertension. His neurological examination revealed bilateral paralysis of the lower extremities. In the upper extremities he had weakness and sensory loss at the level of C6. Rectal tone was decreased and without sensation. Cervical and thoracic spine magnetic resonance imaging showed spondylotic disc disease, with disc herniation at C6-7 causing severe spinal canal stenosis. Despite i.v. methylprednisolone, pressors, and a prolonged intensive care unit course, the patient was discharged 5 weeks later with continued neurological deficits. Anterior spinal cord syndrome results from compression of the anterior spinal artery and often occurs in the absence of traumatic injury. The recognition, management, and prognosis of this condition are discussed. © 2010 Elsevier Inc. All rights reserved.
Keywords: atenolol; beta adrenergic receptor blocking agent; ibuprofen; illicit drug; infusion fluid; methylprednisolone; phenylephrine; abdominal pain; adult; airway; article; case report; cigarette smoking; deep vein thrombosis; dyspnea; emergency care; gastritis; gastrointestinal hemorrhage; hand paresthesia; headache; hospitalization; human; hypertension; hypotension; intensive care; intervertebral disk hernia; leg injury; length of stay; lethargy; male; muscle reflex; muscle tone; neck pain; neurologic examination; nuclear magnetic resonance imaging; paralysis; primary medical care; priority journal; rehabilitation care; spinal cord compression; spinal cord disease; spondylosis; stenosis; stress; thorax pain; tracheostomy; treatment duration; urine incontinence; ventilator associated pneumonia

Bilateral diaphragmatic paralysis: A sinister cause of respiratory failure - Smith T.; Hercules A.; Rana S.; Lega M. (Journal of General Internal Medicine, 2010)
LEARNING OBJECTIVE 1: To identify the causes of bilateral diaphragmatic paralysis. LEARNING OBJECTIVE 2: To explain how bilateral diaphragmatic paralysis causes respiratory failure and sleep disorders and discuss the therapeutic modalities employed in treating this disorder. CASE: An 86 year old male with a complex past medical history, including CHF, hypertension, COPD, along with presumed obstructive and central sleep apnea was admitted to our ICU with hypercarbic respiratory failure. Earlier that day he had undergone a colonoscopy as part of a work up for a 50 lb weight loss. On discharge he developed acute respiratory failure and altered mental status. ABG showed a pH of 7.05, PCO2 of 118, and PO2 of 280, on supplemental oxygen. He was treated with mechanical ventilation but continued to be symptomatic and was sent to an LTAC for rehabilitation. Over a period of 4 months the patient had repeated episodes of respiratory failure requiring management with BIPAP and intubation. His baseline CO2 oscillated in the 60's but rose to 130's during these episodes. The patient was exquisitely sensitive to benzodiazepines and could not tolerate being in the recumbent position; which frequently triggered his episodes. He was generally asymptomatic in the Fowler's position. Complete pulmonary function studies were performed, showing mild evidence of obstruction out of proportion with the significant reduction of his mechanics, with reduced mean inspiratory and expiratory pressures. CT of the brain and thorax failed to elucidate the underlying cause. An MRI was not obtained since the patient had a cardiac pacemaker. A sniff test performed under fluoroscopy revealed that both diaphragms were paralyzed and fixed in position without any paradoxical motion. Further exploration ensued and an EMG demonstrated evidence of a diffuse denervating process involving multiple cervical and lumbosacral myotomes, the overall picture being that of ALS. The patient declined tracheostomy with ventilator support. He was placed on continuous BIPAP therapy since it was thought that diaphragmatic pacing might not have been helpful given his other co morbidities. DISCUSSION: Bilateral diaphragmatic paralysis is a rare disease that can occur secondary to numerous processes. These include the immediate post operative phase of cardiac surgery (especially if ice was used for myocardial protection), traumas, mediastinal tumors, myelopathies, myopathies and non infectious polyneuropathies. Idiopatic forms have also been described. Since the diaphragm is the principal respiratory muscle, its paralysis has a significant effect on the ability of the respiratory system to adequately perform its function leading to respiratory distress and failure. It typically is accompanied by dyspnea, especially on exertion, and ortopnea. Because the respiratory distress is exaggerated in the supine position sleep disorders are common. The activities of the complimentary respiratory muscles decrease during the REM cycles compromising respiratory function. This provokes hypoxia and nocturnal hypercarbia which disturbs sleep and often leads to the misdiagnosis of obstructive and central sleep apnea. Functionally, bilateral diaphragmatic paralysis is characterized by a restrictive ventilatory defect with a decrease in FVC of 25% of more in the supine position as compared to being vertical. DLCO is typically preserved but MIP and MEP are usually reduced. Severe hypercarbia is rare if the disorder is isolated therefore, the search for other neuromuscular disorders such as ALS should be undertaken when present. Traditionally, severe cases have been treated with positive pressure ventilation via tracheostomy but recent reports have demonstrated equal efficacy and lower cost with NIPPV like BIPAP. Diaphragmatic pacing has also been used but its prohibitive cost and invasive nature makes it less of an attractive option.
Keywords: oxygen; benzodiazepine derivative; diaphragm paralysis; respiratory failure; internal medicine; society; patient; sleep disorder; respiratory distress; hypercapnia; central sleep apnea syndrome; breathing muscle; diaphragm; supine position; tracheostomy; rare disease; heart surgery; protection; injury; mediastinum tumor; myopathy; polyneuropathy; paralysis; respiratory system; dyspnea; respiratory function; hypoxia; sleep; diagnostic error; neuromuscular disease; positive end expiratory pressure; male; medical history; hypertension; colonoscopy; body weight loss; acute respiratory failure; mental health; exercise; rehabilitation; intubation; nuclear magnetic resonance imaging; electromyogram; lung function; obstruction; mechanics; brain; artificial ventilation; sinus node; fluoroscopy; myotome; ventilator; therapy; morbidity; thorax; pH

Mild pathological changes of ALS in spite of the longest clinical course - Mochizuki Y.; Shimizu T.; Mizutani T. (Neuropathology, 2010)
A 48-year-old man developed right hand weakness. The symptoms progressed very slowly. Tracheostomy positive pressure ventilation became occasionally needed about 13 years from the onset, and always necessary at 25 years from onset. Three years later he died of malignant lymphoma. The duration of this illness was 28 years and the longest among 126 autopsied ALS cases in our hospital. The brain weighed 1,190 g. Although the spinal cord was markedly atrophic, preserved motor neurons were scattered. In the pyramidal tracts,the large myelinated fibers were lost, whereas the small fibers were preserved. The other fibers in the spinal cord were well preserved despite the marked atrophy of the spinal cord. The TDP-43 positive inclusions and Bunina bodies were not found. Atrophy of the spinal cord was similar to that of other ALS cases with long duration. The major lesions of this case was limited to the motor system. The neuropathological findings described above were consistent with the clinical features of this patient.
Keywords: neuropathology; disease course; society; Japanese (people); spinal cord; fiber; atrophy; myelinated nerve; pyramidal tract; motor system; patient; clinical feature; male; tracheostomy; positive end expiratory pressure; lymphoma; general aspects of disease; hospital; brain; motoneuron; weakness

Transnasal odontoid resection followed by posterior decompression and occipitocervical fusion in children with Chiari malformation Type I and ventral brainstem compression - Hankinson T.C.; Grunstein E.; Gardner P.; Spinks T.J.; Anderson R.C.E. (Journal of Neurosurgery: Pediatrics, 2010)
Object. In rare cases, children with a Chiari malformation Type I (CM-I) suffer from concomitant, irreducible, ventral brainstem compression that may result in cranial neuropathies or brainstem dysfunction. In these circumstances, a 360° decompression supplemented by posterior stabilization and fusion is required. In this report, the authors present the first experience with using an endoscopic transnasal corridor to accomplish ventral decompression in children with CM-I that is complicated by ventral brainstem compression. Methods. Two children presented with a combination of occipital headaches, swallowing dysfunction, myelopathy, and/or progressive scoliosis. Imaging studies demonstrated CM-I with severely retroflexed odontoid processes and ventral brainstem compression. Both patients underwent an endoscopic transnasal approach for ventral decompression, followed by posterior decompression, expansive duraplasty, and occipital-cervical fusion. Results. In both patients the endoscopic transnasal approach provided excellent ventral access to decompress the brainstem. When compared with the transoral approach, endoscopic transnasal access presents 4 potential advantages: 1) excellent prevertebral exposure in patients with small oral cavities; 2) a surgical corridor located above the hard palate to decompress rostral pathological entities more easily; 3) avoidance of the oral trauma and edema that follows oral retractor placement; and 4) avoidance of splitting the soft or hard palate in patients with oral-palatal dysfunction from ventral brainstem compression. Conclusions. The endoscopic transnasal approach is atraumatic to the oral cavity, and offers a more superior region of exposure when compared with the standard transoral approach. Depending on their comfort level with endoscopic surgical techniques, pediatric neurosurgeons should consider this approach in children with pathological entities requiring ventral brainstem decompression.
Keywords: adolescent; Arnold Chiari malformation; article; atlantooccipital fusion; basilar impression; brain decompression; brain disease; case report; child; computer assisted tomography; dysphagia; experience; hard palate; headache; human; laminectomy; male; mouth cavity; mouth edema; mouth injury; nuclear magnetic resonance imaging; odontoid process; priority journal; recurrent disease; school child; scoliosis; spinal cord disease; spine fusion; spine surgery; tracheostomy; transnasal odontoid resection; ventral brainstem compression

Safe performance of spinal anesthesia in a critical patient with neurofibromatosis, pectus carinatum, and temporomandibular joint dysfunction: A case report - Zencirci B. (Patient Safety in Surgery, 2010)
Background: Neurofibromatosis is a syndrome caused by the abnormal deposition of neural tissues of the nervous system, endocrine system, visceral structures, and skin. On the other hand, pectus carinatum and temporomandibular joint dysfunction are illnesses that adversly affect the respiratory system and cause additional problems in airway management.Case Presentation: Fifty-eight-year-old Turkish male patient had neurofibromatosis, pectus carinatum and temporomandibular joint dysfunction. The case was due to be operated on with the diagnosis of incarcerated umbilical hernia. Spinal anesthesia was successfully performed and the duration of the surgery was 1 hour. No postoperative complications were observed and he was discharged from the hospital on the 3rd post-operative day.Conclusion: The anesthetic management of patients with neurofibromatosis requires attention to all possible abnormalities and associated disturbances. Furthermore, the presence of pectus carinatum and temporomandibular joint dysfunction also increase the potential risks. The operation was successfully completed with spinal anesthesia that was carefully applied upon taking the required measures and considering all pathologies that may accompany the case and complications that may occur. © 2010 Zencirci; licensee BioMed Central Ltd.
Keywords: bupivacaine; C reactive protein; midazolam; Ringer lactate solution; adult; anamnesis; anesthesia induction; article; blood pressure measurement; case report; electrocardiography; heart rate; heart right bundle branch block; hernia incarceration; human; intensive care unit; laboratory test; leukocytosis; male; neurofibromatosis; operation duration; physical examination; pigeon thorax; postoperative period; premedication; preoperative evaluation; protein blood level; pulse oximetry; safety; spinal anesthesia; temporomandibular joint disorder; tracheostomy

Survey of physician recommendation of long-term invasive ventilation for children with spinal muscular atrophy type I: Pilot survey - Benson R.C.; Hsia D.W.; Hardy K.A. (American Journal of Respiratory and Critical Care Medicine, 2010)
Introduction: Spinal Muscular Atrophy Type I (SMA I) is a neurodegenerative disease that leads to progressive muscular weakness and ultimately death during infancy from chronic respiratory failure. There is considerable debate regarding the ethics of invasive mechanical ventilation for SMA I patients, who eventually become “locked-in” and are unable to communicate pain or discomfort. We conducted this pilot survey to determine which interventions physicians recommend for respiratory care of SMA I, and to assess awareness of consensus guidelines published by the International Standard of Care Committee for Spinal Muscular Atrophy in 2007. Methods: This was a descriptive cross-sectional survey of 34 pediatric pulmonologists and intensivists present at the 2009 Northern California Pediatric Intensive Care Network conference. Questions explored physician demographics, attitudes and experience with SMA and end-of-life care, knowledge of consensus guidelines, and recommendations for respiratory care of SMA I. Results: 10 pediatric pulmonologists and 24 intensivists were surveyed, including 8 fellows and 26 attendings. Results summarized in table below. 41% of physicians were aware of consensus guidelines. 97% informed their patients about the option of noninvasive ventilation (NIV) for chronic respiratory failure, but only 24% recommended this intervention. While 91% informed their patients about the option of tracheostomy/invasive ventilation for chronic respiratory failure, only 32% felt this was an acceptable intervention, and only 6% recommended this intervention. Despite this, 59% felt that physicians do not have the right to refuse tracheostomy/invasive ventilation for SMA I patients. Conclusions: We found that the majority of physicians surveyed opposed tracheostomy and invasive ventilation for SMA I, although most felt that it was not right for the physician to refuse this intervention if requested. Fewer physicians in this pilot survey recommended tracheostomy and invasive ventilation than prior surveys in the literature. A much larger international survey is underway to identify regional practice differences that may contribute to variability of care for SMA I. By highlighting these differences and how they contribute to medical decision-making, we aim to encourage dialogue amongst physicians that will ultimately improve standardization of respiratory care for SMA I, reduce costly invasive interventions, and minimize suffering of patients and families. (Table presented).
Keywords: human; air conditioning; society; child; spinal muscular atrophy; physician; patient; respiratory care; consensus; chronic respiratory failure; tracheostomy; infancy; intensive care; death; health care quality; muscle weakness; degenerative disease; pain; artificial ventilation; standardization; United States; terminal care; medical decision making; noninvasive ventilation; ethics

Utility of bedside ultrasound in the prediction of difficult airway - Adhikari S.R.; Zeger W.; Craven I.; Crum T.; Schmier C.; Pang H.; Frrokaj I. (Academic Emergency Medicine, 2010)
Objective: Prediction of difficult laryngoscopy (DL) in emergency department (ED) patients with altered mental status is challenging. Common screening tests for DL cannot be applied in emergency intubations of these patients. The objective of this study is to assess the utility of bedside ultrasound (US) to predict DL. Methods: Prospective group sequential study at an academic medical center. Inclusion criteria: Adult patients undergoing endotracheal intubation prior to any surgery. Exclusion criteria: Patients with upper airway pathologies, cervical spine fractures, and tracheostomy tube. Patients were enrolled on randomly chosen study days. The following variables were collected preoperatively: BMI, dental abnormalities, thyromental distance, TMJ mobility, neck movements, modified Mallampati scale, and neck circumference. An emergency physician sonologist blinded to above variables obtained US measurements of base of the tongue and anterior neck soft tissue thickness at hyoid bone (HBSTT), thyrohyoid membrane (THMSTT), and vocal cords (VCSTT) levels. Laryngoscopy view was graded using Cormack and Lehane classification by anesthesiologists blinded to US measurements. The Kruskal-Wallis test was used to examine the associations. The Wilcoxon test was used for pairwise comparisons. Results: Forty-six patients were enrolled in the study (female-30, male-16). The mean age was 54 years +/- 12.6 (SD). 6/46 (13%, 95% CI 3-27%) of patients were classified as having DL by anesthesiologists. The sonographic measurement of HBSTT was significantly higher in the DL group compared to the easy laryngoscopy group (p=0.02). US measurements of the base of the tongue and THMSTT were also high in patients with DL. US measurements correlated better with DL than Mallampati classification and thyromental distance. Conclusions: In our pilot study, US measurement of anterior neck soft tissue thickness at hyoid bone level appears to be a good predictor of DL.
Keywords: prediction; airway; society; emergency medicine; ultrasound; human; patient; neck; laryngoscopy; hyoid bone; anesthesist; soft tissue; classification; thickness; tongue; emergency; screening test; male; cervical spine fracture; mental health; female; Kruskal Wallis test; tracheostomy tube; pathology; membrane; upper respiratory tract; surgery; endotracheal intubation; emergency physician; neck circumference; adult; vocal cord; university hospital; intubation; emergency ward; rank sum test; pilot study; bone level

Long-Term Survival After Open Repair of Chronic Distal Aortic Dissection - Zoli S.; Etz C.D.; Roder F.; Mueller C.S.; Brenner R.M.; Bodian C.A.; Di Luozzo G.; Griepp R.B. (Annals of Thoracic Surgery, 2010)
Background: The optimal treatment of chronic distal aortic dissection remains controversial, with endovascular stent-graft techniques challenging traditional surgery. Methods: From January 1994 to April 2007, 104 patients (82 male, median age 60.5 years) with chronic distal aortic dissection underwent surgical repair, 0 to 21 years after initial diagnosis of acute type A or B dissection (median 2.1 years). Twenty-three (22%) patients underwent urgent-emergent surgery. Mean aortic diameter was 6.9 ± 1.4 cm. Indications for surgery, other than aortic expansion, were pain in 6 (6%) patients, malperfusion in 6 (6%), and rupture in 11 (11%). Forty-nine (47%) had previous cardioaortic surgery (29% dissection-related), 21 (20%) had coronary artery disease, 12 (12%) had Marfan syndrome, and 4 (4%) were on chronic dialysis. Twenty-six (25%) had a thrombosed false lumen. Thirty (29%) patients required reimplantation of visceral arteries; 8.3 ± 2.7 segmental artery pairs were sacrificed. Results: Hospital mortality was 9.6% (10 patients). Paraplegia occurred in 5 (4.8%). Twenty-seven patients (26%) experienced adverse outcome (death within one year, paraplegia, stroke, or dialysis). Adverse outcome was associated with atheroma (p = 0.04, odds ratio = 4.3). Survival was 78% at 1, 68% at 5, and 59% at 10 years (average follow-up, 7.7 ± 4.1 years). Freedom from distal aortic reoperation was 99% at 1, 93% at 5, and 83% at 10 years. After one year, patients enjoyed longevity equivalent to a normal age-sex matched population (standardized mortality ratio = 1.38, p = 0.23). By multivariate analysis, atheroma (p = 0.0005, relative risk = 9.32) and age (p = 0.0003, relative risk = 1.15/year) were risk factors for long-term survival. Conclusions: The efficacy of open repair for distal chronic dissection is highlighted by normal survival after the first year, and a low reoperation-reintervention rate. © 2010 The Society of Thoracic Surgeons.
Keywords: adult; adverse outcome; aged; aorta; aortic dissection; aortic surgery; article; atheroma; chronic distal aortic dissection; cohort analysis; coronary artery disease; dialysis; emergency surgery; female; follow up; heart arrest; human; longevity; lung complication; major clinical study; male; Marfan syndrome; mortality; multivariate analysis; overall survival; paraplegia; postoperative complication; priority journal; reimplantation; reoperation; risk factor; spinal cord injury; cerebrovascular accident; survival time; thrombosis; tracheotomy

From case to case: nursing patients with a tracheostomy - Messer M. (Pflege Zeitschrift, 2010)
Keywords: adult; article; brain injury; human; in service training; long term care; male; nursing; nursing home; paraplegia; spinal cord injury; tracheostomy

A national survey of paediatric long-term ventilation in the UK - Wallis C.; Jardine E.; Beaton S.; Paton J. (Archives of Disease in Childhood, 2010)
Aims: The last decade has seen a significant increase in the number of children receiving long-term ventilatory (LTV) support. There are a number of reasons for this including improved home ventilators for children, better designed paediatric face masks and a new ethos for long-term respiratory support at home. A previous survey undertaken in 1997 revealed 136 such children. The current number and status are required for allocation of healthcare resources for these high-cost, complex children. Methods: Because of the protean nature of this cohort, it was elected to do a spot census. A standard questionnaire was devised by consensus and 39 lead clinicians were identified who supervise children on LTV in the UK. All children (<17 years) receiving ventilatory support for all/part of the 24-h day for a period of at least 3 months at midnight on the 30th September 2008 were included. Data were entered to an online form and after anonymisation and encryption were stored at a central data monitoring centre. Results: 944 children/young people were identified. 58% were male and 91% lived at home. 212 children were ventilated by tracheostomy while 714 used facial mask interface. Three children had phrenic nerve pacing in addition to a tracheostomy. 18 were unknown. The medical causes for ventilatory support were divided into three main categories: Respiratory: (350) of which upper airway obstruction and obesity dominated; 11 had chronic lung disease of prematurity; CNS: (184) of which 57 had congenital central hypoventilation, 22 had high spinal injury; 21 acquired hypoventilation; Musculoskeletal: (410) the commonest cause was Duchenne muscular dystrophy (92); 64 children had spinal muscular atrophy (SMA) type II and 12 SMA type I. Conclusions: This study has shown a very substantial increase in the numbers of children on LTV since the last UK survey. The increased use of non-invasive ventilation in neuromuscular patients is the main contributor. The vast majority of the children (including those on 24-h tracheostomy ventilation) are managed at home. These data will inform future health provision and also form the basis for a wider study into other aspect of home ventilation in childhood.
Keywords: air conditioning; child health; United Kingdom; pediatrics; college; child; tracheostomy; hypoventilation; chronic lung disease; prematurity; spine injury; Duchenne muscular dystrophy; spinal muscular atrophy; patient; health; childhood; ventilator; face mask; assisted ventilation; health care; population research; questionnaire; consensus; monitoring; male; phrenic nerve; upper respiratory tract obstruction; obesity; central nervous system

Dysphagia in acute tetraplegics: A retrospective study - Seidl R.O.; Nusser-Müller-Busch R.; Kurzweil M.; Niedeggen A. (Spinal Cord, 2010)
Study design: Retrospective study. Objectives: Swallowing disorder in patients with tetraplegia represents a problem. Incidence and clinical data were examined to determine the influencing factors. Setting: Level I trauma Center, Berlin, Germany. Method: Retrospective study (1 September 1997-31 December 2002) on hospitalized patients with acute tetraplegia. The patients swallowing ability was examined both clinically and endoscopically, and the results correlated with clinical data. Results: A total of 175 patients (144 (82.29%) male patients and 31 (17.71%) female patients (4.6:1) were studied. The peak age groups (43.45, ± 18.98, 14-89 years) were 20-30 years and over 60 years. C4-C6 were most commonly affected. Tetraplegia was trauma-related in 147 (84%) patients. Twenty-eight (16.0%) patients appeared to be suffering from a swallowing disorder on first feeding, 23 (82.14%) patients with dysphagia were tracheotomized. The level of tetraplegia (x2=19.8; P<0.05), tracheotomy (x2 21.7; P;t;0.05) and the duration of ventilation (X2 24.84, P<0.05) were all found to be statistically significant factors in the development of a swallowing disorder. Age, surgical approach, level of tetraplegia, severity of paralysis and the need for tracheotomy were predictive of dysphagia in 73.14% patients. Five patients with dysphagia died (because of causes other than dysphagia) and 10 patients were discharged with a feeding tube. Conclusion: No single trigger for a swallowing disorder in acute tetraplegia was found. A combination of multiple factors (level of tetraplegia, severity of paralysis, tracheotomy, accompanying injuries and accompanying illnesses) restricts swallowing and compensation of changes, to the extent that a swallowing disorder becomes apparent. © 2010 International Spinal Cord Society All rights reserved.
Keywords: acute disease; adolescent; adult; aged; article; artificial ventilation; cause of death; cervical spine injury; clinical examination; disease association; disease severity; dysphagia; esophagoscopy; feeding; feeding apparatus; female; Germany; groups by age; hospital patient; human; major clinical study; male; priority journal; quadriplegia; retrospective study; risk factor; surgical approach; swallowing; tracheotomy; treatment duration; spine fracture

The choice of plain tracheostomy tube for long-term ventilation in adults: 22 Years of domiciliary ventilation for high tetraplegia - Singaravelu S.K.; Watt J.W.H. (British Journal of Intensive Care, 2010)
Background: Long-term invasive ventilation with an uncuffed tracheostomy tube requires that the tube be selected with care to avoid complication and ensure comfort, and provide sufficient insufflation leak for speech whilst avoiding hypoventilation. Aim/Patients and methods: A retrospective review was undertaken to help define characteristics in common among 64 adult patients on domiciliary ventilation discharged from the Northwest Regional Spinal Injuries Centre between 1983 and 2005. All but four receiving ventilation with room air had plain tracheostomy tubes. Radiography in the coronal and sagittal views had usually been to aid selection of a tube, sufficient in size to prevent nocturnal hypoventilation, and to match the tube curvature to the patient's anatomy. Measurements of the tube size and trachea from the radiological images were made using a Vernier calliper to correct for magnification. Results: In males, the median tracheostomy tube inside diameter was 8.0 mm (range 6-11 mm), and in females 7.5 mm (range 6-8 mm). The mean calibre reduction ratio between trachea and tube outside diameter was 0.58. A total of eight different types of tracheostomy tubes have been used in order to match the patients' anatomy and ventilation requirements.
Keywords: adult; ambient air; article; artificial ventilation; female; human; hypoventilation; long term care; major clinical study; male; quadriplegia; radiography; retrospective study; room ventilation; spine injury; tracheostomy; tube

Lateral Mediastinal Tracheostomy in Benign Disease: An Uncommon Procedure for a Rare Indication - Deslauriers N.; Jacques F.; Danino A.; Harris P.; Martin J.; Liberman M.; Duranceau A.; Ferraro P. (Annals of Thoracic Surgery, 2010)
Tracheostomy is sometimes required for long-term ventilation in patients with a challenging cervical anatomy. We present a case of a patient requiring prolonged mechanical ventilation with prohibitive cervical anatomy for standard tracheostomy secondary to severe ankylosing spondylitis and a cervical spine fracture. © 2010 The Society of Thoracic Surgeons.
Keywords: adult; ankylosing spondylitis; article; artificial ventilation; case report; cervical spine fracture; computer assisted tomography; human; male; nasotracheal intubation; priority journal; respiratory distress; surgical technique; tracheostomy; treatment indication

Laryngeal fracture in a pediatric patient - Abdallah C.; Morrow M.; Jaryszak E.; Shah R.K. (Anesthesia and Analgesia, 2010)
Introduction : Open or closed injuries to the larynx and trachea can occur from direct trauma but are unusual in children due to the relatively high position of the larynx in the neck. Closed injury is associated with high prehospital mortality. Case Report : A 10 year old boy had fallen onto a park bench striking his neck. He was sent home with mild pain in his neck. Later that evening, he had shortness of breath, tachypnea, voice change and episodes of non bloody emesis. He was taken to a local hospital and immediately transferred to a tertiary care academic medical center. Physical examination was notable for signs of abrasion on the anterior neck, and the presence of significant crepitus in the upper chest. A computed tomography showed laryngeal rupture with extensive subcutaneous air tracking into the mediastinum. As the pediatric laryngeal framework is cartilaginous, fractures were not able to be radiographically discerned. Cervical spine injury was ruled out. A flexible nasopharyngolarngoscopy demonstrated a patent airway. The patient was brought to the operating room, spontaneously breathing. Premedication with intravenous midazolam 0.05 mg/kg was administered. Anesthesia was initiated with sevoflurane in O2, fentanyl 1 mcg /kg and propofol 1.5 mg/ kg to keep the patient spontaneously breathing and anesthetized. Anesthesia was maintained with an intravenous propofol infusion at 300 mcg/kg/min. A Parsons laryngoscope was used to cannulate the upper airway. It was grade 1 view. Topical lidocaine was sprayed. There was massive edema of the left vocal fold with hematoma and ecchymosis in the ventricle. Bronchoscopy and rigid esophagoscopy did not show evidence of esophageal injury or trauma. The patient was atraumatically intubated with a 5 mm ID endotracheal tube. The neck was explored, there was a fracture extending from the laryngeal prominence of the thyroid cartilage inferiorly, extending approximately 2 cm and deviating towards the left side. Approximation of the fractured wound edges was made (Fig. 1) and a Penrose drain placed. A conscious decision was made not to place a tracheostomy at this time. The patient tolerated the procedure well and was transferred intubated to the intensive care unit. A successful tracheal extubation after a direct laryngoscopy and bronchoscopy was done on post-operative day four. There were no complications. Discussion : Blunt trauma to the larynx is an uncommon, often fatal injury. Conventional management consists of awake tracheostomy (1). Spontaneous ventilation while maintaining adequate level of anesthesia and careful handling of the airway allowed direct repair of this laryngeal trauma. Excessive positive pressure by face mask, coughing, struggling, nitrous oxide, cricoid pressure, and overzealous attempts at intubation may result in further airway damage and should be avoided as were done in this case. (Figure presented) .
Keywords: propofol; midazolam; sevoflurane; fentanyl; nitrous oxide; lidocaine; fracture; patient; human; anesthesia; society; neck; injury; breathing; airway; larynx; bronchoscopy; tracheostomy; case report; tertiary health care; mortality; vomiting; hospital; university hospital; physical examination; abrasion; voice change; operating room; tachypnea; patent; endotracheal tube; cervical spine injury; dyspnea; larynx cartilage; procedures; extubation; premedication; larynx injury; face mask; coughing; child; infusion; laryngoscope; mediastinum; ecchymosis; rupture; pain; hematoma; computer assisted tomography; vocal cord; edema; esophagoscopy; esophagus injury; wound; intensive care unit; upper respiratory tract; laryngoscopy; blunt trauma; thorax; boy; trachea; cricoid cartilage; intubation; male

