Cuff deflation: rehabilitation in critical care. - Bach J.R.; Gonçalves M.R.; Rodriguez P.L.; Saporito L.; Soares L. (American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 2014)
This is a case series of rehabilitation failures that resulted in severe reactive depression from patients unnecessarily bereft of verbal communication by being left to breathe or be ventilated via tracheostomy tubes, with or without inflated cuffs, for months to years.
Keywords: adjustment disorder; adult; article; case report; human; intensive care; male; methodology; middle aged; muscular dystrophy; noninvasive ventilation; speech; spinal cord injury; tracheostomy; young adult

Multidisciplinary interventions in motor neuron disease - Williams U.E.; Philip-Ephraim E.E.; Oparah S.K. (Journal of Neurodegenerative Diseases, 2014)
Motor neuron disease is a neurodegenerative disease characterized by loss of upper motor neuron in the motor cortex and lower motor neurons in the brain stem and spinal cord. Death occurs 2-4 years after the onset of the disease. A complex interplay of cellular processes such as mitochondrial dysfunction, oxidative stress, excitotoxicity, and impaired axonal transport are proposed pathogenetic processes underlying neuronal cell loss. Currently evidence exists for the use of riluzole as a disease modifying drug; multidisciplinary team care approach to patient management; noninvasive ventilation for respiratory management; botulinum toxin B for sialorrhoea treatment; palliative care throughout the course of the disease; and Modafinil use for fatigue treatment. Further research is needed in management of dysphagia, bronchial secretion, pseudobulbar affect, spasticity, cramps, insomnia, cognitive impairment, and communication in motor neuron disease.
Keywords: acetylcysteine; amitriptyline; atropine; baclofen; botulinum toxin B; carbamazepine; ciliary neurotrophic factor; citalopram; dantrolene; dextromethorphan plus quinidine; diazepam; etiracetam; modafinil; phenytoin; quinidine; quinine sulfate; recombinant somatomedin C; riluzole; tetrazepam; tizanidine; verapamil; zolpidem; assisted ventilation; bronchus secretion; cognitive defect; cost effectiveness analysis; disability; disease course; dysphagia; early diagnosis; electrostimulation; fatigue; health care cost; hospitalization; human; hypersalivation; insomnia; interpersonal communication; living will; medical care; medical specialist; meta analysis (topic); motor neuron disease; muscle cramp; neuroprotection; noninvasive ventilation; nutritional support; palliative therapy; parenteral nutrition; patient care; patient selection; physiotherapy; quality of life; review; spasticity; survival time; telemonitoring; terminal care; tracheostomy

Progressive dysautonomia in two patients with xeroderma pigmentosum group A - Kobayashi O.; Miyahara H.; Abe N.; Goto C.; Okanari K.; Akiyoshi K.; Korematsu S.; Izumi T. (Pediatric Neurology, 2014)
Background: Xeroderma pigmentosum group A (XPA) is a rare autosomal-recessive disorder caused by a defect in nucleotide excision repair. Progressive dysautonomia in patients with XPA is rarely described. Patients Two juvenile male patients with XPA suffered from dysphagia, sleep interruption, and dysuria from the age of 10 to 19 years, successively. These autonomic symptoms might have been caused by progressive descending degeneration of cranial nerves IX and X and the sacral parasympathetic nerve, including Onuf's nucleus. One patient died from sudden cardiopulmonary arrest during postural change and tracheal suction. Results Heart rate variability analyses of these patients revealed parasympathetic dysautonomia, based on decreased high-frequency values. Conclusions The insidiously progressive dysautonomia in these two patients with XPA suggested progressive descending degeneration extending from the medulla oblongata to the sacral spinal cord, which is an ominous sign of end-stage disease and a risk factor of sudden death attributable to XPA. © 2014 Elsevier Inc. All rights reserved.
Keywords: proton pump inhibitor; adult; article; aspiration; autonomic nervous system; bladder distension; body position; brain; brain atrophy; brain stem; cardiopulmonary arrest; cardiovascular mortality; case report; cause of death; cerebellar ataxia; cerebellum; corpus callosum; coughing; cranial nerve; disease course; disease exacerbation; dysautonomia; dysphagia; dysuria; gait disorder; gait disturbance; gastroesophageal reflux; gene mutation; heart rate; heart rate variability; hiatus hernia; hospitalization; human; intellectual impairment; male; nerve degeneration; neurogenic bladder; nuclear magnetic resonance imaging; parasympathetic function; parasympathetic nerve; perception deafness; peripheral neuropathy; priority journal; quadriplegia; residual urine; restriction fragment length polymorphism; sleep disorder; sleep interruption; sleep interruption; spinal cord; stridor; sudden cardiac death; sympathetic function; tracheotomy; xeroderma pigmentosum; xeroderma pigmentosum group a; young adult

Observational study of spinal muscular atrophy type I and implications for clinical trials - Finkel R.S.; McDermott M.P.; Kaufmann P.; Darras B.T.; Chung W.K.; Sproule D.M.; Kang P.B.; Reghan Foley A.; Yang M.L.; Martens W.B.; Oskoui M.; Glanzman A.M.; et al. (Neurology, 2014)
Objectives: Prospective cohort study to characterize the clinical features and course of spinal muscular atrophy type I (SMA-I). Methods: Patients were enrolled at 3 study sites and followed for up to 36 months with serial clinical, motor function, laboratory, and electrophysiologic outcome assessments. Intervention was determined by published standard of care guidelines. Palliative care options were offered. Results: Thirty-four of 54 eligible subjects with SMA-I (63%) enrolled and 50% of these completed at least 12 months of follow-up. The median age at reaching the combined endpoint of death or requiring at least 16 hours/day of ventilation support was 13.5 months (interquartile range 8.1-22.0 months). Requirement for nutritional support preceded that for ventilation support. The distribution of age at reaching the combined endpoint was similar for subjects with SMA-I who had symptom onset before 3 months and after 3 months of age (p 5 0.58). Having 2 SMN2 copies was associated with greater morbidity and mortality than having 3 copies. Baseline electrophysiologic measures indicated substantial motor neuron loss. By comparison, subjects with SMA-II who lost sitting ability (n510) had higher motor function, motor unit number estimate and compound motor action potential, longer survival, and later age when feeding or ventilation support was required. The mean rate of decline in The Children's Hospital of Philadelphia Infant Test for Neuromuscular Disorders motor function scale was 1.27 points/year (95% confidence interval 0.21-2.33, p 5 0.02). Conclusions: Infants with SMA-I can be effectively enrolled and retained in a 12-month natural history study until a majority reach the combined endpoint. These outcome data can be used for clinical trial design.
Keywords: adult; aged; airway obstruction; article; child; chronic patient; clinical feature; clinical trial (topic); female; heart arrest; human; lung infection; major clinical study; male; mortality; motor performance; noninvasive ventilation; nutritional support; observational study; priority journal; spinal muscular atrophy; Werdnig Hoffmann disease; tracheostomy

Neuroblastoma with symptomatic epidural compression in the infant: The AIEOP experience - De Bernardi B.; Quaglietta L.; Haupt R.; Castellano A.; Tirtei E.; Luksch R.; Mastrangelo S.; Viscardi E.; Indolfi P.; Cellini M.; Tamburini A.; Erminio G.; et al. (Pediatric Blood and Cancer, 2014)
Background: Symptoms of epidural compression (SEC) in children with neuroblastoma (particularly infants) may be misinterpreted, leading to delay in diagnosis. Patients and Methods: Clinical, imaging and follow-up data of 34 infants with neuroblastoma and SEC diagnosed between 2000 and 2011 at Italian AIEOP centers were retrieved and reviewed. Results: Median age at initial SEC was 104 days (IQR 47-234). Main symptoms included motor deficit (85.3%), pain (38.2%), bladder and bowel dysfunctions (20.6% each). In the symptom-diagnosis interval (S-DI) (median, 12 days; IQR 7-34), the frequency of grade 3 motor deficit increased from 11.8% to 44.1% and that of bladder dysfunction from 20.6% to 32.4%. S-DI was significantly longer (P=0.011) for patients developing grade 3 motor deficit. First treatment of SEC was neurosurgery in 14 patients, and chemotherapy in 20. SEC regressed in 11 patients (32.3%), improved in 9 (26.5%), and remained stable in 14 (41.2%), without treatment-related differences. Median follow-up was 82 months. At last visit, 11 patients (32.3%) were sequelae-free while 23 (67.7%) had sequelae, including motor deficit (55.9%), bladder (50.0%) and bowel dysfunctions (28.4%), and spinal abnormalities (38.2%). Sequelae were rated severe in 50% of patients. Severe sequelae scores were more frequent in patients presenting with spinal canal invasion >66% (P=0.039) and grade 3 motor deficit (P=0.084). Conclusions: Both neurosurgery and chemotherapy provide unsatisfactory results once paraplegia has been established. Sequelae developed in the majority of study patients and were severe in a half of them. Greater awareness by parents and physicians regarding SEC is warranted. © 2014 Wiley Periodicals, Inc.
Keywords: carboplatin; cyclophosphamide; doxorubicin; etoposide; vincristine; abdominal distension; article; bladder dysfunction; cancer combination chemotherapy; cancer grading; cancer survival; clinical article; enteropathy; event free survival; female; follow up; Horner syndrome; human; infant; infant disease; laminectomy; male; motor dysfunction; multicenter study (topic); neuroblastoma; neurosurgery; overall survival; pain; priority journal; respiratory distress; spinal cord compression; symptomatic epidural compression; tracheostomy; tumor invasion; urine incontinence; urine retention; vertebral canal

Use of airtraq optical laryngoscope for naso-tracheal intubation in anaesthetized patients - Malik S.; Jamil S.N.; Malik S.; Varshney R. (Acta Medica International, 2014)
Reported is a case of successful Nasotracheal intubation using Airtraq optical laryngoscope in a patient of fracture zygomatic arch with cervical spine injury. The patient had predicted difficult direct laryngoscopy with restricted mouth opening.
Keywords: midazolam; ondansetron; suxamethonium; thiopental; tramadol; adult; Airtraq Optical laryngoscope; article; case report; cervical spine injury; human; informed consent; male; middle aged; nasotracheal intubation; plastic surgery; rigid laryngoscope; tracheotomy; zygoma arch fracture

Ganglioglioma in brainstem: Case report and a review of literatures - Kim S.-D.; Kim J.H.; Lee C.-Y.; Kim H.-W. (Journal of Korean Neurosurgical Society, 2014)
Ganglioglioma is an infrequent tumor of the central nervous system (CNS); mostly supratentorial region. But, they can occur anywhere in the central nervous system such as brainstem, cerebellopontine angle (CPA), thalamus, optic nerve and spinal cord. Although it occurs rarely, ganglioglioma should be included in the differential diagnosis of a posterior fossa mass because early recognition is important for treatment and patient counseling. © 2014 The Korean Neurosurgical Society.
Keywords: antibiotic agent; chromagranin; glial fibrillary acid protein; peptides and proteins; protein S 100; synaptophysin; unclassified drug; article; aspiration pneumonia; ataxia; brain stem tumor; case report; cervical spinal cord; child; computer assisted tomography; consciousness; cranial nerve paralysis; craniotomy; drainage catheter; female; follow up; glioma; hemiparesis; histopathology; human; human tissue; immunohistochemistry; laminectomy; neurologic disease; neurologic examination; nose feeding; nuclear magnetic resonance imaging; nystagmus; obstructive hydrocephalus; pons angle; school child; seizure; sleep disordered breathing; tracheostomy

Montgomery© T-tubes in the management of multilevel airway obstruction in mucopolysaccharidosis - Soni-Jaiswal A.; Penney S.E.; Jones S.A.; Walker R.; Rothera M.P.; Bruce I.A. (International Journal of Pediatric Otorhinolaryngology, 2014)
Keywords: endotracheal tube; glycosaminoglycan; adolescent; airway obstruction; article; artificial ventilation; bone marrow transplantation; case report; child; computer assisted tomography; disease course; dyspnea; endotracheal tube; granulation tissue; hospital readmission; human; Hunter syndrome; Hurler syndrome; limb weakness; macroglossia; male; Maroteaux Lamy syndrome; mitral valve replacement; mucopolysaccharidosis; nuclear magnetic resonance imaging; otorhinolaryngology microdebrider; oxygen consumption; preschool child; respiratory arrest; respiratory function; retrospective study; spinal cord compression; spinal cord decompression; tracheomalacia; tracheostomy; tracheostomy tube; tube removal; walking difficulty; Bivona; Flextend; Medtronic Skimmer; Microcuff; Montgomery; Shiley

Vertebral artery injury in a patient with fractured C4 vertebra - Banić T.; Banić M.; Cvjetko I.; Somun N.; Bilić V.; Vidjak V.; Pavić V.; Coć I.; Kokić T.; Kejla Z. (Acta Clinica Croatica, 2014)
Vertebral artery injuries due to cervical spine trauma, although rarely described in the literature, are relatively common. While most of them will remain asymptomatic, a small percentage of patients may suffer life threatening complications. We report a case of the right vertebral artery injury in a patient with fracture of C4 vertebra, successfully treated with endovascular approach. A 78-year-old male patient was hospitalized for cervical spine injury caused by falling off the tractor. Radiological assessment revealed fracture of C4 vertebra with proximal two-thirds of C4 body dislocated five millimeters dorsally. Significant swelling of soft prevertebral tissues distally of C2 segment was also present. During emergency surgery using standard anterior approach for cervical spine, excessive bleeding started from the injured right vertebral artery. Bleeding was stopped by tamponade with oxidized regenerated cellulose sheet and C4-C5 anterior fixation; then partial reduction of displacement was done. Fifteen days later, after angiography, endovascular repair of the right vertebral artery was performed using percutaneous stent graft. Follow up computed tomography scan angiography showed valid stent patency without contrast extravasation. In cases of cervical spine trauma, surgeon should always be prepared to manage injury of vertebral artery. Bleeding can primarily be stopped by hemostatic packing, and definitive repair can be successfully achieved by endovascular approach using percutaneous stent graft.
Keywords: acetylsalicylic acid; analgesic agent; clopidogrel; fresh frozen plasma; low molecular weight heparin; methylprednisolone; oxidized regenerated cellulose; proton pump inhibitor; aged; anticoagulant therapy; artery injury; artery rupture; article; artificial ventilation; bone graft; case report; cervical spine dislocation; cervical spine injury; cervical spine radiography; colloid; computed tomographic angiography; continuous infusion; contrast medium extravasation; corticosteroid therapy; crystalloid; edema; emergency surgery; endotamponade; endovascular surgery; erythrocyte concentrate; falling; follow up; fourth cervical vertebra; fracture reduction; graft patency; hematoma; hemostasis; human; intensive care unit; discectomy; male; operative blood loss; osteochondrosis; preoperative evaluation; spine stabilization; spondylosis; surgical approach; tracheostomy; vascular stent; vertebra body; vertebral artery; vertebral artery injury; Surgicel