Tracheal laceration associated with cervical spine injury-case report. - Sobiech S.; Onichimowski D.; Gawlikowska E. (Ortopedia, traumatologia, rehabilitacja, 2010)
Mortality as a result of cervical spine injuries is predominantly associated with respiratory complications. Besides atelectasis, pneumonia, or respiratory failure, possible complications also include damage to anatomical structures of the respiratory tract. CASE REPORT: We present the case of a 44-year-old man who suffered a cervical spine injury with associated tracheal laceration after a fall from a height of about 2 meters. Vertebrae C3, C4, C5 were damaged with anterior dislocation at the C3/C4 level. Because of the development of respiratory failure, the patient was intubated and mechanical ventilation was commenced. In view of a complete and irreversible spinal cord injury, the patient was not qualified for an emergency stabilisation of the vertebral fractures. Surgery was further delayed because of increasing signs of a respiratory infection. On the 12th ICU day, a perforation of the anterior tracheal wall was identified during an elective tracheotomy. Due to the presence of pus at the tracheostomy site and air leakage around the tracheostomy tube cuff, the patient was intubated with a double-lumen endotracheal tube. On the 23th ICU day, acute problems with mechanical ventilation developed due to persisting air leakage around the tube cuff accompanied by signs suggestive of a tracheo-oesophageal fistula. Replacement of the double-lumen tube with a single-lumen one and a bronchoscopy was followed by cardiac arrest. Resuscitation led to the return of circulation over four hours, followed by death of the patient in the setting of increasing shock. The cervical spine injury suffered by the patient can be classified as Magerl's B1.2.3 and additionally as a Category C injury. These are the most severe injuries which may be accompanied by tracheal or oesophageal damage. In such cases, it is advisable to carry out detailed work-up to detect any damage to structures adjacent to the spine, in particular the trachea and oesophagus. Early stabilisation of severe spinal fractures allows for intraoperative assessment of the adjacent structures. A delay in diagnosing damage to the trachea or oesophagus is associated with poorer prognosis and a potential inability to treat the injuries due to developing inflammatory complications.
Keywords: adult; article; bronchoscopy; case report; cervical spine; endotracheal intubation; fatality; human; injury; laceration; male; methodology; radiography; respiratory tract infection; spinal cord injury; trachea

Author's reply to the Letter to the Editor of Chao Wang and Shenglin Wang (ESJO-D-09-00515) concerning "the single transoral approach for Os odontoideum with irreducible atlantoaxial dislocation" by Wang X, Fan CY, Liu ZH, Eur Spine J. 2009 Jul 14. [Epub ahead of print] - Liu Z.-H. (European Spine Journal, 2010)
Keywords: atlantoaxial dislocation; bone screw; cervical spine; computer assisted tomography; fluoroscopy; human; letter; nuclear magnetic resonance imaging; odontoid process; osteosynthesis; priority journal; spinal cord decompression; spine fusion; tracheotomy

Cervical tuberculous spondylodiscitis - Sánchez Barrueco A.; Zayas Pavón G.; García Fernández A. (Acta Otorrinolaringologica Espanola, 2010)
Keywords: ethambutol; isoniazid; levofloxacin; meropenem; pyrazinamide; rifampicin; aged; arm weakness; article; bacterium culture; case report; cervical myelopathy; cervical spine; cervical tuberculous spondylodiscitis; cervicotomy; computer assisted tomography; epidural space; human; male; Mycobacterium tuberculosis; neurosurgery; nuclear magnetic resonance imaging; pain; spastic paraplegia; spinal cord compression; spine surgery; tracheotomy; tuberculin test; tuberculous spondylitis; vertebra body

Pediatric Rehabilitation: 2. Environmental Factors Affecting Participation - Murphy N.; Trovato M.; Kim H.; Kim C.T.; Moberg-Wolff E. (PM and R, 2010)
Objective: This self-directed learning module highlights the environmental factors that influence the participation of children and youth with disabilities in life situations, including activities of self-care, mobility, socialization, education, recreation, and community life. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. This module emphasizes the participation of children with disabilities in adapted sports and reviews mobility devices to promote function, in the context of the International Classification of Functioning and in reference to the Americans with Disabilities Act. It provides the physiatrist with strategies to promote community participation, functional independence and healthcare transitions for children with disabilities as they approach adulthood. The goal of this article is to improve the learner's treatment strategies to maximize the participation of children and youth with disabilities in all settings, particularly schools and communities. © 2010 American Academy of Physical Medicine and Rehabilitation.
Keywords: article; artificial ventilation; backache; environmental factor; family counseling; fatigue; foster care; fracture; handicapped child; health insurance; hospital discharge; human; hydrocephalus; knee pain; leukodystrophy; myopathy; obesity; paraplegia; patient care; patient participation; pediatric rehabilitation; priority journal; school; self concept; shoulder pain; spinal dysraphism; spinal cord injury; sport; stomach tube; tracheostomy; treatment planning; walking aid; wheelchair

Transoral approaches to the cervical spine - Hsu W.; Wolinsky J.-P.; Gokaslan Z.L.; Sciubba D.M. (Neurosurgery, 2010)
A NUMBER OF anterior approaches to the craniocervical junction have been described to allow exposure to the midline and lateral aspects of both the cranial base and upper cervical spine. The transoral-transpharyngeal approach, a technique that is well known to many spine surgeons, provides surgical access to the anterior clivus, C1, and C2. Transoral approaches provide the fundamental anatomy and technique upon which the more complex jaw-splitting approaches are based. This article discusses fundamental concepts regarding anatomy, perioperative considerations, and technical aspects critical to this important approach to the craniocervical junction. The transoral-transpharyngeal approach remains the "gold standard" for anterior approaches to the cervical spine. Endoscopic endonasal and endoscopic transcervical approaches are promising alternatives that may become more mainstream as experience with these approaches increases. Copyright © 2010 by the Congress of Neurological Surgeons.
Keywords: gelfoam; hemostatic agent; artery injury; brain stem; cervical spine; computer assisted tomography; cranial nerve; dens axis resection; dysphagia; endoscopic surgery; face deformity; gold standard; human; liquorrhea; maxilla osteotomy; nasopharynx tumor; nerve function; palatopharyngeal incompetence; patient positioning; perioperative period; postoperative hemorrhage; preoperative care; priority journal; review; rheumatoid arthritis; spine surgery; surgical anatomy; surgical approach; surgical technique; tracheostomy; transoral transpharyngeal approach; vertebral artery

Penetrating neck trauma causing tracheal rupture, spinal cord injury, and massive pneumocephalus - Archan S.; Gumpert R. (American Journal of Emergency Medicine, 2010)
Keywords: metal; suxamethonium; adult; article; atelectasis; bleeding; case report; cervical spine; computer assisted tomography; cyanosis; diagnostic error; disease association; dyspnea; emergency physician; esophagus injury; fluid resuscitation; Glasgow coma scale; hematopneumothorax; hemorrhagic shock; human; injury severity; intubation; lung contusion; male; motor performance; multiple trauma; neck injury; occupational accident; oxygenation; pathophysiology; penetrating trauma; pneumocephalus; pneumomediastinum; priority journal; spinal cord injury; spine scintiscanning; thorax radiography; thyroid gland; trachea injury; tracheoesophageal fistula; tracheotomy; spine fracture

Mechanical insufflation exsufflation: Practice patterns among respiratory therapists in ontario - Prevost S.; Brooks D.; Bedard M.; Bwititi P. (Canadian Journal of Respiratory Therapy, 2010)
INTRODUCTION: The mechanical insufflator exsufflator (MIE) is effective in assisting cough and in helping to avoid unplanned hospitalizations, tracheostomy and long-term ventilation in patients with neuromuscular disease or spinal cord injury. In spite of this, the availability and usage of the device in Canada is not known. OBJECTIVE To investigate practice patterns and availability of the MIE in Ontario hospitals. METHODS: A cross-sectional, self-administered mail survey was sent to a random sample of 400 respiratory therapists practicing within 96 Ontario hospitals. RESULTS: A total of 114 (28%) completed surveys were returned from 62 (65%) hospitals. Twenty hospitals (32%) had a MIE. Predominantly the respiratory therapist was the health care provider using the MIE. The device was most commonly used in the intensive care unit and medical/surgical units in patients with neuromuscular diseases or spinal cord injuries. Optimal pressure spans of 35 cmH2O to 40 cmH2O were used by 54% of respondents. Fourteen of the 20 hospitals with a MIE had policies or guidelines in place and 4 of those hospitals had established staff competencies. Measurements of peak cough flow, maximal inspiratory/expiratory pressure and vital capacity were reported to be infrequently performed. CONCLUSIONS: This study demonstrated the MIE device is not widely available in Ontario hospitals and there are variations in how the devices are applied possibly resulting in suboptimal therapy. A comprehensive educational program on MIE devices that incorporates best practices and a practical component is recommended for current providers as well as for inclusion in student curriculum.
Keywords: Canada; aeration; respiratory therapist; human; education; hospital; devices; neuromuscular disease; patient; coughing; spinal cord injury; therapy; vital capacity; forced expiratory volume; policy; intensive care unit; air conditioning; health care personnel; random sample; tracheostomy; student; curriculum; hospitalization

Up the spinal canal without a paddle: Consideration of neurology's role in spinal cord injury - Tansey K. (Archives of Neurology, 2010)
Keywords: artificial ventilation; autonomic dysfunction; autonomic dysreflexia; bladder training; cancer rehabilitation; cerebrospinal fluid analysis; certification; constipation; curriculum; deep vein thrombosis; diagnostic error; diaphragm; editorial; follow up; Guillain Barre syndrome; human; intensive care unit; Internet; lung embolism; medical education; medical student; nerve cell plasticity; neurologic disease; neuropathic pain; neurosurgery; pathophysiology; patient education; physical medicine; practice guideline; priority journal; quality of life; reimbursement; resident; sedation; spasticity; specialization; spinal cord disease; spinal cord injury; spine stabilization; cerebrovascular accident; tracheostomy; treatment outcome; urinary tract infection; vertebral canal

Paraneoplastic jaw dystonia and laryngospasm with antineuronal nuclear autoantibody type 2 (anti-Ri) - Pittock S.J.; Parisi J.E.; McKeon A.; Roemer S.F.; Lucchinetti C.F.; Tan K.M.; Keegan B.M.; Hunter S.F.; Duncan P.R.; Baehring J.M.; Matsumoto J.Y.; Lennon V.A. (Archives of Neurology, 2010)
Background: Opsoclonus-myoclonus syndrome and breast carcinoma were initially described as neurologic and oncologic accompaniments of antineuronal nuclear autoantibody type 2 (ANNA-2, also known as anti-Ri). However, the neurologic spectrum of ANNA-2 autoimmunity is broader, includes a syndrome of jaw dystonia and laryngospasm, and can be accompanied by lung carcinoma. Objective: To describe clinically (with a video) ANNA-2-associated jaw dystonia and laryngospasm, its pathologic correlates, and therapeutic outcomes. Design: Retrospective case series with prospective clinical follow-up. Setting: Mayo Clinic's Neuroimmunology Laboratory, Rochester, Minnesota. Patients: Consecutive patients with ANNA-2 seropositivity identified since January 1, 1990. Main OutcomeMethods: Clinical (in 9 patients) and neuropathologic (in 2 patients) findings were reviewed. Results: Of 48 patients with ANNA-2 seropositivity, 9 (19%) had multifocal neurologic manifestations that included jaw dystonia and laryngospasm. Among 6 patients with jaw dystonia, 5 had severely impaired nutrition, causing profound weight loss. Five patients had documented laryngospasm, which contributed to 1 patient's death. Neuropathologic examination revealed diffuse infiltration by CD8+ T lymphocytes, with axonal loss and gliosis in brain-stem and descending spinal cord tracts. Some patients improved symptomatically after immunosuppressant or cytotoxic therapies; 1 patient improved after treatment with botulinum toxin. One patient who underwent tracheostomy because of recurrent laryngospasm was alive and well longer than 3 years after symptom onset. Conclusions: Jaw dystonia and laryngospasm are common accompaniments of ANNA-2 autoimmunity and are associated with significant morbidity. We propose that selective damage to antigen-containing inhibitory fibers innervating bulbar motor nuclei by CD8 + T lymphocytes (histopathologically observed infiltrating brain-stem reticular formation) is the proximal cause of this syndrome. Early and aggressive therapy offers the prospect of neurologic improvement or stabilization. ©2010 American Medical Association. All rights reserved.
Keywords: amitriptyline; antineuronal nuclear autoantibody type 2; antinuclear antibody; baclofen; botulinum toxin; clonazepam; cyclophosphamide; dexamethasone; doxorubicin; immunoglobulin; lorazepam; methylprednisolone; paclitaxel; prednisone; tamoxifen citrate; temazepam; trihexyphenidyl; unclassified drug; adult; aged; article; brain stem; case study; CD8+ T lymphocyte; clinical article; disease association; disease severity; drug megadose; dystonia; female; follow up; gliosis; histopathology; human; immunosuppressive treatment; jaw disease; larynx spasm; male; malnutrition; medical record review; mortality; neuropathology; outcome assessment; paraneoplastic jaw dystonia; paraneoplastic syndrome; priority journal; prospective study; recurrent disease; retrospective study; spinal cord; tracheostomy; treatment response; United States; body weight loss

Temporary tracheostomy required as an infant may be a risk factor for future centrally mediated disordered sleep ventilation - Adderley R.; Wensley D. (Cerebrospinal Fluid Research, 2010)
Background: Children with spina bifida experience lifelong complex medical issues. The problems of locomotion, and neurogenic bowel and bladder are well appreciated, and the necessity of shunting obstructive hydrocephalus is equally well known. There are however, serious, less common problems associated with control of ventilation. Most common is vocal cord dysfunction, with unilateral or bilateral vocal cord paresis, and as a consequence, upper airway obstruction. Rarer still, are patients with life threatening breath holding spells, central apnea, or mixed central and obstructive apnea. In many cases, surgical decompression of the posterior fossa can result in return of vocal cord function, and relief of obstructive apnea. In a few cases tracheostomy is required. With a Chairi II malformation, the upper medulla, where the nuclei of cranial nerves IX and X lie close to the rostral tracts of the respiratory centre, may have an abnormal and tenuous blood supply. The medulla may be compromised by bony pressure or by compromise of the blood supply (herniation or chronic arachnoiditis). Materials and methods: The Spinal Cord Program at British Columbia's Children's Hospital has cared for 956 patients since 1982. Over the same period, the Home Tracheostomy Care/ Home Ventilation Program has cared for 346 children, eight with spinal dysrhaphism. Two girls with meningomyelocoele and Arnold Chiari type II malformations, who had required tracheostomies as infants, presented as adolescents with symptoms suggestive of disordered sleep ventilation. Both had required a tracheostomy despite timely posterior fossa decompression, but over time (years), gag and vocal cord function returned, and they were successfully decannulated. Patient 1, with a lumbosacral meningomyelocoele was referred to the Home Ventilation Program at fourteen years of age when her mother, a registered nurse reported erratic breathing at night, with weight loss, and deteriorating school performance. Patient 2, with a lumber meningomyelocoele presented at fifteen years of age complaining of daytime somnolence, but denied morning headaches. In both cases polysomnography showed a similar, chaotic pattern of respiration with frequent arousals and severely fragmented sleep. Computerized Tomography showed no change in ventricular size in either case. Results: Both patients were started on nighttime noninvasive ventilation (NIPPV) with rapid resolution of symptoms. Conclusions: Children with meningomyelocoele, particularly those who appear to have had resolution of infantile bulbar dysfunction, may present later in life with severely disordered sleep ventilation, and warrant careful lifelong followup, with a low threshold for polysomnography and institution of ventilatory support.
Keywords: air conditioning; spinal dysraphism; sleep; tracheostomy; hydrocephalus; infant; risk factor; society; patient; vocal cord; apnea; child; congenital malformation; vascularization; polysomnography; posterior fossa; registered nurse; breathing; night; body weight loss; academic achievement; daytime somnolence; headache; arousal; computer assisted tomography; bulbar paralysis; bladder; shunting; vocal cord paralysis; upper respiratory tract obstruction; neurogenic bowel; breath holding; locomotion; decompression surgery; follow up; cranial nerve; hernia; arachnoiditis; spinal cord; Canada; girl; adolescent; decompression; mother; pediatric hospital

Airway management in acute tetraplegics: A retrospective study - Seidl R.O.; Wolf D.; Nusser-Müller-Busch R.; Niedeggen A. (European Spine Journal, 2010)
The objective of this study was to develop an evidence-based airway management protocol for patients with acute tetraplegia. The method consisted of an analysis of the medical records of patients (September 1997-December 2002) with a spinal cord injury and a neurological deficit less than 8 weeks old. Of the 175 patients, 72 (41, 14%) were tracheotomised. This was influenced by the origin of the paralysis, Frankel score, and number of cervical spine operations, accompanying injuries and accompanying illnesses. Tracheotomy did not affect the duration of treatment, duration of ventilation or length of stay in the intensive care unit. The need for a tracheotomy was able to be predicted in 73.31% with neurological level, Frankel score and severity of accompanying injuries. In patients with acute tetraplegia, primary tracheotomy is indicated in sub C1-C3 with Frankel stage A/B, sub C4-C6 with Frankel stage A/B with trauma and accompanying injuries/accompanying illnesses, and in patients with complex cervical spine trauma that requires a combined surgical approach. In other patients, an attempt at extubation should be made. © 2010 Springer-Verlag.
Keywords: adolescent; adult; aged; airway conductance; article; artificial ventilation; cervical spine injury; disease severity; female; human; intensive care; intubation; length of stay; major clinical study; male; medical record; neurologic disease; priority journal; quadriplegia; rating scale; spinal cord injury; tracheotomy; treatment duration; treatment outcome

Efficacy of spinal needle aspiration for epiglottic abscess in 90 patients with acute epiglottitis - Kim S.G.; Lee J.H.; Park D.J.; Hong J.W.; Kim T.H.; Kim M.G.; Shim J.S.; Yeo S.G. (Acta Oto-Laryngologica, 2009)
Conclusion. Patients with epiglottic abscesses showed more severe symptoms than those with acute epiglottitis and were at increased risk of airway compromise. All 11 patients with epiglottic abscesses underwent spinal needle aspiration;all were cured without severe complications. These findings indicate that spinal needle aspiration is both safe and effective in patients with epiglottic abscesses. Objectives. Acute epiglottitis is a disease that may become serious or even fatal because of sudden upper airway obstruction. An epiglottic abscess may result from a coalescent epiglottic infection due to acute epiglottitis or secondary infection of an epiglottic mucocele. There have been few reports comparing acute epiglottitis with epiglottic abscess. We therefore assessed the clinical characteristics of each condition, as well as the efficacy of spinal needle aspiration and drainage of epiglottic abscesses. Patients and methods. We retrospectively reviewed the records of 90 hospitalized patients diagnosed with acute epiglottitis and epiglottic abscess by flexible nasopharyngolaryngoscopy between March 2006 and February 2008. All patients were treated with medication;in addition, those with epiglottic abscess underwent spinal needle aspiration. Results. Of 90 patients, 79 had acute epiglottitis and 11 had epiglottic abscesses. Acute epiglottitis was most common in May (16.5%) and epiglottic abscesses were most common in June (27.3%). The most common symptoms were sore throat (91.1%), dysphagia (38.9%), voice change (33.3%), and dyspnea (16.7%). All patients were treated with antibiotics and steroids. The mean length of hospitalization was 5 days. No patient required a tracheostomy or orotracheal intubation.
Keywords: abscess drainage; acute epiglottitis; adolescent; adult; aged; article; fine needle aspiration biopsy; child; dysphagia; dyspnea; female; hospitalization; human; major clinical study; male; priority journal; retrospective study; sore throat; voice change

Optimizing speech production in the ventilatorassisted individual following cervical spinal cord injury a preliminary investigation - MacBean N.; Ward E.; Murdoch B.; Cahill L.; Solley M.; Geraghty T.; Hukins C. (International Journal of Language and Communication Disorders, 2009)
Background: Mechanical ventilation is commonly used during the acute management of cervical spinal cord injury, and is required on an ongoing basis in the majority of patients with injuries at or above C3. However, to date there have been limited systematic investigations of the options available to improve speech while ventilatorassisted postcervical spinal cord injury. Aims: To provide preliminary evidence of any benefits gained through the addition of positive end expiratory pressure PEEP andor a tracheostomy speech valve to the condition of leak speech. Methods & Procedures: Speech production in the three conditions was compared in two ventilatorassisted participants using a series of instrumental and perceptual speech measures. Outcomes & Results The addition of PEEP or the use of a speech valve resulted in speech that was superior to leak speech for both participants however, individual variation was present. Conclusions & Implications: Leak speech alone or with the addition of PEEP or a tracheostomy speech valve can facilitate functional communication for the ventilated patient, though PEEP and valve speech were found to be superior in the current study. These findings will be of assistance for clinicians counselling the growing population of patients who may require tracheostomy positive pressure ventilation longterm regarding communication options.
Keywords: adult; article; cervical spinal cord injury; clinical article; controlled study; human; interpersonal communication; male; positive end expiratory pressure; speech; tracheostomy; ventilator

Editorial: Spinal muscular atrophy: The challenges of 'doing the right thing' - Wilton N.C.T. (Paediatric Anaesthesia, 2009)
Keywords: antibiotic agent; survival motor neuron protein 1; survival motor neuron protein 2; aeration; antibiotic therapy; artificial ventilation; assisted ventilation; atelectasis; breathing disorder; bulbar paralysis; disease course; disease severity; Duchenne muscular dystrophy; dysphagia; editorial; forced expiratory volume; gastroesophageal reflux; gene disruption; gene expression; human; Kugelberg Welander disease; lifespan; lung edema; lung function test; morbidity; motoneuron; motor dysfunction; neuromuscular disease; physiotherapy; pneumonia; positive end expiratory pressure; postoperative analgesia; priority journal; quality of life; recurrent infection; reflex; reflex disorder; respiratory failure; respiratory function; spinal muscular atrophy; spirometry; stomach fundoplication; stomach tube; sucking reflex; survival rate; tooth disease; tracheostomy; feeding tube; walking difficulty; Werdnig Hoffmann disease

Life threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy in multi-trauma patient with cervical spine injury. - Bartolek D.; Somun N.; Bartolek F.; Zdravcević-Sakić K.; Lajtman Z.; Banić T.; Cavrić G.; Kovabić-Vicić V. (Collegium antropologicum, 2009)
Percutaneous tracheostomy (PCT) is a safe method under proper patient selection, increased technical experience and bronchoscopy- or ultrasound-guided procedure. Trauma patients with cervical spine fractures and spinal cord injury are at a high risk for respiratory failure and require a definitive airway followed by prolonged mechanical ventilation. We would like to present multiple, life- threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy (GWDF) in one trauma patient with a cervical spine injury. With this case report we would like to lay emphasis on the importance of continuously bronchoscopy- or ultrasound-guided PTC in trauma patients, especially with cervical spine injury, as the need to respect the steep-learning curve in its performance.
Keywords: aged; article; bronchoscopy; case report; cervical spine; esophagus perforation; human; injury; devices; male; minimally invasive surgery; multiple trauma; pneumomediastinum; pneumothorax; spine fracture; trachea; tracheostomy

Neuromodulation on cervical spinal cord combined with hyperbaric oxygen in comatose patients-a preliminary report - Liu J.-T.; Lee J.-K.; Tyan Y.-S.; Liu C.-Y.; Chen Y.- H.; Lin T.-B. (Surgical Neurology, 2009)
Background: Because both SCS and HBO therapy have shown some promise in treating patients with states of reduced consciousness, we evaluated the combination of therapies in a prospective trial in comatose patients. Methods: Twelve patients who had received median nerve stimulation for 3 months without improvement in consciousness received cSCS for 1 year combined with simultaneous HBO therapy for the first 3 months. Another group enrolled 12 patients who received median nerve stimulation only were served as control. Results: Six patients emerged from coma at 1 year (after conclusion of treatment). Glasgow Coma Scale score, SPECT imaging, and PVS scores (state and reaction subscores) of the 12 patients were all significantly increased at 1 year compared with enrollment (P < .05). Neither respirator nor tracheostomy was needed to assist respiration in any patient. Only 1 of 12 patients still needed nasogastric tube feeding at 1 year. By contrast, control patients (without cSCS and HBO therapy) showed no apparent improvement. Conclusion: Increase of GCS score, cerebral blood perfusion, and PVS scores were observed in comatose patients treated with combined cSCS and HBO therapy. © 2009.
Keywords: adult; aneurysm rupture; article; brain blood flow; brain perfusion; cervical spinal cord; clinical article; clinical assessment; comatose patient; controlled study; electrode; electroencephalography; female; Glasgow coma scale; heart arrest; human; hyperbaric oxygen therapy; male; median nerve; neuromodulation; nose feeding; occupational therapy; outcome assessment; persistent vegetative state; physiotherapy; single photon emission computed tomography; spinal cord stimulation; subarachnoid hemorrhage; treatment duration

Safety of percutaneous tracheostomy in trauma patients - Maldonado I.; Becker S.; Fernandez C. (Critical Care Medicine, 2009)
Introduction: Percutaneous tracheostomy is a common procedure in many Trauma Intensive Care units. A concern about the safety of performing percutaneous tracheostomy in patients with no cervical spine clearance or cervical spine injury exists. This concern has had an impact on the consideration to perform percutaneous tracheostomies in this group of patients. Most experts recommend the use of fiberoptic bronchoscopy assistance during percutaneous tracheostomy. Hypothesis: Performing percutaneous tracheostomy in trauma patients with either no cervical spine clearance status or cervical spine injury status is as safe as open tracheostomy. Methods: From January 2001 to December 2007 we retrospectively evaluated the medical records of all patients with blunt trauma who required tracheostomy in a Level II Trauma Center. Data was gathered from a trauma registry database and medical records. Patients were divided in two groups. Open Tracheostomy (OT) and Percutaneous Tracheostomy (PT). Patient age. Injury Severity Score (ISS). type of tracheostomy insertion method. cervical spine clearance status prior to tracheostomy. presence of cervical spine injury. use of bronchoscopy assistance in percutaneous tracheostomy. and immediate complications post tracheostomy were recorded for each patient. Results: The total number of tracheotomies during the study period was 220 of which 125 (56%) were PT and 95(44%) were OT. Both groups were similar in age. sex and ISS distribution. Of the OT group. 60 (63%) were done in patients with no cervical spine clearance or cervical spine injury. There were no immediate complications reported in the OT group. The PT group had 63 cases (50.4%) done with no preoperative cervical spine clearance or positive for cervical spine injury. The PT group underwent the procedure without bronchoscopy assistance in 95% of the cases. Two cases (1.5%) in the PT group were reported with postoperative bleeding from the tracheostomy site that did not required intervention. Both cases were PT done without bronchoscopy assistance and did not have pre-operative cervical spine clearance. No other immediate complications were reported in the PT group. Conclusions: The results of this study suggest that PT is safe in trauma patients without preoperative cervical spine clearance or with cervical injuries as compared with the OT group. Most of the PT cases were done without bronchoscopy assistance (95%). This finding suggests the need of further study to clarify the role of bronchoscopy assistance in PT.
Keywords: tracheostomy; patient; injury; safety; intensive care; society; cervical spine; cervical spine injury; bronchoscopy; medical record; blunt trauma; emergency health service; register; data base; injury scale; fiberoptic bronchoscopy; intensive care unit; tracheotomy; postoperative hemorrhage; hypothesis

A regional survey of paediatric consultants' practices and attitudes in the management of spinal muscular atrophy type 1 - Heraghty J.L.; Hilliard T.N.; Majumdar A.; Jardine P.; Fleming P.J.; Henderson A.J. (Thorax, 2009)
The management options for spinal muscular atrophy (SMA) are changing with an increase in the use of non-invasive and invasive ventilation. However, there are few empirical data to support the practice of long-term ventilation in improving quality of life in these patients. Without active respiratory management, children with SMA usually die within the first 2 years of life. We designed a survey to assess current attitudes and practices in the management of this condition in a single geographical region of the UK. Methods: In November 2008 a web-based anonymous survey was sent to all paediatric consultants within the region who would have potential contact with a child with SMA. Following a brief clinical scenario of an infant with SMA type 1, a number of management options were suggested regarding general health care, antibiotics for infection, feeding options, immunisations, ventilation for acute illness and long-term home ventilation. For each option, respondents were asked if they would (a) not discuss, (b) discuss but not recommend or (c) recommend the intervention. Results: 72% (133/185) of consultants completed the survey. They were representative of the surveyed population in terms of place of work and specialty practice. 83% of respondents would recommend nasogastric feeding, 79% oral antibiotics and 39% intravenous antibiotics during infections. 73% would recommend influenza and pneumococcal vaccination and 44% would recommend RSV prophylaxis. Non-invasive ventilation (NIV) would be recommended for the acute management of a respiratory infection by 52% but only 14% would recommend intubation and ventilation, although 82% said they would discuss this with the family. A high proportion of respondents would discuss long-term ventilation with NIV (72%) or tracheostomy (73%) ventilation but only 18% would recommend NIV and 8% would recommend long-term tracheostomy ventilation. Recommending referral to specialist services varied by specialty; 83% to palliative care, 79% to neurology and 65% to respiratory medicine. Conclusions: This preliminary survey suggests a variation in what interventions are recommended to families of children with SMA type 1 but indicates that a high proportion of respondents would discuss the majority of management options with the family.
Keywords: antibiotic agent; consultation; winter; society; spinal muscular atrophy; air conditioning; child; infection; tracheostomy; quality of life; patient; United Kingdom; infant; health care; feeding; population; nose feeding; influenza; vaccination; prophylaxis; respiratory tract infection; intubation; medical specialist; palliative therapy; neurology; acute disease

Diaphragmatic paralysis in a patient with spinal cord infarction - Matsumoto H.; Nakayama T.; Hamaguchi H.; Nakamori T.; Ikagawa T.; Oda T.; Imafuku I. (Internal Medicine, 2009)
This report describes the rare case of a 72-year-old woman with spinal cord infarction who presented with persistent diaphragmatic paralysis. Her neurological examination showed tetraplegia, sensory loss to pain and thermal stimulations, and paradoxical abdominal movement. Chest X-ray and diaphragmatic fluoroscopy revealed absent diaphragmatic movement. A cervical magnetic resonance image showed bilateral anterior spinal cord lesions from the level of the second to the fifth cervical vertebrae. Diaphragmatic paralysis should be recognized as a clinical sign of cervical spinal cord infarction. Particular attention must be given to paradoxical abdominal movement during respiration in this disorder. © 2009 The Japanese Society of Internal Medicine.
Keywords: acetylsalicylic acid; antihypertensive agent; heparin; aged; article; Babinski reflex; body temperature; case report; consciousness; diaphragm paralysis; dyspnea; elderly care; female; fluoroscopy; human; hypertension; magnetic resonance angiography; nuclear magnetic resonance imaging; oxygen saturation; polysomnography; positive end expiratory pressure; pulse rate; quadriplegia; spinal cord ischemia; tendon reflex; thorax radiography; tracheostomy; tracheotomy

Respiratory problems in spinal muscular atrophy in the paediatric age group - Testa M.B.C.; Paglietti M.G.; Pavone M.; Schiavino A.; Pedace C.; Cutrera R. (Paediatrics and Child Health, 2009)
The patient with neuromuscular disability (spinal muscular atrophy, muscular dystrophy, myopathy, amyotrophic lateral sclerosis, post-poliomyelitis syndrome or neuropathy) represents a typical example of a child with chronic respiratory disease requiring either hospitalisation or domiciliary assistance. For these patients, respiratory disease represents the main cause of morbidity and mortality, due primarily to weakness of the respiratory muscles, an ineffective cough and abnormal swallowing. A multidisciplinary approach, with the aim of improving the patient's quality of life, is therefore required. Such an approach involves various strategies, for example use of the cough-assist machine (a non-invasive respiratory physiotherapy that safely and consistently removes secretions in patients with an ineffective ability to cough), monitoring of nutritional status, the prevention of chest deformities, and the use of mechanically assisted ventilation - both non-invasive and invasive ventilation via a tracheotomy. © 2009.
Keywords: bicarbonate; adverse outcome; amyotrophic lateral sclerosis; article; artificial ventilation; aspiration pneumonia; bicarbonate blood level; breathing exercise; breathing muscle; child; chronic respiratory tract disease; claustrophobia; clinical assessment; coughing; dysphagia; end tidal carbon dioxide tension; eye irritation; face erythema; function test; gas exchange; groups by age; human; hypercapnia; hypotension; hypoventilation; hypoxemia; lung clearance; morbidity; mortality; muscular dystrophy; myopathy; neuropathy; nose cavity; nose obstruction; nutritional assessment; otalgia; oxygen mask; pediatrics; physical examination; pneumothorax; polysomnography; positive end expiratory pressure; postpoliomyelitis syndrome; pulse oximetry; quality of life; REM sleep; sinusitis; sleep disordered breathing; spinal muscular atrophy; thorax deformity; tracheotomy; transcutaneous carbon dioxide monitoring; ulcer

Primary pyogenic infection of the cervical spine in intravenous drug users - Street J.; Lenehan B.; Fisher C. (Spine, 2009)
Objectives: To evaluate the demographics, presentation, treatment and outcomes of primary Pyogenic infection of the cervical spine in a population of intravenous drug users. Methods: Data on all patients with primary pyogenic infection of the cervical spine presenting to a quaternary referral center was obtained from a prospectively maintained database. Results: Over the 5 year study period there were 102 patients treated for Primary Pyogenic Infection of the Cervical Spine of which 51 were Intravenous Drug Users (IVDU). Of this IVDU group there were 34 males. Mean age was 43years (range 25 - 57). 23 had HIV, 43 Hepatitis C and 13 Hepatitis B. All were using cocaine, 26 were also using Heroin and 44 more than 3 recreational drugs. 30 patients presented with axial pain with a mean duration of 51 days (range 3-120). 31 were ASIA D or worse with 8 ASIA A. Mean Motor Score of patients with deficit was 58.6. Most common ASIA Motor Levels were C4 and C5. Mean duration of neurological symptoms was 7 days (range 1-60). None had previous surgery for spinal infection. 26 were receiving IV antibiotics for known spinal infection. Mean presenting Temperature was 37.4 degrees C(range 35.9 - 39.9, 19 > 37.5C), mean ESR 60.8 (range 6 - 140, 43 > 20), mean CRP 87.75 (1.5-253, 46 > 20), meanWCC 10.2 (range 3.7 - 30.4, 14 > 11) and 33 patients had positive blood cultures (19 MSSA, 9 MRSA). 44 patients were treated surgically. 22 had a posterior approach alone, 13 had anterior only while 9 required combined.Mean operative time was 263 mins (range 62 - 742). 13 required tracheostomy. 7 required early revision for hardware failure and 2 for surgical wound infection. Mean duration of antibiotic treatment was 49 days (range 28-116). 26 patients had single agent therapy. 17 hadMSSAand 17MRSA.At discharge 28 patients had neurological improvement (mean 20 ASIA points, range 1-55), 11 had deterioration (mean 13, range 1-50) and 5 were unchanged. There were no in-hospital deaths. At 2 years after index admission 13 patients were dead and the remainder had failed to attend the unit for follow-up. Conclusions: Primary pyogenic infection of the cervical spinal in IVDU's typically presents with sepsis and acute cervical quadriplegia. Surgical management must be prompt and aggressive with significant neurological improvement expected in the majority of patients.
Keywords: recreational drug; cocaine; diamorphine; antibiotic agent; cervical spine; infection; intravenous drug abuse; society; patient; Quaternary (period); surgery; temperature; blood culture; tracheostomy; computer; surgical infection; antibiotic therapy; therapy; deterioration; hospital; follow up; sepsis; quadriplegia; death; population; data base; male; Human immunodeficiency virus; hepatitis C; hepatitis; pain; neurologic disease; methicillin resistant Staphylococcus aureus

Chest radiography after tracheostomy: Is there a benefit? - Agarwal S.; Tobler W.; Mella J.; Selvam A.; Ng J.; Burke P. (Critical Care Medicine, 2009)
Introduction: Routine Chest X-Ray (CXR) after tracheostomy remains a widely accepted practice despite lack of evidence supporting clinical utility. Hypothesis: Establishment of a policy utilizing clinical exam after tracheostomy will reduce cost and minimize patient exposure to radiation. Methods: A retrospective review of all tracheostomy at a trauma intensive care unit over a 5 year period was performed. Preoperative and postoperative CXR and chart documentation were evaluated to determine clinical significance. Significant findings on CXR included new pneumothorax/subcutaneous emphysema or an increase in consolidation or effusion. The cost of portable CXR was estimated to be $500 per event. Results: A total of 255 tracheostomies were included: 131 open tracheostomies (105 male, 26 female) and 112 percutaneous tracheostomies (93 male and 19 females) and 22 patients were excluded due to inadequate documentation. Age ranged from 12-93 years. Procedures were performed from hospital day 1 to day 46. Indications included respiratory failure (214) and traumatic brain or spinal cord injury (41). Positive findings were found on 7 CXR after the procedure: 6 patients were managed prior to CXR based on clinical presentation, and the 7th patient was observed for a deep sulcus sign which resolved spontaneously. An additional 4 patients had worsening clinical picture without change in CXR. The remaining 244 patients (95.6%) had no change in CXR after the procedure and a stable clinical picture. A cost savings of $122,000 could have been realized if a protocol utilizing clinical exam been utilized. Conclusions: Routine CXR following tracheostomy fails to provide additional information above clinical examination. Clinical deterioration should be the stimulus for radiographic examination. Such a protocol can result in significant cost savings and minimize patient exposure to radiation.
Keywords: tracheostomy; intensive care; society; thorax radiography; patient; exposure; radiation; male; female; cost control; documentation; clinical examination; emphysema; hospital; respiratory failure; brain; spinal cord injury; deterioration; policy; hypothesis; stimulus; radiodiagnosis; injury; intensive care unit; effusion

Spinal muscular atrophy type 1: Prolongation of survival by noninvasive respiratory aids - Bach J.R.; Gupta K.; Reyna M.; Hon A. (Pediatric Asthma, Allergy and Immunology, 2009)
Previous reports on spinal muscular atrophy type 1 (SMA-1) underestimate potential survival because of failure to optimally use noninvasive respiratory muscle aids including mechanically assisted coughing and noninvasive ventilation (NIV) at full support settings. We report our center's experience in prolonging survival for these patients. We focus on early initiation of nasal noninvasive ventilation, mechanically assisted coughing, and pulse oximetry monitoring during acute respiratory tract infections to guide use of assistive technologies. Seventeen SMA-1 patients with ventilation via tracheostomy are living, with a mean age of 78.2 (range 65-179) months. Ten died at a mean age of 61.6 (range 16-270) months of age. Twenty five of 27 were not able to regain autonomous breathing ability after the tracheostomy. None of the 21 who had not developed the ability to verbalize before undergoing tracheotomy did so after tracheotomy. Six patients had comprehendible speech at the time of tracheotomy and retained some ability to vocalize subsequently. Seventy-two SMA-1 patients using noninvasive ventilation are alive at mean age 86.1 (range 13-196) months; 13 died at 52.3 (range 13-111) months. Sixty seven of the 75 could communicate verbally. The noninvasive ventilation patients had significantly more hospitalizations than tracheostomy patients until age 3 (P < 0.001) but not thereafter. SMA-1 survival past adolescence is possible using both noninvasive ventilation and tracheostomy ventilation. The tracheostomy-ventilated patients had greater levels of ventilator dependence and reduced verbal abilities. © 2010 Mary Ann Liebert, Inc.
Keywords: adolescent; assisted ventilation; child; clinical article; coughing; human; intensive care; male; non invasive procedure; outcome assessment; preschool child; priority journal; respiratory failure; review; school child; speech intelligibility; spinal muscular atrophy; survival time; tracheotomy; vocalization

Selective intrabronchial air insufflation: A potentially life saving treatment for acute lobar collapse - Wohlauer M.; Moore E.; Haenel J.; Burlew C.; Barnett C. (Critical Care Medicine, 2009)
Background: Lobar atelectasis is a frequently encountered problem in the ICU, caused by a variety of mechanisms. There are few options for critically ill patients when traditional methods fail, posing a formidable challenge for the intensivist. A middle aged female unrestrained passenger in a motor vehicle crash was transferred to Denver Health Medical Center, the regional Level One Trauma Center, with a C4 tetraplegia and complete right carotid artery occlusion. She arrived intubated, on pressors, with a heart rate in the 40's. She underwent operative fixation of her spinal cord injury and a tracheostomy was performed for respiratory failure. On hospital day 8 she became febrile, hypotensive and increasingly hypoxemic with a P:F ratio of 95. A chest radiograph demonstrated collapse of the right lower lobe. She developed profound hypoxemia, with persistent right lower lobe collapse (see image). Increased PEEP exacerbated her condition due to high peak pressures. She underwent emergent repeat FFB followed by selective intrabronchial air insufflation (SII) to expand the atelectatic lung (see image). The radiograph reflects immediate clinical improvement, with decreased oxygen requirements and normalization of blood pressure upon reinflation of the distal airways. Methods: Selective Intrabronchial Air Insufflation: An adapter from a Mallinckrodt 3.0 mm uncuffed tracheal tube is inserted on to a bronchoscope [Mallinckrodt Inc., St. Louis, MO]. The bronchoscope is inserted, and the patient's airways are examined. After routine suctioning and lavage, the bronchoscope is advanced into the collapsed bronchial segment. The suction tubing is occluded in order to prepare for selective air insufflation. After attaching a manual resuscitator (i.e. bag valve mask), 5-10 positive pressure breaths are applied into every segment of collapsed lobe while monitoring for hypotension. These breaths are delivered by interfacing the manual resuscitator connected to the 3.0 mm adapter, via a three-way stopcock to the FFB instrument port. Discussion: Lobar atelectasis is a frequently encountered problem in the ICU, caused by a variety of mechanisms including resorption atelectasis due to airway obstruction, passive atelectasis from hypoventilation, compressive atelectasis from abdominal distension, and adhesive atelectasis due to increased surface tension. Common treatments include chest physiotherapy, bronchodilators, fiberoptic bronchoscopy, Dnase, positive end-expiratory pressure, and surfactant. As alveolar radius decreases, surface tension increases resulting in alveoli collapse. Once collapsed, a substantial airway pressure must be generated in order to reexpand the distal airways. Traditional respiratory therapy can cause injurious transpulmonary pressures in the non-collapsed lung leading to injury, however, SII easily re-expanded collapsed lobes without overinflation in a canine study. A series of 17 ICU patients previously published by our institution showed FFB with SII to be 82% effective in patients with lobar collapse. Selective intrabronchial air insufflation (SII) is a simple and potentially life-saving adjunct to FFB in the treatment of ICU patients with acute pulmonary lobar collapse.(Figure presented).
Keywords: adhesive agent; deoxyribonuclease; hypertensive factor; antihypertensive agent; surfactant; aeration; intrabronchial drug administration; intensive care; society; atelectasis; patient; airway; bronchoscope; lung; breathing; positive end expiratory pressure; surface tension; book; monitoring; hypotension; endotracheal tube; airway obstruction; hypoventilation; abdominal distension; breathing exercise; fiberoptic bronchoscopy; radius; airway pressure; artificial ventilation; injury; critically ill patient; middle aged; female; motor vehicle; health; emergency health service; quadriplegia; carotid artery obstruction; spinal cord injury; heart rate; respiratory failure; hospital; tracheostomy; thorax radiography; hypoxemia; X ray film; oxygen consumption; blood pressure; lavage; suction

Cervical spinal cord infarction after posterior fossa surgery: A case-based update - Martínez-Lage J.F.; Almagro M.-J.; Izura V.; Serrano C.; Ruiz-Espejo A.M.; Sánchez-Del-Rincón I. (Child's Nervous System, 2009)
Background: Several positions are currently utilized for operating patients with posterior fossa lesions. Each individual position has its own risks and benefits, and none has demonstrated its superiority. A dreaded, and probably underreported, complication of these procedures is cervical cord infarction with quadriplegia. Discussion: We reviewed eight previous reported instances of this devastating complication aimed at ascertaining its pathogenesis to suggest preventive strategies. Several hypotheses have been put forward to explain the occurrence of this complication. Some factors involved in the production of cervical cord infarction include patient"s position (seated or prone), hyperflexion of the neck, excessive spinal cord traction, canal stenosis, and systemic arterial hypotension. We hypothesize that spinal cord infarction in our patient might have resulted from compromised blood supply to the midcervical cord caused by tumor infiltration of the cervical leptomeninges in addition to a brief episode of arterial hypotension during venous air embolism. Case report: We treated an 8-year-old girl who developed quadriplegia after surgery for a fourth ventricular ependymoma. Postoperative magnetic resonance imaging demonstrated cervical cord infarction. Evoked potentials confirmed the diagnosis. Conclusions: With this report, we want to draw the attention of neurosurgeons to the possibility of the occurrence of this dreadful complication during posterior fossa procedures. Retrospectively, the only measures that might have helped to avoid this complication in our patient would have been using the prone position and intraoperative monitoring of evoked potentials. © 2009 Springer-Verlag.
Keywords: dexamethasone; Ki 67 antigen; protein p53; acoustic neuroma; adolescent; adult; aged; air embolism; anorexia; Arnold Chiari malformation; astrocytoma; bradycardia; brain fourth ventricle; brain ventricle peritoneum shunt; cervical spinal cord; cervical spinal cord infarction; cervical spinal cord injury; child; choriocarcinoma; choroid plexus papilloma; clinical article; cranial nerve paralysis; drowsiness; drug megadose; early diagnosis; ependymoma; evoked brain stem response; evoked response; somatosensory evoked potential; female; headache; heart ventricle pressure; human; hydrocephalus; hyperreflexia; hypotension; laminectomy; male; medulloblastoma; neck pain; neurography; neuropathology; nuclear magnetic resonance imaging; paraplegia; paresis; paresthesia; pathogenesis; patient positioning; phrenic nerve; posterior fossa; postoperative care; preschool child; priority journal; quadriplegia; review; school child; systolic blood pressure; tomotherapy; tracheotomy; vascularization; vertebral canal stenosis; vertigo; vomiting

Use of isocentric fluoroscopy during transoral odontoidectomy - Mammis A.; Yanni D.S.; Goldstein I.M. (Journal of Clinical Neuroscience, 2009)
The intra-operative isocentric C-arm (Siremobil Iso-C 3D; Siemens Medical Solutions, Erlangen, Germany) allows for the acquisition and immediate interpretation of multiplanar three-dimensional images. The utility of isocentric fluoroscopy in surgery of the spine has been well described, in patients with percutaneous kyphoplasty, anterior cervical discectomy and fusion, fracture repair, as well as in percutaneous instrumentation at cervical, thoracic and lumbar levels. Two patients who underwent transoral odontoidectomy are presented in whom isocentric fluoroscopy was utilized to provide an intra-operative CT scan. Use of this technology allowed the surgeon to detect residual bone peri-operatively, thus allowing for a more extensive decompression and excellent clinical results. Intra-operative isocentric fluoroscopy in transoral odontoidectomy allows for peri-operative detection of residual bone fragments and intra-operative confirmation of complete decompression. © 2009 Elsevier Ltd. All rights reserved.
Keywords: Arnold Chiari malformation; article; basilar impression; case report; cervical spine; child; computer assisted tomography; craniectomy; dens axis resection; Down syndrome; female; fluoroscopy; follow up; fracture fixation; human; discectomy; kyphoplasty; laminectomy; lumbar spine; male; mild cognitive impairment; muscle hypertonia; nuclear magnetic resonance imaging; perioperative period; peroperative care; physical examination; postoperative care; preschool child; priority journal; radiography; range of motion; sleep disordered breathing; spinal cord compression; spinal cord surgery; spine surgery; subluxation; surgical approach; surgical technique; thoracic spine; three dimensional imaging; tracheostomy; traction therapy; Miami-J; Siremobil Iso

Multidisciplinary management of Hunter syndrome - Muenzer J.; Beck M.; Eng C.M.; Escolar M.L.; Giugliani R.; Guffon N.H.; Harmatz P.; Kamin W.; Kampmann C.; Koseoglu S.T.; Link B.; Martin R.A.; et al. (Pediatrics, 2009)
Hunter syndrome is a rare, X-linked disorder caused by a deficiency of the lysosomal enzyme iduronate-2-sulfatase. In the absence of sufficient enzyme activity, glycosaminoglycans accumulate in the lysosomes of many tissues and organs and contribute to the multisystem, progressive pathologies seen in Hunter syndrome. The nervous, cardiovascular, respiratory, and musculoskeletal systems can be involved in individuals with Hunter syndrome. Although the management of some clinical problems associated with the disease may seem routine, the management is typically complex and requires the physician to be aware of the special issues surrounding the patient with Hunter syndrome, and a multidisciplinary approach should be taken. Subspecialties such as otorhinolaryngology, neurosurgery, orthopedics, cardiology, anesthesiology, pulmonology, and neurodevelopment will all have a role in management, as will specialty areas such as physiotherapy, audiology, and others. The important management topics are discussed in this review, and the use of enzyme-replacement therapy with recombinant human iduronate-2-sulfatase as a specific treatment for Hunter syndrome is presented. Copyright © 2009 by the American Academy of Pediatrics.
Keywords: epinephrine; anticonvulsive agent; antihistaminic agent; beta adrenergic receptor stimulating agent; corticosteroid; glycosaminoglycan; iduronate 2 sulfatase; placebo; airway obstruction; anaphylaxis; audiology; behavior disorder; bronchoscopy; carpal tunnel syndrome; clinical assessment; clinical feature; clinical trial; communicating hydrocephalus; controlled clinical trial; decompression surgery; diagnostic imaging; drug dose reduction; drug eruption; drug fever; drug induced headache; drug tolerability; drug withdrawal; dysphagia; echocardiography; enzyme activity; enzyme replacement; erythema; fibroblast; flushing; genotype; hearing aid; hearing impairment; heart disease; human; Hunter syndrome; Hurler syndrome; intubation; lung function test; lysosome; multiple organ failure; myringotomy; nerve cell differentiation; nervous system injury; nuclear magnetic resonance imaging; optic nerve lesion; orthopedic surgery; palliative therapy; phenotype; physical examination; physiotherapy; plasma transfusion; positive end expiratory pressure; priority journal; randomized controlled trial; review; seizure; short stature; side effect; skeleton malformation; spinal cord compression; stem cell transplantation; terminal care; tooth malformation; tracheotomy; upper respiratory tract obstruction; urticaria; valvular heart disease; X chromosome linked disorder; elaprase

Delayed homicides and the proximate cause. - Lin P.; Gill J.R. (The American journal of forensic medicine and pathology : official publication of the National Association of Medical Examiners, 2009)
Delayed homicides result from complications of remote injuries inflicted by "the hands of another." The investigation of delayed homicides may be a challenge due to a number of factors including: failure to report the death to the proper authorities, lack of ready and adequate documentation of the original injury and circumstances, and jurisdictional differences between the places of injury and death. The certification of these deaths also requires the demonstration of a pathophysiologic link between the remote injury and death. In sorting through these issues, it is helpful to rely upon the definition of the proximate cause of death. Over a 2-year period in New York City, there were 1211 deaths certified as homicide of which 42 were due to injuries sustained greater than 1 year before death. The survival interval ranged from 1.3 to 43.2 years. The most common immediate causes of death were: infections (22), seizures (7), and intestinal obstructions/hernias (6). Common patterns of complications included infection following a gunshot wound of the spinal cord, seizure disorder due to blunt head trauma, and intestinal obstruction/hernia due to adhesions from an abdominal stab wound. Spinal cord injuries resulted in paraplegia in 14 instances and quadriplegia in 8. The mean survival interval for paraplegics was 20.3 years and 14.8 years for quadriplegics; infections were a frequent immediate cause of death in both groups, particularly infections due to chronic bladder catheterization. The definition of proximate cause originated with civil law cases and was later applied to death certification as the proximate cause of death. The gradual extinction of the "year and a day rule" for the limitation of bringing homicide charges in delayed deaths may result in more of these deaths going to trial. Medical examiners/coroners must be able to explain the reasoning behind these death certifications and maintain consistent standards for the certification of all delayed deaths due to any injury (homicides, suicides, and accidents).
Keywords: anticoagulant agent; adolescent; adult; aged; article; bleeding; catheter infection; cause of death; child; death certificate; female; forensic medicine; graft rejection; hernia; homicide; human; infection; intestine obstruction; liver transplantation; lung embolism; male; middle aged; mortality; paraplegia; penetrating trauma; quadriplegia; renal replacement therapy; seizure; spinal cord injury; statistics; time; tracheostomy; United States; vein thrombosis

Osteoradionecrosis of the cervical spine presenting with quadriplegia in a patient previously treated with radiotherapy for laryngeal cancer: A case report - Van Wyk F.C.; Sharma M.-P.; Tranter R. (Journal of Medical Case Reports, 2009)
Introduction. Osteoradionecrosis of the mandible and temporal bones has been extensively reported in literature, but cases of avascular necrosis of the cervical spine following radiotherapy to the larynx appear to be extremely rare. A review of the English language literature has shown only one other case where radiotherapy treatment of a laryngeal carcinoma has resulted in osteoradionecrosis of the cervical spine. Case presentation. We present the case of a 65 year old male patient who suffered from osteoradionecrosis of the cervical spine 20 years after radiotherapy treatment for a T1aN0M0 laryngeal carcinoma resulting in quadriplegia. Conclusions. Radiotherapy carries a long-term risk of complications, including osteoradionecrosis which may present 20 years later with significant implications. © 2009 licensee BioMed Central Ltd.
Keywords: analgesic agent; adult; article; bone necrosis; cancer staging; case report; cellulitis; cervical spine osteoradionecrosis; dizziness; external beam radiotherapy; fibrosis; follow up; histopathology; hoarseness; human; human tissue; laryngeal biopsy; laryngectomy; laryngoscopy; larynx carcinoma; male; neck pain; neurosurgery; nuclear magnetic resonance imaging; paresthesia; priority journal; quadriplegia; radiation injury; shoulder pain; spinal cord compression; squamous cell carcinoma; tracheostomy; walking difficulty

Tracheostomy timing in traumatic spinal cord injury - Romero J.; Vari A.; Gambarrutta C.; Oliviero A. (European Spine Journal, 2009)
The study conducted is the retrospective study and the main objective is to evaluate the benefits and safety of early versus late tracheostomy in traumatic spinal cord injury (SCI) patients requiring mechanical ventilation. Tracheostomy offers many advantages in critical patients who require prolonged mechanical ventilation. Despite the large amount of patients treated, there is still an open debate about advantages of early versus late tracheostomy. Early tracheostomy following the short orotracheal intubation is probably beneficial in appropriately selected patients. It is a retrospective clinical study and we evaluated clinical records of 152 consecutive trauma patients who required mechanical ventilation and who received tracheostomy. The results show that the early placement (before day 7 of mechanical ventilation) offers clear advantages for shortening of mechanical ventilation, reducing ICU stay and lowering rates of severe orotracheal intubation complication, such as tracheal granulomas and concentric tracheal stenosis. On the other hand, we could not demonstrate that early tracheostomy avoids neither risk of ventilator-associated pneumonia nor the mortality rate. In SCI patients, the early tracheostomy was associated with shorter duration of mechanical ventilation, shorter length of ICU stay and decreased laryngotracheal complications. We conclude by suggesting early tracheostomy in traumatic SCI patients who are likely to require prolonged mechanical ventilation. © 2009 Springer-Verlag.
Keywords: adolescent; adult; aged; article; artificial ventilation; bleeding; controlled study; endotracheal intubation; female; granuloma; hospitalization; human; intensive care unit; logistic regression analysis; major clinical study; male; medical record; mortality; multivariate analysis; pneumonia; priority journal; spinal cord injury; trachea stenosis; tracheostomy; wound dehiscence

Placement and complications of cervical pedicle screws in 144 cervical trauma patients using pedicle axis view techniques by fluoroscope - Yukawa Y.; Kato F.; Ito K.; Horie Y.; Hida T.; Nakashima H.; MacHino M. (European Spine Journal, 2009)
Cervical pedicle screw fixation is an effective procedure for stabilising an unstable motion segment; however, it has generally been considered too risky due to the potential for injury to neurovascular structures, such as the spinal cord, nerve roots or vertebral arteries. Since 1995, we have treated 144 unstable cervical injury patients with pedicle screws using a fluoroscopy-assisted pedicle axis view technique. The purpose of this study was to investigate the efficacy of this technique in accurately placing pedicle screws to treat unstable cervical injuries, and the ensuing clinical outcomes and complications. The accuracy of pedicle screw placement was postoperatively examined by axial computed tomography scans and oblique radiographs. Solid posterior bony fusion without secondary dislodgement was accomplished in 96% of all cases. Of the 620 cervical pedicle screws inserted, 57 (9.2%) demonstrated screw exposure (<50% of the screw outside the pedicle) and 24 (3.9%) demonstrated pedicle perforation (>50% of the screw outside the pedicle). There was one case in which a probe penetrated a vertebral artery without further complication and one case with transient radiculopathy. Pre- and postoperative tracheotomy was required in 20 (13.9%) of the 144 patients. However, the tracheotomies were easily performed, because those patients underwent posterior surgery alone without postoperative external fixation. The placement of cervical pedicle screws using a fluoroscopy-assisted pedicle axis view technique provided good clinical results and a few complications for unstable cervical injuries, but a careful surgical procedure was needed to safely insert the screws and more improvement in imaging and navigation system is expected. © 2009 Springer-Verlag.
Keywords: adolescent; adult; aged; article; bone radiography; cervical spine injury; computer assisted tomography; controlled study; female; fluoroscopy; fracture fixation; human; major clinical study; male; pedicle screw; postoperative complication; priority journal; radiculopathy; tracheotomy; treatment outcome