Phrenic nerve stimulation for diaphragm pacing in a quadriplegic patient - Son B.-C.; Kim D.-R.; Kim I.-S.; Hong J.T. (Journal of Korean Neurosurgical Society, 2013)
Chronic hypoventilation due to injury to the brain stem respiratory center or high cervical cord (above the C3 level) can result in dependence to prolonged mechanical ventilation with tracheostomy, frequent nosocomial pneumonia, and prolonged hospitalization. Diaphragm pacing through electrical stimulation of the phrenic nerve is an established treatment for central hypoventilation syndrome. We performed chronic phrenic nerve stimulation for diaphragm pacing with the spinal cord stimulator for pain control in a quadriplegic patient with central apnea due to complete spinal cord injury at the level of C2 from cervical epidural hematoma. After diaphragmatic pacing, the patient who was completely dependent on the mechanical ventilator could ambulate up to three hours every day without aid of mechanical ventilation during the 12 months of follow-up. Diaphragm pacing through unilateral phrenic nerve stimulation with spinal cord stimulator was feasible in an apneic patient with complete quadriplegia who was completely dependent on mechanical ventilation. Diaphragm pacing with the spinal cord stimulator is feasible and effective for the treatment of the central hypoventilation syndrome. © 2013 The Korean Neurosurgical Society.
Keywords: antibiotic agent; warfarin; adult; article; artificial ventilation; case report; clinical examination; diaphragm movement; dyspnea; electrode; electromyography; end tidal carbon dioxide tension; epidural hematoma; female; fluoroscopy; human; implantable pulse generator; implanted phrenic nerve stimulator; mobilization; nerve stimulation; nuclear magnetic resonance imaging; oxygen saturation; paraplegia; phrenic nerve; phrenic nerve pacing; pneumonia; quadriplegia; respiratory distress; tachypnea; tendon reflex; thromboembolism; Eclipse Neurologial Workstation; Eon-Mini Rechargeable; Quatrode

Complications due to the use of BMP/INFUSE in spine surgery: The evidence continues to mount - Epstein N. (Surgical Neurology International, 2013)
Increasingly, adverse events (AE) attributed to utilizing BMP/INFUSE (Bone Morphogenetic Protein, Medtronic, Memphis, TN, USA) "off-label" in spine surgery are being reported. In 2008, the Food and Drug Administration (FDA) issued a warning that in anterior cervical spine surgery, the "off-label" use of BMP/INFUSE contributed to marked dysphagia, hematoma, seroma, swelling, and/or the need for intubation/tracheostomy. Subsequent studies have cited the following AE; heterotopic ossification (HO), osteolysis, infection, arachnoiditis, increased neurological deficits, retrograde ejaculation, and cancer. Furthermore, in 2011, Carragee et al. noted that 13 of the original industry-sponsored BMP/INFUSE spinal surgery studies failed to acknowledge multiple AE. Additionally, in 2012, Comer et al. observed that the frequency of retrograde ejaculation reported for BMP/INFUSE used "on-label" to perform Anterior Lumbar Interbody Fusion/Lumbar Tapered Fusion-Cage Device (ALIF/LT-Cage) was also largely "under-reported." To summarize, there is mounting evidence in the spinal literature that utilizing BMP/INFUSE in spinal fusions contributes to major perioperative and postoperative morbidity.Copyright: © 2013 Li CH.
Keywords: amplify; collagen sponge; corticosteroid; infuse; methylprednisolone; recombinant bone morphogenetic protein 2; unclassified drug; arachnoiditis; article; bone malformation; bone pain; bone transplantation; cancer risk; cost benefit analysis; drug contraindication; drug cost; drug efficacy; drug megadose; drug safety; drug surveillance program; dysphagia; evidence based medicine; food and drug administration; health care cost; hematoma; heterotopic ossification; heterotopic retroperitoneal ossification; heterotopic retroperitoneal ossification; human; iliac crest; infection; intervertebral disk degeneration; intubation; lumbar tapered fusion device system; morbidity; neoplasm; neurologic disease; neurosurgery; nonhuman; off label drug use; osteolysis; pain; perioperative period; postoperative period; priority journal; pseudarthrosis; public health; quality adjusted life year; radiculitis; radiculopathy; randomized controlled trial (topic); respiratory distress; retrograde ejaculation; risk benefit analysis; seroma; side effect; soft tissue inflammation; spine fusion; spine fusion implant; spine surgery; spondylolisthesis; surgical infection; swelling; thromboembolism; tissue engineering; tracheostomy; urine retention; visual analog scale; body weight loss; amplify; infuse

Value of preventive tracheotomy in patients with acute cervical spinal cord injury - Wu H.-T.; Zhao C.-P.; Li Z.; Yan J.-C.; Hao J.-D.; Li Z.-Y. (National Medical Journal of China, 2013)
Objective: To evaluate the value of preventive tracheotomy in patients with acute cervical spinal cord injury. Methods: A retrospective analysis was performed on 54 cases of severe C4-C8 cervical spinal cord injury patients undergoing anterior fixation. They were classified as A and B according to the criteria of American Spinal Injury Association. And no tracheotomy was performed preoperatively. The patients with a high risk of dyspnea and with an indication for preventive tracheotomy received a preventive tracheotomy right after anterior fixation. 11 cases were classified into tracheotomy group and 43 cases were in non-tracheotomy group. The preoperative and hospital stays, incidence of hyoxemia and pulmonary infection, incidence of surgical incision site infection and mortality were analyzed between two groups. Results: The preoperative and hospital stays of tracheotomy group were shorter than those of non-tracheotomy group (2.9±1.2 vs 5.7±4.4 days, 10.3±4.0 vs 16.5±9.2 days). The incidence of hyoxemia was lower in tracheotomy group (9.1% vs 44.2%). There was difference existed between two groups. 44.2% patients in the non-tracheotomy group underwent tracheotomy or endotracheal intubation for dyspnea and hyoxemia. There was no significant difference between two groups in the incidence of pulmonary infection (9.1% vs 7.0%) or surgical incision site infection (0 vs 2.3%). The mortality of non-tracheotomy group was 3.07 folds of that of tracheotomy group (9.1% vs 27.9%). But there was no significant statistical difference. Conclusion: The preventive tracheotomy is an effective solution for the patients with respiratory compromises, a high risk of dyspnea and with an indication for preventive tracheotomy. The preventive tracheotomy for severe cervical spinal cord can improve respiratory function effectively and fixation may be performed earlier. And there are lower rates of mortality and infection. Copyright © 2013 by the Chinese Medical Association.
Keywords: anterior spine fusion; article; cervical spinal cord injury; cervical spine; controlled study; dyspnea; endotracheal intubation; high risk patient; hospitalization; human; hypoxemia; lung infection; major clinical study; preoperative period; preventive tracheotomy; retrospective study; surgical infection; surgical mortality; tracheotomy

History of hereditary motor and sensory neuropathy with proximal dominant involvement (HMSN-P) - Takashima H. (Clinical Neurology, 2013)
We established a new disease autosomal dominant hereditary motor and sensory neuropathy with proximal dominant involvement (HMSNP) in 1997, in Okinawa, Japan. This disease is characterized by proximal dominant neurogenic atrophy with fasciculations, painful muscle cramp, obvious sensory nerve involvement, areflexia, high incidence of elevated creatine kinase levels, hyperlipidemia and hyperglycemia. (MIM %604484). HMSNP is so called or HMSNO (HMSN OKINAWA type),. These clinical features resembled those of Kennedy-Alter-Sung syndrome. Most HMSNP patients have severe muscle atrophy and finally the tracheostomy and artificial ventilation are required. Therefore, we initially thought to classify HMSNP into a subtype of motor neuron disease (MND) like familial amyotrophic lateral sclerosis (FALS) or spinal muscular atrophy (SMA). However, the general consensus for MND was no sensory involvement. Therefore, as the disease showed severe sensory involvement, we categorized HMSNP in subtype of HMSN at that time. We also reported the pathology of HMSNP, showing severely decreased anterior horn cells, decreased posterior horn cells, and loss of posterior funiculus in the spinal cord.
Keywords: creatine kinase; amyotrophic lateral sclerosis; anterior horn cell; areflexia; article; artificial ventilation; autosomal dominant inheritance; clinical feature; fasciculation; hereditary motor sensory neuropathy; human; hyperglycemia; hyperlipidemia; incidence; Japan; motor neuron disease; muscle atrophy; muscle cramp; posterior horn cell; sensory nerve; spinal cord; spinal muscular atrophy; tracheostomy

Critical care management of patients with acute spinal cord injury - Lo V.; Esquenazi Y.; Han M.-K.; Lee K. (Journal of Neurosurgical Sciences, 2013)
Spinal cord injury (SCI) inevitably extends beyond neurologic consequences. The relationship between the spinal cord and its control of other organ systems make SCI management complex, requiring treatment on a multisystem approach. Patients frequently have hemodynamic instability and respiratory insufficiency secondary to the neurologic insult. Rigorous monitoring and anticipation of potential complications are essential in managing SCI, requiring a level of care provided in a neurocritical care unit. This review covers the pathophysiology, initial assessment, and stabilization in addition to acute management of cardiovascular and respiratory issues following SCI. Subsequent potential complications of deep vein thrombosis, gastrointestinal, and urinary systems and their management in the critical care setting are also addressed in this review.
Keywords: epinephrine; dobutamine; dopamine; heparin; low molecular weight heparin; methylprednisolone; noradrenalin; phenylephrine; anticoagulant therapy; cervical spinal cord injury; cervical spine fracture; clinical assessment; computer assisted tomography; deep vein thrombosis; diaphragm paralysis; forced vital capacity; fracture reduction; Glasgow coma scale; human; hypotension; immobilization; intensive care; intubation; kidney failure; life expectancy; lung embolism; nonhuman; nuclear magnetic resonance imaging; nutritional support; paralytic ileus; pathophysiology; patient care; range of motion; review; sensorimotor function; spinal cord decompression; spinal cord injury; spine radiography; steroid therapy; tracheobronchial toilet; tracheostomy; urinary tract infection

Rare site hemorrhages in patients with hemophilia - Toshniwal M.; Chandrakala S.; Mahesh R.; Jijina F.; Ghosh K. (Indian Journal of Hematology and Blood Transfusion, 2013)
Introduction: Patients with congenital or acquired clotting disorders are at increased risk for experiencing spontaneous hemorrhage into unusual sites. Besides hemarthrosis that are frequently observed in Hemophiliacs, bleeding may also rarely occur in various soft tissues or solid organs. Subdural hematomas and other central nervous system (CNS) hemorrhages are uncommon but represent a major cause of death and disability. Spontaneous spinal subdural hematoma is a rare subtype of CNS hemorrhage in patients with hemophilia, reported in only a handful of cases in the literature. Epidural hematomas have been reported somewhat more frequently, but are still rare. Diffuse alveolar hemorrhage is hardly been reported in cases of hemophilia. We report nine cases of hemophilia from our comprehensive hemophilic care center of western India presenting with bleeding at very rare and unusual sites. Four cases presented with severe anemia, jaundice, dyspnea and hemoptysis with HRCT chest suggestive of diffuse alveolar hemorrhage. All were managed conservatively with adequate factor replacement and supportive treatment. Two young adult patients had history of jerk while riding bike in village and after 3-4 days presented with paraparesis of subacute onset with bowel and bladder involvement with MRI spine showing spinal subdural hematoma, managed with factor replacement. Another 5 year old boy presented with acute onset weakness in both lower limbs after trivial trauma whose MRI spine revealed large epidural hematoma. This was treated with adequate and timely factor replacement leading to complete neurological and functional recovery. A young patient presented first time with swelling of neck, rapidly progressive dyspnoea and stridor after mild trauma to the neck by slipping from staircase. On examination had neck muscle hematoma and ultimately needed tracheotomy as life saving measure. A 22 year male presented with fever and pain in abdomen, USG was s/o splenic rupture with perislpenic hematoma with left sided pleural effusion. Patient factor assay was factor VIII levels<1 %. He was managed conservatively.
Keywords: blood clotting factor 8; patient; human; hemophilia; Indian; society; hematology; blood transfusion; bleeding; male; spinal hematoma; epidural hematoma; dyspnea; spine; injury; lung hemorrhage; neck; central nervous system; hemarthrosis; examination; stridor; neck muscle; muscle hematoma; swelling; leg; disability; boy; risk; blood clotting disorder; bladder; intestine; paraplegia; cause of death; adult; thorax; hemoptysis; nuclear magnetic resonance imaging; weakness; subdural hematoma; jaundice; pleura effusion; hematoma; spleen rupture; anemia; abdomen; pain; fever; tracheotomy; assay; India; solid; soft tissue