Circumferential fixation with craniofacial miniplates for a cervical spine injury in a child: Case report - Patel N.B.; Hazzard M.A.; Ackerman L.L.; Horn E.M. (Journal of Neurosurgery: Pediatrics, 2009)
Unstable pediatric cervical spine injuries present significant challenges in terms of fixation. Given the smaller cervical vertebral bodies in the preschool-aged population, commercially available pediatric cervical fixation instrumentation may be unsuitable because of the inappropriately large size of the screws and plates. The authors describe a 2-year-old girl who sustained an unstable C6-7 distraction injury during a motor vehicle accident. Because of the small size of her vertebral bodies, standard cervical spine instrumentation was not feasible, and posterior wiring alone was believed to be insufficient because of the complete distraction of all 3 spinal columns. The patient was taken to the operating room where craniofacial plates with an inherent locking mechanism were used to circumferentially stabilize the cervical spine. Follow-up examination 6 months postoperatively demonstrated stable cervical spine alignment and fusion with no evidence of the failure of either the anterior or posterior hardware. The use of craniofacial miniplates with an intrinsic locking mechanism represents a superior alternative for both anterior and posterior cervical fixations when spinal instrumentation is needed in the pediatric age group.
Keywords: article; artificial ventilation; bone plate; case report; cervical spine injury; cervical spine radiography; child; computed tomographic angiography; feeding apparatus; female; follow up; general anesthesia; hospital discharge; human; interlocking nail; intubation; lung contusion; neck; neurologic examination; nuclear magnetic resonance imaging; operating room; plate fixation; postoperative period; preschool child; priority journal; spine fusion; spine stabilization; suture; tracheostomy; traffic accident; vertebra body; vertebral artery

Concomitant distal aortic perfusion and passage of a retrograde aortic occlusion balloon for complex aortic operations - Watson D.; Barbosa R.; Ansel G. (Interactive Cardiovascular and Thoracic Surgery, 2009)
Objectives: We investigated a unique method utilising a Heartport bifurcated arterial cannula and a compliant aortic occlusion balloon (CODA, Cook, Inc.) to provide both distal perfusion and provide bloodless distal arterial occlusion in thoraco-abdominal aneurysm repair. Methods: Between February 2002 and September 2008, 21 patients (4 urgent, 17 elective) underwent thoracic or thoracoabdominal aortic repair with this method. Due to an inability or potential difficulty in gaining distal aortic control because of anatomic or technical difficulty, a CODA balloon was passed through the accessory arterial channel using fluoroscopic guidance. Adjunctive cerebrospinal drainage was used in all cases. Results: Balloon deployment and satisfactory occlusion was attained in all cases. The overall 30-day mortality rate was 9%. Among urgent patients, the mortality rate was 50% vs. 0% for elective patients. Renal failure occurred in 9% of cases. Six patients (28%) had pulmonary complications. Transient encephalopathy occurred in two patients. Spinal cord neurologic deficit and stroke were avoided in all patients. There was no incidence of significant arterial injury, although one patient required femoral patch arterioplasty at the completion of decannulation. Conclusions: Distal aortic perfusion and passage of a retrograde aortic occlusion balloon did not increase the incidence of death and morbidity to a greater rate than with conventional methods of distal aortic control. We recommend the application of this method to maintain ongoing distal aortic perfusion in instances where distal control with a clamp is not feasible or creates the potential for catastrophic intraoperative bleeding.
Keywords: perfusion; balloon occlusion; thorax surgery; aortic occlusion; patient; mortality; brain disease; spinal cord; cerebrovascular accident; artery injury; artery reconstruction; death; morbidity; clamp; artery occlusion; aneurysm; cannula; aortic reconstruction; occlusion; kidney failure; bleeding

Apnea and macrocephaly-cutis marmorata telangiectatica congenita - Franklin B.; Gasco J.; Rangel-Castilla L.; Nauta H.J.W. (Brain and Development, 2009)
The authors report a case of an infant girl with macrocephaly-cutis marmorata telangiectatica congenita (Macrocephaly-CMTC). This patient presented with developmental delay, mild subcostal retractions, and occasional apneic spells. An MRI demonstrated mild to moderate lateral ventricle hydrocephalus, left hemi-megalencephaly, and left cerebellar tonsillar herniation with full occlusion of the cisterna magna. Her foramen magnum was narrowed, measuring 17.5 mm in transverse diameter. This value was significantly below the 50th percentile for age, which is 23.5 mm. Together, these findings were suggestive of cervicomedullary cord compression, concerning for sudden death. The patient underwent posterior fossa decompression by suboccipital craniectomy and cervical laminectomy. Initially due to hypertrophy and paralysis of the left true and false vocal cords, endotracheal intubation was not achieved, requiring tracheostomy tube placement. To our knowledge this is the first report of apnea in a patient diagnosed with M-CMTC, likely due to cervicomedullary cord compression and perhaps exacerbated by unilateral laryngeal hypertrophy. M-CMTC is a newly-described hemi-hypertrophy syndrome affecting the neurodevelopment of affected children. The authors emphasize airway obstruction secondary to unilateral hypertrophy of the vocal cords in addition to brainstem compromise as a consideration for the etiology of apnea in M-CMTC patients presenting with signs and symptoms of cervicomedullary cord compression. © 2008 Elsevier B.V. All rights reserved.
Keywords: Alexander disease; apnea; article; brain hernia; case report; craniectomy; cutis marmorata telangiectatica congenita; female; human; hydrocephalus; infant; laminectomy; nuclear magnetic resonance imaging; physical examination; spinal cord compression; sudden death; tracheostomy; vocal cord paralysis

Critical care after major trauma: We need to think beyond the unit - Lavery G.G.; Bhavsar M. (British Journal of Intensive Care, 2009)
To facilitate the delivery of best care to the victim of major trauma, intensivists need to have knowledge in areas beyond the boundaries of mainstream critical care. Early in trauma care, key decisions regarding the need for damage control surgery should be made with input from critical care staff. The major trauma victim should have a tertiary trauma assessment to reduce the risk of missed injuries. The management of patients with potential spinal instability should reflect that prolonged immobilisation, while possibly reducing the risk of worsening neurological damage, is also a significant safety risk. Appropriate use of imaging should ensure very few patients, without demonstrable spinal injury, have spinal precautions in force for more than 48-72 hrs. Knowledge of compartment syndromes (extremity and abdominal) will assist in the early recognition and management of these conditions. Issues such as, 1) long-term management of patients with tracheostomy and 2) the potential for rehabilitation should be addressed as part of the critical care treatment plan for the trauma patent.
Keywords: abdominal compartment syndrome; chronic obstructive lung disease; clinical assessment; compartment syndrome; exercise tolerance; follow up; health care management; health care personnel; human; immobilization; intensive care unit; laparotomy; limb; long term care; medical decision making; nervous system injury; patient care; patient safety; quality of life; review; risk; spine injury; spine instability; tracheostomy; treatment planning

Chiari-I “Benign but not so Benig” - A clinical case - Vora N.; Steers A.J.W.; Verity K.; Baxter A.; McLellan A.E. (European Journal of Paediatric Neurology, 2009)
Introduction: Chiari-I malformation is often asymptomatic and found incidentally on neuroimaging. This case highlights a rare and devastating complication of the condition. Case History: A previously well 13year girl with normal development presented to local hospital with 4 days history of cough, cold, left ear pain and ear discharge. She had headache, neck stiffness, vomitting, high temperature and was confused. She was thought to have meningitis and appropriate management was started. Two hours after admission she had an acute episode of tonic posturing, desaturation and apnoea. She was intubated for ventilation. On examination she was making no respiratory effort and had no spontaneous movement. Her pupils were reactive and eye movements intact. Investigations revealed elevated inflammatory markers. Blood and CSF PCRs negative for routine bacterial and viral pathology. CT Brain showed herniation of cerebellar tonsils through foramen magnum. MRI Brain revealed bilateral cerebellar infarcts, herniation of cerebellar tonsils through foramen magnum, consistent with coning and upper cervical cord and lower brain stem ischemia in the territory of PICA In an attempt to prevent further cord ischaemia she had a posterior cranio-vertebral decompression to C3 and resection of infracted cerebellum and cerebellar tonsils. She remains ventilated via a tracheostomy and undergoing Neurorehabilitation. Neuropsychology assessment demonstrated intact cognitive function. Discussion: She had an underlying Chiari-I malformation and coincidental acute otitic inflammatory process produced vascular changes and swelling within the posterior fossa and foraminal impaction which led to an increasingly severe ischemia, resulting in cerebellar infarction and infarction of lower medulla and upper end of cervical spinal cord. Chiari-I is thought to be benign and if asymptomatic should not require treatment but very rarely it can lead to life threatening brainstem coning. Chiari-I is generally a benign condition but not so benign in this case.
Keywords: marker; society; ischemia; tonsil; infarction; cervical spinal cord; brain; Arnold Chiari malformation; hernia; foramen magnum; brain stem; tracheostomy; neuropsychology; cognition; inflammation; swelling; posterior fossa; cerebellum infarction; neuroimaging; girl; development; hospital; coughing; otalgia; ear; headache; rigidity; high temperature; neck; cerebellum; nuclear magnetic resonance imaging; meningitis; fatty acid desaturation; apnea; air conditioning; examination; eye movement; blood; pathology; decompression; surgery; cerebrospinal fluid

Coexistence of Guillain-Barre syndrome and ADEM in patient with ovarium teratoma-case report - Dunin-Wasowicz D.; Jurkiewicz E.; Jozwiak S. (European Journal of Paediatric Neurology, 2009)
Objective: Neuroimmunological diseases are not rare in children however, coexistence Guillain-Barre syndrome (GBS) and ADEM is unusual. Methods: description of the clinical symptoms and signs, examinations results, treatment and follow-up of the patient. Results: 14 year old girl was admitted to our Department with sudden weakness of lower limbs, swallowing and superficial sensibility disturbances in legs and arms. She suffered from the upper respiratory tract infection without fever for a few days, before the onset of the neurological symptoms and signs. Neurological examination displayed flaccid paresis of all limbs without deep tendon reflexes, swallowing and superficial sensibility disturbances, weak pharyngeal reflex, silent speech and dyspnoea enabling diagnosis of GBS. Only few hours later respiratory failure with consciousness disturbances and anisocoria occurred and she was admitted to the Intensive Care Unit. At that moment MRI brain scans were normal, as well as the one repeated during the second week of the disease. She was treated with artificial ventilation, plasmaferesis (11), immunoglobulins, different steroids, antibiotics, antifungal drugs and rehabilitation. Tracheostomy was also necessary. Three weeks after the onset of the neurological symptoms, brain MRI revealed hypodensic cotrical and subcortical changes in the white matter in both cerebral and cerebellar heminspheres, and spinal cord MRI was normal(ADEM). No response was found in the motor and sensory fibres in NCS examination. BAEP was abnormal with left side lateralization and EEG featured brain oedema. Lumbar puncture was unsuccessful (mother disagreed). After two months, brain MRI revealed regression of the changes and NCS examination presented features of axonal-demyelinating neuropathy. All virological tests and bacterial cultures were negative. The patient presented high hypercalcemia. After five months from the onset of the disease, resection of teratoma in both ovaries was performed. The girl recovered without any disabilities. Conclusion: We diagnosed severe paraneoplastic syndrome.
Keywords: antifungal agent; immunoglobulin; steroid; case report; teratoma; Guillain Barre syndrome; ovary; society; hospital patient; nuclear magnetic resonance imaging; examination; brain; patient; girl; sensibility; leg; neurologic disease; swallowing; hypercalcemia; surgery; disability; paraneoplastic syndrome; follow up; weakness; arm; upper respiratory tract infection; fever; neurologic examination; flaccid paralysis; limb; tendon reflex; reflex; speech; dyspnea; diagnosis; respiratory failure; demyelinating neuropathy; electroencephalogram; consciousness; anisocoria; intensive care unit; brain scintiscanning; artificial ventilation; rehabilitation; tracheostomy; white matter; spinal cord; fiber; edema; lumbar puncture; mother; bacterium culture; child

Airway management in patients with facial trauma - Mohan R.; Iyer R.; Thaller S. (Journal of Craniofacial Surgery, 2009)
Management of the airway is a major concern in patients with maxillofacial trauma (gunshot wounds, facial fractures, cervical spine injuries, laryngotracheal injuries) because a compromised airway can lead to death. The method of intubation to use in these patients remains a controversial topic. Although there are many options available, each one has specific indications, and the choice will ultimately depend on the patient's situation and the expertise of the trauma team. In general, endotracheal intubation is usually not a viable option, but nasotracheal intubation and tracheotomies can be performed. Yet, these 2 procedures are known to also have complications. Two interesting alternatives that can be opted for are the submental and submandibular intubation techniques. © 2009 Mutaz B. Habal, MD.
Keywords: aerophagia; airway; airway obstruction; article; atelectasis; bleeding; cervical spine injury; death; dysphagia; edema; emergency surgery; endotracheal intubation; face fracture; gunshot injury; human; hypotension; infection; keloid; laryngeal nerve; larynx injury; long term care; lung clearance; lung hemorrhage; maxillofacial injury; nasotracheal intubation; nerve injury; pneumonia; priority journal; subcutaneous emphysema; trachea injury; trachea stenosis; tracheoesophageal fistula; tracheotomy

External Control of Exhalation for Cough Assistance: A Method for Patients With Glottis Dysfunction and/or Tracheostomy - Lee S.C.; Park J.H.; Kang S.-W.; Kim D.H.; Song S.H. (Archives of Physical Medicine and Rehabilitation, 2009)
Lee SC, Park JH, Kang S-W, Kim DH, Song SH. External control of exhalation for cough assistance: a method for patients with glottis dysfunction and/or tracheostomy. Objective: To investigate the effectiveness of our method of assisting a cough by mimicking the functions of the glottis in patients with bulbar muscle weakness or paralysis and/or those who had a tracheostomy tube. Design: Before-after trial. Setting: University rehabilitation hospital. Participants: Patients (N=35) with bulbar muscle weakness or paralysis and/or those who had a tracheostomy tube. Interventions: Not applicable. Main Outcome Measures: The unassisted peak cough flow (PCF), the assisted PCF, and the assisted PCF with the external control method mimicking glottis function by an end-inspiratory external closure of the airways. Results: Of the 35 patients, 13 were tracheostomized cervical cord injury patients, 11 were neuromuscular disease (NMD) patients with glottis dysfunction only, and 11 were NMD patients with a tracheostomy and glottis dysfunction. Assisted PCF with the external control method were higher than unassisted PCF and/or assisted PCF in all patients. Assisted PCF with the external control methods were measured in all of the patients even when the unassisted PCFs and/or assisted PCFs could not be measured. For patients with measurable assisted PCFs, the assisted PCF with the external control methods were significantly higher than the assisted PCFs. Conclusions: We showed the effectiveness of our method of assisting a cough by external control of the glottis in patients with bulbar muscle weakness or paralysis and/or those who had a tracheostomy tube who cannot effectively cough with the help of existing cough assistance methods. © 2009 American Congress of Rehabilitation Medicine.
Keywords: adult; article; bulbar paralysis; cervical spinal cord injury; clinical article; coughing; exhalation; female; glottis; human; larynx disorder; male; neuromuscular disease; peak expiratory flow; tracheostomy

Posttraumatic tracheal stenosis after complex fracture of the upper cervical spine : A rare complication - Dudda M.; Frangen T.M.; Muhr G.; Schinkel C. (Unfallchirurg, 2009)
Combined injuries of the upper cervical spine are rare and can lead to life-threatening positional changes of the respiratory tract. Hence, it is very important to recognize tracheal and soft tissue injuries and to treat these adequately. We report on the clinical course and outcome of a case with a delayed high-grade tracheal stenosis after cervical spine injury, which could only be treated by emergency tracheotomy and partial transverse trachea resection.The 25-year-old female suffered a complex dislocated upper cervical spine fracture with a Jefferson fracture, an odontoid fracture and a dislocated C6/7 luxation fracture after a motor vehicle accident. Immediately after trauma inspiratory stridor was reported. Postoperatively, the tracheal stenosis increased and the histological examination of tissue collected during emergency bronchoscopy showed granulation tissue.Even if fractures of cervical spine injuries are treated successfully, soft tissue and tracheal injuries cannot be precluded. Therefore, it is most important that such patients are followed-up closely to classify the problem and to determine the ideal time for surgical treatment of tracheal injuries and stenoses. © 2009 Springer Medizin Verlag.
Keywords: adult; article; bronchoscopy; case report; cervical spine fracture; female; granulation tissue; histopathology; human; human tissue; odontoid process fracture; stridor; trachea resection; trachea stenosis; tracheotomy; traffic accident

Experimental study of a late response recorded from the thoracic wall after phrenic nerve stimulation - Rouaud T.; Magot A.; Guihéneuc P.; Perrouin Verbe B.; Truffert A.; Péréon Y. (Clinical Neurophysiology, 2009)
Objectives: The phrenic nerve cervical stimulation induces an early motor diaphragmatic M response that may be recorded from the 7th ipsilateral intercostal space (ICS). Some responses with prolonged latency and of unclear origin can be recorded from the same recording site. The aim of the study was to determine the electrophysiological characteristics and the neuroanatomical pathways underlying the long-latency responses (LLRs) recorded from the 7th ICS. Methods: We studied seven healthy volunteers, five patients with spinal cord injury and five patients with diaphragmatic palsy. All underwent phrenic nerve conduction study. An LLR was sought for at different stimulation sites using various stimulus intensities. Results: A polyphasic LLR was recorded from the 7th ICS in all healthy subjects. It was mainly elicited by nociceptive stimulations, not only of the phrenic, but also of the median nerves. Its latency was longer than 70 ms, with a wide inter- and intra-individual variability. Amplitude was highly variable and some habituation phenomenon occurred. The LLR was retained in most tetraplegic patients after phrenic nerve stimulation, but absent otherwise. It was present in all patients with diaphragmatic palsy after phrenic nerve stimulation. Conclusion: The LLR is likely to be produced by both intercostal and diaphragm muscles. It is a polysynaptic and multisegmental spinal response, probably conveyed by small-diameter nociceptive A-δ and/or C fibres and modulated by a supraspinal control. Significance: The LLR recorded from the chest wall may constitute, by analogy with the nociceptive component of the lower limb flexion reflex in humans, a protective and withdrawal spinal reflex response. © 2009 International Federation of Clinical Neurophysiology.
Keywords: adult; amplitude modulation; article; artificial ventilation; brain electrophysiology; clinical article; controlled study; diaphragm paralysis; electromyogram; experimental study; female; habituation; human; intercostal nerve; latent period; male; median nerve; muscle potential; nerve conduction; nerve stimulation; neuroanatomy; nociceptive stimulation; phrenic nerve; phrenic nerve pacing; priority journal; spinal cord injury; spinal reflex; thorax wall; tracheotomy

Management of cervical spine injuries in young children: Lessons learned: Report of 2 cases - Smith J.L.; Ackerman L.L. (Journal of Neurosurgery: Pediatrics, 2009)
Previous studies have shown that the correct use of car safety seats can protect infants and children from vehicular injury. Although child passenger devices are increasingly used in the US, motor vehicle crashes continue to be the leading cause of death and acquired disability in infants and children younger than 14 years of age. These events are likely related, at least in part, to the high percentage of children who are unrestrained or improperly restrained. The authors present 2 cases of severe cervical spine trauma in young children restrained in car safety seats during a motor vehicle crash: 1) a previously healthy 14-month-old girl who was improperly restrained in a forward-facing booster seat secured to the vehicle by a lap belt, and 2) a previously healthy 30-month-old girl who was a rear seat passenger restrained in a car safety seat. This study points out the unique challenges encountered in treating cervical spine injuries in infants and young children, as well as the lessons learned, and emphasizes the significance of continuing efforts to increase family and public awareness regarding the importance of appropriate child safety seat selection and use.
Keywords: antibiotic agent; infusion fluid; methylprednisolone; article; artificial ventilation; blood analysis; blood culture; case report; cervical spine injury; cervical spine radiography; child; computer assisted tomography; death; drug megadose; female; fluoroscopy; follow up; hospital admission; hospital discharge; human; discectomy; magnetic resonance angiography; neurologic examination; nuclear magnetic resonance imaging; patient transport; pelvis radiography; preschool child; priority journal; rehabilitation center; respiratory failure; spine fusion; stomach tube; supine position; thorax radiography; tracheostomy; traffic accident; traffic safety; vital sign

Tracheostomy in the ICU: An analysis of 443 procedures - Marbán A.; López J. (Critical Care, 2009)
Introduction: The aim of this study is to analyse our experience with tracheostomies performed in the critical care unit of a tertiary university hospital. Methods: A retrospective clinical records review of patients who underwent this procedure in a 7-year period. Results: From January 2001 to December 2007, 6,333 patients were admiTed to our unit; 1,528 needed mechanical ventilation (MV) for more than 48 hours and 443 underwent tracheostomy. The median age was 56 years (14 to 88 years); 66% were male. The median APACHE II score was 20 (4 to 44). The main diagnoses were polytrauma including head injury in 24.2%, other structural neurological diseases in 21%, and prolonged weaning of various aetiologies in 35%. The percutaneous dilational technique was used in the majority of cases (90%). The mean duration of MV prior to tracheostomy was 13.8 days (SD = 6.4). The overall complication rate was 6%. Intraprocedural complications were atelectasis (0.4%) and bleeding (2%). Two of the patients needed surgical control or transfusion (0.4%). Two stoma infections developed in the open tracheostomy group. The most frequent complication was tracheal stenosis, encountered in 15 patients (3%). The ICU mortality was 20.7%. Of the 351 patients discharged from the ICU, 45.8% were decannulated prior to discharge from the ICU and 31% in the ward; 23% of them could not be decannulated at any moment. Ward mortality in the group of patients decannulated in the ICU was 5%, 10% in the patients decannulated in the ward and 37% in those who failed decannulation, for a total of 50 deaths before hospital discharge (11%). The main diagnoses of the patients who died on the ward were: residual encephalopathy in 62% (postanoxic, posTraumatic or other causes), severe chronic respiratory failure in 10%, spinal cord injury in 6%, and neuromuscular disease in 4%. Conclusions: We had a low rate of early complications, similar to other series, with no procedure-related deaths [1]. Our main complication was airway stenosis. As in other studies, patients who needed a tracheostomy belonged to a group of patients with a high severity and mortality. Some of them do not recover a satisfactory neurological and functional status to be decannulated and present a high ward mortality.
Keywords: tracheostomy; intensive care; emergency medicine; patient; ward; mortality; Tertiary (period); diagnosis; death; brain disease; chronic respiratory failure; spinal cord injury; neuromuscular disease; airway; stenosis; functional status; university hospital; medical record review; artificial ventilation; male; multiple trauma; head injury; neurologic disease; weaning; etiology; atelectasis; bleeding; transfusion; stoma; infection; trachea stenosis; hospital discharge; APACHE

Combined spinal epidural anaesthesia for ex utero intrapartum treatment (EXIT) procedure - Govindarajan A.; Atkinson S. (Anaesthesia, 2009)
EXIT (ex utero intrapartum treatment) procedure refers to surgical delivery of a fetus while maintaining fetoplacental circulation until the obstructed fetal airway has been secured. Neuraxial anaesthesia has been sparingly reported to be used as a sole anaesthetic for EXIT procedure [1]. Case report A 37-year-old multiparous woman with five previous normal deliveries presented at 36 weeks gestation with polyhydramnios. Ultrasound scan revealed a 10 x 7 cm sized cystic swelling in the fetus's submandibular region. An EXIT was planned to secure the airway either by bronchoscopy, direct laryngoscopy or tracheostomy. The mother had a potentially difficult airway (Mallampatti grade III, prominent upper incisors and receding mandible), so a combined spinal epidural anaesthetic (CSE) was performed with intrathecal 0.5% heavy bupivacaine and 300 μg diamorphine. Supplementation via epidural catheter was not required. Prior to uterine incision an intravenous infusion of nitroglycerine was started to provide uterine relaxation and delay placental separation. With the uteroplacental circulation intact, the newborn was intubated with difficulty by direct laryngoscopy, following which the umbilical cord was cut, the placenta delivered and the nitroglycerine infusion discontinued. The EXIT procedure lasted for 15 min, during which maternal hemodynamic stability was maintained. APGAR scores were 3 and 5 at 1 min and 5 min respectively following cessation of feto-placental circulation. Estimated blood loss was 800 ml and blood transfusion was not needed. Discussion EXIT procedure allows for controlled management of potentially life-threatening airway obstruction in the newborn. We successfully used neuraxial anaesthesia in conjunction with intravenous nitroglycerin to provide controlled uterine relaxation without any untoward maternal complications.
Keywords: glyceryl trinitrate; anesthetic agent; bupivacaine; diamorphine; epidural anesthesia; Ireland; United Kingdom; airway; fetus; placenta circulation; newborn; laryngoscopy; uterus relaxation; anesthesia; umbilical cord; supplementation; infusion; bleeding; blood transfusion; airway obstruction; instrumental delivery; case report; female; vaginal delivery; pregnancy; hydramnios; ultrasound; swelling; bronchoscopy; placenta; mother; incisor; mandible; epidural drug administration; tracheostomy; intrathecal drug administration; epidural catheter; uterus; incision; intravenous drug administration; Apgar score

Permanent cardiac pacemaker for cardiac arrest following cervico-dorsal spinal injury - Sanghvi A.V.; Chhabra H.S.; Nigam V.; Tandon V.; Mascarenhas A.A. (European Spine Journal, 2009)
Bradycardia and rarely cardiac arrest as a complication of cervical spine injury due to reduced sympathetic activity is well known, which usually settles down in 4-6 weeks of injury. There are few case reports in literature of high cervical spinal cord injury requiring permanent cardiac pacemaker due to this complication, but an injury as low as cervico-dorsal junction requiring permanent cardiac pacemaker has never been reported. A 47-year-old male suffered traumatic C7-D1 dislocation and continued to have severe bradycardia with multiple episodes of cardiac arrest till 2 months after injury, which finally warranted permanent cardiac pacemaker as a life saving measure. Following permanent cardiac pacemaker no cardiac arrest occurred and the patient was successfully rehabilitated. The case directs our attention to a rare complication of cardiac arrest occurring in an injury as low as cervico-dorsal junction when all other causes are ruled out and shows importance of using permanent cardiac pacemaker to ensure patient safety in community. © 2009 Springer-Verlag.
Keywords: antiinfective agent; atropine; ephedrine; oxygen; adult; article; attention; blood gas; bone graft; case report; cervical spine; cervical spine dislocation; cervical spine injury; community; cortical bone; dyspnea; electrocardiogram; heart arrest; heart massage; heart rate; heart rehabilitation; human; hypotension; infection; life; low drug dose; male; nuclear magnetic resonance imaging; oxygen saturation; patient safety; priority journal; sinus bradycardia; sinus node; tracheostomy; ventilator

Juvenile familial ALS: an autopsy case involving multiple systems with basophilic inclusions - Mochizuki Y.; Isozaki E.; Hashimoto T.; Shibuya M.; Oyanagi K.; Mizutani T. (Neuropathology, 2009)
A 40-year-old woman had clinical diagnosis of familial ALS with 27 years duration of illness. Muscle weakness progressed rapidly resulting into tracheostomy positive pressure ventilation started 1.5 years from the onset. After 2.5 years, had not been able to move even a bit voluntarily. The brain weighed 715 g. The frontal lobe was especially atrophic, and the brainstem and the spinal cord were thin. Neuronal loss of the motor nuclei in the spinal cord and brainstem, and fiber loss of the corticospinal tract were marked. The findings in the involved areas, such as the globus pallidus, substantia nigra, and Clarke's column, resembled those of respirator-assisted long survival sporadic ALS cases. Basophilic cytoplasmic inclusions (BI) were found in the spinal anterior horns, reticular formation, striatum, frontal cortex, pontine nuclei and cerebellar dentate nucleus. The inclusions were TDP-43-, α-internexin-negative. Although the clinical progression of this patient was rapid as the juvenile ALS cases with BI, the degeneration was more extensive in this case. The limbic system was well preserved, and the finding was different form that in basophilic inclusion body disease.
Keywords: neuropathology; society; juvenile; autopsy; Japanese (people); brain stem; cell inclusion; spinal cord; globus pallidus; substantia nigra; ventilator; survival; spinal cord ventral horn; reticular formation; corpus striatum; frontal cortex; dentate nucleus; patient; degeneration; limbic system; female; diagnosis; muscle weakness; tracheostomy; positive end expiratory pressure; brain; frontal lobe; motoneuron nucleus; fiber; pyramidal tract; general aspects of disease

An autopsy case of motor neuron disease presented with oculomotor palsy - Konno H.; Tanaka Y.; Takahashi T.; Yoshioka M.; Onodera H. (Neuropathology, 2009)
He felt a difficulty in breathing and uneasy pronunciation at 8 months before death, when he was 81 years old. About 3 months later, he had lost any abilities of speaking, swallowing and writing because of his generalized muscular weakness. He had a tracheotomy, and assist ventilation was started. At the 4th month after the disease onset, the oculomotor palsy was appeared and increased. The poor response of doll's eye and Bell's phenomenon suggested that it was infranuclear paralysis. Histopathology disclosed loss of motoneurons and gliosis in the anterior horn of spinal cord, 12th and 7th cranial nerve nuclei and ambiguus nucleus. Bunina bodies and round bodies, mmunopositive for ubiquitin and TDP-43 antibodies, were also seen in the remnant neurons. The 3rd and 6th cranial nerve nuclei, concerning to oculomotor function, showed mild neuronal loss and the presence of inclusion bodies, same as those seen in the other motor neurons. Betz' giant cells were lost from cerebral motor cortex. There was pyramidal tract degeneration in the cord and brain stem. The neurogenic muscular atrophy was seen.
Keywords: ubiquitin; antibody; society; Japanese (people); autopsy; ophthalmoplegia; motor neuron disease; neuropathology; cranial nerve; motoneuron; histopathology; eye; spinal cord ventral horn; spinal cord; ambiguus nucleus; gliosis; nerve cell; eye movement control; giant cell; motor cortex; pyramidal tract; degeneration; brain stem; hereditary motor sensory neuropathy; death; speech; breathing; swallowing; writing; muscle weakness; air conditioning; tracheotomy; paralysis; cell inclusion

Hypoventilation after spinal cord injury - Castriotta R.J.; Murthy J.N. (Seminars in Respiratory and Critical Care Medicine, 2009)
There are ∼12,000 new cases per year in the United States of spinal cord injury (SCI) with life expectancies from 11 to 14 years (ventilator dependent) to 44 years (non-ventilator dependent). Those with SCI (C2-C8) are at great risk for developing hypoventilation, especially during sleep, and this risk increases along with the risk of sleep disordered breathing as they age. Most will have significantly reduced vital capacity and ventilatory reserve because of interruption of neural pathways to the diaphragm, chest, and abdomen, resulting in a restrictive ventilatory impairment with intact diffusing capacity. Diagnosis entails measurement of pCO2 with capnography both awake and during sleep, optimally along with polysomnography to evaluate for all forms of sleep disordered breathing. Treatment options include diaphragmatic pacing, full positive pressure ventilation through tracheostomy, and noninvasive positive pressure ventilation. Some may require mechanical ventilation only during sleep. Copyright © 2009 by Thieme Medical Publishers, Inc.
Keywords: artificial ventilation; breathing muscle; capnometry; diaphragm paralysis; disease association; electromyogram; endotracheal intubation; human; hypoventilation; life expectancy; lung function test; muscle training; negative pressure ventilation; nerve stimulation; pathophysiology; polysomnography; positive end expiratory pressure; priority journal; review; sleep disordered breathing; spinal cord injury; tracheostomy; ventilator; ventral root; vital capacity

Editorial: Percutaneous tracheostomy coming of age for the neurointensivist? - Hoekema D. (Neurocritical Care, 2009)
Keywords: bleeding; editorial; endotracheal tube; health care cost; intensive care; lower respiratory tract infection; neurosurgery; pneumothorax; priority journal; spinal cord injury; surgical infection; trachea injury; trachea stenosis; tracheostomy; traumatic brain injury

Airway management in trauma - Langeron O.; Birenbaum A.; Amour J. (Minerva Anestesiologica, 2009)
Maintenance of a patent and prevention of aspiration are essential for the management of the trauma patient, that requires experienced physicians in airway control techniques. Difficulties of the airway control in the trauma setting are increased by the vital failures, the risk of aspiration, the potential cervical spine injury, the combative patient, and the obvious risk of difficult tracheal intubation related to specific injury related to the trauma. Endotracheal intubation remains the gold standard in trauma patient airway management and should be performed via the oral route with a rapid sequence induction and a manual in-line stabilization maneuver, to decrease the risks previously mentioned. Different techniques to control the airway in trauma patients are presented: improvement of the laryngoscopic vision, lighted stylet tracheal intubation, retrograde technique for orotracheal intubation, the laryngeal mask and the intubating laryngeal mask airways, the combitube and cricothyroidotomy. Management of the airway in trauma patients requires regular training in these techniques and the knowledge of complementary techniques allowing tracheal intubation or oxygenation to overcome difficult intubation and to prevent major complications as hypoxemia and aspiration.
Keywords: etomidate; midazolam; suxamethonium; airway obstruction; anesthesia; aspiration; cervical spine injury; conference paper; drug mechanism; endotracheal intubation; epistaxis; extracorporeal oxygenation; human; hypoxemia; laryngeal mask; laryngoscopy; lung injury; nose injury; spine stabilization; tracheotomy; Combitude

Crisis resource management of the airway in a patient with klippel-feil syndrome, congenital deafness, and aortic dissection - Khawaja O.M.; Reed J.T.; Shaefi S.; Chitilian H.V.; Sandberg W.S. (Anesthesia and Analgesia, 2009)
Klippel-Feil syndrome is a visually arresting deformity wherein severe restriction of cervical motion predicts a difficult airway. Even minor distraction of the neck risks cervical spine or neurologic injury, so regional techniques, awake fiberoptic intubation, or awake tracheostomy are recommended anesthetic approaches. We present a case of aortic dissection in a Klippel-Feil syndrome patient for whom congenital bilateral deafness, coupled with the urgency of the surgery, mitigated against the recommended first-choice techniques. Using anesthesia crisis resource management methods, a multi-member team rehearsed predefined roles and then managed the airway via inhaled induction of anesthesia, followed by flexible fiberoptic intubation. © 2009 International Anesthesia Research Society.
Keywords: esmolol; nitroprusside sodium; suxamethonium; adult; airway; anesthesia; anesthesia induction; aortic dissection; article; case report; congenital deafness; fiber optics; human; intubation; Klippel Feil syndrome; male; priority journal; resource management; surgical technique

Respiration and amyotrophic lateral sclerosis/motor neuron disease: The role of the diaphragm after a decade of experience with diaphragm pacing - Onders R.; Katirji B.; Schilz R.; Elmo M.J.; Kaplan C.; Ignagni A. (Amyotrophic Lateral Sclerosis, 2009)
Background: Diaphragm pacing (DPS) has been used in a series of trials to help respiration ranging from spinal cord injured (SCI) patients with pure upper motor neuron (UMN) loss of control to patients with pure lower motor neuron (LMN) loss from phrenic nerve transection along with direct analysis of stimulation of normal subject diaphragms. ALS/MND involves both UMN and LMN involvement of the diaphragm. Objectives: To describe how ALS/MND diaphragm pathophysiology can affect respiration. Methods: Prospective, nonrandomized, controlled, interventional trials under IRB and/or FDA approval for use of DPS in human subjects at a single institution. Comparisons of diaphragm function from normal to different diseases states were compared to ALS/MND. Results: From 1999 to 2009 over 128 human diaphragms were surgically evaluated for motor point stimulation for ventilation with over 250 patient-years of DPS use. Subjects ranged from 12 weeks to 77 years old. Diaphragm evaluations included normal subjects undergoing elective laparoscopy to SCI patients on ventilators over 25 years. ALS/MND diaphragms evaluated varied from FVC of 89% predicted to continuous mechanical ventilation with tracheostomy for 18 months. Pre-operative pulmonary function tests do not predict surgical stimulation results. Patients can have high FVC but poor diaphragm function or low FVC and excellent stimulatable diaphragms. ALS/MND involvement of the diaphragm is heterogeneous. It can be visualized as radial bands or regions of loss of motor units and can functionally involve each hemi-diaphragm differently. Using frequency stimulation to differentiate muscle fiber type, ALS/MND diaphragms that had primarily UMN involvement or suppression of diaphragm function with NIV demonstrated conversion to fast twitch (type IIb) muscle fibers. DPS can convert ALS/MND diaphragms to more functional type I muscle fibers. Used in conjunction with NIV, DPS can prevent atrophy and conversion. Implanted DPS electrodes can be used to assess diaphragm burst activity which appears to correlate with strength of diaphragm contraction and can be serially followed. This has been utilized to identify and treat central sleep apnea in ALS/MND. ALS/MND patients with primary LMN involvement have diffusely thin non-stimula-table diaphragms. DPS increases respiratory compliance by 17% which decreases the work of breathing. ALS/MND patients may develop daytime hypoventilation leading to hypercarbia which DPS can overcome. During disease course use of DPS can go from several 30 minutes conditioning sessions a day to 24 hours continuous use to maintain ventilation with the need to turn off DPS if death is sought. In tracheostomy mechanical ventilated patients, some with intact phrenic motor neurons remaining, DPS decreases peak airway pressure and improves posterior lobe ventilation leading to less atelectasis and risk for pneumonia. Conclusion: ALS/MND patients with respiratory complaints and intact phrenic motor neurons that the patient cannot control due to UMN involvement are candidates to improve diaphragm movement and ventilation with DPS.
Keywords: diaphragm; nerve cell; patient; stimulation; air conditioning; motoneuron; muscle cell; human; tracheostomy; lung function test; death; ventilated patient; airway pressure; atelectasis; risk; pneumonia; diaphragm movement; spinal cord; phrenic nerve; nerve transection; pathophysiology; intervention study; food and drug administration; ventilator; artificial ventilation; motor unit; atrophy; electrode; central sleep apnea syndrome; hypoventilation; hypercapnia; disease course; conditioning; laparoscopy

Adolescent paraplegia, morbid obesity, and pickwickian syndrome: outcome of gastric bypass surgery - Miyano G.; Kalra M.; Inge T.H. (Journal of Pediatric Surgery, 2009)
Loss of mobility, such as what occurs as a consequence of spinal cord injury or malformation, is a risk factor for excess weight gain and can confound weight management efforts. Despite well-documented outcomes of bariatric surgery in ambulatory patients, little information is available regarding weight loss surgery in adult or adolescent paraplegic patients. A 15-year-old adolescent boy with a body mass index of 60 kg/m2 and complete paraplegia caused by spina bifida developed metabolic dysfunction, severe obstructive sleep apnea, and hypoxemia syndrome. In an effort to avoid a tracheostomy for worsening pickwickian syndrome, he was referred for weight loss surgery. Laparoscopic Roux-en-Y gastric bypass surgery was safely performed and resulted in loss of 55% of body weight (83.8% excess weight loss) for 2 years. Risk factors for cardiovascular disease markedly improved, and polysomnography demonstrated complete reversal of sleep apnea with substantial subjective improvement in daytime breathlessness and quality of life. Body composition analysis demonstrated preferential reduction in body fat mass compared with lean mass, without detrimental effect on bone mineral density. This case illustrates that paraplegia does not necessarily impair either weight loss efficacy or comorbidity resolution after Roux-en-Y gastric bypass surgery. © 2009 Elsevier Inc. All rights reserved.
Keywords: calcium; cyanocobalamin; glucose; low density lipoprotein cholesterol; multivitamin; vitamin D; adolescent; article; bladder catheterization; body composition; body fat; body mass; body weight; bone density; cardiovascular risk; case report; clinical feature; disease course; disease severity; dyspnea; human; hyperglycemia; hyperinsulinemia; hypoxemia; laparoscopic surgery; male; metabolic disorder; morbid obesity; neurogenic bladder; obesity hypoventilation syndrome; paraplegia; patient safety; physiotherapy; polysomnography; priority journal; quality of life; Roux Y anastomosis; sleep disordered breathing; spinal dysraphism; gastric bypass surgery; tracheostomy; treatment outcome; vitamin supplementation; body weight loss

Outcomes of patients with spinal cord injury before and after introduction of an interdisciplinary tracheostomy team. - Cameron T.S.; McKinstry A.; Burt S.K.; Howard M.E.; Bellomo R.; Brown D.J.; Ross J.M.; Sweeney J.M.; O'Donoghue F.J. (Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2009)
OBJECTIVES: To assess outcomes in patients with spinal cord injury (SCI) and a tracheostomy tube (TT), before and after the introduction of a tracheostomy review and management service (TRAMS) for ward-based patients. DESIGN: Matched-pairs design with two cohorts, before and after the intervention. SETTING: 900-bed tertiary hospital in Melbourne, Victoria. PARTICIPANTS: SCI patients with a TT that was removed: 34 patients in the post-TRAMS period (September 2003 to September 2006) were matched to 34 from the pre-TRAMS period (September 1999 to December 2001). INTERVENTION: TRAMS was introduced as a consultative team of specialist physicians, clinical nurse consultants, physiotherapists and speech pathologists. The team coordinated tracheostomy care, conducted twice-weekly rounds, and provided policy, education, and support. MAIN OUTCOME MEASURES: Comparison of length of stay (LOS), duration of cannulation (DOC), improved communication through use of a one-way valve, number of adverse events and related costs. RESULTS: Median patient LOS decreased from 60 days (interquartile range [IQR], 38-106) to 41.5 days (IQR, 29- 62) (P = 0.03). The pre-TRAMS median DOC decreased from 22.5 days (IQR, 17-58) to 16.5 days (IQR, 12-25) (P = 0.08). Speaking-valve use increased from 35% (12/34) to 82% (28/34) (P < 0.01). Median time to a valve trial decreased from 22 days (IQR, 13-44) to 6 days (IQR, 4-10) after TT insertion (P < 0.01). There were two tracheostomy-related medical emergency calls pre-TRAMS and none post-TRAMS. There were no tracheostomy-related deaths in either group. The annual cost savings from implementing TRAMS were about eight times greater than the cost of service provision. CONCLUSION: Implementing a tracheostomy review and management service improved outcomes for SCI patients: they left acute care sooner, spoke sooner, and the TT was removed earlier, with associated cost savings.
Keywords: adult; article; cervical spine; cohort analysis; cost control; endotracheal intubation; evaluation study; female; health care quality; human; intensive care; length of stay; male; middle aged; organization and management; patient care; spinal cord injury; tracheostomy; treatment outcome; vertebra

Neurophysiological study in patients with amyotrophic lateral sclerosis in a totally locked-in state - Shimizu T.; Kawata A.; Komori T.; Hayashi H.; Oyanagi K. (Amyotrophic Lateral Sclerosis, 2009)
Background: Fifteen to eighteen percent of amyotrophic lateral sclerosis (ALS) patients present with ophthalmoplegia and fall into a totally locked-in state (TLS) after initiation of tracheostomy positive-pressure ventilation (TPPV). Objectives: To assess the neurophysiological function in TLS-ALS patients using the techniques of somatosensory evoked potentials (SEP) and electroencephalogram (EEG). Methods: SEPs were recorded by electrical stimulation of the median nerve at the wrist in seven TLS patients (3 men and 4 women, age: 53 to 81 years). All patients showed complete ophthalmoplegia and tetraplegia with TPPV all day long. Communication with them was entirely impossible. The brain MR images showed severe frontotemporal atrophy in all of the patients. The disease duration ranged from 5 to 13 years and the duration of ventilator use was 3 to 10 years. One patient (66 year-old man) had a superoxide dismutase 1 (SOD1) gene mutation (Exon 5, Cys146Arg). Erb's potential, cervical/brainstem N13 potential (C5S-Fz), parietal N20 (CP3/4-Fz) and frontal N30 (F3/4-A), and central conduction time (latency differences between N13 peak and N20 peak) were analyzed. EEG was recorded from the scalp monopolar electrodes placed on Fp1/2, F3/4, C3/4, P3/4, O3/4, F7/8, T3/4 regions, for about 15 to 30 minutes in the afternoon. The frequency analysis of the EEG was performed for a relatively stable 5 seconds of the total recording time using the technique of Fast Fourier Transform (FFT). Results: Six out of the seven patients showed decreased or abolished parietal N20 and frontal N30. The latencies of N13 and central conduction time were also delayed. The patient with SOD1 gene mutation showed poor Erb's potentials and no responses of the brainstem and cortical components. In EEG analysis, only two patients showed occipital alpha waves with slow frequency range (8 to 10 Hz), and the other three showed theta to delta waves predominantly on the central-frontal regions. In one patient with involuntary jaw movements, the FFT analysis could not be examined due to EMG artifact. The patients with occipital slow alpha waves showed preserved parietal N20 components, and the patients with no N20 components showed theta to delta range EEG without alpha waves. Discussion and Conclusions: Along with disease progression of ALS, the sensory system could be involved. The lesions might be in the spinal cord, brainstem and primary sensory cortex. SOD1-associated ALS might involve the peripheral sensory neurons. EEG is desynchronized and slowed in the advanced stages, suggesting impaired consciousness of the patients. There might be a correlation between the presence of N20 in SEP and the result of EEG-FFT analysis. In TLS-ALS patients, communication aids should be applied during the stages with preserved SEPs and alpha rhythms of EEG.
Keywords: copper zinc superoxide dismutase; patient; electroencephalogram; amyotrophic lateral sclerosis; somatosensory evoked potential; alpha rhythm; ophthalmoplegia; gene mutation; latent period; brain stem; sensory nerve cell; consciousness; communication aid; tracheostomy; positive end expiratory pressure; electrostimulation; median nerve; wrist; female; quadriplegia; interpersonal communication; brain; nuclear magnetic resonance; atrophy; disease duration; ventilator; male; exon; scalp; electrode; Fourier transformation; frequency analysis; recording; delta rhythm; jaw movement; artifact; disease course; sensory system; spinal cord; sensory cortex; electromyogram

A follow-up study for spinal surgery after the onset of symptoms of ALS - Liu X.; Fan D.; Zhang J.; Kang D. (Amyotrophic Lateral Sclerosis, 2009)
Background and Objectives: Distinguishing between cervical spondylotic myelopathy (CSM) and ALS can be difficult, because of their similar clinical manifestations. Sometimes, CSM may coexist with ALS since both diseases preferentially affect individuals of middle or old age. Attempts to differentiate between CSM and ALS must persist until diagnosis of one (or both) of the disorders is made, since both the prognosis and treatment of the two are different. Choice of surgical treatment remains controversial. We investigated 19 patients with ALS to clarify the complications of cervical spondylosis and to explore the influence of surgical treatment for their prognosis in a retrospective study. Methods: A total of 329 consecutive patents with definite or probable ALS were enrolled. The clinical features, especially the history of spinal surgical treatment, were recorded. The patients were followed up every 3 months from visit to death or tracheostomy. Results: Of 329 sporadic ALS cases, we found cervical spondylosis in 156 patients (47.4%); 19 (5.8%) of them underwent spinal surgical treatment in the early stage of the course of their ALS. No differences between ALS patients who underwent spinal surgery and other ALS patients were noted regarding age at symptom onset, gender and ALSFRSR at time of diagnosis (P > 0.05). However, the time from symptom onset to diagnosis was significantly longer in patients with spinal surgery (P < 0.001). In the follow-up study, although these patients consulted our clinic because their motor symptoms had progressed after spinal surgery, we found that there were no differences in the rate of disease progression and survival between two groups (P < 0.05). Conclusions: Our results indicate that nearly half of all ALS patients have their disease complicated by cervical spondylosis, some of whom even underwent spinal surgery. Although the surgery did not obviously hasten the rate of disease progression and shorten survival, it lengthens the time from disease onset to diagnosis. A careful differential diagnosis for ALS is necessary before making decisions about spinal surgery.
Keywords: spine surgery; spinal cord disease; prognosis; follow up; patient; surgery; diagnosis; cervical spondylosis; disease course; survival; patent; clinical feature; death; tracheostomy; gender; hospital; differential diagnosis; senescence; retrospective study

Survival probabilities of patients with childhood spinal muscle atrophy - Mannaa M.M.; Kalra M.; Wong B.; Cohen A.P.; Amin R.S. (Journal of Clinical Neuromuscular Disease, 2009)
OBJECTIVE:: Medical and technological advances over the past 2 decades have resulted in improved patient care for children with spinal muscular atrophy (SMA). The objective of the present study was to describe changes in the life expectancy of pediatric patients with SMA over time and to compare these findings with previously reported survival patterns. METHODS:: Medical records of all patients diagnosed with SMA over a 16-year period (1989-2005) at Cincinnati Children's Hospital Medical Center were reviewed. Data pertaining to date of birth, type of SMA, medical and surgical interventions, pulmonary complications, and date of death were obtained. RESULTS:: Kaplan-Meier survival analyses showed a significant improvement in survival probabilities in the severest form of SMA. CONCLUSIONS:: We found a positive trend in the survival of patients with severe SMA. Although we cannot attribute this trend to any single factor, it is likely that advances in pulmonary care and aggressive nutritional support have played a significant role. Copyright © 2009 by Lippincott Williams & Wilkins.
Keywords: article; artificial ventilation; child; clinical article; controlled study; female; human; life expectancy; lung complication; male; medical record; preschool child; priority journal; school child; spinal muscular atrophy; survival rate; tracheostomy

Tetraplegia and respiratory failure following mild cervical trauma in a child with Cornelia de Lange syndrome - Del Gaudio A.; Varano L.; Perrotta F.; Sorrentino E.; Pagano A. (Minerva Anestesiologica, 2009)
Here we report a 6-year-old female patient with Cornelia de Lange syndrome who developed tetraplegia and respiratory failure after a seemingly trivial spinal trauma due to an spinal malformation that has not yet been described.
Keywords: article; atelectasis; case report; cervical spine injury; child; clinical feature; computer assisted tomography; de Lange syndrome; endotracheal intubation; falling; female; gastrostomy; human; intensive care unit; neurologic examination; nuclear magnetic resonance imaging; nutritional support; patient referral; positive end expiratory pressure; preschool child; quadriplegia; radiologist; respiration depression; respiratory failure; spine malformation; stomach paresis; thorax radiography; tracheostomy; unconsciousness

Mortality and morbidity associated with correction of severe cervical hyperextension - Poulter G.T.; Garton H.J.L.; Blakemore L.C.; Hensinger R.N.; Graziano G.P.; Farley F.A. (Spine, 2009)
STUDY DESIGN.: Three case reports of patients with treatment of severe cervical hyperextension. OBJECTIVE.: Cervical hyperextension is a rare spine deformity that is associated with myopathies. Previous reports of surgical correction have reported no major operative complications. This report outlines our experience with 3 patients who experienced significant complications. SUMMARY OF BACKGROUND DATA.: The limited literature on the treatment of cervical hyperextension has good to excellent outcomes. METHODS.: Three case reports are presented. RESULTS.: Three cases with severe cervical hyperextension with intraoperative correction had associated morbidity and mortality. One case had a failed intubation requiring tracheotomy. This was followed by a successful posterior release with halo traction for 2 weeks and then an instrumented posterior cervical fusion. This patient died at home 2 weeks after surgery. The second and third cases had an intraoperative spinal cord injury during a posterior release for cervical hyperextension. CONCLUSION.: Patients with severe cervical hyperextension have high neurologic perioperative risk. © 2009, Lippincott Williams & Wilkins.
Keywords: adult; anamnesis; article; case report; cervical hyperextension; cervical spine; clinical feature; compression garment; disease severity; endotracheal intubation; somatosensory evoked potential; human; kyphoscoliosis; laminectomy; lordosis; male; morbidity; mortality; nuclear magnetic resonance imaging; orthopedic surgery; paresthesia; postoperative complication; priority journal; quadriplegia; radiography; spinal cord injury; spine malformation; tracheotomy; traction therapy; weakness

Case series: anesthetic management of patients with spinal and bulbar muscular atrophy (Kennedy's disease). - Niesen A.D.; Sprung J.; Prakash Y.S.; Watson J.C.; Weingarten T.N. (Canadian journal of anaesthesia = Journal canadien d'anesthésie, 2009)
PURPOSE: Kennedy's disease (KD) is a rare, X-linked recessive, neurodegenerative disorder of lower motor neurons characterized by progressive proximal limb and bulbar muscular atrophy with spontaneous laryngospasm, which may present an anesthetic risk. We undertook a computerized search of the Mayo Clinic medical records database between January 1996 and May 2008 for patients with KD undergoing general anesthesia. Medical records were reviewed for anesthetic techniques and perioperative complications. CLINICAL FEATURES: We identified six patients with KD, confirmed by DNA testing, who underwent 13 general anesthetics. Succinylcholine was used in two patients, and non-depolarizing neuromuscular blockers in seven cases, all without adverse effects. Although laryngospasm was not identified in any patient, one patient with advanced disease experienced postoperative glottic edema, worsening respiratory distress, bulbar dysfunction, requiring tracheostomy and prolonged ventilatory support. One patient experienced a pneumothorax. CONCLUSION: The potential for bulbar dysfunction and muscle weakness in patients with KD places them at risk for perioperative complications from anesthesia. Anesthesia providers should be cognizant of the different potential anesthetic risk factors in these patients.
Keywords: neuromuscular blocking agent; neuromuscular depolarizing agent; suxamethonium; adult; aged; article; factual database; general anesthesia; human; larynx spasm; male; methodology; middle aged; pathophysiology; postoperative complication; retrospective study; spinal muscular atrophy

Pressure ulcer risk factors in persons with SCI: Part I: Acute and rehabilitation stages - Gélis A.; Dupeyron A.; Legros P.; Benaïm C.; Pelissier J.; Fattal C. (Spinal Cord, 2009)
Background: Pressure ulcers (PUs) are a common complication following a spinal-cord injury (SCI). Good prevention requires identifying the individuals at risk for developing PUs. Risk assessment scales used nowadays were designed on pathophysiological concepts and are not SCI-specific. Recently, an epidemiological approach to PU risk factors has been proposed to design an SCI-specific assessment tool. The first results seem quite disappointing, probably becuase of the level of evidence of the risk factors used. Objective: To determine PU risk factors correlated to the patients with SCI, medical care management during the acute as well as in the rehabilitation and chronic stages. This first part focuses on identifying the risk factors during the acute and rehabilitation stages. Materials and methods: Systematic review of the literature. Results: Six studies met our inclusion criteria. The risk factors during the acute stage of an SCI are essentially linked to care management and treatment modalities. There is insufficient evidence to make a recommendation on medical risk factors, except for low blood pressure on admission to the Emergency Room, with a moderate level of evidence. Regarding the rehabilitation stage, no study was deemed relevant. Discussion and conclusions: Additional observational studies are needed, for both the acute and rehabilitation stages, to improve this level of evidence. However, this systematic review unveiled the need for a carefully assessed t care management and the related practices, especially during the acute stage of an SCI. © 2009 International Spinal Cord Society All rights reserved.
Keywords: creatinine; clinical practice; creatinine blood level; decubitus; demography; emergency care; functional status; hospitalization; human; hypotension; length of stay; lung disease; mental health; osteosynthesis; patient care; patient transport; priority journal; rehabilitation care; review; risk assessment; risk factor; spinal cord injury; systematic review; tracheotomy; urine incontinence

A comparative analysis of open and endovascular repair for the ruptured descending thoracic aorta - Patel H.J.; Williams D.M.; Upchurch Jr. G.R.; Dasika N.L.; Deeb G.M. (Journal of Vascular Surgery, 2009)
Background: Successful repair of the ruptured (non-traumatic) descending thoracic aorta (rTA) remains a formidable clinical challenge. Although effective for rTA, traditional open repair (DTAR) has significant associated morbidity. With expanding indications for thoracic endovascular aortic repair (TEVAR), we describe our experience with TEVAR and DTAR in this high-risk setting to elucidate their evolving roles. Methods: Since the inception of our thoracic aortic endovascular program in 1993, 69 patients underwent DTAR (34) or TEVAR (35) for rTA. Patients underwent TEVAR if they were considered nonoperative candidates because of extensive comorbidities (n = 31; 88.6%) or had extremely favorable anatomy for endovascular repair (eg, mid-descending saccular aneurysm, n = 4). Aortic pathology causing rupture was fusiform aneurysm (18), saccular aneurysm/ulcer (22), and dissection (29). Associated aortobronchial fistulae (12) and aortoesophageal (1) fistulae were also present in 18.8%. Arch repair was needed in 46; total descending repair was needed in 33. Follow-up was 100% complete (mean 37.4 months). Results: Mean age was 65.9 years (DTAR 60.3 year vs TEVAR 71.3 years, P = .005). In-hospital or 30-day mortality was seen in 13 patients (TEVAR n = 4; 11.4% vs DTAR n = 9; 26.5%, P = .13). Median length of stay was shorter after TEVAR (8 days vs DTAR 15 days, P = .02). Mean Kaplan-Meier survival was similar between groups (TEVAR 67.4 months vs DTAR 65.0 months, P = .7). By multivariate analysis, independent predictors of a composite outcome of early mortality, stroke, permanent spinal cord ischemia, or need for dialysis or tracheostomy included the presentation with hemodynamic instability (P < .001) and treatment with conventional open repair (P = .02). Conclusion: An endovascular approach for the ruptured (non-traumatic) descending thoracic aorta reduces early morbidity, mortality, and duration of hospitalization, while providing equivalent late outcomes even in an older group largely considered high risk for open repair. These data support a paradigm shift, with TEVAR emerging as the preferred therapy for all patients presenting with descending aortic rupture. © 2009 Society for Vascular Surgery.
Keywords: abdominal aortic aneurysm; adult; aged; aneurysm rupture; aortic arch; aortic disease; aortic reconstruction; aortobronchial fistula; aortoesophageal fistula; article; chronic obstructive lung disease; comorbidity; comparative study; congestive heart failure; coronary artery disease; descending aorta; dialysis; dissecting aneurysm; endovascular surgery; female; hemodynamics; hospitalization; human; major clinical study; male; morbidity; mortality; outcome assessment; peripheral occlusive artery disease; priority journal; saccular aneurysm; spinal cord ischemia; cerebrovascular accident; endovascular aneurysm repair; tracheostomy