An analysis of surgical feeding tube placement in trauma patients - Fox N.; Hall H.; Patel Y.; Capano-Wehrle L.; Torjman M.; Seamon M. (Critical Care Medicine, 2013)
Introduction: While surgical feeding tube (SFT) placement is common in trauma patients, the indications for SFT placement are poorly defined. Patient selection is critical as complications attributable to SFTs are reported in up to 20% of patients. We hypothesized that a significant number of SFTs placed in trauma patients were unnecessary. Our primary study objective was to determine clinical predictors of prolonged SFT use to avoid the unnecessary placement of SFTs. Methods: A retrospective review of patients (≥ 18 yrs) at our Level 1 trauma center with an ICU LOS ≥ 4 days that had a SFT placed (2007-2010) was conducted. “Necessary” SFT use was defined per established guidelines as either daily tube feeding through discharge or ≥ 28 day and “unnecessary” SFT use as all others. Clinical variables and outcomes were analyzed with respect to SFT use and type (PEG v. open). Univariate and multivariate analyses determined predictors of necessary SFT placement. Results: Study patients (n=398) were 49 ± 21 years of age with an ISS of 20 ± 9, primarily blunt injuries (90%) and an ICU LOS of 19 ± 11 days. Of 398 SFTs, 300 (73%) were necessary and 98 (27%) unnecessary (duration of unnecessary SFT use, 14 ± 8 days). No differences in gender, ISS, GCS or the presence of thoracic injury were identified between patients with necessary or unnecessary SFTs (all p >0.05). When stratified by SFT type, necessary SFTs were more common in patients that had PEG (n=278) rather than open (n=120) SFTs (81% v. 62%;p=0.001). After controlling for potential confounding variables, multiple variable logistic regression analysis revealed that advancing age (OR 1.02 per year, 1.00-1.03), traumatic brain (OR 2.47, 1.33-4.51) or spinal cord injury (OR 13.10, 3.03-56.62) and tracheostomy placement (OR 5.29, 2.72-12.32) each independently predicted necessary SFT placement. Conclusions: Our results suggest that patients with advancing age, traumatic brain or spinal cord injuries and those that have a tracheostomy placed are more likely to have necessary SFTs placed. The placement of SFTs in patients without these clinical characteristics should be performed with caution as they are more likely to be unnecessary.
Keywords: intensive care; injury; human; patient; feeding apparatus; society; spinal cord injury; brain; tracheostomy; multivariate analysis; logistic regression analysis; enteric feeding; confounding variable; thorax injury; gender; blunt trauma; emergency health service; patient selection

Acute on chronic respiratory failure in 79 year old male - Patel D.; Hamarshi M. (Critical Care Medicine, 2013)
Introduction: 79 year old male presented with generalized weakness, slurred speech, altered mental status and labored breathing for several hours along with 20 pound weight loss over 6 months. Patient had three admissions at different hospital over the last 3 months for similar but milder presentation. Past work up included CT scan of the chest which was unrevealing and pulmonary function test (PFT) which showed restrictive lung disease with FEV1 of 48%, FVC of 44% of predicted and FEV1/FVC 84, though he was given the diagnosis of chronic obstructive pulmonary disease (COPD) as an explanation of his hyperbaric respiratory failure. Physical exam in the ED was pertinent for tachycardia, labored shallow breathing and lethargy. Auscultation of his chest demonstrated bilateral decreased breath sound. An arterial blood gas analysis showed pH of 7.04, PaCO2 of >130.00 mmHg and PaO2 of 218 mmHg on 100% oxygen. Chest x-ray and CT scan of the head were both unremarkable for acute process. Hypercarbia was initially attributed to possible COPD and obstructive sleep apnea (OSA). Patient's trachea immediately intubated and mechanical ventilation was begun. After borderline spontaneous breathing trial, patient was extubated next morning. Patient required bi-level noninvasive positive pressure mechanical ventilation (NIPPV) for moderate respiratory distress after extubation. A repeat physical examination was remarkable for impaired dorsiflexion of right ankle, tongue fasciculation and weak negative inspiratory force. There was no evidence of upper motor neuron dysfunction. Work up for neuromuscular weakness included antiacetylcholine receptor antibody, which was negative and electromyography, which demonstrated 2+ fasciculation and fibrillation potentials in >3 muscle groups. A diagnosis of progressive muscular atrophy (PMA) with early respiratory failure was made; it is believed to be a rare form of Amyotrophic Lateral Sclerosis (ALS). After discussing the merits and demerits of invasive mechanical ventilation via tracheostomy and gastrostomy tube insertion, he opted for comfort care. ALS is a neurodegenerative disease characterized by progressive muscular paralysis due to degeneration of lower and upper motor neurons in the primary motor cortex, brainstem, and spinal cord. Muscular paralysis is progressive and typically leads to death due to respiratory failure within 2-5 years of onset. However, only 3.0% of patients with ALS present with respiratory symptoms and 14% of this subpopulation requires mechanical respiratory support, a rare presentation of ALS. Clinical features of early respiratory failure like dyspnea on minor exertion, early morning headache, daytime fatigue and weight loss may be subtle and often overlooked. The classic form of ALS presents with both upper motor neuron (UMN) and lower motor neuron (LMN) findings, but it can be as in our case limited to LMN only and is referred to as PMA. Compared to ALS, patients with PMA are more likely to be males and live longer. Management of ALS in all of its forms is supportive, multidisciplinary and palliative. Early use of NIPPV in ALS patients prolong survival and improve quality of life. Invasive mechanical ventilation, implying the use of an endotracheal tube or a tracheostomy may be considered. Patient with bulbar dysfunction may need gastrostomy to support nutrition. A FVC of <50% of the predicted value has been shown to be associated with poor prognosis. Arriving to accurate diagnosis in timely manner is critical for health care team to expedited discussion with patient and family about management plan and encourage them to consider advanced directives regarding end of life. Patients should be provided with a realistic prognostication of the course of their disease and in the event of decline of full mechanical ventilation, patient and family should be provided with assurance that palliative care strategies can control symptoms in the terminal phase of illness.
Keywords: receptor antibody; oxygen; intensive care; male; society; chronic respiratory failure; human; patient; artificial ventilation; motoneuron; respiratory failure; breathing; diagnosis; thorax; chronic obstructive lung disease; weakness; paralysis; body weight loss; computer assisted tomography; tracheostomy; fasciculation; abnormal respiratory sound; mental health; arterial gas; diseases; tongue; ankle; lethargy; extubation; quality of life; respiratory distress; tachycardia; headache; trachea; exercise; dyspnea; survival; endotracheal tube; physical examination; bulbar paralysis; prognosis; health care; sleep disordered breathing; auscultation; hospital; electromyography; hypercapnia; lung disease; degeneration; lung function test; stomach tube; amyotrophic lateral sclerosis; comfort; degenerative disease; pH; primary motor cortex; brain stem; spinal cord; death; assisted ventilation; clinical feature; blood gas analysis; fatigue; progressive muscular atrophy; gastrostomy; nutrition; muscle; palliative therapy; slurred speech; thorax radiography

Utilization of bioelectrical impedance analysis in the ICU acquired weakness - Chang J.Y.; Kim K.; Han M.-K.; Park S.-H.; Cho Y.J. (Critical Care Medicine, 2013)
Introduction: ICU acquired weakness (ICUAW) is defined as a presence of muscle wasting and neuromuscular dysfunction in critically ill patients without plausible etiology. ICUAW is associated with increased mortality, prolonged mechanical ventilation, and impaired post ICU independent life. Bioelectrical impedance analysis (BIA) is an easy, noninvasive method of estimating body composition using different electrical impedance of tissue components. We have attempted to investigate correlation between serial BIA tests and muscle power examinations in the ICUAW case. A 39-year old patient with a history of acute myeloid leukemia on a remission state after chemotherapy and allogeneic peripheral blood stem cell transplantation, was admitted with general weakness and immobilization due to thoracic spine compression fracture. Respiratory failure with hypoxemia and hypercapnia was developed due to hospital acquired pneumonia on the right lower lobe and recurrent left pneumothorax. He was transferred to medical ICU and mechanical ventilator was applied. Chest tube was inserted and intravenous antibiotics were administered. After proper management for 2 weeks, He was recovered from pneumonia and pneumothorax, but muscle power became weakened and atrophy progressed during the ICU stay. He was not able to sit on a bed for himself. Weaning from mechanical ventilator had failed, tracheostomy was done and BIPAP was applied instead. Muscle power grades of all extremities at ICU admission were IV. At 9th day of ICU stay, the motor power of shoulder abduction, adduction of right and left was IV/IV-, IV/IV-, elbow flexion and extension IV-/IV-, IV/IV, wrist flexion and extension, hand grip were all IV on medical research council (MRC) scale. The motor power of hip flexion, extension was III/IV-, III/IV, Knee flexion, extension IV-/ IV-, IV/ IV, ankle dorsiflexion, plantar flexion III/IV, III/IV. Considering the weakness was developed after the onset of pneumonia, generalized involving both proximal and distal muscles, MRC sum score below 48, and dependency on mechanical ventilation, the diagnosis was compatible with ICUAW. The BIA results of skeletal muscle mass (SMM) and Fat free mass (FFM, listed in brackets) was 16kg (32.1kg) at 3rd day of ICU stay, continuous declined to 14.6kg (30.1kg) at 9th day of ICU stay. Appendicular muscle mass of right arm, left arm, right leg and left leg at 3rd day after ICU admission were 0.8, 0.9, 6.2, 6.5kg each. After 9th day of ICU admission, both lower extremities muscle mass decreased from to 6.2kg to 5.0kg at right side and 6.5kg to 5.2kg at left side. Passive range of motion of each joint was maintained during the ICU stay to prevent joint contracture. Physical therapy including range of motion against resistance (RROM) with cycle ergometer and sitting to chair exercise was started at 22th day after ICU admission. After two weeks of physical therapy, the muscle strength of extremities was slightly improved before physical therapy from grade IV- to IV+ in both shoulder adduction and abduction, IV-to IV in right elbow flexion and hip extension, IV to IV+ in right wrist flexion, III to IV- in both ankle dorsiflexion compared with the result of muscle power examination at 9th day. Total SMM and FFM slightly increased from 14.6 to 15.0 and 30.1 to 30.7kg. Appendicular muscle mass of right arm, left arm, right leg and left leg increased from 1.0, 0.9, 5.0, 5.2 to 1.2, 1.0, 5.6, 5.5kg. The change of truncal muscle mass was not correlated with that of partial pressure of arterial CO2 or ventilatory parameters. As a medical condition of the patient was fluctuating, the clinical muscle power after a month was not improved and so was the BIA result. The changes of total skeletal and appendicular muscle mass were proportional to the clinically detected muscle strength. Based on the result, further study is planned to determine whether the BIA could predict occurence and clinical course of ICUAW using variable BIA parameters.
Keywords: antibiotic agent; intensive care; weakness; society; impedance; muscle strength; muscle mass; leg; arm; human; physiotherapy; hip; mechanical ventilator; pneumothorax; abduction; range of motion; shoulder; adduction; elbow flexion; wrist; artificial ventilation; ankle; examination; pneumonia; parameters; patient; chemotherapy; remission; non invasive procedure; hospital acquired pneumonia; acute myeloid leukemia; critically ill patient; hypercapnia; hypoxemia; pressure; joint contracture; mortality; neuromuscular disease; respiratory failure; chest tube; compression fracture; diagnosis; knee function; hand grip; thoracic spine; etiology; immobilization; tracheostomy; weaning; medical research; allogeneic peripheral blood stem cell transplantation; atrophy; muscle; skeletal muscle; fat free mass; bicycle ergometer; sitting; exercise; tissues; disease course; body composition; muscle atrophy

Mechanical ventilation weaning and extubation after spinal cord injury: A western trauma association multicenter study - Kornblith L.Z.; Kutcher M.E.; Callcut R.A.; Redick B.J.; Hu C.K.; Cogbill T.H.; Baker C.C.; Shapiro M.L.; Burlew C.C.; Kaups K.L.; DeMoya M.A.; Haan J.M.; et al. (Journal of Trauma and Acute Care Surgery, 2013)
BACKGROUND: Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. METHODS: Under the auspices of theWestern Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. RESULTS: A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge.One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p G 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05). CONCLUSION: While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned before discharge. In patients with SCI, tracheostomy is associated with major morbidity, and its use, especially among patients with cervical SCI, deserves further study. © 2013 by Lippincott Williams & Wilkins.
Keywords: acute lung injury; adult; aged; artificial ventilation; cause of death; cervical spinal cord injury; comorbidity; conference paper; confidence interval; extubation; female; human; injury severity; major clinical study; male; morbidity; multicenter study; priority journal; respiratory failure; retrospective study; spinal cord injury; tracheostomy; treatment outcome; United States; ventilator associated pneumonia

Endovascular versus open elephant trunk completion for extensive aortic disease - Roselli E.E.; Subramanian S.; Sun Z.; Idrees J.; Nowicki E.; Blackstone E.H.; Greenberg R.K.; Svensson L.G.; Lytle B.W. (Journal of Thoracic and Cardiovascular Surgery, 2013)
Objectives To compare the outcomes between patients undergoing endovascular (EEC) or open (OEC) approaches to second-stage elephant trunk completion (EC). Methods From 1993 to 2010, 225 patients underwent second-stage EC (EEC, n = 92; OEC, n = 133). Propensity matching was performed for a fair comparison. Results The EEC patients were older, more likely to have atrial fibrillation, and had a smaller proximal aorta. The 30-day mortality was 6.2% (6.5% EEC vs 6% OEC, P =.88). No difference was found in bleeding (8.8%), stroke (3%), renal failure (4%), or spinal cord injury (4%); however, the OEC patients required tracheostomy more often (10 vs 1, P =.014). Survival after second-stage EC at 6 months and 1 and 5 years was 91%, 90%, and 77%, respectively. Survival and major morbidity did not differ after matching (44 pairs). However, the EEC group had shorter stays (9.9 ± 13 vs 13 ± 9 days, P <.0001) and received less blood (3 ± 8 vs 6 ± 8 U, P =.0001) than did the OEC group. This was maintained after matching. During follow-up, 32 endoleaks (3 type I, 27 type II, 2 type III) occurred; 26 (28%) EEC and 13 of 76 (17%) OEC patients underwent reoperation. The approach was not related to the risk of death in either hazard phase, but a larger descending diameter predicted a greater risk in the early phase. Conclusions Death and complications occur similarly after OEC or EEC. The early toll might be greater after OEC, at the cost of reintervention for EEC. EEC expands the options to older patients and allows for earlier completion. Second-stage repair should not be delayed, and all patients require lifelong imaging surveillance. Copyright © 2013 by The American Association for Thoracic Surgery.
Keywords: adult; aged; aortic disease; article; bleeding; cardiopulmonary bypass; cerebrovascular accident; endoleak; endovascular elephant trunk completion; endovascular surgery; female; follow up; atrial fibrillation; hemiplegia; human; intermethod comparison; kidney failure; long term survival; major clinical study; male; morbidity; mortality; open elephant trunk completion; priority journal; reoperation; respiratory failure; thoracotomy; tracheostomy; treatment outcome