Adrenal gland injury secondary to blunt traumatic mechanisms: A marker of overall injury severity - Stawicki S.P.; Seamon M.J.; Carvalho C.M.; Bhoot N.; Sharma R.; Schrag S.P.; Steinberg S.M. (Endokrynologia Polska, 2009)
Introduction: Adrenal gland injuries (AGI) are seen increasingly frequently owing to advances in modern imaging techniques. This study describes a series of patients with blunt AGI, with the emphasis on AGI as a marker of injury severity, CT-radiographic classification of AGI and associated injury patterns. Material and methods: A retrospective review of blunt trauma patients with AGI was performed. Variables examined included demographics, mechanism of injury, length of hospital and ICU stay, clinical status on admission, AGI characteristics, associated injuries, complications, procedures, mortality and discharge disposition. Results: There were 29 AGI patients with a mean injury severity score of 25. The most common injury mechanisms were motor-vehicular collisions (15/29) and falls (5/29). Right-sided AGI (16/29) outnumbered left-sided (12/29) injuries. The most common CT-radiographic types of AGI were adrenal gland contusions and lacerations with limited "blush". While patterns of injuries differed between right and left-sided AGI, the mean number of injuries did not. The most common associated injuries included extremity (21/29), rib (20/29) and spinal fractures (18/29). Common procedures included orthopaedic fixation (10/29), vena cava filter (8/29) and tracheostomy (5/29). A median of two complications per patient was reported, including adrenal insufficiency in two patients. Mortality was 17%. The median hospital and ICU length of stay were 15 and 12 days, respectively. Conclusions: Adrenal gland injury is associated with significant morbidity and mortality. With modern imaging modalities capable of reliably detecting adrenal injury, the presence of AGI should be considered a marker of overall injury severity. The authors provide a CT - radiographic classification of adrenal injuries.
Keywords: adrenal disease; adrenal gland injury; adrenal insufficiency; adult; article; blunt trauma; clinical article; computer assisted tomography; disease classification; falling; female; fracture fixation; human; injury severity; length of stay; limb fracture; male; mortality; rib fracture; spine fracture; tracheostomy; traffic accident; vena cava filter

Pyogenic spinal infection in intravenous drug users - Street J.; Lenehan B.; Fisher C. (Journal of Spinal Cord Medicine, 2009)
Objectives: To evaluate the demographics, presentation, treatment and outcomes of spinal infection in a population of intravenous drug users. Design: Prospective cohort study. Methods: Data on all patients with pyogenic spinal infection presenting to a quaternary referral center was obtained from a prospectively maintained database. Results: Over the 5-year study period, 102 patients were treated for primary pyogenic infection of the spine of whom 51 were intravenous drug users (IVDU). Of this IVDU group there were 34 males. Mean age was 43 years (range 25-57 y). 23 had HIV, 43, hepatitis C and 13, hepatitis B. All were using cocaine, 26 were also using heroin and 44 more than 3 recreational drugs. 30 patients presented with axial pain with a mean duration of 51 days (range 3-120 d). 31 were ASIA D or worse with 8 ASIA A. Mean Motor Score of patients with deficit was 58.6. Most common ASIA Motor Levels were C4 and C5. Mean duration of neurological symptoms was 7 days (range 1-60 d). None had previous surgery for spinal infection. 26 were receiving IV antibiotics for known spinal infection. Mean presenting temperature was 37.4°C (range 35.9-39.9,19 > 37.5°C), mean ESR 60.8 (range 6-140, 43 > 20), mean CRP 87.75 (1.5-253, 46 > 20), mean WCC 10.2 (range 3.7-30.4, 14 > 11) and 33 patients had positive blood cultures (19 MSSA, 9 MRSA). 44 patients were treated surgically. 32 had infection of the cervical spine, 9 thoracic and 3 lumbar. 22 had a posterior approach alone, 13 had anterior only while 9 required combined. Mean operative time was 263 min (range 62-742 min). 13 required tracheostomy. 7 required early revision for hardware failure and 2 for surgical wound infection. Mean duration of antibiotic treatment was 49 days (range 28-116 d). 26 patients had single-agent therapy. 17 had MSSA and 17 MRSA. At discharge 28 patients had neurological improvement (mean 20 ASIA points, range 1-55), 11 had deterioration (mean 13, range 1-50) and 5 were unchanged. There were no in-hospital deaths. At 2 years after index admission, 13 patients were dead and none were attending the unit for follow-up. Conclusions: Primary pyogenic spinal infection in IV drug users typically presents with sepsis and acute cervical tetraplegia. Surgical management must be prompt and aggressive with significant neurological improvement expected in the majority of patients.
Keywords: diamorphine; recreational drug; antibiotic agent; cocaine; infection; intravenous drug abuse; rehabilitation; spinal cord; patient; surgery; Quaternary (period); pain; neurologic disease; temperature; blood culture; cervical spine; tracheostomy; computer; surgical infection; antibiotic therapy; deterioration; hospital; death; follow up; therapy; drug use; sepsis; population; Human immunodeficiency virus; cohort analysis; data base; spine; male; hepatitis C; hepatitis; quadriplegia

Persistent dysphagia and mechanical glottic paralysis : CCCCCComplications of a ventral fracture spondylodesis with Forestier's disease - Löhrer L.; Schmid S.; Hofbauer V.R.; Hartensuer R.; Raschke M.J.; Vordemvenne T. (Unfallchirurg, 2009)
Persistent dysphagia after ventral instrumentation of a patient with a cervical spine fracture and diffuse idiopathic skeletal hyperostosis (DISH, or Forestier's disease) is a rare but dramatic complication. In this case report some pathogenetic factors are discussed. Accurate resection of the spondylophytes should be considered to avoid a ventral protrusion of the plate. © 2008 Springer Medizin Verlag.
Keywords: adult respiratory distress syndrome; aged; ankylosing hyperostosis; article; artificial ventilation; bone plate; case report; cervical spine fracture; computed tomographic angiography; decompression; dysphagia; human; devices; laryngoscopy; male; pathogenesis; postoperative complication; prosthesis infection; spine radiography; spine surgery; spondylodesis; tracheotomy; vocal cord paralysis

Advance care directives for people with spinal cord injury: A neglected need - Marshall R. (Topics in Spinal Cord Injury Rehabilitation, 2008)
Advance care directives are rarely used by people with chronic spinal cord injury, but they could be used more often to protect not only against unwanted treatments but to ensure that desired treatment occurs, particularly as there may be differing perceptions regarding quality of life between the patient and those providing acute care. © 2008 Thomas Land Publishers, Inc.
Keywords: artificial ventilation; health care need; human; intensive care unit; medical decision making; patient care; quality of life; resuscitation; review; spinal cord injury; tracheostomy

Definitive establishment of airway control is critical for optimal outcome in lower cervical spinal cord injury. - Hassid V.J.; Schinco M.A.; Tepas J.J.; Griffen M.M.; Murphy T.L.; Frykberg E.R.; Kerwin A.J. (The Journal of trauma, 2008)
BACKGROUND: Respiratory complications can undermine outcome from low cervical spinal cord injury (SCI) (C5-T1). Most devastating of these is catastrophic loss of airway control. This study sought to determine the incidence and effect of catastrophic airway loss (CLA) and to define the need for elective intubation with subsequent tracheostomy to prevent potentially fatal outcomes. METHODS: A database of 54,838 consecutive patients treated in a level I trauma center between January 1988 and December 2004 was queried to identify patients with low cervical SCI, without traumatic brain injury. Patients were then stratified into complete or incomplete SCI groups, based on clinical assessment of their SCI. Mortality, age, injury severity, need for intubation, and tracheostomy were analyzed for each group using Fisher's exact test or Student's t test, as appropriate, accepting p < 0.05 as significant. RESULTS: One hundred eighty-six patients met inclusion criteria. The majority of low cervical spinal cord injuries were complete (58%). Overall, 127 (68%) patients required intubation, 88 (69%) required tracheostomy, and 27 died (15% of study population). Between each group there were significant differences in age and Injury Severity Score, however, within each group there were no significant differences in either. Eleven CSCI patients were not intubated; four of whom were at family request. Six of the remaining seven patients encountered fatal catastrophic airway loss. One patient was discharged to rehabilitation. Patients with incomplete SCI required intubation less frequently (38%); however, 50% of those required tracheostomy for intractable pulmonary failure. CONCLUSIONS: These data indicate that regardless of severity of low cervical SCI, immediate, thorough evaluation for respiratory failure is necessary. Early intubation is mandatory for CSCI patients. For incomplete patients evidence of respiratory failure should prompt immediate airway intervention, half of whom will require tracheostomy.
Keywords: adolescent; adult; apnea; article; cervical spine; child; cross-sectional study; endotracheal intubation; female; human; incidence; injury; injury scale; intensive care unit; male; middle aged; mortality; respiratory failure; resuscitation; retrospective study; spinal cord injury; spine fracture; survival rate; tracheostomy

OUTCOME after spinal-cord injury: Influence of specific treatment and prevention modalities - Wyndaele J.J. (Spinal Cord, 2008)
Keywords: papaverine; artificial ventilation; editorial; electrostimulation; ergometry; exercise; health hazard; health services research; human; information processing; nerve stimulation; nonhuman; obesity; phrenic nerve; priority journal; quality of life; respiratory failure; smoking; spinal cord blood flow; spinal cord injury; tracheostomy; treatment outcome; validation process; vestibular stimulation

The use of tracheal stoma stents in high spinal cord injury: A patient-friendly alternative to long-term tracheostomy tubes - Hall A.M.; Watt J.W.H. (Spinal Cord, 2008)
Study design: Case series. Setting: North West Regional Spinal Injuries Unit, Southport and Formby District General Hospital, UK. Objectives: To identify a novel type of tracheal stents for use in patients with high spinal cord injury. Patients with high spinal cord injury (above C4) frequently have significant respiratory impairment and may require long-term access to the trachea for respiratory support. For the most part, tracheostomy tubes are used for this purpose but a tracheal stoma stent can offer a suitable alternative in selected cases and deserves wider recognition. Methods: Following completion of a patient questionnaire survey, the authors describe the use of stoma stents in nine patients, five of whom had full-time diaphragm pacing. The stent in these cases is for retention of access for positive pressure ventilation, and for the prevention of obstructive sleep apnoea. This was also the indication in one self-ventilating patient with tetraplegia and sleep apnoea. Two patients with recurrent chest infections, in whom chest physiotherapy was difficult, benefited from the stoma stents. One patient, after ventilator weaning, required a further 4 months of tracheal access on account of episodic hypoventilation and temporarily had a tracheal stent as an inpatient. Conclusion: Patients who have had the benefit of tracheal stents report significant improvement in relation to local discomfort, tracheobronchial secretions and vocalization. With suitable training, the stents can be changed and cleaned easily in the home setting. © 2008 International Spinal Cord Society All rights reserved.
Keywords: article; artificial ventilation; assisted ventilation; breathing exercise; chest infection; clinical article; diaphragm; health survey; human; hypoventilation; priority journal; quadriplegia; questionnaire; recurrent infection; sleep disordered breathing; spinal cord injury; stent; stoma stent; trachea; tracheostomy

Case 138: Idiopathic spinal cord herniation1 - Gandhi D.; Goyal M.; Bourque P.R. (Radiology, 2008)
History A 66-year-old woman presented with numbness in the anteromedial aspect of her right thigh and difficulty with right leg movement for the past year. She did not have back pain or lower limb pain, nor did she have a history of relevant trauma. At the time of presentation, her arterial hypertension and osteoarthritis were being treated. She had a history of localized laryngeal amyloidosis, which was found at 30 years of age and treated with laser excision and tracheostomy. Physical examination revealed mild spasticity and impaired pain and temperature sensation in the right leg. She underwent magnetic resonance (MR) imaging, myelography, and postmyelography computed tomography (CT) of the thoracic spine. © RSNA, 2008.
Keywords: aged; anamnesis; case report; clinical feature; computer assisted tomography; female; hernia; human; idiopathic disease; myelography; nuclear magnetic resonance imaging; physical examination; priority journal; review; spasticity; spinal cord disease; thoracic spine

Median labiomandibular glossotomy approach to the craniocervical region - Brookes J.T.; Smith R.J.H.; Menezes A.H.; Smith M.C. (Child's Nervous System, 2008)
Introduction: In children as well as adults, adequate access to the craniocervical junction and upper cervical vertebra can usually be achieved with a transoral-transpalatopharyngeal route. However, when access is necessary to achieve the C5 level and the upper cervical spine in children, this is very difficult. This is particularly so when the incisor opening is less than 2.5 cm. The median labiomandibular glossotomy provides such an approach. Materials and methods: Our experience with five children is presented in a representative case: a 4-year-old male with a family history of spondyloepiphyseal dysplasia presented with mild quadriparesis, 2 years earlier. This had rapid progression with severe upper cervical kyphosis. A standard transoral-transpalatopharyngeal approach or a lateral extrapharyngeal approach would not achieve exposure of the pathology. Hence, a median labiomandibular glossotomy was utilized for ventral decompression with an anterior interbody fusion between C2 and C4. Crown halo cervical traction was placed intraoperatively before a tracheostomy and tonsillectomy. A median labiomandibular glossotomy was then made with resection of the displaced odontoid process and the vertebral bodies of C3 and C4. This was followed by an anterior interbody fusion between the C2 and C4 vertebrae with costal rib grafts. Result and conclusion: He was successfully decannulated during the second postoperative week upon resolution of lingual edema. A planned staged dorsal occipitocervical fusion was performed 6 months later, at which time the ventral fusion was quite solid. He had full neurological recovery. © Springer-Verlag 2008.
Keywords: anterior spine fusion; article; atlantooccipital joint; brace; case report; cervical spine; clinical feature; decompression surgery; disease course; disease severity; family history; follow up; human; kyphosis; male; median labiomandibular glossotomy; odontoid process; peroperative care; postoperative care; postoperative period; preschool child; priority journal; quadriplegia; rib graft; spinal cord compression; spondyloepiphyseal dysplasia; surgical approach; surgical technique; tonsillectomy; tracheostomy; traction therapy; treatment indication; treatment response; vertebra body

Surgical approaches: Postoperative care and complications "posterolateral-far lateral transcondylar approach to the ventral foramen magnum and upper cervical spinal canal" - Menezes A.H. (Child's Nervous System, 2008)
Background: Lesions that affect the lower clivus, foramen magnum, the craniocervical junction, and the upper cervical spinal canal that are anterolateral and at times intradural require access ventral to the cerebellum and spinal cord. The posterolateral transcondylar approach provides such a route. In addition, posterior craniocervical stabilization can be accomplished at the same time. The author has reviewed the technique as well as the surgical results here. Materials and methods: The posterolateral transcondylar approach to the craniocervical junction was utilized in children with schwannoma, meningioma, and chordoma affecting the cervicomedullary junction. Other entities such as neurenteric cysts and hemangioblastoma were also seen. Extradural tumors such as aneurysmal bone cysts of the atlas and the axis vertebrae as well as proatlas segmentation abnormalities and bone tumors were seen. The stability of the craniocervical junction was assessed preoperatively so that a fusion procedure could be accomplished at the same operative setting, if necessary. Preoperative evaluation of the lower cranial nerves was vital. The surgical procedure was accomplished in the prone position. The occipital bone removal was carried out up to the sigmoid sinus and toward the jugular bulb. Relocation of the vertebral artery was made at the atlas vertebra and thus provided posterolateral exposure into the posterior fossa and upper cervical spinal canal. Occipital condyle removal was limited to one-third of the medial occipital condyle. Results: Twenty-five children underwent a posterolateral transcondylar approach. New lower cranial nerve dysfunction occurred in two and only one required a tracheostomy. This was seen in a child with clivus chordoma. A complete removal was accomplished in meningioma and schwannoma as well as in neurenteric cyst and hemangioblastoma. Clivus chordomas required more than one surgical procedure. The tumors of the bone were all treated with simultaneous fusion. Conclusions: The posterolateral transcondylar route is a versatile avenue to approach a variety of lesions ventrolateral to the brain stem and upper cervical cord. Exposure is quite satisfactory with minimal or no retraction of important neurovascular structures in the region. Modifications of this theme can be applied as the lesions require. © Springer-Verlag 2008.
Keywords: aneurysmal bone cyst; article; atlantooccipital joint; first cervical vertebra; body position; bone tumor; brain stem; cervical spinal cord; cervical spine; child; chordoma; clinical article; clivus; computer assisted tomography; cranial nerve paralysis; foramen magnum; hemangioblastoma; human; joint stability; meningioma; neurilemoma; nuclear magnetic resonance imaging; occipital bone; posterior fossa; postoperative care; postoperative complication; preoperative evaluation; priority journal; spine fusion; spine stabilization; spine tumor; surgical approach; surgical technique; tracheostomy; treatment response; vertebral artery; vertebral canal

Slow ventilator weaning after cervical spinal cord injury - Atito-Narh E.; Pieri-Davies S.; Watt J.W.H. (British Journal of Intensive Care, 2008)
Aim: The aim of the cross-sectional study was to look for factors leading to success in ventilator weaning after acute spinal cord injury. Methods: Referrals to the North West Regional Spinal injuries Centre over a 12-year period were reviewed for patients ventilated for >21 days before referral and who had been deemed to have failed to wean. Of 126 patients referred, 13 had already been ventilated for 102 days mean. After referral they were weaned in 56 days mean by progressive ventilator-free breathing. Average vital capacity improved from 525 to 1415 ml. Despite bacteriological colonisation, antibiotic therapy was required in only four cases following the transfer. Results: The consistent factors underpinning successful weaning after spinal cord damage were accurate neurological assessment; prevention of pulmonary atelectasis by physiotherapy; ventilator-free breathing graduated according to vital capacity; rest periods with controlled ventilation; cuff deflation with translaryngeal air flow, and regular tracheostomy tube changes.
Keywords: adult; aged; article; artificial ventilation; atelectasis; bacterial colonization; cervical spinal cord injury; female; human; larynx; major clinical study; male; physiotherapy; tracheostomy; vital capacity

Abnormalities of respiratory control and the respiratory motor unit - Nogués M.A.; Benarroch E. (Neurologist, 2008)
Background: Control of ventilation depends on a brainstem neuronal network that controls activity of the motor neurons innervating the respiratory muscles. This network includes the pontine respiratory group and the dorsal and ventral respiratory groups in the medulla. Neurologic disorders affecting these areas or the respiratory motor unit may lead to abnormal breathing. Review Summary: The brainstem respiratory network contains neurons critical for respiratory rhythmogenesis; this network receives inputs from peripheral and central chemoreceptors sensitive to levels of carbon dioxide (PaCO2) and oxygen (PaO2) and from forebrain structures that control respiration as part of integrated behaviors such as speech or exercise. Manifestations associated with disorders of this network include sleep apnea and dysrhythmic breathing frequently associated with disturbances of cardiovagal and sympathetic vasomotor control. Common disorders associated with impaired cardiorespiratory control include brainstem stroke or compression, syringobulbia, Chiari malformation, high cervical spinal cord injuries, and multiple system atrophy. By far, neuromuscular disorders are the more common neurologic conditions leading to respiratory failure. Conclusions: Respiratory dysfunction constitute an early and relatively major manifestation of several neurologic disorders and may be due to an abnormal breathing pattern generation due to involvement of the cardiorespiratory network or more frequently to respiratory muscle weakness. Copyright © 2008 by Lippincott Williams & Wilkins.
Keywords: carbon dioxide; oxygen; abdominal wall musculature; acute respiratory failure; amyotrophic lateral sclerosis; Arnold Chiari malformation; artificial ventilation; bethlem myopathy; botulism; brain stem; breathing muscle; breathing pattern; carbon dioxide tension; chemoreceptor; clinical feature; degenerative disease; demyelinating disease; depression; diaphragm paralysis; dysautonomia; dystrophinopathy; Eaton Lambert syndrome; enzyme deficiency; exercise; facioscapulohumeral muscular dystrophy; forebrain; gene mutation; glucan 1,4 alpha glucosidase deficiency; Guillain Barre syndrome; hypoventilation; intensive care unit; intercostal nerve; intoxication; intubation; limb girdle muscular dystrophy; lung ventilation; motoneuron; motor unit; muscle disease; muscular dystrophy; myasthenia gravis; myopathy; myotonic dystrophy; nerve cell; nerve cell network; nerve fiber; neuromuscular disease; neuromuscular transmission; noninvasive positive pressure ventilation; nuclear magnetic resonance imaging; oculopharyngeal muscular dystrophy; oxygen tension; Parkinson disease; parkinsonism; pathophysiology; periodic paralysis; phrenic nerve; physiology; poliomyelitis; polyneuropathy; positive end expiratory pressure; positron emission tomography; priority journal; respiration control; respiratory distress; respiratory failure; respiratory function; respiratory tract disease; review; Shy Drager syndrome; sleep disordered breathing; speech; spinal cord; spinal cord compression; spinal cord injury; spinal muscular atrophy; cerebrovascular accident; sudden infant death syndrome; supine position; syringomyelia; tracheostomy; vasomotor reflex; vital capacity; body weight loss; white matter

Therapy of X-linked adrenoleukodystrophy - Semmler A.; Köhler W.; Jung H.H.; Weller M.; Linnebank M. (Expert Review of Neurotherapeutics, 2008)
X-linked adrenoleukodystrophy (X-ALD; OMIM #300100) is caused by defects of the ABCD1 gene on chromosome Xq28, resulting in an impairment of peroxisomal β-oxidation and the accumulation of saturated very long chain fatty acids (VLCFAs). Primary manifestations occur in the CNS, the adrenal cortex and the testes' Leydig cells. The clinical presentation shows a marked variability which is not explained by the different X-ALD genotypes. Phenotypes range from rapidly progressive cerebral disease with childhood (childhood cerebral ALD [CCALD]) or adulthood (adult cerebral ALD [ACALD]) onset leading to death within a few years, over adult-onset adrenomyeloneuropathy (AMN) with or without focal CNS demyelination, AMN converting into a rapidly progressive, cerebral demyelinating phenotype resembling CCALD, to slow disease progression over decades, or adrenal insufficiency only. Approximately 50% of female heterozygotes develop moderate spastic paresis resembling the AMN phenotype. This review focuses on current experiences with different therapeutic approaches. Lorenzo's oil did not prove to be effective in cerebral inflammatory disease variants, but asymptomatic patients, and speculatively AMN variants without cerebral involvement, as well as female carriers may benefit from early intake of oleic and erucic acids in addition to VLCFA restriction. Hormone-replacement therapy is necessary in all patients with adrenal insufficiency. Hematopoietic stem cell transplantation has been reported to be effective in presymptomatic or early symptomatic CCALD, and may well also be a final therapeutic option in early ACALD patients. Early detection of mutation carriers and timely initiation of therapy is important for the effectiveness of all therapeutic efforts. Gene therapy of endogenous hematopoietic stem cells, pharmacological upregulation of other genes encoding proteins involved in peroxisomal β-oxidation, reduction of oxidative stress, and possibly lovastatin are candidates for future X-ALD therapies. © 2008 Expert Reviews Ltd.
Keywords: 4 phenylbutyric acid; ABC transporter; ABC transporter D1; ABC transporter D2; acetylcysteine; alpha tocopherol; ascorbic acid; beta interferon; cyclophosphamide; erucic acid; glucocorticoid; hydroxymethylglutaryl coenzyme A reductase inhibitor; immunoglobulin; Lorenzo oil; mevinolin; mineralocorticoid; oleic acid; placebo; sildenafil; snake venom; unclassified drug; very long chain fatty acid; Addison disease; adrenal insufficiency; adrenoleukodystrophy; anemia; artificial ventilation; clinical trial; diagnostic error; diet restriction; DNA polymorphism; drug efficacy; encephalitis; endocrine function; fatty acid oxidation; gastrointestinal symptom; gene expression; gene mapping; gene mutation; gene therapy; genetic counseling; genotype phenotype correlation; gingivitis; graft versus host reaction; hematopoietic stem cell transplantation; hormone substitution; human; impotence; leukopenia; multiple sclerosis; nonhuman; nuclear magnetic resonance imaging; pathophysiology; review; side effect; social support; spinal cord atrophy; spinal cord injury; thrombocytopenia; tracheotomy

Upper airway obstruction after cervical spine fusion surgery: Role of cervical fixation angle - Lee Y.-H.; Hsieh P.-F.; Huang H.-H.; Chang K.-C. (Acta Anaesthesiologica Taiwanica, 2008)
Upper airway obstruction is one of the life-threatening events in cervical spine surgery. The risk is particularly great during the period immediately after operation. We present the case of a 56-year-old female with breast cancer and metastasis to the cervical spine. The surgical procedure involved C2-C3 laminectomy, posterior fixation (C0-C5), and C2 neurectomy. Tracheal extubation was carried out in the intensive care unit, and upper airway obstruction immediately followed. Emergency cricothyrotomy was performed under well-managed ventilation with a laryngeal mask after several failed intubation attempts. Over-flexion of the cervical spine fixation and severe prevertebral soft tissue swelling were the most probable causes of upper airway obstruction. With a well-adjusted angle for fixation of the cervical spine under fluoroscopic guidance before the procedure, such a surgical mishap could be avoided. Reintubation with a fiberscope might be considered first, and sustaining intubation for 2-3 days postoperatively could be safer in such high risk patients. © 2008 Taiwan Society of Anesthesiologists.
Keywords: adult; article; artificial ventilation; breast cancer; case report; cervical spine; clinical feature; disease severity; emergency surgery; extubation; female; general anesthesia; human; laminectomy; laryngeal mask; mastectomy; nasotracheal intubation; neurectomy; nuclear magnetic resonance imaging; oxygen saturation; soft tissue disease; spine fusion; spine metastasis; surgical approach; tracheotomy; upper respiratory tract obstruction

Successful surgical management of a delayed pharyngo-esophageal perforation after anterior cervical spine plating - Solerio D.; Ruffini E.; Gargiulo G.; Camandona M.; Raggio E.; Solini A.; Dei Poli M. (European Spine Journal, 2008)
A case report of a 41-year-old man who had a delayed pharyngo-esophageal perforation without instrumentation failure 7 years after anterior cervical spine plating is presented and the literature on this issue is reviewed. This injury resulted from repetitive friction/traction between the retropharyngo-esophageal wall and the cervical plate construct leading to a pseudodiverticulum and perforation. Successful treatment of the perforation was obtained after surgical repair using a sternocleidomastoid muscle flap. This case stresses the necessity of careful long-term follow-up in patients with anterior cervical spine plating for early detection of possible perforation and the use of muscle flap as the treatment of choice during surgical repair. © 2008 Springer-Verlag.
Keywords: adult; arthrodesis; article; assisted ventilation; bone plate; bronchus secretion; case report; cervical spine; computer assisted tomography; enteric feeding; esophagoscopy; esophagus perforation; follow up; human; jejunostomy; male; nasogastric tube; pharynx disease; priority journal; sternocleidomastoid muscle; tracheotomy

Preoperative laryngeal nerve screening for revision anterior cervical spine procedures - Paniello R.C.; Martin-Bredahl K.J.; Henkener L.J.; Riew K.D. (Annals of Otology, Rhinology and Laryngology, 2008)
Objectives: Anterior cervical spine procedures carry an inherent risk of recurrent laryngeal nerve (RLN) injury. Patients with persistent RLN paresis may be asymptomatic because of compensation from the opposite side. If such patients undergo an opposite-side anterior approach for revision surgery, they are at risk for a second RLN injury, creating the potential for bilateral vocal fold paresis and possible need for tracheotomy. A program of routine screening for laryngeal paresis was implemented for these patients. This retrospective study reviews the results of this screening process. Methods: Patients referred for preoperative laryngeal nerve screening were identified. Their charts were reviewed for the results of the videolaryngoscopic examination, and for any recommendations made based on the findings. Relevant history and other physical findings were recorded. Results: Fifty screening laryngeal examinations were performed in 47 patients, of whom 31 (66%) had previously undergone a single anterior cervical approach procedure, and 16 (34%) had undergone more than one. Thirteen of the examinations (26%) revealed abnormal laryngeal findings, including paresis or paralysis in 11 cases (22%), of which 5 were asymptomatic. The findings resulted in a recommendation of a cervical approach from the already-involved side. None of the revision procedures resulted in bilateral vocal fold paralysis. The risk of laryngeal nerve injury appears to increase as higher cervical levels are approached. Conclusions: Minimally symptomatic injuries of the laryngeal nerves from prior neck surgery create a potential serious risk of bilateral vocal fold paralysis with subsequent procedures. Preoperative laryngeal screening is a simple and effective method for reducing this risk. © 2008 Annals Publishing Company. All rights reserved.
Keywords: adult; aged; anterior cervical spine procedure; article; clinical article; female; human; laryngeal nerve paralysis; laryngoscopy; male; nerve paralysis; preoperative laryngeal nerve screening; priority journal; recurrent laryngeal nerve; retrospective study; screening; spine surgery; vocal cord paralysis

Diaphragm pacing restores olfaction in tetraplegia - Adler D.; Gonzalez-Bermejo J.; Duguet A.; Demoule A.; Le Pimpec-Barthes F.; Hurbault A.; Morélot-Panzini C.; Similowski T. (European Respiratory Journal, 2009)
High cervical spinal cord injuries induce extreme handicap and tactile isolation. Tracheotomised tetraplegic patients are also bound to be olfaction deprived. By restoring negative pressure inspiration, diaphragm pacing (DP) should improve olfaction. We tested olfaction in 10 consecutive tetraplegics during positive pressure mechanical ventilation and DP, using the University of Pennsylvania Smell Identification Test (UPSIT). Quality of life was assessed using the Satisfaction with Life Scale (SWLS). Self-perceived benefits of DP were studied using an in-house questionnaire. Olfaction was very poor during positive pressure mechanical ventilation (UPSIT, mean±SD 17.1±6.4, anosmia or severe microsmia). It improved during DP (35.2±1.9, normosmia or mild microsmia; p<0.0001) and SWLS was 18.5±4.2. Nine patients stated that DP had improved their quality of life. This was driven by better mobility (ranked first), improved self-image and relationships with others (ranked second), improved olfaction and better feeling of security (both ranked third). Improved olfaction is among the benefits of DP and should be mentioned to patients considered for this therapy. Furthermore, attention to olfaction is warranted in tracheotomised ventilator-dependent patients, as a putative path towards improvement of quality of life. Copyright©ERS Journals Ltd 2009.
Keywords: adult; article; cervical spinal cord injury; clinical article; female; human; human relation; hypothesis; male; mobilization; negative pressure ventilation; nerve stimulation; phrenic nerve; phrenic nerve pacing; positive end expiratory pressure; priority journal; quadriplegia; quality of life; questionnaire; rating scale; Satisfaction with Life Scale; screening test; self concept; smelling; tracheotomy; treatment outcome; University of Pennsylvania Smell Identification Test

Diagnosis and Clinical Management of Spinal Muscular Atrophy - Han J.J.; McDonald C.M. (Physical Medicine and Rehabilitation Clinics of North America, 2008)
Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disease characterized by degeneration of lower motor neurons, with resulting progressive muscle weakness. The clinical phenotype and disease severity can be varied and occupy a wide spectrum. Although many advances have been made regarding our understanding of SMA, no cure is yet available. The care of patients who have SMA can often be complex, with many medical issues to consider. When possible, a multidisciplinary team approach is effective. The current understanding of SMA, and the clinical management and rehabilitative care of patients who have SMA, are discussed in this article. © 2008 Elsevier Inc. All rights reserved.
Keywords: calcium; creatine kinase; vitamin D; action potential; artificial ventilation; blood analysis; body composition; bulbar paralysis; cast application; chromosome 5q; clinical examination; clinical feature; conservative treatment; creatine kinase blood level; criterion variable; daily life activity; diagnostic procedure; diagnostic test; diagnostic value; disease activity; disease classification; disease course; disease marker; disease severity; dysphagia; echocardiography; electrocardiogram; electrodiagnosis; electromyography; family counseling; fasciculation; forced expiratory volume; fracture; functional assessment; functional status; gait disorder; gene deletion; gene frequency; gene identification; gene mutation; genetic counseling; genetic epidemiology; heart disease; heart function; heterozygote; hip contracture; hip dislocation; histopathology; human; infant feeding; infantile hypotonia; kyphoscoliosis; kyphosis; laboratory diagnosis; laboratory test; life expectancy; limb movement; limb weakness; lung clearance; lung disease; lung function test; motoneuron; motor nerve conduction; muscle atrophy; muscle biopsy; muscle contracture; muscle exercise; muscle function; muscle strength; muscle weakness; nerve cell degeneration; newborn assessment; nonhuman; nutritional status; onset age; osteopenia; patient care; patient monitoring; phenotype; physical examination; polysomnography; predictive validity; priority journal; prognosis; psychosocial care; range of motion; rehabilitation; respiratory care; review; scoliosis; sensitivity and specificity; sleep disordered breathing; spinal muscular atrophy; spine fusion; spine malformation; spirometry; subluxation; survival; symptomatology; tendon reflex

Sigmoid fixation associated with rectopexy using a laparoscopic approach could prevent relapse of rectal prolapse in pediatric patients with spinal dysraphia - Montes-Tapia F.; Cura-Esquivel I.; Garza-Luna U.; Martínez-Flores G.; Muñoz-Maldonado G.; Abrego-Moya V. (Journal of Pediatric Surgery, 2008)
Recurrent rectal prolapse, resistant to medical treatment, is an indication for surgical treatment. Patients with spinal dysraphia frequently have already been treated by sclerotherapy or other surgical techniques, but unsuccessfully. Methods: We present 2 patients, who underwent laparoscopic rectopexy, with spinal dysraphia and complete rectal prolapse relapse after conservative treatment. In these patients, we performed, as an additional technique, fixation of the rectosigmoid to avoid recurrence by invagination or prolapse of the anterior wall. Results: Follow-up at 14 and 11 months, respectively, did not find any recurrence. Conclusion: We suggest that laparoscopic rectopexy with sigmoid fixation should be considered as an alternative for the treatment for patients with spinal dysraphia and rectal prolapse to avoid recurrence. © 2008 Elsevier Inc. All rights reserved.
Keywords: laxative; Arnold Chiari malformation; article; bone radiography; case report; childhood disease; conservative treatment; diet therapy; follow up; gastrointestinal surgery; human; invagination; laparoscopic surgery; male; newborn; priority journal; proctopexy; rectosigmoid fixation; rectum prolapse; recurrent disease; spinal dysraphism; stomach fundoplication; surgical technique; thorax radiography; tracheostomy

Surface functional electrical stimulation of the abdominal muscles to enhance cough and assist tracheostomy decannulation after high-level spinal cord injury - Lee B.B.; Boswell-Ruys C.; Butler J.E.; Gandevia S.C. (Journal of Spinal Cord Medicine, 2008)
Objective: Evaluation of noninvasive stimulation modalities to augment cough and assist tracheostomy decannulation in high-level tetraplegia. Study Design: Single case study. Methods: A 65-year-old man with C4 ASIA C tetraplegia had delayed rehabilitation due to a tracheostomy and recurrent pneumonia primarily resulting from ineffective cough. Anterior surface electrical stimulation (SES) of the abdominal musculature was conducted to train an effective cough and enable decannulation. Training occurred daily for 4 weeks. The patient was tested 1 year later with posterolateral SES to determine the relative clinical effect of this delivery method. Results: At baseline, the addition of anterior SES increased maximal expiratory pressure (80%), maximal expiratory cough pressure (67%), and peak expiratory flow rate (11 %). Three weeks after training began, the patient was decannulated following a program of SES and assisted and voluntary coughing. Upon testing 1 year later, SES with posterolaterally placed electrodes also produced an enhancement of voluntary cough attempts. Conclusions: Noninvasive SES can potentially assist decannulation of tracheostomies. © 2008 by the American Paraplegia Society.
Keywords: abdominal wall musculature; adult; article; case report; coughing; decannulation; electrode; electrostimulation; investigative procedures; human; male; pneumonia; recurrent disease; rehabilitation care; spinal cord injury; tracheostomy

Critical Burn Patient with an Unknown Neuromuscular Disease: Conclusion - Knight IV W.A.; Gunderman M.; Hinckley W.R. (Air Medical Journal, 2008)
A 37-year-old man was severely burned while trying to fill a lighter with fuel while smoking. He sustained full-thickness (third-degree) burns over 60% to 70% of his body, including the oropharynx. A ground-based paramedic was unable to orotracheally intubate the patient after the administration of morphine and diazepam. The flight crew's assessment found an awake, alert man who was unable to speak because of his oral injuries. The Glasgow Coma Scale was estimated to be 10. In addition, the patient was wheelchair-bound from an undefined neuromuscular disease. The patient was successfully intubated by the flight team as in the following description. © 2008 Air Medical Journal Associates.
Keywords: bicarbonate; calcium; cisatracurium; diazepam; etomidate; furosemide; glucose; insulin; morphine; pancuronium; polystyrenesulfonate sodium; rocuronium; salbutamol; suxamethonium; vecuronium; adult; aircraft; aircraft accident; airway dynamics; article; burn; case report; clinical feature; compartment syndrome; critically ill patient; electrocardiogram; emergency care; endotracheal intubation; environmental temperature; Glasgow coma scale; heart arrhythmia; human; hyperkalemia; male; neuromuscular disease; paralysis; paramedical personnel; patient care; priority journal; spinal cord injury; spinocerebellar degeneration; tracheotomy; wheelchair

Rigid spine syndrome: A radiologic and manometric study of the pharynx and esophagus - Stübgen J.-P. (Dysphagia, 2008)
The rigid spine syndrome (RSS) is not a recognized cause of dysphagia. The "vacuolar variant" of RSS causes mild, generalized, and slowly progressive weakness. Respiratory evaluation detected severe restrictive chest wall defect and significant respiratory muscle weakness. We identified nine patients at our Neuromuscular Clinic over a period of years. The aim of this evaluation was to ascertain whether pharyngoesophageal dysfunction caused cough (2/9), intermittent oropharyngeal dysphagia (4/9), and aspiration pneumonia (3/9). Pharyngeal and esophageal functions were evaluated separately by conventional cineradiography and intraluminal esophageal manometry over a one-year study period. An age- and gender-matched volunteer group without swallowing complaints partook in the manometric component of the study. There were seven male and two female patients. The mean age of patients was 19.1 years (17.8 years for controls), and the age range was 11-36 years (13-32 years for controls). The mean disease duration was 17.2 years (range = 8-31 years). Patients were commonly underweight (7/9). Cineradiology detected abnormal swallow physiology of pharyngeal striated muscle (1/9) and of esophageal smooth muscle (2/9). Mean manometric pressures in patients were not significantly different from control data. Manometry detected "nonspecific" contractility abnormalities (3/9) that were not reflected in the mean data. The relative lack of instrumental findings suggested minor upper alimentary tract dysmotility in patients with the RSS. The myopathy that underlies this syndrome likely caused dysfunction of the striated muscle of the pharyngeal constrictors and upper esophageal sphincter. The documented abnormalities of esophageal smooth muscle motility were nonspecific and tenuously associated with the muscle disorder. The incongruity between complaints of intermittent dysphagia and study results was perhaps due to transient pharyngoesophageal dysmotility, altered swallowing mechanics of limited cervical spine mobility, altered swallowing perception after previous intubation/tracheostomy, or a "functional" upper intestinal complaint. © 2007 Springer Science+Business Media, LLC.
Keywords: adolescent; adult; age distribution; article; aspiration pneumonia; breathing muscle; cineradiography; clinical article; controlled study; coughing; dysphagia; esophagus function; female; histopathology; human; human tissue; intubation; male; manometry; myopathy; oropharynx; priority journal; rigid spine syndrome; school child; sex ratio; swallowing; thorax radiography; tracheostomy

Boussignac continuous positive airway pressure for weaning with tracheostomy tubes - Dieperink W.; Aarts L.P.H.J.; Rodgers M.G.G.; Delwig H.; Nijsten M.W.N. (Respiration, 2008)
Background: In patients who are weaned with a tracheostomy tube (TT), continuous positive airway pressure (CPAP) is frequently used. Dedicated CPAP systems or ventilators with bulky tubing are usually applied. However, CPAP can also be effective without a ventilator by the disposable Boussignac CPAP (BCPAP) system that is normally used with face masks. Objective:It was the aim of this audit to evaluate the feasibility of low-level BCPAP in patients who were weaned with a TT. Methods: All patients at our surgical intensive care unit who received a TT for weaning were considered for application of BCPAP. Once patients had received minimal pressure support from the mechanical ventilator, the BCPAP device was connected to the TT three times a day for 30 min with pressure set to 3-5 cm H2O, FiO2 at 0.4 and with humidification. BCPAP was then gradually extended to 24 h/day. Patient acceptance, complications and outcome were recorded. Results: 58 patients received a TT to facilitate weaning. They had a median stay of 52 days in the intensive care unit during which they had an endotracheal tube for 22 days and a TT for 28 days. 50 of these patients (86%) received BCPAP for a median of 16 days. The lightweight BCPAP system was well tolerated without tube obstructions or accidental decannulations and may have contributed to patient mobility. No patient remained on ventilatory support after hospital discharge. In-hospital and 1-year survival were 86 and 71%, respectively. Conclusions: BCPAP is a feasible and safe method for weaning tracheostomy patients. Copyright © 2007 S. Karger AG.
Keywords: adult; aged; article; artificial ventilation; controlled study; endotracheal tube; female; follow up; human; intensive care unit; major clinical study; male; mediastinitis; patient attitude; patient mobility; polyneuropathy; positive end expiratory pressure; pressure support ventilation; priority journal; respiratory distress syndrome; spinal cord transsection; survival rate; tracheostomy; tracheotomy tube; treatment outcome

Spinal cord compression by an old untreated asymptomatic cervical spine injury - A rare case of misdiagnosed identity - Mehta A.; Gupta S.; Angral R.; Lachala S. (Journal of Anaesthesiology Clinical Pharmacology, 2008)
Keywords: antibiotic agent; immunoglobulin; multivitamin; potassium; thiopental; vecuronium; analgesia; anamnesis; anesthesiological procedure; antibiotic therapy; article; artificial ventilation; bone transplantation; case report; cervical spine dislocation; cervical spine injury; clinical examination; computer assisted tomography; diagnostic error; endotracheal intubation; gas; Guillain Barre syndrome; human; intensive care unit; limb weakness; male; nasogastric tube; neuroimaging; nuclear magnetic resonance imaging; nutrition; odontoid process fracture; physiotherapy; potassium intake; respiratory failure; school child; seizure; spinal cord compression; tracheostomy

An autopsy case of amyotrophic lateral sclerosis with ampulla cardiomyopathy - Matsuyama Y.; Sasagasako N.; Koike A.; Matsuura M.; Koga T.; Kawajiri M.; Ohyagi Y.; Iwaki T.; Kira J.-I. (Clinical Neurology, 2008)
We herein report an autopsy case of a 63-year-old man with amyotrophic lateral sclerosis (ALS) who developed "ampulla cardiomyopathy." At the age of 56, he noticed a progressive weakness in his right upper extremity. One year later, a progressive weakness of the left upper extremity began. Dropped head and progressive weakness of the lower extremities emerged at the ages of 61 and 62, respectively. Intravenous immunoglobulin and plasma-exchange therapies did not improve his weakness. At the age of 63, one month before his death, he was hospitalized due to aspiration pneumonia. A tracheostomy was performed to secure his airway. Four days after the operation, an ST elevation of his electrocardiogram was incidentally found on the ECG monitor. An echocardiogram revealed diffuse hypokinesia of the wall of the left ventricle except in the basal portion, which is the typical finding of "ampulla cardiomyopathy." Wall motion of the left ventricle improved and his circulatory condition was stabilized after treatment, but his condition thereafter worsened again and he died 3 weeks later. An autopsy examination revealed diffuse fibrosis and degeneration of the cardiomyofibers. Neuropathological examination revealed neuronal cell loss, Bunina bodies and skein-like inclusions in the hippoglossal nuclei. In the thoracic spinal cord, degenarated anterior horn cells were seen and macrophage permeation in the corticospinal tract were shown by CD68 immunostaining. Therefore, the final neuropathological diagnosis was ALS. This report is the first autopsy case of ALS complicated with "ampulla cardiomyopathy.".
Keywords: CD68 antigen; immunoglobulin; adult; amyotrophic lateral sclerosis; anterior horn cell; arm weakness; article; aspiration pneumonia; autopsy; cardiomyopathy; case report; echocardiography; electrocardiogram; heart left ventricle wall; cardiac muscle cell; heart muscle fibrosis; histopathology; human; human tissue; hypoglossal nucleus; hypokinesia; immunohistochemistry; macrophage; male; plasmapheresis; pyramidal tract; ST segment elevation; thoracic spinal cord; tracheostomy

Long-Term Ventilation for High-Level Tetraplegia: A Report of 2 Cases of Noninvasive Positive-Pressure Ventilation - Toki A.; Tamura R.; Sumida M. (Archives of Physical Medicine and Rehabilitation, 2008)
Toki A, Tamura R, Sumida M. Long-term ventilation for high-level tetraplegia: a report of 2 cases of noninvasive positive-pressure ventilation. Ventilator-dependent patients with tetraplegia rarely use noninvasive positive-pressure ventilation (NPPV) for long-term ventilation. We report 2 patients with high-level traumatic tetraplegia who were able to return home after being changed from traditional ventilation to NPPV. When they were referred to our hospital from acute care hospitals 2 to 6 months after injury, both were on tracheostomy ventilation with a cuff inflated 24 hours a day, and tidal volume (Vt) settings were low. In case 1, a man with complete C1 tetraplegia was admitted to our hospital 6 months after injury. We changed ventilator settings to high Vt and introduced NPPV. He was discharged home with NPPV with a volume-setting ventilator. Case 2 involved a man in his late twenties with complete C1 tetraplegia who was discharged home with NPPV. After discharge, he trained in glossopharyngeal breathing by himself, enabling him to breathe up to 1900mL of maximum insufflation capacity. Both have lived nearly 1 year without pulmonary complications in the community. They use visiting nurses 3 times a week and services of visiting caregivers. Further study is needed to determine the usefulness of NPPV for long-term ventilatory management. © 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.
Keywords: adult; article; artificial ventilation; case report; emergency care; human; long term care; male; outcome assessment; positive end expiratory pressure; quadriplegia; spinal cord injury; tracheostomy; treatment outcome; treatment response; ventilator; vital capacity

Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all?. Part 2: ATLS, maxillofacial injuries and airway management dilemmas - Perry M.; Morris C. (International Journal of Oral and Maxillofacial Surgery, 2008)
Maxillofacial trauma poses an obvious threat to the patient's airway, which may not be immediately evident. In the multiply injured patient, the co-existence of actual or potential injuries elsewhere may complicate airway management, notably in the presence of full spinal immobilization. Following high-velocity trauma, injuries to the cervical spine must be assumed to be present. They also need to be ruled out in an appropriate and timely manner, as patients may wish to sit up. Assessment and management of the airway in maxillofacial trauma can be difficult, requiring a senior anaesthetist or other individual appropriately trained in emergency airway care. A number of management options may exist to protect the airway, each with advantages and drawbacks. Agitation and vomiting can occur unexpectedly and need to be managed safely with due consideration to the spine. Oral and maxillofacial surgeons need to be aware of these dilemmas and their early warning signs, and be skilled in emergency surgical airway procedures, especially if involved as part of the trauma team. Prolonged immobilization is associated with significant morbidity and mortality. A number of protocols currently exist for 'clearing' the spine. Imaging now plays a greater role, especially in the obtunded, unconscious or intubated patient, and this is discussed. © 2007 International Association of Oral and Maxillofacial Surgeons.
Keywords: glucocorticoid; methylprednisolone; agitation; airway; airway obstruction; alcohol intoxication; analgesia; bleeding; brain injury; cervical spine; cervical spine injury; clinical feature; clinical practice; disease association; drug megadose; edema; endotracheal intubation; face injury; health hazard; human; hypovolemia; immobilization; intracranial pressure; intubation; long term care; lung clearance; mandible fracture; maxillofacial injury; morbidity; mortality; oxygenation; patient assessment; patient care; patient monitoring; pulse oximetry; review; spinal cord injury; tracheostomy; tracheotomy; vestibular disorder; vomiting

An assessment of early tracheostomy after anterior cervical stabilization in patients with acute cervical spine trauma - Berney S.; Opdam H.; Bellomo R.; Liew S.; Skinner E.; Egi M.; Denehy L. (Journal of Trauma - Injury, Infection and Critical Care, 2008)
BACKGROUND: The optimal timing of tracheostomy after anterior cervical spine surgery remains controversial because of the potential for deep infection. The aims of this study were to compare the infection rates in patients requiring tracheostomy who underwent anterior versus posterior cervical spine surgery, and to report the timing of tracheostomy tube placement in such patients. METHOD: All patients admitted to a referral Intensive Care Unit for spinal trauma from January 1998 until May 2005, who underwent surgical stabilization with instrumentation and also received a tracheostomy, were retrospectively evaluated for demographic data, severity of neurologic injury, and complications including infection to a surgical site and timing and type of tracheostomy procedure. RESULTS: We identified 71 patients, all who had a diagnosis of acute cervical spine injury. Thirty-two (45%) underwent anterior stabilization, 15 (21%) had posterior stabilizations, and 24 (34%) required both anterior and posterior approaches. The mean time from stabilization to tracheostomy for an anterior approach was 3.8 ± 2.6 days. There was no significant difference in the timing of tracheostomy for different surgical approaches. Seventeen patients (25%) had a positive culture of their cervical and or tracheostomy incision site. Only one patient, however, had infection with the same organism at both the tracheostomy site and the anterior stabilization site. Suspected infection was managed with antibiotics and no further surgical intervention was required. CONCLUSIONS: Early tracheostomy after spinal stabilization is associated with a low risk of infection even after the anterior approach. © 2008 Lippincott Williams & Wilkins, Inc.
Keywords: antibiotic agent; adolescent; adult; aged; article; cervical spine injury; controlled study; female; human; infection rate; intermethod comparison; major clinical study; male; postoperative care; postoperative complication; priority journal; spine stabilization; tracheostomy

The use of mechanical ventilation is appropriate in children with genetically proven spinal muscular atrophy type 1: the motion for - Bach J.R. (Paediatric Respiratory Reviews, 2008)
The purpose of this paper is to report prolongation of survival for Werdnig-Hoffman's disease (spinal muscular atrophy type 1, SMA 1) by use of non-invasive respiratory muscle aids compared with tracheostomy, and to present reasons for offering this as an option to the parents of these children. Ninety per cent of typical untreated SMA 1 patients die before 12 months of age and 100% by 24 months of age. Tracheostomy can prolong survival to over 20 years of age in some cases, but patients with tubes do not develop the ability to speak and lose all ability to breathe from the point of the tracheotomy. In contrast, the majority of non-invasively managed SMA 1 patients develop the ability to communicate verbally and maintain some autonomous breathing ability. Clinicians' treatment paradigms associate ventilatory support with invasive tubes and do not recognise aiding respiratory muscles. Clinicians also significantly underestimate the care providers' view of the patient's quality of life. As a result, they rarely offer non-invasive means to prolong life. In conclusion, both non-invasive aids and tracheostomy can prolong survival for SMA 1 patients, and it should be left up to the family to decide which, if either, they would like to use. © 2007 Elsevier Ltd. All rights reserved.
Keywords: artificial ventilation; assisted ventilation; breathing disorder; breathing muscle; death; endotracheal tube; health care delivery; human; non invasive procedure; priority journal; quality of life; review; speech disorder; survival time; tracheostomy; treatment outcome; verbal communication; Werdnig Hoffmann disease

Intermittent atlantoaxial subluxation caused by a prolapsing neurofibroma: Case report - Kelleher M.O.; Quarishi N.A.; Tan G.; Guha A.; Massicotte E.M. (Journal of Neurosurgery: Spine, 2008)
In this report, the authors describe a unique case of intermittent high cervical cord compression caused by a prolapsing neurofibroma at the C1-2 level. This 21-year-old man with known neurofibromatosis Type 1 presented with a mass between the anterior arch of the atlas and the odontoid peg, causing atlantoaxial dissociation and cord compression. The cervicomedullary compression appeared to be caused in part by the neurofibroma but also by the abnormal alignment and thickening of the ligaments between the clivus and C-2. Preoperative imaging repeated on the morning of surgery revealed that the atlantoaxial dissociation had reduced with relief of cord compression and the lesion prolapsed inferiorly. The authors discuss this unusual lesion and describe the associated operative findings and surgical management.
Keywords: adult; article; atlantoaxial subluxation; case report; computer assisted tomography; human; male; neurofibromatosis; nuclear magnetic resonance imaging; spinal cord compression; tracheostomy

Editorial Overview: Is the use of invasive ventilation appropriate in children with genetically proven spinal muscular atrophy type 1? - Tobin B. (Paediatric Respiratory Reviews, 2008)
Keywords: artificial ventilation; child care; editorial; endotracheal intubation; endotracheal tube; face mask; health care availability; health practitioner; hospitalization; human; intensive care; invasive procedure; medical decision making; non invasive procedure; physiotherapy; priority journal; resource allocation; responsibility; risk benefit analysis; surgical risk; tracheostomy; Werdnig Hoffmann disease

Percutaneous tracheostomy for the management of the patient with a difficult airway - Suzuki H.; Aoyagi M. (Japanese Journal of Anesthesiology, 2008)
Background : In recent years, percutaneous tracheostomy has been performed in patients with adverse conditions such as short neck, obesity, coagulopathy or in emergency. Methods : We performed percutaneous tracheostomy with Griggs' or Ciaglia's technique in five patients with difficult airways due to laryngeal tumors, a laryngeal edema, a neck cancer or a cervical injury. Results : Well-trained anesthesiologists performed all procedures. In four patients, percutaneous tracheostomy was completed rapidly without any complications. The rest of patients underwent orotracheal intubation successfully with a percutaneous tracheostomy set prepared for an emergency situation. We call this setting "Stand-by PCT". Conclusions : We believe that percutaneous tracheostomy in well-trained hands can be used safely for the management of the patient with a difficult airway.
Keywords: anesthesia; anesthesist; article; blood clotting disorder; cervical spinal cord injury; endotracheal intubation; health service; human; intensive care; larynx edema; larynx tumor; neck cancer; neck malformation; obesity; surgical technique; tracheostomy

Medical rehabilitation of the patients with spinal cord injury caused by aortic aneurysm and its operation - Ohsawa S.; Tamaki M.; Hirabayashi S. (Spinal Cord, 2008)
Objectives: To determine the natural course of spinal cord injury (SCI) after aortic aneurysm surgery. Setting: Acute care and semi-acute wards in Osaka Rosai Hospital, Japan. Methods: From 1998 to 2003, 12 patients with thoracic SCI (eight men and four women; mean age: 69 years) were enrolled and evaluated by the American Spinal Injury Association (ASIA) impairment scale and Functional Independence Measure (FIM), and the results were analyzed. Results: The level of SCI was distributed from T5 to L1. The ASIA impairment scale was A in four patients, B in four, C in three and D in one. Finally, six patients were discharged to home, and two patients died during hospitalization. Excluding the value of the deceased patients, the mean motor FIM was initially 32±15.6 (13-59) points and became 61±21.4 (29-88) points at discharge. Referencing the databases of SCI in Japan and USA revealed that the complication rates of pneumonia and aspiration were higher in our cases. The motor FIM before rehabilitation and at discharge were relatively lower than in the databases, but the gain and the rate of gain were similar to the Japanese database. Conclusion: SCI associated with aortic aneurysm surgery was noticed especially in the elderly patients using airways (for example, tracheostomy). The higher age and recurrent nerve palsy were associated with deconditioning state to develop aspiration pneumonia. This state impaired the general condition, and such vicious cycle led to poor prognosis and functional outcome. © 2008 International Spinal Cord Society All rights reserved.
Keywords: adult; age distribution; aged; aneurysm surgery; article; aspiration pneumonia; clinical article; controlled study; dissecting aneurysm; female; Functional Independence Measure; hospital discharge; hospitalization; human; Japan; male; pneumonia; priority journal; rating scale; sex ratio; spinal cord injury; thoracic aorta aneurysm; thoracic spinal cord; United States