Case report of Os odontoideum causing Ondine's curse - Campbell E.; Brown J. (British Journal of Neurosurgery, 2013)
Ondine's curse or central hypoventilation syndrome is most common congenital disorder which is diagnosed in infancy. In the majority of cases, no structural abnormality is identified. We describe the case of an 18-year-old patient who presented with Ondine's curse secondary to an os odontoideum. © 2013 The Neurosurgical Foundation.
Keywords: adult; air conditioning; ambient air; apnea; arterial gas; article; atrophy; breathing; breathing pattern; case report; cervical spinal cord; cervical spine; congenital central hypoventilation syndrome; consciousness disorder; cyanosis; daytime somnolence; dyspnea; falling; female; foramen magnum; human; hypoxia; inspiratory capacity; intubation; nuclear magnetic resonance imaging; odontoid process; oxygen saturation; pneumonia; priority journal; rehabilitation; respiratory failure; sedation; spinal cord compression; spine fusion; tracheostomy; voluntary movement

Editorial Critique - Wyrzykowski A.D. (Journal of Trauma and Acute Care Surgery, 2013)
Keywords: artificial ventilation; cervical spine injury; human; injury severity; note; priority journal; spinal cord injury; tracheostomy; ventilator

Does laminoplasty really improve neurological status in patients with cervical spinal cord injury without bone and disc injury? A prospective study about neurological recovery and early complications - Mazaki T.; Ito Y.; Sugimoto Y.; Koshimune K.; Tanaka M.; Ozaki T. (Archives of Orthopaedic and Trauma Surgery, 2013)
Purpose: Cervical spinal cord injury without bone and disc injury in patients with spinal cord compression is a fairly common problem in Japan. Because elderly Japanese population tend to have cervical spinal canal stenosis. However, there has been no consensus in the treatment of these patients. We conducted a prospective study to evaluate treatment outcomes and complications of these patients. Methods: Twenty-five patients had been enrolled in this study. Patients who had paralysis of ASIA impairment scale (AIS) A, B or C were included. With each new patient, we alternated whether he/she received surgical treatment (group S) or conservative treatment (group C). Eleven patients were assigned to each group. We compared the two groups' courses of treatment and complications by evaluating their neurological symptoms using the AIS and ASIA motor score (MS) documenting them at the time of injury and 3 months later. Results: The majority of clinical paralysis was found at the C3/4 level for both the groups. According to complications, there were seven urinary tract infections and four pneumonias in group S and one urinary tract infection and three pneumonias in group C. Both groups had an average MS of 42 at the time of injury. Three months later, the average MSs were 59 points in group S and 65 points in group C. Conclusions: In the present study, we found no significant difference in paralysis improvement between surgical and conservative treatment, although we observed a higher frequency of complications with surgery. © 2013 Springer-Verlag Berlin Heidelberg.
Keywords: adult; aged; American Spinal Injury Association impairment scale; article; cervical spinal cord injury; clinical article; conservative treatment; controlled clinical trial; controlled study; female; human; laminoplasty; male; paralysis; pneumonia; priority journal; prospective study; tracheotomy; urinary tract infection

Rash decisions-dermatological manifestations preceding a progressive neurological syndrome - Doherty G.; Vincent A.; Cox A. (Journal of Neurology, Neurosurgery and Psychiatry, 2013)
We describe the case of a 72 year old woman who presented with sequential cranial nerve palsies preceded by irritation, pain and a vesicular rash in the sensory distributions of the affected nerves. She had signs and symptoms suggestive of aphagia and Ramsey-Hunt syndrome. Further vesicular eruptions roughly obeying dermatomal boundaries on the limbs and trunk were observed. She was initially thought to have disseminated VZV/ HZV infection and was commenced on IV aciclovir. Investigations seeking evidence for viral particles in skin lesions and CSF, and for evidence of immunosuppression or malignancy, were all negative. Between days 35 and 40 she developed hypertension, seizures, a left facial nerve palsy and encephalopathy. This was complicated by a pneumonia requiring invasive ventilation on intensive care. She developed an itchy maculopapular rash with vesiculation of all four limbs. On day 66 she developed truncal and limb rigidity, which became extreme over two weeks, and was associated with pyramidal weakness. The rash was biopsied demonstrating a leucocytoclastic vasculitis. At the nadir of her illness she was encephalopathic, tracheostomy-and NG feeding- dependent, quadriparetic and bedbound due to severe rigidity (leading rapidly to Achilles tendon contractures). She was found to be glycine receptor (GlyR) antibody positive, without antibodies against amphiphysin or GAD65. She was initially treated with a combination of corticosteroids and intravenous immunoglobulin (IVIG), resulting in resolution of her cranial nerve palsies, and a reduction in her rigidity and rash. Imaging using CT, PET, USS and mammography was undertaken to exclude malignancy-associated antibody production. MRI imaging of the brain and spinal cord was essentially normal. CSF analysis demonstrated only the presence of intrathecal IgG synthesis. Her treatment and rehabilitation continues. This case adds to the small number of reports in the literature of a Stiff Person Syndrome (SPS) plus syndrome considered to be caused by antibodies directed against the extracellular GlyR target on the synaptic neuronal surface.1 2 Our case demonstrates further clinical variability within this unusual disorder. The GlyR is expressed in skin, and the presence of zoster-like dermatological lesions may provide a clinical clue as to the underlying aetiology in similar cases. Many of the features seen in this case have been previously described, however in this case the features emerged sequentially with rigidity, the cardinal feature of this group of diseases, emerging last. The clinical manifestations of the cases of GlyR antibody associated SPS plus disease described, closely resemble the clinical manifestations of genetic mutations of GlyR subunits and associated proteins, and of poisoning with the GlyR antagonist strychnine. This adds to the evidence that these antibodies play a direct role in the pathogenesis of disease, and that the use of immunosuppressive treatment is justified. Indeed our patient has made a substantial recovery with aggressive immunotherapy. To date no associated malignancy has been associated with GlyR antibody-mediated SPS plus disease, and our case supports these findings.
Keywords: antibody; strychnine; aciclovir; corticosteroid; immunoglobulin; glycine receptor; amphiphysin; immunoglobulin G; protein; receptor antibody; human; neurologist; neurologic disease; college; physician; rash; rigidity; diseases; limb; vesicular rash; cranial nerve paralysis; immunosuppressive treatment; imaging; cerebrospinal fluid; weakness; infection; physical disease by body function; pneumonia; herpes zoster oticus; nerve; maculopapular rash; facial nerve paralysis; hypertension; seizure; antibody production; brain disease; intrathecal drug administration; air conditioning; intensive care; mutation; intoxication; pathogenesis; vasculitis; female; skin defect; pain; aphagia; tendon contracture; virus particle; achilles tendon; immobility; mammography; brain; spinal cord; synthesis; rehabilitation; stiff man syndrome; skin; etiology; feeding; tracheostomy; patient; immunotherapy; nuclear magnetic resonance imaging

Infection rate after transoral approach for the upper cervical spine - Mosafer A.; Shousha M.; Böhm H. (European Spine Journal, 2013)
Introduction: The upper cervical spine is classically approached from anterior via the transoral-transpharyngeal approach. However, this is still not in common use due to concerns about exposure and infection. The purpose of this study is to analyse the incidence and risk factors of local infection after transoral approach for lesions in the upper cervical spine. Material and Methods: In the time between 1994 and 2012, the transoral approach to the upper cervical spine has been used in 139 patients in our institution. The clinical and radiological data of these patients were retrospectively analysed. The mean age at presentation was 53.6 years (range: 5 to 87 years), and more than half of the patients were males (58.3%). The majority of cases were suffering from rheumatic diseases (43.9%), while tumour destruction was the indication for surgery in 23.7% of the cases. 23% had fracture of the upper cervical spine and spondylitis was found in 7 patients (5%). The technique applied involved an anterior transoral approach without tracheotomy using a flexible oral endotracheal tube. Exposure was obtained using a selfretaining mouth retractor by means of a midline incision of the posterior wall of the pharynx. In no case was it necessary to divide the mandible, tongue, soft palate, or uvula. The most common procedure was dens resection (58.3%), and a metal implant was used in 47 cases (33.8%), mostly in cases with tumours and fractures. The mean follow-up period was 4.5 years. Results: Analysis of the records revealed that 16/139 patients (11.5%) underwent a second transoral surgery. Three cases underwent a planned removal of implant after fracture union. In the remaining 13 /139 patients (9.35%), the second transoral surgery was due to a complication. In seven patients (5%), the revision was due to a mechanical or neurological insult in the early postoperative period with immediate good results. One patient with plasmacytoma C2 presented with recurrence and extrusion of the implanted cage one year postoperatively necessitating plastic coverage of the pharyngeal wall. In the remaining five patients (3.59%), infection of the pharyngeal wound did occur. The risk factors and management of this art of complication were evaluated. Discussion and conclusion: The incidence of postoperative infection after transoral surgery in this series was 3.59%. Age and gender were not statistically significant risk factors for infection. No postoperative infection occurred in patients presenting with spondylitis. Infection occurred exclusively in rheumatic and tumour cases. The presentation was mostly in the first three months. A single patient with cage reconstruction after giant cell tumour C2 presented with a late infection five years postoperatively. Debridement and primary closure was possible in two patients, while flap coverage of the pharyngeal wall was necessary in three patients. The presence of implant did not have a statistically significant effect on the occurrence of infection. However, infection in the presence of titanium cage mostly necessitated flap coverage of the pharyngeal wall after removal of the cage.
Keywords: metal; plastic; infection rate; cervical spine; human; patient; infection; surgery; pharynx; risk factor; implant; exposure; fracture; postoperative infection; spondylitis; neoplasm; retractor; endotracheal tube; rheumatic disease; gender; incision; plasmacytoma; fracture healing; tracheotomy; follow up; odontoid process; male; procedures; postoperative period; palate; wound; soft palate; tongue; mandible; titanium cage; giant cell tumor; debridement

Challenges in pediatric spine surgery: Surgical management of dens aplasia and craniocervical instability in a sixmonths-old child - A Case Report - Krishnan R.; Mochert J.; Schumacher M. (European Spine Journal, 2013)
Introduction: We report a case of a 6-months-old boy who presented to our hospital with progressive paraparesis and breathing disorder due to aplasia of the dens caused by a form of Morquio syndrome with instability of the craniocervical junction due to aplasia of the dens. Material/Methods: The patient is a full-term firstborn of first degree cousins. At six months age he was readmitted with altered level of consciousness and convulsions. He was intubated. CT scan and LP were unremarkable. After repeated extubation failures a tracheostomy was done. Clinically he featured central hypotonia with poor head control, clonus of lower limbs and inability to roll over. No dysmorphic features. No organomegaly. MRI showed anomaly of C1 and C2 with hypoplastic atlas and axis, displacement of C1 and C2 posteriorly with atlantoaxial subluxation causing compression of the cord and subsequent myelomalacia (Fig. 1) and CSF circulation disorder with bilateral hygroma. Immobilization with a custom SOMI brace was done and the boy was taken to surgery. Rib grafting with non resorbable sutures and fusion of occiput to C2 was done with intraoperative 3D imaging (O-Arm). The further course was complicated after graft dislocation due to immobilization failure on the 18th postoperative day. Revision surgery was done for him with additional rib graft interposition and fusion of C0 to C3, further resection of the ring of C1 and decompression. Postoperative immobilization was done with improved custom brace but failed again due to severe pressure sores on the head and neck with super-infection. Daily wound care including surgical debridement and VAC of the deep skin lesions was done by an interdisciplinary team for 8 weeks. After healing of the skin lesions, sedation was stopped and the boy was slowly weaned from ventilation and mobilized in a soft collar. Results: The patients neurological deficits slowly recovered and the postoperative images showed a good correction of the craniocervical alignment and improvement of the CSF circulation disorder. Follow up six months after the surgery showed good clinical and radiological results. (Figure 2). Conclusion: The unstable craniocervical junction of the immature and dysplastic spine in the very young is a challenging situation. In this case surgery was indicated for the progressive neurological deterioration to decompress and stabilize the craniocervical junction. The severe complications in this case due to failure of postoperative immobilization were only manageable with a multidisciplinary team. To our knowledge this is the first technical report giving detailed information about the operative approach to the dysmorphic and immature craniocervical junction and the management of postoperative complications due to failure of immobilization, which is a challenge in these toddlers. (Figure presented).
Keywords: human; odontoid process; aplasia; child; surgery; case report; spine surgery; immobilization; boy; male; patient; cerebrospinal fluid circulation disorder; brace; skin defect; paraplegia; Morquio syndrome; hospital; compression; atlantoaxial subluxation; hygroma; rib; rib graft; clonus; muscle hypotonia; follow up; air conditioning; leg; deterioration; cerebrospinal fluid; tracheostomy; extubation; computer assisted tomography; debridement; suture; imaging; arm; convulsion; neck; decubitus; consciousness; superinfection; wound care; decompression; healing; sedation; breathing disorder; spine; postoperative complication; toddler; nuclear magnetic resonance imaging

Surgical treatment and perioperative complications in patients with ankylosing spondylitis spine fractures - Török E.; Gempt J.; Meyer B.; Ryang Y.-M. (European Spine Journal, 2013)
Objective: Spine fractures often occur in patients with ankylosing spondylitis caused by minor trauma. Due to the low prevalence of the pathology, only few series are published and treatment guidelines are missing. Methods: We retrospectively reviewed our clinical database for pats. suffering from ankylosing spondylitis who underwent surgical treatment for spine fractures between 03/2008 and 05/2013. Surgical time, hospital-/ICU-stay, pre- and postop. neurological symptoms, co-morbidities, perioperative complications and surgical strategy were assessed. Results: 17 pts (10 m /1 f; mean age 74 yrs, range 47 - 90) were operated for traumatic Bechterew fractures (10 cervical, 6 thoracic, 1 lumbar) in a total of 34 surgeries with a mean operation time of 155 ± 58 min (60 - 309). 14 (82%) pats. suffered from more than 1 relevant co-morbidity prior to trauma. Mean hospital stay was 26 ± 17 d (6 - 70). 10 (59 %) pats. needed ICU treatment (mean stay 13 ± 17 d, range 1 - 51) due to medical deterioration (6 x pneumonia, 2 x cardiac arrest 1 x cement embolism, 2x sepsis, 2 x kidney failure,1 x postoperative agitation). There were different operating strategies for cervical spine fractures: In 9/10 cases a 360 ° fusion was applied (5 x anterior - posterior, 4 x post. - ant.). In 2 cases surgery was realized 1-staged, in 7 cases 2-staged with a mean interval of 5 ± 3 d (1 - 10). 1 pat. received mere dorsal instrumentation. Preexisting poor medical condition and clinical deterioration obviated a secondary ventral procedure. 5/7 (71 %) of the pats. with thoracic / lumbar fractures received a 360° fusion with primary posterior stabilization with or w/o laminectomy and secondary ventral corpectomy during the same hospital stay. 2 pats. received mere percutaneous posterior instrumentation. 8 pats. (47 %) had preoperative neurological deficits of whom 2/8 pats. improved, 6/8 pats. were unchanged postop. 3 severe intraop. complications occurred (1 successful reanimation, 1 cement embolism, 1 VA-dissection w/o neurological sequelae). There were 2 mild / moderate intraop. complications (1 durotomy, 1 rod malposition). 3 pats. had revision surgeries for superficial wound infection, screw-loosening 3 months after the first operation and for early implant failure 24 hrs after ACDF with secondary fracture dislocation and permanent neurological deterioration. This pat. was immediately revised anteriorly and received dorsal instrumentation during the same surgical procedure. 7 (41%) pats. experienced medical complications (4 pats.: i.e. pneumonia, kidney failure), or neurological deterioration (3 pats.) prior to surgery. These pats. had significantly longer hospital- (40 ± 18 d vs. 18 ± 8 d, p < 0.05) and ICU-stays (30 ± 16 d vs. 2 ± 3 d, p < 0.05). 27 medical complications occurred in 10 pts (59 %): 7 pneumonias, 6 tracheotomy, 5 renal failures, 2 venous thromboses, 2 pleural effusions, 2 sepsis, 2 cardiac arrest, 1 urinary tract infection, 1 pneumothorax, 1 stroke, 1 GI-bleeding with laparatomy and wound infection. 2 of these pats. (12 %) died during hospital stay from severe medical complications. Conclusion: Dorso-ventral spine instrumentation for ankylosing spondylitis fractures seem to be the surgical strategy of choice in these patients. The interval between trauma and surgery and in between 2-staged surgeries should be as brief as possible, as the patients are at high risk for neurological or medical deterioration prior to surgery resulting in significantly longer hospital- and ICU-stays. Surgery-associated complications were rare but the rate of medical complications was high in this patient group.
Keywords: cement; peroperative complication; patient; human; ankylosing spondylitis; spine fracture; surgery; deterioration; devices; kidney failure; hospital; injury; pneumonia; fracture; hospitalization; sepsis; embolism; wound infection; heart arrest; morbidity; cervical spine fracture; neurologic disease; agitation; data base; ant; pathology; prevalence; spine; bleeding; cerebrovascular accident; pneumothorax; urinary tract infection; pleura effusion; vein thrombosis; tracheotomy; surgical technique; fracture dislocation; implant; dissection; resuscitation; laminectomy; procedures; operation duration; risk

Airway management in cervical spine ankylosing spondylitis: Between a rock and a hard place - Eipe N.; Fossey S.; Kingwell S.P. (Indian Journal of Anaesthesia, 2013)
We report the perioperative course of a patient with long standing ankylosing spondylitis with severe dysphagia due to large anterior cervical syndesmophytes at the level of the epiglottis. He was scheduled to undergo anterior cervical decompression and the surgical approach possibly precluded an elective pre-operative tracheostomy. We performed a modified awake fibreoptic nasal intubation through a split nasopharyngeal airway while adequate oxygenation was ensured through a modified nasal trumpet inserted in the other nares. We discuss the role of nasal intubations and the use of both the modified nasopharyngeal airways we used to facilitate tracheal intubation. This modified nasal fibreoptic intubation technique could find the application in other patients with cervical spine abnormalities and in other anticipated difficult airways.
Keywords: lidocaine; sevoflurane; aged; ankylosing spondylitis; article; bronchoscope; capnometry; case report; cervical spine; dysphagia; human; male; nasopharynx airway; nasotracheal intubation; nerve block; osteophyte; respiration control; spinal cord decompression; tracheostomy

Total aortic arch replacement with the frozen elephant trunk technique: 10-year follow-up single-centre experience - Ius F.; Fleissner F.; Pichlmaier M.; Karck M.; Martens A.; Haverich A.; Shrestha M. (European Journal of Cardio-thoracic Surgery, 2013)
OBJECTIVES: Since August 2001, the frozen elephant trunk (FET) technique has been used at our institution to treat degenerative or dissecting aneurysms involving the aortic arch and descending aorta as a potential 'single-stage' procedure. The aim of this study was to review our FET experience and to present the 10-year results. METHODS: Between August 2001 and January 2012, 131 patients underwent FET implant with three different prostheses: the custommade Chavan-Haverich (n = 66), the Jotec E-vita (n = 30) and the Vascutek Thoraflex (n = 35) prostheses. Concomitant procedures included aortic valve-sparing operations (David, n = 17) and aortic root replacement (Bentall, n = 25). Patient records and the first postoperative and last available computer tomography (CT) were retrospectively reviewed. RESULTS: Incidence of rethoracotomy for bleeding, stroke, spinal cord injury, prolonged ventilatory support (>96 h) and acute renal failure requiring dialysis were 18, 11, 1, 41 and 16%, respectively. In-hospital mortality was 15%. The mean follow-up was 42 ± 37 (range 1-134 months). At 1, 5 and 10 years, survivals were 82 ± 3, 72 ± 5 and 58 ± 8%, respectively. Freedoms from distal aortic operation were 81 ± 4, 67 ± 5 and 43 ± 13%, respectively. Thirty-six patients underwent 40 distal aortic operations, either open surgical (n = 22, 55%) or endovascular (n = 18, 45%). Chronic aortic dissection was identified as an independent risk factor for distal aortic operation (odds ratio = 3.8; 95% confidence interval 1.5-9.3; P = 0.004). At last CT control, false-lumen thrombosis rates up to 93% were achieved around the stent graft. CONCLUSIONS: An FET concept adds to the armament of the surgeon in the treatment of complex and diverse aortic arch pathologies. The preoperative patient risk profile explains the postoperative morbidity and in-hospital mortality. The FET can potentially be still a 'one-stage' procedure in selected patients. However, the extension of FET to patients with extensive aortic aneurysms has led to an increase in second-stage procedures. © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: acute kidney failure; aged; aortic dissection; aortic prosthesis; aortic rupture; aortic surgery; aortic arch surgery; aortic root surgery; article; artificial ventilation; bleeding; cerebrovascular accident; female; follow up; frozen elephant trunk technique; human; intensive care unit; length of stay; major clinical study; male; medical record review; mortality; multiple organ failure; pneumonia; postoperative complication; priority journal; risk factor; spinal cord injury; survival rate; survival time; thoracotomy; tracheotomy; vocal cord paralysis; Chavan-Haverich; Jotec E-vita; Thoraflex

Respiratory management in the patient with spinal cord injury - Galeiras Vázquez R.; Rascado Sedes P.; Mourelo Fariña M.; Montoto Marqués A.; Ferreiro Velasco M.E. (BioMed Research International, 2013)
Spinal cord injuries (SCIs) often lead to impairment of the respiratory system and, consequently, restrictive respiratory changes. Paresis or paralysis of the respiratory muscles can lead to respiratory insufficiency, which is dependent on the level and completeness of the injury. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Vital capacity (VC) is an indicator of overall pulmonary function; patients with severely impaired VC may require assisted ventilation. It is best to proceed with intubation under controlled circumstances rather than waiting until the condition becomes an emergency. Mechanical ventilation can adversely affect the structure and function of the diaphragm. Early tracheostomy following short orotracheal intubation is probably beneficial in selected patients. Weaning should start as soon as possible, and the best modality is progressive ventilator-free breathing (PVFB). Appropriate candidates can sometimes be freed from mechanical ventilation by electrical stimulation. Respiratory muscle training regimens may improve patients' inspiratory function following a SCI. © 2013 Rita Galeiras Vázquez et al.
Keywords: beta 2 adrenergic receptor stimulating agent; bronchodilating agent; cholinergic receptor blocking agent; abdominal distension; aeration; aerophagia; artificial ventilation; atelectasis; barotrauma; breathing exercise; breathing muscle; bronchospasm; cervical spinal cord injury; conservative treatment; electrotherapy; endotracheal intubation; extubation; human; hypoventilation; implanted phrenic nerve stimulator; intermittent positive pressure ventilation; lung complication; muscle training; noninvasive ventilation; pacemaker; percussion; pneumonia; positive end expiratory pressure; postoperative complication; postural drainage; quadriplegia; randomized controlled trial (topic); recurrent disease; rehydration; respiratory distress; respiratory failure; respiratory function; review; spinal cord injury; systematic review (topic); thoracic spinal cord; thorax injury; tracheostomy; tracheotomy; vena cava filter; ventilator; vibration; weaning

Admission ASIA motor score predicting the need for tracheostomy after cervical spinal cord injury - Menaker J.; Kufera J.A.; Glaser J.; Stein D.M.; Scalea T.M. (Journal of Trauma and Acute Care Surgery, 2013)
BACKGROUND: Respiratory compromise and the need for tracheostomy are common after cervical spinal cord injury (cSCI). The purpose of the study was to evaluate if admission American Spinal Injury Association (ASIA) motor score is associated with the need for tracheostomy following cSCI. METHODS: The trauma registry identified patients with isolated cSCI during a 3-year period. Patients with an Abbreviated Injury Scale score greater than 3 in other body regions were excluded. Medical records were reviewed for demographics, admission ASIA motor score, ASIA Impairment Scale (AIS), anatomic level of injury, need for a tracheostomy, and length of stay (LOS). Logistic regression models were constructed to examine the effect of admission ASIA motor scores on the outcome of tracheostomy. Cox proportional hazards models were fit to determine risk factors for time to tracheostomy. RESULTS: A total of 128 patients were identified. Seventy-four patients had a tracheostomy performed on mean (SD) hospital Day 9 (4). Median admission ASIA motor score was 22.0 (interquartile range [IQR], 8-54). Median anatomic level of injury was 5 (IQR, 4-6). Patients requiring tracheostomy had significantly lower median admission ASIA motor score (9 [IQR, 3-17] vs. 57 [IQR, 30-77], p < 0.001) and were more likely to be an AIS A. There was no difference in median anatomic level of injury (5 [IQR, 4-5.8] vs. 5 [IQR, 4-6], p = nonsignificant). ASIA motor scores less than 10 had an unadjusted odds ratio for requiring tracheostomy of 56 (95 confidence interval, 7-426). Following adjustment for independent risk factors, the odds ratio for ASIA motor score less than 10 remained statistically significant at 22 (confidence interval, 3-180). Among patients with incomplete cSCI, ASIA motor scores increased significantly from AIS B to AIS D, while Injury Severity Score (ISS), LOS and intensive care unit LOS declined significantly. Of those patients without a tracheostomy, 100% had an ASIA motor score greater than 10, 98% had an ASIA motor score greater than 20, and 86% had an ASIA motor score greater than 25. Among patients with an ASIA motor score less than 10, 100% had a tracheostomy; among patients with an ASIA motor score less than 20, 96% had a tracheostomy. Among patients with a tracheostomy, 91% were an AIS B or C, while 85% of patients classified as AIS D did not have a tracheostomy. CONCLUSION: Tracheostomy after cSCI is common. Lower admission ASIA motor score and complete cSCI are significantly associated with the need for tracheostomy. Anatomic level of injury was not associated with tracheostomy after cSCI. Classification of incomplete patients by AIS indicates that ASIA motor score may be used as a surrogate for grade of injury. When looking only at patients with an incomplete cSCI, those with an admission ASIA score of less than 10 should have an early tracheostomy. Those with an AIS D scale should not be considered for early tracheostomy. © 2013 Lippincott Williams and Wilkins.
Keywords: adult; American Spinal Injury Association impairment scale; article; cervical spinal cord injury; controlled study; female; hospital admission; human; injury scale; injury severity; intensive care unit; length of stay; major clinical study; male; medical record review; prediction; priority journal; register; risk factor; tracheostomy

Spinal cord avulsion in the pediatric population: Case study and review - Phillips B.C.; Pinckard H.; Pownall A.; Öcal E. (Pediatric Emergency Care, 2013)
Spinal cord injury without radiographic abnormality (SCIWORA) is a rare phenomenon, but with advances in imaging and improvements in magnetic resonance imaging more cases are being identified. Even more uncommon is the finding of spinal cord avulsion as a type of SCIWORA with only single case reports in the literature. We present the case reports of 2 patients both experiencing spinal cord avulsion as a type of SCIWORA, secondary to improper lap-belt restraint during a motor vehicle accident. Copyright © 2013 by Lippincott Williams & Wilkins.
Keywords: dopamine; noradrenalin; steroid; article; bradycardia; case report; child; childhood injury; computer assisted tomography; contusion; emergency care; feeding apparatus; human; hypotension; male; nuclear magnetic resonance imaging; occupational therapy; physiotherapy; preschool child; school child; speech therapy; spinal cord avulsion; spinal cord injury; tracheostomy; traffic accident