Upper aerodigestive tract sequelae in severe enterovirus 71 infection: Predictors and outcome - Tsou Y.-A.; Cheng Y.-K.; Chung H.-K.; Yeh Y.-C.; Lin C.-D.; Tsai M.-H.; Chang J.-S. (International Journal of Pediatric Otorhinolaryngology, 2008)
Objective: Enterovirus 71 (EV71) infection sequelae can be severe and life-threatening, and long-term follow-up outcomes remain unknown. Therefore, we conducted a retrospective follow-up study to review airway and neurological sequelae development in patients with severe EV71 infection. We also studied the incidence and risk factors for tracheotomy and gastrostomy requirement. Patients and methods: We investigated 202 EV71-infected children according to their disease stage. Seventy-two of them were diagnosed to have EV71 encephalitis, which was characterized by myoclonus, ataxia, nystagmus, oculomotor palsy and bulbar palsy or combinations of these conditions. All the 72 patients required endotracheal intubation due to respiratory failure or ventilator dependence; among these, 14 underwent tracheostomy and 10 underwent gastrostomy. All patients were followed-up for at least 3 years after discharge. Predictors of tracheostomy and gastrostomy requirement were age <2 years, body weight <10th percentile, pulmonary hemorrhage or edema, meningeal symptoms and magnetic resonance imaging (MRI) findings of upper spinal cord and brainstem. We determined outcome based on persistent tracheostomy or gastrostomy requirement and whether patients developed positive neurological sequelae. Results: Significant tracheostomy and gastrostomy predictors were age <2 years, pulmonary edema or hemorrhage, hypotension, hemiparesis and positive MRI findings. Statistical analysis revealed pulmonary edema and hypotension as index predictors of tracheostomy requirement and pulmonary edema as the significant risk factor for gastrostomy. Conclusions: Long-term neuropsychological impact was observed on children who present the signs of the pulmonary edema or hypotension in the early onset of the EV71 infection. EV71-infected patients who develop neurological pulmonary edema or hypotension should be hemodynamically stabilized and undergo early tracheostomy to prevent further complications. This may improve the decannulation success rate after the brainstem function recovers. © 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: article; artificial ventilation; ataxia; body weight; brain stem; bulbar paralysis; controlled study; disease severity; encephalitis; endotracheal intubation; Enterovirus A71; Enterovirus infection; female; follow up; gastrostomy; human; hypotension; long term care; lung edema; lung hemorrhage; major clinical study; male; medical record review; morbidity; myoclonus; neurologic disease; nuclear magnetic resonance imaging; nystagmus; ophthalmoplegia; pathogenesis; preschool child; priority journal; respiratory failure; respiratory tract infection; spinal cord; surgical risk; surgical technique; tracheostomy

Respiratory management during the first five days after spinal cord injury - Berlly M.; Shem K. (Journal of Spinal Cord Medicine, 2007)
Summary: Respiratory complications are the most common cause of morbidity and mortality in acute spinal cord'injury (SCI), with an incidence of 36% to 83%. Eighty percent of deaths in patients hospitalized with cervical SCI are secondary to pulmonary dysfunction, with pneumonia the cause in 50% of the cases. The number of respiratory complications during the acute hospital stay contributes significantly to the length of hospital stay and cost. Four factors (use of mechanical ventilation, pneumonia, the need for surgery, and use of tracheostomy) explain nearly 60% of hospital costs and may be as important a predictor of hospital cost as level of injury. Atelectasis (36.4%), pneumonia (31.4%), and ventilatory failure (22.6%) are the most common complications during the first 5 days after injury. Ventilatory failure occurs on average 4.5 days after injury. Transfer to an SCI center specializing in acute management of tetraplegia has been shown to significantly reduce the number of respiratory complications. This review concentrates on the first 5 days after injury, focusing on complications, predictive factors, prevention, and management of those complications.
Keywords: acetylcysteine; aminophylline; bicarbonate; cromoglycate disodium; methylprednisolone; oxandrolone; theophylline; acute disease; artificial ventilation; assisted ventilation; atelectasis; bronchospasm; clinical assessment; cost benefit analysis; disease severity; drug megadose; endotracheal intubation; hematopneumothorax; hospital cost; hospitalization; human; incidence; infection risk; intermittent positive pressure ventilation; length of stay; lung edema; lung embolism; morbidity; mortality; mucus secretion; pleura effusion; pneumonia; quadriplegia; respiratory failure; review; risk reduction; spinal cord injury; thorax drainage; thorax injury; tidal volume; total parenteral nutrition; tracheostomy; vital capacity; mucomyst

Anterior spondylosis of the cervical spine causing dyspnea and sleep disturbance - Eysel-Gosepath K.; Fürderer S.; Delank K.-S.; Schröder U.; Eysel P. (HNO, 2007)
Background. Cervical osteochondrosis is a rare differential diagnosis leading to dysphagia, inspiratory stridor and obstructive sleep apnea syndrome (OSAS). Patients and methods. We report six cases of patients with episodes of neck pain (n=6), pain reflected to the arm (n=1), sleep apnea (n=5), inspiratory stridor (n=3) and/or unclear dysphagia (n=6), who presented between 2000 and 2003 at the Römerwallklinik Mainz and the university hospitals of Mainz and Cologne. None of these patients had symptoms of spinal or radicular compression. All underwent otorhinolaryngological and radiological examination followed by excision of anterior spondylophytes and intervertebral fusion. One patient required immediate tracheotomy due to perforation of the pharyngeal wall associated with severe supraglottic swelling. Results. All patients were free of inspiratory stridor postoperatively. Symptoms of dysphagia disappeared in four patients and were reduced in two. Three of five patients were free of apnea. OSAS had improved in two. Neck pain was eliminated in four cases and markedly improved in two cases. Conclusions. In case of symptoms of pharyngeal compression and OSAS, a vertebragenic cause should be considered. © 2007 Springer Medizin Verlag.
Keywords: aged; article; case report; cervical spine; dyspnea; female; human; male; middle aged; neck pain; sleep disordered breathing; spondylosis; treatment outcome

Heterotopic ossification of the vocal cords after spinal cord injury - Zellig G.; Zwecker M.; Weingarden H.; Wolf M. (Journal of Spinal Cord Medicine, 2007)
Background/Objective: To report a rare complication of heterotopic ossification of the vocal cords after spinal cord and multiple organ injuries. Study Design: Case report. Setting: Acute rehabilitation in the Department of Neurologic Rehabilitation. Results: A 55-year-old patient sustained spinal cord injury and multitrauma after falling from a height. Approximately 3 months later, after weaning from mechanical ventilation, plugging of the cannula resulted in severe stridor indicating upper airway obstruction. A computed tomography scan showed bilateral vocal cord fixation in a para-median position, with hyperossification of the vocal processes of the arytenoids. Direct laryngoscopy revealed interarytenoid ossification, and sawing through the ossification resulted in remobilization of the vocal cords enabling decannulation. Conclusions: Heterotopic ossification of the vocal cords was found to be an early complication of acute spinal cord injury and multiple trauma. This rare complication should be considered in the differential diagnosis of patients showing signs of upper airway obstruction.
Keywords: etidronic acid; adult; airway obstruction; article; case report; clinical feature; computer assisted tomography; human; laryngoscopy; larynx cartilage; ossification; spinal cord injury; vocal cord

Severe upper airway obstruction due to retropharyngeal haematoma formation following cervical trauma - Haarmann S.; Budihardja A.S.; Mücke T.; Schwaegerl C.; Wolff K.D. (Mund - Kiefer - und Gesichtschirurgie, 2007)
Mechanical airway obstruction secondary to retropharyngeal bleeding is rare. In most cases such a complication is described after head and neck trauma. Complicating factors include anticoagulant therapy, tumour, aneurysm, infection or major cervical spine injury. A precise initial diagnosis is necessary to avoid a life-threatening situation. Lateral X-ray and computed tomography is essential for safe management. Treatment depends upon size of the haematoma as well as the clinical course of the patient. Smaller haematomas may be observed. Lager haematomas and those that fail to reabsorb should undergo drainage. © Springer-Verlag 2007.
Keywords: aged; airway obstruction; article; blunt trauma; case report; contrast medium extravasation; hematoma; human; image processing; injury; intensive care; male; neck injury; neck muscle; pharynx disease; radiography; spiral computer assisted tomography; tracheostomy

Pitfalls in treatment of acute cervical spinal cord injury using high-dose methylprednisolone: a retrospect audit of 111 patients - Lee H.-C.; Cho D.-Y.; Lee W.-Y.; Chuang H.-C. (Surgical Neurology, 2007)
Background: Earlier studies suggested that the use of high-dose IV MP was the gold standard of care for the treatment of ASCI, but this has been debated. This study aims to identify the effects of high-dose MP in treatment of cervical SCI and how the treatment might be improved. Methods: The medical records of 138 patients with cervical spinal injury secondary to blunt injuries were retrospectively reviewed to determine the steroid administration protocol, effects, and complications. The findings on admission were compared with those at discharge and at the most recent outpatient follow-up visit. Significant neurologic improvement was defined as increase in at least 1 clinical grade according to the Frankel classification system. Results: Significantly more motor and sensory recovery was noted (complete ASCI, 69% vs 0; incomplete ASCI, 70% vs 50%) in patients treated with surgery and MP than in patients without such treatment. Moreover, 87% (14/16) of patients with complete ASCI (unlike patients with incomplete [8/28, 28.6%] and mild [2/14, 14.3%] ASCI) treated with MP had steroid-related complications, and 1 patient died from sepsis related to a perforated peptic ulcer. Mean hospitalization was significantly shorter for the patients who underwent tracheostomy (49 days, ranged from 22 to 110 days) vs nontracheostomy(94 days, ranged from 28-268 days). Conclusion: Early intervention with surgery and MP is critical. Although treatment with MP for 24 or 48 hours significantly improves motor and sensory function of patients with ASCI, harmful side effects limit its functional efficacy in patients with complete ASCI. Early tracheostomy can shorten hospital stay in patients with complete ASCI. © 2007 Elsevier Inc. All rights reserved.
Keywords: methylprednisolone; adolescent; adult; aged; article; controlled study; disease course; disease severity; drug effect; drug efficacy; drug megadose; female; follow up; hospitalization; human; major clinical study; male; medical record; motor performance; neurologic examination; outcome assessment; peptic ulcer; school child; sensory evaluation; sepsis; spinal cord decompression; spinal cord injury; survival rate; tracheostomy; treatment failure; treatment outcome; unspecified side effect

Two cases of myelopathy highlight the importance of investigating weakness in ICU - Plunkett E.V.E.; Seyfried O.; Mateen M.; Ghosh I.R. (British Journal of Intensive Care, 2007)
Two myelopathic cases highlight the importance of investigation of weakness in intensive care. In both cases evidence of weakness prompted imaging which confirmed the diagnosis. E Plunkett et al. recommend that all cases of weakness be investigated; the detection of neurological deficits coexisting with critical illness may enable either specific therapy to improve outlook, or the timely confirmation of a goarded outlook.
Keywords: adult; anamnesis; article; case report; chronic obstructive lung disease; female; human; intensive care unit; male; mastoiditis; multiple organ failure; nuclear magnetic resonance imaging; renal replacement therapy; septicemia; spinal cord disease; Staphylococcus aureus; tracheostomy

Paraplegia as a result of tracheal resection in a 17-year-old male - Silver J.R. (Spinal Cord, 2007)
Study design: Case report and literature review. Setting: Outpatient review in the UK on a young male from the USA. Objectives: To report on a healthy young male who developed an incomplete paraplegia following flexion of the cervical spine after surgery to relieve tracheal stenosis. Conclusion: Spinal cord injury following prolonged flexion of the cervical spine after surgery to relieve tracheal stenosis can cause paraplegia. The postulated mechanism is traction upon the thoracic cord. © 2007 International Spinal Cord Society All rights reserved.
Keywords: gadolinium; adolescent; anamnesis; article; case report; cervical spine; flexor reflex; hospital discharge; human; male; medical literature; nuclear magnetic resonance imaging; outpatient; paraplegia; patient referral; priority journal; spinal cord disease; thoracic spinal cord; trachea resection; trachea stenosis; tracheostomy; treatment outcome; United Kingdom; United States; vascular myelopathy

Penetrating injury of the upper cervical spine by a chopstick - Case report - Yamaguchi S.; Eguchi K.; Takeda M.; Hidaka T.; Shrestha P.; Kurisu K. (Neurologia Medico-Chirurgica, 2007)
A 35-year-old man presented with penetrating spinal injury after attempting suicide by stabbing a wooden chopstick into his mouth. The object penetrated the pharynx, and the tip entered the spinal canal of the atlantoaxial vertebrae. Emergent surgery disclosed that the tip of the chopstick had penetrated between the dural sac and the vertebral artery. There was no dural tear or vertebral artery injury. The foreign body was removed successfully from the oral side. He recovered without neurological sequelae.
Keywords: adult; article; case report; cervical spine injury; chopstick; clinical examination; clinical feature; emergency surgery; foreign body; human; laminectomy; male; neurologic examination; nuclear magnetic resonance imaging; penetrating trauma; postoperative period; stab wound; suicide attempt; tracheotomy; treatment outcome; vertebral artery; wood

Extensive endobronchial calcification contributing to hypoxia in a quadriplegic patient [33] - Imberti R.; Pricca P.; Pietrobono L.; Langer M. (Anesthesia and Analgesia, 2007)
Keywords: adult; artificial ventilation; bronchiole; bronchus obstruction; calcification; case report; computer assisted tomography; human; hypoxia; letter; male; oxygenation; priority journal; quadriplegia; small airway disease; spinal cord injury; tracheostomy

Cervical hematoma after discectomy for spondylosis. An indication of urgent tracheotomy - Pino Rivero V.; Pantoja Hernández C.G.; Mora Santos M.E.; Gonzalez Palomino A.; Ambel Albarrán A.; Rodríguez Sánchez J.A.; Blasco Huelva A. (Anales otorrinolaringológicos ibero-americanos, 2007)
We report the clinical case of a hematoma after surgery of cervical spondylosis which required an urgent tracheotomy due to failure in the orotracheal intubation. This illness in advanced degree, so called cervical spondylotic myelopathy, is the most serious consequence of cervical intervertebral disc degeneration.
Keywords: aged; article; case report; cervical spine; hematoma; human; male; nuclear magnetic resonance imaging; pathology; postoperative complication; respiratory failure; spondylosis; tracheotomy

Survey of use of the insufflator-exsufflator in patients with spinal cord injury - Schmitt J.K.; Stiens S.; Trincher R.; Lam M.; Sarkarati M.; Linder S.; Ho C.H. (Journal of Spinal Cord Medicine, 2007)
Background/Objective: The insufflator-exsufflator has been shown to be effective in assisting cough in individuals with spinal cord injury. However, many institutions do not use this device. The study was performed to assess use of the device and attitudes among health care providers. Methods: We developed a questionnaire with 4 categories of questions: knowledge of the device, type of facility, clinical practice with the device, and patient and provider satisfaction. The questionnaire was mailed to members of the American Paraplegia Society. Results: Eighty-six questionnaires (16%) were returned. The device was being used in 49% of the institutions. The device was most commonly used with a tracheostomy; use did not correlate with size or type of facility. Patient and provider satisfaction with the insufflator-exsufflator was high. Conclusions: The insufflator-exsufflator is used as a means of removal of secretions in approximately one half of institutions polled. Satisfaction with the device is high.
Keywords: abdominal discomfort; aeration; article; bradycardia; coughing; devices; health care delivery; health care personnel; health personnel attitude; human; nausea; paraplegia; patient care; patient satisfaction; questionnaire; spinal cord injury; tachycardia; technical aid; thorax pressure; tracheostomy

Spinal muscular atrophy type 1: Is long-term mechanical ventilation ethical? Commentary - Ryan M. (Journal of Paediatrics and Child Health, 2007)
Keywords: artificial ventilation; disease course; face mask; human; note; phenotype; priority journal; respiratory failure; spinal muscular atrophy; survival; tracheostomy

Spinal muscular atrophy type 1: Is long-term mechanical ventilation ethical? Commentary - Jacobe S. (Journal of Paediatrics and Child Health, 2007)
Keywords: artificial ventilation; critical illness; disability; human; intensive care; long term care; medical ethics; medical specialist; note; parental attitude; priority journal; respiratory failure; spinal muscular atrophy; tracheotomy; treatment withdrawal

Spinal muscular atrophy type 1: Is long-term mechanical ventilation ethical? Commentary - Isaacs D. (Journal of Paediatrics and Child Health, 2007)
Keywords: artificial ventilation; caregiver; conflict; counseling; disability; hospital personnel; human; intensive care; note; palliative therapy; parental attitude; pediatrician; priority journal; quality of life; respiratory failure; spinal muscular atrophy; tracheostomy; treatment withdrawal; feeding tube

Surgical strategy for severe cervical spine dislocations - Wang X.W.; Yuan W.; Chen D.Y.; Chen X.S.; Zhou X.H.; Ye X.J.; Chen H.J.; Han Z.; Kang J. (Zhonghua wai ke za zhi [Chinese journal of surgery], 2007)
OBJECTIVE: To evaluate the rate of open reduction and surgical strategy of severe cervical dislocation. METHODS: From March 2001 to March 2006, the data of 92 cases of cervical dislocation over 1/2 were retrospectively studied. Garden Well traction with 1 - 3 kg weight were performed before operation. The patients were performed with diskectomy and reduction with anterior approach initially, for those that can not be reduced, corpectomy were performed and reduction procedures were repeated. The posterior reduction and fixation were followed when reduction can not be reached with anterior approach only. The succeed rate of reduction, rate of tracheotomy were recorded and fusion rate, Frankel score and visual analog scale (VAS) were evaluated. RESULTS: Reduction succeed in 38 cases after diskectomy, 44 after corpectomy and 7 after combined anterior-posterior-anterior procedure. Three cases got incompleteness reduction. Tracheotomy was done in 29 cases. The Frankel score increased 0.5 degree and VAS was 2 averagely at the last follow-up. CONCLUSIONS: The succeed rate of anterior open reduction was 89.2%, and only 10.8% patients needs an additional combined posterior and anterior approach. For patients with completed spinal cord injury with dislocation above C(4), or with dislocation below C(5) but the edema on MRI T2 image are above C(4) level need tracheotomy. The operation be done until respiratory function stable. For patients with completed spinal cord injury with dislocation below C(4) and uncompleted spinal cord injury with dislocation above C(4), the rate of tracheotomy is relatively lower and early operation is recommended.
Keywords: article; bone transplantation; cervical spine; decompression surgery; dislocation; female; follow up; human; injury; discectomy; laminectomy; male; methodology; osteosynthesis; retrospective study; spine fracture; spine fusion; traction therapy; treatment outcome

Ventilatory dysfunction in motor neuron disease: When and how to act? - Rocha J.A.; Miranda M.J. (Acta Medica Portuguesa, 2007)
Amyotrophic lateral sclerosis is a devastating progressive neurodegenerative disorder, involving motor neurons in the cerebral cortex, brainstem and spinal cord. Mean duration of survival from the time of diagnosis is around 15 months, being pulmonary complications and respiratory failure responsible for more than 85% of deaths. Albeit the inevitability of respiratory failure and short-term death, standardized intervention protocols have been shown to significantly delay the need for invasive ventilatory support, thus prolonging survival and enhancing quality of life. The authors present an intervention protocol based on clinical progression and respiratory parameters. Decisions regarding initiation of non-invasive positive pressure ventilation (NIPPV) and mechanically assisted coughing, depend on development of symptoms of hypoventilation and on objective deteoration of respiratory parameters especially in what concerns bulbar muscle function. These include maximum inspiratory capacity (MIC), difference between MIC and vital capacity (MIC-VC), and assisted peak cough flow (PCF). These standardized protocols along with patient and caregivers education, allow for improved quality of life, prolonged survival and delay or eventually prevent the need for tracheotomy and invasive ventilatory support. Supplemental oxygen should be avoided in these patients, since it precludes use of oxymetry as feedback for titrating NIPPV and MAC, and is associated with decreased ventilatory drive and aggravated hypercapnia.
Keywords: amyotrophic lateral sclerosis; assisted ventilation; disease association; human; lung ventilation; mortality; motor neuron disease; quality of life; respiratory failure; review; survival

Variability in rates of arthrodesis procedures for patients with cervical spine injuries with and without associated spinal cord injury - Daniels A.H.; Arthur M.; Hart R.A. (Journal of Bone and Joint Surgery - Series A, 2007)
Background: Cervical spine injury, with or without spinal cord injury, is an important cause of morbidity and mortality in the United States. While substantial regional variation has been shown in per capita rates of elective cervical spine surgery, similar data regarding arthrodesis rates for traumatic cervical injury have not been reported, to our knowledge. We assessed the rates of cervical spinal arthrodesis for patients who had a cervical spine injury with or without an associated spinal cord injury. Methods: The data for the present study came from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2002. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients with a cervical vertebral fracture or dislocation with or without an associated spinal cord injury. Hospitals were grouped according to their teaching status, location (urban or rural), and volume of cervical spine injury patients. The rates of spinal arthrodesis and halo/tong placement were compared for patients within each diagnostic category. Results: Twenty-eight thousand, five hundred and eighteen patients with a cervical spine injury were analyzed. Spinal arthrodesis was performed for 16.5% of patients who had a cervical fracture without an associated spinal cord injury, for 50.4% of patients who had a cervical spine fracture with an associated spinal cord injury, and for 44.1% of patients who had a cervical dislocation. With the numbers available, the rates of arthrodesis for patients who had a fracture without a spinal cord injury and for patients who had a cervical dislocation were not significantly different between high and low-volume centers, although the rate for patients who had a cervical fracture with a spinal cord injury was significantly higher at high-volume hospitals. The rates of arthrodesis did not vary significantly between urban teaching and nonteaching hospitals, with the numbers available, for patients in any of the three diagnostic categories. Individual hospitals had a threefold to fivefold variation in the arthrodesis rate for patients with a cervical spine injury, depending on the diagnostic category. Conclusions: The present study demonstrated substantial differences in the rate of arthrodesis for patients with cervical spine trauma, depending on the diagnostic category. The variations in the rates of arthrodesis within diagnostic categories appear to be lower than the previously reported variation in the rates of elective cervical spine procedures. Copyright © 2007 by The Journal of Bone and Joint Surgery, Incorporated.
Keywords: arthrodesis; article; cervical spinal cord injury; cervical spine fracture; cervical spine injury; health care cost; health care utilization; hospitalization; human; International Classification of Diseases; major clinical study; orthosis; priority journal; scoring system; spinal cord injury; spine fracture; spine injury; spine surgery; teaching hospital; tracheostomy

Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach. Technical note - Wolinsky J.-P.; Sciubba D.M.; Suk I.; Gokaslan Z.L. (Journal of Neurosurgery: Spine, 2007)
Symptomatic irreducible basilar invagination has traditionally been approached through a transoral-transpharyngeal route with resection of the anterior portion of C-1 and the odontoid. Modification of this exposure with either a Le Fort osteotomy or a transmandibular osteotomy and circumglossal approach has increased the access to pathological conditions in this region. These traditional routes all require traversing the oral cavity and accepting the associated potential complications. The authors have developed a novel surgical approach, an endoscopic transcervical odontoidectomy, which allows access for resection of the odontoid and for brainstem and spinal cord decompression without traversing the oral cavity. In this paper they describe the technique and its advantages and present three cases in which patients underwent the endoscopic transcervical odontoidectomy for basilar invagination. Three consecutive patients (age range 42-74 years) who had irreducible basilar invagination underwent the endoscopic transcervical odontoidectomy. All were symptomatic and had neck pain and myelopathy. All were evaluated preoperatively and postoperatively with computed tomography and magnetic resonance imaging. In all cases the procedure resulted in complete decompression. There were no serious complications. No patient required prolonged intubation, tracheostomy, or enteral tube feeding. One patient had an intraoperative cerebrospinal fluid leak, which had no postoperative sequelae. The authors present an alternative surgical approach for treating ventral compression of the brainstem and spinal cord. The technique is safe and effective for decompression and provides a surgical route that can be added to the armamentarium of treatments for pathological conditions in this region.
Keywords: adult; aged; article; brain stem; brain stem injury; case report; cervical spine; clinical feature; computer assisted tomography; dens axis resection; endoscopic surgery; female; human; intubation; liquorrhea; male; neck pain; nuclear magnetic resonance; odontoid process; postoperative care; preoperative evaluation; spinal cord decompression; spinal cord disease; spine surgery; surgical approach; surgical technique; tracheotomy; feeding tube

Optimal Trauma Outcome: Trauma System Design and the Trauma Team - Markovchick V.J.; Moore E.E. (Emergency Medicine Clinics of North America, 2007)
Trauma is the number one killer of Americans under age 34; optimal trauma care is provided when there is a well-functioning, comprehensive system. This article reviews the development of trauma centers in the United States, recommending that the number of trauma centers be optimized so that resources and expense be kept to a minimum. The role of specialists in the care of trauma patients has evolved over the past few decades. Efforts and protocols for trauma care should be based on objective quality outcome data, with the goal of making the most efficient use of resources for the best possible outcomes. © 2007 Elsevier Inc. All rights reserved.
Keywords: blunt trauma; disease severity; emergency care; emergency health service; emergency medicine; emergency ward; femur fracture; flail chest; Glasgow coma scale; gunshot injury; head injury; health survey; human; injury; injury scale; neck injury; pelvis fracture; pelvis injury; penetrating trauma; priority journal; review; scoring system; spinal cord injury; thoracotomy; thorax injury; tracheotomy; United States

Prevention of respiratory complications of spinal cord injury: A challenge to "model" spinal cord injury units - Bach J.R. (Journal of Spinal Cord Medicine, 2006)
Keywords: acute respiratory failure; amyotrophic lateral sclerosis; cannulation; clinical protocol; cost effectiveness analysis; coughing; Duchenne muscular dystrophy; editorial; expiratory flow; human; inspiratory capacity; intermittent positive pressure ventilation; invasive procedure; lung clearance; morbidity; muscle function; neuromuscular disease; neuromuscular system; non invasive procedure; patient safety; quadriplegia; respiratory tract disease; respiratory tract infection; respiratory tract intubation; speech; spinal cord injury; spinal muscular atrophy; suction; swallowing; tracheostomy; ventilator

Spinal cord gliomas and hydrocephalus: Utility of neuroendoscopy - Galarza M.; Peretta P.; Gazzeri R.; Cinalli G.; Forni M.; Morra I.; Ragazzi P.; Sandri S. (Minimally Invasive Neurosurgery, 2006)
Objective: The aim of this study is to report on the role of neuroendoscopy during the management of hydrocephalus that led to the diagnosis of intracranial tumoral dissemination and the subsequent finding of a spinal cord glioma. Methods and Results: We present two children each with an intramedullary astrocytoma that presented initially with hydrocephalus without spinal cord symptoms. In both cases leptomeningeal gliomatous dissemination was asserted during routine endoscopy for the management of hydrocephalus. The diagnosis of a cervical and a lower thoracic intramedullary tumor was made soon after on magnetic resonance imaging. Conclusions: Spinal cord MRI with contrast should be considered initially in selected cases of hydrocephalus without evident diagnosis. The intraoperative diagnosis of gliomatous dissemination and secondary hydrocephalus due to unrecognized spinal cord gliomas was possible, in our experience, with the routine use of the neuroendoscope. © Georg Thieme Verlag KG Stuttgart.
Keywords: antineoplastic agent; anamnesis; article; astrocytoma; brain biopsy; cancer chemotherapy; cancer grading; case report; cerebrospinal fluid examination; cervical spinal cord; clinical feature; controlled study; craniectomy; glioma; human; human tissue; hydrocephalus; immunohistochemistry; infant; leptomeninx; male; neuroendoscopy; neurologic examination; nuclear magnetic resonance imaging; preschool child; respiratory failure; spinal cord tumor; thoracic spinal cord; tracheostomy; treatment outcome

Effusion of the hips in a patient with tetraplegia - Kupfer M.; Dholakia M.; O'Neill B.J. (Journal of Spinal Cord Medicine, 2006)
Background: Patients with spinal cord injury are at risk for knee effusion, most likely as a result of repetitive microtrauma. Patients with paralysis are susceptible to effusions of the hip similar to those seen in documented cases regarding the knee. The etiology is likely similar and is related to repetitive microtrauma, such as that experienced when aggressive range of motion exercises are applied. Design: Case report. Setting: Acute rehabilitation department of a spinal cord injury center. Findings: A 19-year-old man with a complete cervical spinal cord injury presented to acute rehabilitation on postinjury day 25 with a C6 American Spinal Injury Association classification A injury, complete. He was found to have bilateral hip effusions. Joint aspiration yielded a right sterile hydroarthrosis and a left sterile hemarthrosis. During his rehabilitation stay, the patient developed one mildly elevated alkaline phosphatase level, but he showed no radiographic evidence of heterotopic ossification and maintained full passive range of motion of the hips. Conclusion: This case indicates that hip effusion may be a similar, less-common occurrence than knee effusion in patients with spinal cord injury. In this case, bilateral aseptic hip effusion was not associated with heterotopic ossification. More research is needed to determine the etiology and sequelae of this condition.
Keywords: alkaline phosphatase; enoxaparin; adult; alkaline phosphatase blood level; arthrodesis; article; bleeding; bone graft; case report; clinical feature; computer assisted tomography; deep vein thrombosis; epidural hemorrhage; human; joint aspiration; joint dislocation; joint effusion; lung embolism; male; nuclear magnetic resonance imaging; percutaneous endoscopic gastrostomy; quadriplegia; rehabilitation care; respiratory failure; soft tissue swelling; spinal cord hemorrhage; spinal hematoma; spine fracture; substance abuse; swelling; tracheotomy