Evaluation at five years of post-acute unit (UPR) at the Saint-Hélier Pole, Rennes - Autret K.; Durufle-Tapin A.; Robineau S.; Nicolas B.; Gallien P.; Petrilli S.; Le Meur C. (Annals of Physical and Rehabilitation Medicine, 2013)
Introduction.- Post-intensive care rehabilitation services aren't currently normalized by any text. The 2012 brain injuries and spinal cord injuries action program plans a study of this type of structure. Method.- Four UPR beds were created in 2008 at the Pôle Saint-Hélier in Rennes. In 2010, four extra beds were opened.We suggest a five years existence assessment of this unit, from January 2008 to December 2012. Epidemiological data (age, sex), medical (pathology type, occurrence of a tracheotomy, enteral feeding) and administrative (average duration of hospital stay, hospital service of origin and leaving mode) were collected. Results.- Eighty-one patients were admitted in UPR in five years. The UPR admission delay is four weeks. The median age of the patients is 50.72 years. Pathologies are primarily cerebral lesions (stroke, brain injury, anoxia...), then spinal cord injuries or rehabilitation after multi-visceral failure. Seventy-five patients had a tracheotomy at the time of their admission. Sixty-nine had a gastrostomy. The average duration of stay in UPR is 11.8 weeks. At five years, 62 of the 81 patients had left the hospital, including 43 who could go back to home. Conclusion.- The activity of a UPR, between acute care services and rehabilitation, meets a need for public health. This type of unit allows patients to access early rehabilitation care in a medically monitored environment. The issue of downstream chain remains the main obstacle to a steady output flow and to the decrease of stay duration in upstream services.
Keywords: Christian; adaptation; epidemiology; human; patient; brain injury; pathology; rehabilitation; spinal cord injury; tracheotomy; brain damage; epidemiological data; environment; hospital service; intensive care; hospitalization; emergency care; enteric feeding; gastrostomy; rehabilitation center; anoxia; cerebrovascular accident; hospital; public health; rehabilitation care

Successful weaning after cervical spinal cord injury. Preliminary reslts in 34 tetraplegic patients - Hamsen U.; Ramczykowski T.; Kuhs O.; Aach M.; Schildhauer T.A.; Swol J. (Intensive Care Medicine, 2013)
Introduction. Cervical spinal cord injury with tetraplegia lead to respiratory failure and long-term invasive ventilation. Due to the spinal shock the mucosal clearance is reduced. There is a high risk of ventilator-associated pneumonia. The swallow disability is often present. The paralysis of the intercostal musculature leads to dependence of respirator. METHODS. All patients suffered from acute spinal cord injury with tetraplegia. Injury, clinical course and outcome data was extracted retrospectively using the ICU database. To evaluate predictors for successful weaning we assessed 34 consecutive patients (31 male, 3 female; age 60.7 ±: 17.3 years) treated in our center between 1.10.2010 and 1.12.2011. RESULTS. 32 of 34 patients were discharged from hospital, 2 patients died within hospital stay. 33 patients received tracheostoma for weaning. Mean days ventilated before performed tracheostomy was 9.6 ±: 8.7. 28 patients left hospital weaned from ventilator (88 %). 13 of 28 patients left hospital without tracheostoma. Mean duration of ventilation was 30.1 ±: 24.7 days. CONCLUSIONS. Tetraplegic patients are often at an advanced age ([50 years old), which is an unfavorable situation for weaning. Percutaneous tracheostomy simplifies phoniation because the stoma is better sealed. Percutaneous gastrostomy prevents microaspiration and recurrent pneumonia. Weaning from mechanical ventilation is possible and should be aimed once the patient has adapted to the new situation of tetraplegia after resolution of spinal shock.
Keywords: weaning; cervical spinal cord injury; patient; human; society; intensive care; hospital; quadriplegia; air conditioning; ventilator; trachea stoma; tracheostomy; spinal cord injury; risk; muscle; pneumonia; paralysis; respiratory failure; male; disability; stoma; swallow (bird); ventilator associated pneumonia; hospitalization; data base; disease course; injury; gastrostomy; artificial ventilation; female

An autopsied case of progressive supranuclear palsy presenting with cerebellar ataxia and severe cerebellar involvement - Iwasaki Y.; Mori K.; Ito M.; Tatsumi S.; Mimuro M.; Yoshida M. (Neuropathology, 2013)
A Japanese male patient presented with gait disturbance at the age of 69 years. His principal symptom was cerebellar ataxia for several years. He was initially diagnosed as having olivopontocerebellar atrophy because dysarthria and ataxia gradually developed, and head CT scan showed apparent atrophy of the cerebellum and brainstem and dilatation of the fourth ventricle. Later, he showed vertical gaze palsy, dysphagia, retrocollis, parkinsonism, axial dominant rigidity and grasp reflex, and therefore, the diagnosis was modified to progressive supranuclear palsy (PSP). Progressive atrophy of the frontotemporal lobe, cerebellum and brainstem, and dilatation of the lateral, third and fourth ventricles were evident on MRI. Gastrostomy and tracheotomy were performed 9 and 10 years after onset, respectively, and the patient died after 11 years disease duration. At autopsy the brain weighed 1000g and showed atrophy of the frontotemporal lobe, cerebellum and brainstem. Neurofibrillary tangles, mainly globose-type revealed by Gallyas-Braak silver staining, were extensively observed in the cerebral cortex and subcortical grey matter. Numerous glial fibrillary tangles, including tuft-shaped astrocytes and coiled bodies, and extensive argyrophilic threads were also recognized, particularly in the frontal lobe, basal ganglia, cerebellar white matter, brainstem and spinal cord. The Purkinje cell layer showed severe neuron loss with Bergmann's gliosis, and the dentate nucleus showed severe neuron loss with grumose degeneration. Tau-positive/Gallyas-positive inclusions in the Purkinje cells and the glial cells of the Purkinje cell layer were observed. Pathological findings of the present patient were consistent with the diagnosis of PSP, but the olivopontocerebellar involvement, particularly in the cerebellum, was generally more severe, and the quantity of tau-positive/Gallyas-positive structures were more abundant than in typical PSP cases. The existence of a distinct, rare PSP subtype with severe olivopontocerebellar involvement, "PSP-C", which tends to be clinically misdiagnosed as spinocerebellar degeneration in the early disease stage, is noteworthy. The present case corresponded to this rare subtype of PSP. © 2013 Japanese Society of Neuropathology.
Keywords: tau protein; aged; article; astrocyte; ataxia; autopsy; brain atrophy; brain cortex; brain fourth ventricle; brain stem; brain ventricle dilatation; brain weight; case report; cause of death; cerebellar ataxia; cerebellum atrophy; cerebellum disease; cervical dystonia; coiled body; computer assisted tomography; dentate nucleus; depigmentation; diagnostic error; disease duration; dysarthria; dysphagia; frontal lobe; gastrostomy; gaze paralysis; glia cell; gliosis; globus pallidus; gray matter; human; human tissue; immunohistochemistry; Japanese (people); male; mortality; muscle rigidity; neurofibrillary tangle; neuroimaging; neuropathology; nuclear magnetic resonance imaging; olivopontocerebellar atrophy; parkinsonism; priority journal; progressive supranuclear palsy; Purkinje cell; reflex; silver staining; spinal cord; spinocerebellar degeneration; subcortex; substantia nigra; subthalamic nucleus; temporal lobe; tracheotomy; white matter

A cursed case of respiratory failure - Sajjad H.; Nostrand K.V.; Graham Carlos W. (Chest, 2013)
INTRODUCTION: Ondine's curse is a condition which involves autonomic respiratory failure during sleep that is fatal if untreated. This disorder can be inherited and present during infancy as congenital central hypoventilation or it can present during adulthood when it is called primary alveolar hypoventilation. Uncommonly it presents as a brain or high cervical spinal cord injury. Worldwide approximately 200 cases have been reported with very few presenting as adults. We present a case of this rare disease following pontomedullary hemorrhage in an adult woman. CASE PRESENTATION: A 77 year-old African American woman with history of hypertension and peripheral vascular disease was hospitalized for dizziness secondary to carbon monoxide exposure. On hospital day four she developed new onset slurred speech, right sided facial droop and confusion requiring intubation and mechanical ventilation. Head computer tomography (CT) showed hemorrhage involving the right posterior medulla. She could not be liberated from the ventilator due to frequent, prolonged apneas while asleep consistent with Ondine's curse. These episodes continued despite minimizing sedating medications and trialing various modes of mechanical ventilation. In an effort to increase alveolar ventilation acetazolamide was started. It appeared to be effective as evidenced by decreased apneic spells. Despite less frequent apneas the patient ultimately required a tracheostomy and remains on mechanical ventilation when sleeping. DISCUSSION: Hypoventilation syndromes are common following cerebrovascular accidents. However, hypoventilation that occurs exclusively during sleep, the dreaded «curse» of Ondine, is quite rare. This case reviews treatment considerations including acetazolamide and early tracheostomy. The tracheostomy simplifies ventilation while asleep whereas the acetazolamide increases ventilatory drive. While our patient remained «cursed» during her inpatient stay, the literature suggests that she may improve over the coming months, regaining her autonomic drive. CONCLUSIONS: Ondine's Curse is a rare syndrome that affects autonomic ventilatory drive during sleep. This case reviews treatment considerations including acetazolamide and early tracheostomy that may improve overall outcomes.
Keywords: acetazolamide; carbon monoxide; respiratory failure; human; tracheostomy; sleep; artificial ventilation; hypoventilation; bleeding; apnea; patient; adult; female; cervical spinal cord injury; hypertension; infancy; African American; cerebrovascular accident; peripheral vascular disease; brain; lung ventilation; lung alveolus hypoventilation; diseases; drug therapy; ventilator; computer assisted tomography; adulthood; rare disease; intubation; slurred speech; hospital; exposure; air conditioning; hospital patient; dizziness

Ventilator-associated pneumonia in trauma patients with open tracheotomy: Predictive factors and prognosis impact - Chaari A.; Kssibi H.; Zribi W.; Medhioub F.; Chelly H.; Algia N.B.; Hamida C.B.; Bahloul M.; Bouaziz M. (Journal of Emergencies, Trauma and Shock, 2013)
Objective: To assess the predictive factors of ventilator associated pneumonia (VAP) occurrence following open tracheotomy in trauma patients. Materials and Methods: We conducted an observational, prospective study over 15 months, between 01/08/2010 and 30/11/2011. All trauma patients (except those with cervical spine trauma), older than 15 years, undergoing open tracheotomy during their ICU stay were included. All episode of VAP following tracheotomy were recorded. Predictive factor of VAP onset were studied. Results: We included 106 patients. Mean age was 37.9 ± 15.5 years. Mean Glasgow coma Scale (GCS) was 8.5 ± 3.7 and mean Injury Severity Score (ISS) was 53.1 ± 23.8. Tracheotomy was performed for 53 patients (50%) because of prolonged ventilation whereas 83 patients (78.3%) had tracheotomy because of projected long mechanical ventilation. Tracheotomy was performed within 8.6 ± 5.3 days. Immediate complications were bleeding events (22.6%) and barotrauma (0.9%). Late complications were stomal infection (28.3%) and VAP (52.8%). In multivariate analysis, independent factors predicting VAP onset were delayed tracheotomy (OR = 0.041; CI95% [1.02-7.87]; P = 0.041) and stomal infection (OR = 3.04; CI95% [1.02-9.93]; P = 0.045).Thirty three patients died in ICU (31.1%) without significant impact of VAP on mortality. Conclusion: Late tracheotomy and stomal infection are independent factors predicting VAP onset after open tracheotomy in trauma patients. The occurrence of VAP prolongers mechanical ventilation duration and intensive care unit (ICU) length of stay (LOS) but doesn't increase mortality.
Keywords: abdominal injury; adult; anisocoria; article; artificial ventilation; barotrauma; catheter infection; clinical trial; female; follow up; Glasgow coma scale; head injury; hospitalization; human; injury scale; intensive care unit; major clinical study; male; observational study; pelvis injury; postoperative complication; postoperative hemorrhage; postoperative infection; predictive value; priority journal; prognosis; prospective study; stomal infection; thorax injury; tonic clonic seizure; tracheotomy; ventilator associated pneumonia

Prolonged bradycardia and asystole in high spinal cord injury patients: Risk factors and management - Shaikh N.; Raza A.; Hanssens Y.; Malmstrom M.F. (Intensive Care Medicine, 2013)
Introduction. High spinal cord injury (HSCI) is one of the devastating traumatic injuries. Eighty percent of these patients are young male, and 93 % of them will have major neurological disabilities having great financial impact on patient0s family as well as the health care system. There is paucity of literature about prolonged bradycardia in HSCI patients. OBJECTIVES. To evalaute the prevalence, duration, risk factors, precipitating factors for prolonged bradycardia, and its association with pneumonia, positioning or endotracheal suction in the HSCI patients. METHODS. All patients who were admitted to the intensive care unit (ICU) of Hamad General Hospital, a tertiary hospital, with spinal cord injury above level of dorsal (D4) were enrolled in this study. Data collected include: patient's demographic data, mechanism, level and type of spinal injury, associated injuries, injury severity score (ISS), spinal shock vasopressors used, time of occurrence of bradycardia, treatment of bradycardia, chest X-ray finding at the occurrence of bradycardia, relation of bradycardia with endotracheal suctioning or position of the patient, ICU stay, tracheostomy, any other complications and outcome. RESULTS. During the study period (from January 2004 through December 2009), 138 patients were admitted to the ICU with HSCI. The majority of patients were male (96 %). The most frequently associated injury in these patients was skeletal fractures (38.4 %) and most common complication was pneumonia 56 (41 %). Forty five patients (33 %) had prolonged bradycardia; 87 % of these patients had pneumonia when bradycardia occurred 53.4 % of them had asystole, 77.8 % required tracheostomy. 40 (29 %) of total HSCI patients had spinal shock at admission, 29 (21 %) patients of them had bradycardia at the time of endotracheal suctioning whereas 27 (20 %) patients developed bradycardia at the time of position. Majority of the patients were managed conservatively. Those HSCI patients who developed prolonged bradycardia, their ISS score was statistically higher compared to the HSCI patients without prolonged bradycardia (43.5 ±: 14 vs 34.4 ±: 16.6 p = 0.02). ICU stay (38.8 ±: 29 vs 9.6 ±: 11.9, p = 0.001) and hospital stay (63 ±: 55 vs 27 ±: 34, p = 0.002) were also found significantly higher compared with those HSCI patient without prolonged bradycardia. Multivariate analysis showed that hypotension on admission (OR = 10.66, 95 % C.I. 2.8-40.6, p = 0.001), pneumonia (OR = 3.5, 95 % CI 0.9-14.0, P = 0.05) and tracheostomy (OR = 6.3, 95 % C.I. 1.67-23.5, p = 0.006) were the risk factors for the development of prolonged bradycardia in HSCI patients. CONCLUSIONS. Prolonged bradycardia was significantly associated with higher incidence of asystole. Endotracheal suctioning and positioning of HSCI patients were significant provocative factors for prolonged bradycardia whereas, hypotension on admission, pneumonia and tracheostomy played major role for the development of prolonged bradycardia in these patients.
Keywords: hypertensive factor; heart arrest; spinal cord injury; patient; human; risk factor; society; intensive care; bradycardia; pneumonia; tracheobronchial toilet; tracheostomy; injury; male; hypotension; prevalence; tertiary care center; health care system; general hospital; intensive care unit; spine injury; disability; multivariate analysis; hospitalization; fracture; epidemiology; thorax radiography; injury scale

Rapidly progressive severe tracheal stenosis in a C2 spinal cord injured patient following elective spine surgery: A case report - Sizer C.; Castillo C.; Sizer C. (PM and R, 2013)
Case Description: We report a rare case of rapidly progressive severe tracheal stenosis in a C2 motor incomplete SCI patient following elective anterior cervical decompression with posterior fusion. The patient presented with insidious onset of dyspnea on exertion, weakened speaking voice, and noisy breathing during his rehabilitation process. Bronchoscopy showed a combination of Grade III tracheal stenosis (60% narrowing) and tracheomalacia. Through the multidisciplinary team, including ENT, pulmonology, cardiothoracic surgery and SCI medicine, management was established. Progressive worsening of dyspnea with apneic episodes noticed days before his scheduled tracheal dilatation. Subsequent bronchoscopy showed critical tracheal stenosis (>90%), requiring emergent tracheotomy in the operating room. Setting: Acute inpatient rehabilitation hospital. Results or Clinical Course: The patient returned to the SCI rehabilitation unit to complete his rehabilitation program, eventually returning home with tracheostomy and possible tracheal dilations as an outpatient. Discussion: The rapidly progressive nature of tracheal stenosis in this SCI patient raises many questions and serious concerns for the rehabilitation physician. There is limited data on tracheal stenosis in the SCI population other than a single observational study published in 1987. Often, symptoms of tracheal stenosis present in the rehabilitation setting, placing the responsibility of recognizing and diagnosing this serious complication on the rehabilitation physician. Conclusions: Tracheal stenosis after elective spine surgery is a rare, but potentially life-threatening, complication. It is important for rehabilitation professionals to have a high index of suspicion and awareness of this serious complication to ensure early detection and management.
Keywords: human; trachea stenosis; spinal cord; patient; spine surgery; case report; physical medicine; rehabilitation; bronchoscopy; dyspnea; physician; pulmonology; tracheomalacia; exercise; decompression; breathing; population; voice; outpatient; speech; thorax surgery; hospital; hospital patient; operating room; disease course; tracheostomy; tracheotomy; dilatation; observational study; responsibility; otorhinolaryngology

The effectiveness of early tracheostomy (within at least 10 days) in cervical spinal cord injury patients - Choi H.J.; Paeng S.H.; Kim S.T.; Lee K.S.; Kim M.S.; Jung Y.T. (Journal of Korean Neurosurgical Society, 2013)
Objective: This study aimed to determine the optimal time for tracheostomy by evaluating the benefits and safety of early versus late tracheostomy in spinal cord injury (SCI) patients. Methods: We retrospectively reviewed a total of 254 patients with spinal cord injury. Of them, we selected 21 spinal cord injury patients who required tracheostomy due to long-term mechanical ventilation and analyzed their medical records. The patients were categorized into two groups. Early tracheostomy was performed day 1-10 from intubation in 10 patients and the late tracheostomy was performed after day 10 in 11 cases. We also evaluated the duration of mechanical ventilation, stay in the ICU and complications related to tracheostomy, the injury level of and clinical severity. All data was analyzed using SPSS 18.0/WIN. Results: The early tracheostomy offered clear advantages for shortening the total ICU stay (20.8 day vs. 38.0 day, p=0.010). There was also statistically significant reduction in the total length of time on mechanical ventilation (5.2 day vs. 29.2 day, p=0.009). However, the reductions in the incidence of pneumonia (40% vs. 82%) and the length of ICU stay post to tracheostomy (6 day vs. 15 day) were found to be statistically not significant. There were also no statistically significant differences in the injury level and clinical severity between the groups. Conclusion: We concluded that the early tracheostomy (at least 10 days) is beneficial for SCI patients who are likely to require prolonged mechanical ventilation. © 2013 The Korean Neurosurgical Society.
Keywords: adult; aged; article; artificial ventilation; cervical spinal cord injury; clinical article; clinical effectiveness; controlled study; disease severity; early intervention; female; human; intensive care; length of stay; male; pneumonia; postoperative complication; retrospective study; surgical risk; tracheostomy; treatment duration

Heavy lifting causing hemorrhagic syrinx with subsequent C2 asia a spinal cord injury: A case report - Miller B.A.; Dugan S.E.; Balch J.B.; Polun B.J.; Stambolis V.; Miller B.A. (PM and R, 2013)
Case Description: 59 year-old female with a long history of type II diabetes and hypertension who suffered a C2 ASIA A spinal cord injury following a hemorrhagic syrinx while transferring a patient at work. The patient presented twice to an emergency department with symptoms of increasing extremity weakness and numbness, loss of bowel and bladder function, and neck pain. MRI showed a heterogeneous signal from the inferior medulla to T3. She was diagnosed with a hemorrhagic syrinx. Two days later, she underwent a C1-C7 decompressive laminectomy, had a tracheostomy and PEG tube placed, and spent six weeks at a long-term care facility before being sent to our acute inpatient rehabilitation hospital. Setting: An acute inpatient rehabilitation hospital. Results or Clinical Course: Admission FIM was 48. Her tracheostomy tube was eventually capped and later removed. After a month of rehabilitation, she was able to navigate terrain utilizing a sip and puff system on her power chair, improved her left trapezius elevation to 1/5, and improved her right plantar flexion strength to 1/5. She was discharged home to continue long-term goals such as modified power chair independence over advanced terrain and discerning autonomic dysreflexia signs and symptoms as an outpatient. Discussion: A syrinx is often best seen with a sagittal MRI and can extend multiple levels, most commonly, the cervical region. Presenting symptoms are commonly pain in localized areas and can provide lower motor neuron signs at the lesion level, and various sensory abnormalities from the lesion and below. Any increase in CSF pressure can suddenly increase the syrinx and cause unpredictable results; in our patient's case, transferring a heavy load was hypothesized to have torn her syrinx causing a hemorrhage. She had no history of neck pain prior to her accident and developed neck pain immediately afterwards. A week passed before she presented to the ED. She attempted to treat her pain with over the counter anti-inflammatory, possibly making matters worse. Conclusions: While rare, a syrinx should be on the differential in a patient with a headache or backache, especially if accompanied by appropriate level sensory changes or lower motor neuron signs.
Keywords: spinal cord injury; human; case report; physical medicine; rehabilitation; Asia; patient; neck pain; hospital patient; pain; hospital; motoneuron; weakness; disease course; emergency ward; hypertension; backache; tube; nuclear magnetic resonance imaging; long term care; tracheostomy; tracheostomy tube; laminectomy; non insulin dependent diabetes mellitus; physical disease by body function; autonomic dysreflexia; bladder function; outpatient; independence; intestine; cerebrospinal fluid pressure; bleeding; accident; headache; paresthesia; female; cerebrospinal fluid

Timing of tracheostomy after anterior cervical spine fixation - Stahel P.F.; Moore T.A.; Vanderheiden T.F. (The journal of trauma and acute care surgery, 2013)
Keywords: cervical spine; decompression surgery; female; human; male; postoperative complication; procedures; spinal cord injury; spine fracture; tracheostomy

Re: timing of tracheostomy after anterior cervical spine fixation - Bagley C.A. (The journal of trauma and acute care surgery, 2013)
Keywords: cervical spine; decompression surgery; female; human; male; postoperative complication; procedures; spinal cord injury; spine fracture; tracheostomy

Intracranial hemorrhage after spine surgery Clinical article - Kaloostian P.E.; Kim J.E.; Bydon A.; Sciubba D.M.; Wolinsky J.-P.; Gokaslan Z.L.; Witham T.F. (Journal of Neurosurgery: Spine, 2013)
Object. The authors describe the largest case series of 8 patients with intracranial hemorrhage (ICH) after spinal surgery and identify associated pre-, intra-, and postoperative risk factors in relation to outcome. Methods. The authors retrospectively reviewed the cases of 8 patients treated over 16 years at a single institution and also reviewed the existing literature and collected demographic, treatment, and outcome information from 33 unique cases of remote ICH after spinal surgery. Results. The risk factors most correlated with ICH postoperatively were the presence of a CSF leak intraoperatively and the use of drains postoperatively with moderate hourly serosanguineous output in the early postoperative period. Conclusions. Intracranial hemorrhage is a rare complication of spinal surgery that is associated with CSF leakage and use of drains postoperatively, with moderate serosanguinous output. These associations do not justify a complete avoidance of drains in patients with CSF leakage but may guide the treating physician to keep in mind drain output and timing of drain removal, while noting any changes in neurological examination status in the meantime. Additionally, continued and worsening neurological symptoms after spinal surgery may warrant cranial imaging to rule out intracranial hemorrhage, usually within the first 24 hours after surgery. The presence of cerebellar hemorrhage and hydrocephalus indicated a trend toward worse outcome. © AANS, 2013.
Keywords: adult; aged; anastomosis; ankylosing spondylitis; article; ataxic aphasia; backache; brain hemorrhage; cancer chemotherapy; clinical article; cognition; compression fracture; computer assisted tomography; confusion; conservative treatment; craniotomy; decompression; dysphagia; female; headache; human; hydrocephalus; hypertension; immunosuppressive treatment; intervertebral disk hernia; intraoperative period; kidney transplantation; kyphoscoliosis; laminectomy; limb weakness; liquorrhea; lumbar stenosis; male; motor performance; neck pain; neurogenic bladder; neurologic examination; osteosarcoma; parietal lobe; pelvic osteosarcoma; postoperative period; postural headache; preoperative period; pseudarthrosis; radiculopathy; renal osteodystrophy; retrospective study; risk factor; scoliosis; seizure; spinal cord compression; spine malformation; spine surgery; spondylolisthesis; stenosis; subdural hematoma; surgical drainage; tracheostomy; treatment outcome; ventilator; wound drainage

Complications after long posterior instrumentation patients with cervicothoracic fractures related to ankylosing spine disease: A prospective study in 41 consecutive patients - Robinson Y.; Robinson A.-L.; Olerud C. (European Spine Journal, 2013)
Background: Fractures of the cervicothoracic region related to ankylosing spondylitis (AS) and diffuse idiopathic spinal hyperostosis (DISH) are menacing both sagittal profile and spinal cord. Furthermore low soft tissue covering may lead to increased postoperative infections. Until now there are only few case series published in this regard. The aim of this study is to investigate the common practice of long posterior instrumentation of cervicothoracic fractures with regard to per- and postoperative complications. Methods: During the years 2007 to 2011 41 patients (35 men, 6 women, mean age 71 ± 12 years [48, 95]) with fractures of the cervicothoracic junction related to AS (n = 31) or DISH (n = 10) were treated by posterior instrumentation. 6 patients were smokers. 30 patients had no neurological deficit, 1 was classified Frankel D, 4 Frankel C and 6 Frankel A. All patients were followed prospectively for two years using the standardised protocol of the Swedish Spine Registry SWESPINE. Mortality data was obtained from the Swedish Mortality register. Results: 90 % of the instrumentations were cranially extending to C2, 5 % to C1 and 5 % to occiput. Caudally in 44 % the instrumentation ended at Th3, in 27 % at Th2. 5 patients suffered from postoperative infections, 3 patients suffered from postoperative pneumonia, 2 patients required postoperative tracheostomy, and 1 patient had postoperative liquor leakage due to accidental durotomy. At one-year follow-up the patients reported a neck-pain of 24 ± 25 and an arm-pain of 21 ± 24 on the 100 points VAS scale. Neck pain improved after 2 years to 14 ± 18 VAS. No patient required re-operation due to implant failure or non-union during the first two years. Mean survival was 52 months [95 % CI: 42, 62]. Survival was significantly affected by patient age, gender, smoking, spinal cord injury, and dementia. Outcome and survival were not affected by the type of ankylosing disease or levels of fixation. Discussion: Patients with ankylosing disease suffering from a fracture of the cervicothoracic region are at high risk of developing postoperative complications. These can be complicated by co-morbidity of this rather elderly group of patients. The posterior instrumentation technique is providing sufficient stability allowing early mobilisation, and has lead to stable fusion in all patients in the investigated group. Therefore posterior instrumentation of fractures related to ankylosing spondylitis can be recommended.
Keywords: human; patient; fracture; ankylosing spondylitis; spine disease; prospective study; devices; survival; smoking; postoperative infection; neck pain; mortality; postoperative complication; register; aged; morbidity; risk; dementia; case study; spinal cord injury; gender; pseudarthrosis; implant; male; arm pain; follow up; soft tissue; tracheostomy; pneumonia; spinal cord; hyperostosis; spine; female

Scoring risk factors to early wound dehiscence and progression to metalwork infections after instrumented spinal fusion in children with neuromuscular scoliosis - Bashir M.A.; Athanassacopoulos M.; Hunt R.; Leong J.; Ember T.; Lucas J.; Nadarajah R. (European Spine Journal, 2013)
Abstract title: Scoring Risk Factors to Early Wound Dehiscence and Progression to Metalwork Infections after Instrumented Spinal Fusion in Children with Neuromuscular Scoliosis Aims: 1. Identifying and scoring risk factors that predict early wound dehiscence and progression to metalwork infection. 2. Results of wound healing, eradication of infection and union of with the use of vacuum dressing. 3. Compare results of serial washouts against early vacuum dressing in this group of children with significant medical co-morbidities. Method: A retrospective review of 350 patients with neuromuscular scoliosis who underwent posterior instrumented correction and fusion between 2008 and 2012 at two institutions. 10 patients had an early wound dehiscence which progressed to deep seated infection requiring wound washout(s) and subsequent vacuum dressing. Medical notes, clinical photographs and imaging were reviewed. Minimum follow up period was 14 months. Results: This study shows that readmission to PICU, presence of viscero-cutaneous devices (e.g. PEG, tracheostomy), restrictive lung disease, concomitant infection, polymicrobial (gram negative) organism and hyperlordotic deformities are cumulative risk factors to developing early wound dehiscence leading to deep seated infections. All patients in our series went on to have a sealed, non infected wound with union confirmed on CT. Patients who had multiple serial washouts (n = 3-7), eventually required vacuum dressing. Discussion: By stratifying risk factors in patients with neuromuscular scoliosis, the occurrence of wound dehiscence can be predicted. With higher risk factor scores, early vacuum dressing is recommended as multiple serial wound washouts have poor results and with added morbidity to the patient.
Keywords: wound dehiscence; infection; spine fusion; child; human; scoliosis; risk factor; patient; vacuum; wound; morbidity; concurrent infection; lung disease; tracheostomy; hospital readmission; follow up; wound healing; devices; imaging; deformity; photography; organisms

Evaluation of assisted cough with air stacking in patients with tetraplegia - Torres-Castro R.; Vera R.; Monge G.; Suranyi C.; Avilés P.; Vilaró J. (European Respiratory Journal, 2013)
INTRODUCTION: A significant number of patients with tetraplegia require prolonged mechanical ventilation and use of tracheostomy. For an effective weaning, a thorough analysis of the ability to cough is required. The cough effectiveness is related to the peak cough flow (PCF). Lower PCF values has been described as ineffective and are associated with a greater risk of pulmonary infections. There are techniques to assist cough by increasing the inspiratory volume and the expiratory flow. The manual Air Stacking (AS) technique has been proven as effective in neuromuscular disease. OBJECTIVE: to assess cough efficacy using air stacking and manual compression in patients with tetraplegia with A ASIA Score. METHODS: 11 hospitalized patients with tetraplegia (A ASIA Score) were selected. Measures: PCF during four different interventions: spontaneous maximal expiratory effort (MEE); MEE while receiving abdominal compression (MEE+Abd); MEE after air stacking with a manual resuscitation bag (MEE+AS); and MEE with air stacking and compression (MEE+Add+AS). RESULTS: median age 33 years (16-56 years). The PCF during the different interventions was: MEE 156±53 L/min; MEE+Abd 235±113 L/min; MEE+AS 225±61 L/min, and MEE+Abd+AS 303±96 L/min. We observed PCF increase while applying combination techniques but only significant differences existed between PCF with MEE and MEE+Abd+AS (p=0.0001). CONCLUSION: According to our results, patients with spinal cord injury presented an ineffective cough constituting a risk factor for developing respiratory symptoms. The application of combined techniques (MEE+Abd+AS) can reach near normal PCF values. Those are low cost, simple and easy applied intervention.
Keywords: coughing; chronic disease; human; breathing muscle; patient; quadriplegia; European; society; compression; book; American Spinal Injury Association impairment scale; weaning; artificial ventilation; tracheostomy; hospital patient; expiratory flow; lung infection; risk factor; neuromuscular disease; spinal cord injury; resuscitation; risk

Diaphragmatic pacing: Facilitating early rehabilitation through early ventilator weaning - Acho T.; Young M.; Alfonso L. (Journal of Spinal Cord Medicine, 2013)
Objective: To describe two cases in which diaphragmatic pacer placement facilitated early discharge from acute care and to discuss the benefits of early rehabilitation in spinal cord injury (SCI). Many high-level tetraplegic patients require ventilator assistance, thus preventing active participation in an acute rehabilitation program. Ventilator weaning often leads to prolonged acute care stays and delayed initiation of rehabilitation. This promotes further deconditioning and increases the risks of SCI-related complications. Case 1: An 18-year-old Native-American man involved in a motor vehicle accident (MVA) leaving him with C4 AIS A tetraplegia with motor preservation up to C5 initially. A tracheostomy was placed and patient had subsequent difficulty weaning off the ventilator. On hospital day 37, he underwent diaphragmatic pacer placement. On day 67, he was transferred to inpatient rehabilitation and pacer was turned off on day 104. Rather than spending 104 days in acute care, inpatient rehabilitation was started 37 days earlier. He became modified independent with power wheelchair mobility and setup with basic activities of daily living. Case 2: A 60-year-old Caucasian man involved in a MVA, resulting in C3 AIS A tetraplegia. Tracheostomy was placed on day 6. Difficultly weaning from the ventilator lead to diaphragmatic pacer placement on day 21. Patient was transferred to inpatient rehabilitation on day 52. On day 130, pacer weaning was initiated and achieved by day 151. This resulted in 99 days of rehabilitation that was initiated prior to complete ventilator independence. He became modified independent with power wheelchair mobility and verbally independent to instruct his care. Conclusion: Early weaning reduces ventilator-associated infections, leads to earlier rehabilitation, prevents the effects of deconditioning, and promotes early patient and family education. This helps prevent SCI-related complications including contractures, pressure sores, deep vein thrombosis, urinary tract infections, autonomic dysreflexia, and orthostatic hypotension. Neuropsychological intervention and interaction with other patients with SCI are established earlier, providing coping resources to aid in successful rehabilitation. In conclusion, diaphragmatic pacers allow patients to spend less time in acute care and transition earlier to inpatient rehabilitation. This promotes earlier discharge to the community with less complications, better outcomes, and improved quality of life.
Keywords: rehabilitation; artificial ventilation; spinal cord injury; human; patient; ventilator; hospital patient; weaning; emergency care; male; quadriplegia; tracheostomy; wheelchair; Caucasian; autonomic dysreflexia; daily life activity; orthostatic hypotension; coping behavior; quality of life; urinary tract infection; deep vein thrombosis; hospital; preservation; decubitus; traffic accident; contracture; education; infection; independence; community; American Indian; risk

Timing of tracheostomy after anterior cervical spine fixation. - Stahel P.F.; Moore T.A.; Vanderheiden T.F. (The journal of trauma and acute care surgery, 2013)
Keywords: cervical spine; decompression surgery; female; human; injury; male; methodology; note; postoperative complication; spinal cord injury; spine fracture; tracheostomy

Re: timing of tracheostomy after anterior cervical spine fixation. - Bagley C.A. (The journal of trauma and acute care surgery, 2013)
Keywords: cervical spine; decompression surgery; female; human; injury; male; methodology; note; postoperative complication; spinal cord injury; spine fracture; tracheostomy

Percutaneous endoscopic gastrostomy (PEG) feeding tube migration into the colon. an unusual complication following acute spinal cord injury: A case report - Grove S.; Almoshelli B.; Colachis S.; Grove S. (PM and R, 2013)
Case Description: A 19-year-old man was involved in a motor vehicle crash resulting in T4 complete paraplegia (AIS A). Associated injuries included a ruptured spleen requiring splenectomy, bilateral pneumothoraces with respiratory failure, and a right femur fracture requiring surgical fixation. Both a PEG and a tracheostomy tube were placed due to prolonged ventilatory support and nutritional requirements. Eight weeks following his injury he was successfully weaned from the ventilator and over the next two weeks was advanced to a regular diet. At that time he was admitted to inpatient rehabilitation and was no longer using the PEG tube. Four days after admission, he complained of mild left upper quadrant abdominal pain; his examination was unremarkable. Computed Tomography (CT) of the abdomen identified tenting of the stomach. A dedicated radiograph with contrast revealed that the PEG tube was located outside of the stomach and within the colon with fistula formation between his colon and stomach.Program Description: Percutaneous endoscopic gastrostomy (PEG) tube migration with gastro-colonic fistula formation. Setting: Academic Medical Center. Results or Clinical Course: The surgical consultants recommended removal of the PEG tube which was performed at the bedside. He was monitored closely for signs of peritonitis which did not occur. The remainder of his rehabilitation was unremarkable and he was discharged home after successfully completing the inpatient program. Discussion: Patients with complete spinal cord injuries have altered perception of pain and limited clinical signs of intraabdominal pathology making diagnosis of potentially serious complications very difficult. Close attention to vague abdominal or referred symptoms in this population is critical to allow timely diagnosis and treatment. Conclusions: This unusual case of PEG tube migration illustrates the importance of close attention to vague abdominal or referred symptoms in patients with SCI and altered sensation in order to optimize early detection and treatment of potentially serious abdominal pathology.
Keywords: feeding apparatus; spinal cord injury; human; case report; physical medicine; rehabilitation; percutaneous endoscopic gastrostomy; tube; pathology; hospital patient; diagnosis; patient; stomach; injury; spleen; tracheostomy tube; X ray film; fistula; paraplegia; colon fistula; disease course; nutritional requirement; ventilator; femur fracture; motor vehicle; examination; male; abdominal pain; computer assisted tomography; abdomen; respiratory failure; sensation; diet; university hospital; consultation; peritonitis; population; pain; splenectomy; stomach tube

Helicopter transportation of a sedated, mechanically ventilated patient with cervical cord injury - Kato H.; Nishiwaki Y.; Hosoi K.; Shiomi N.; Hirata M. (Japanese Journal of Anesthesiology, 2013)
We report helicopter transportation of a sedated, mechanically ventilated patient with cervical cord injury. A 20-year-old male sustained traumatic injury to the cervical spinal cord during extracurricular activities in a college. On arrival at the hospital, a halo vest was placed on the patient and tracheostomy was performed. On the 38th hospital day, he was transported a distance of 520 km by helicopter to a specialized hospital in Fukuoka for medical repatriation. Cabin space was narrow. Since power supply and carrying capacity were limited, battery-driven and portable medical devices were used. In consideration for patient's psychological stress, he was sedated with propofol. RSS (Ramsay sedation scale) scores were recorded to evaluate whether the patient was adequately sedated during helicopter transportation. Prior to transport, we rehearsed the sedation using bispectral index monitoring (BIS) in the hospital to further ensure the patient's safety during the transport.
Keywords: propofol; adult; air medical transport; article; artificial ventilation; bispectral index; case report; cervical spinal cord injury; halo brace; human; male; mental stress; patient safety; sedation; tracheostomy; ventilated patient

Intramedullary abscess of the upper cervical spinal cord. Unusual presentation and dilemmas of management: Case report - Sinha P.; Parekh T.; Pal D. (Clinical Neurology and Neurosurgery, 2013)
Keywords: C reactive protein; ceftriaxone; meropenem; vancomycin; abscess; adult; antibiotic therapy; article; astrocytoma; brain ventricle peritoneum shunt; brain ventriculitis; case report; cerebrospinal fluid analysis; cerebrospinal fluid culture; cerebrospinal fluid drainage; cervical spinal cord; cervical spine radiography; computer assisted tomography; cordotomy; cranial nerve; demyelinating disease; differential diagnosis; echocardiography; ependymoma; female; flaccid paralysis; Glasgow coma scale; Gram positive cocci; human; hydrocephalus; lateral brain ventricle; leukocyte count; mean arterial pressure; medical history; nuclear magnetic resonance imaging; protein blood level; pus; spinal cord infection; Streptococcus milleri; tracheostomy; urine culture; ventriculostomy catheter; weakness

Anesthesia and spinal muscle atrophy - Islander G. (Paediatric Anaesthesia, 2013)
Spinal muscle atrophy (SMA) is autosomal recessive and one of the most common inherited lethal diseases in childhood. The spectrum of symptoms of SMA is continuous and varies from neonatal death to progressive symmetrical muscle weakness first appearing in adulthood. The disease is produced by degeneration of spinal motor neurons and can be described in three or more categories: SMA I with onset of symptoms before 6 months of age; SMAII with onset between 6 and 18 months and SMA III, which presents later in childhood. Genetics: The disease is in more than 95% of cases caused by a homozygous deletion in survival motor neuron gene 1 (SMN1). Pathophysiology: The loss of full-length functioning SMN protein leads to a degeneration of anterior spinal motor neurons which causes muscle weakness. Anesthetic risks: Airway: Tracheal intubation can be difficult. Respiration: Infants with SMA I almost always need postoperative respiratory support. Patients with SMA II sometimes need support, while SMA III patients seldom need support. Circulation: Circulatory problems during anesthesia are rare. Anesthetic drugs: Neuromuscular blockers: Patients with SMA may display increased sensitivity to and prolonged effect of nondepolarizing neuromuscular blockers. Intubation without muscle relaxation should be considered. Succinylcholine should be avoided. Opioids: These should be titrated carefully. Anesthetic techniques: All types of anesthetic technique have been used. Although none is absolutely contraindicated, none is perfect: anesthesia must be individualized. Conclusion: The perioperative risks can be considerable and are mainly related to the respiratory system, from respiratory failure to difficult/impossible intubation. © 2013 John Wiley & Sons Ltd.
Keywords: methadone; remifentanil; riluzole; survival motor neuron protein 1; survival motor neuron protein 2; suxamethonium; amyotrophic lateral sclerosis; anesthesia; artificial ventilation; assisted ventilation; blood clotting disorder; bulbar paralysis; cesarean section; congestive cardiomyopathy; drug withdrawal; endotracheal intubation; gastrostomy; general anesthesia; heart arrest; heart disease; human; immobilization; joint contracture; kyphoscoliosis; lung clearance; lung disease; lung function; medical ethics; motoneuron; motor performance; muscle relaxation; muscle weakness; nerve cell degeneration; neuromuscular transmission; nonhuman; noninvasive ventilation; osteopenia; phenotype; postoperative care; prenatal diagnosis; priority journal; proprioceptive feedback; quality of life; regional anesthesia; resuscitation; review; RNA processing; spinal muscular atrophy; stem cell transplantation; stomach fundoplication; sudden infant death syndrome; thrombosis; tracheostomy; tracheotomy

A report of 41 cases of three-column osteotomies of the upper thoracic spine and cervicothoracic junction: Complications, outcomes and differential impact on Spinal pelvic parameters, cervical sagittal alignment and general health status - Tabaraee E.; Theologis A.A.; Funao H.; Bess R.S.; Klineberg E.O.; Smith J.S.; Kebaish K.M.; Deviren V.; Ames C.P. (Spine Journal, 2013)
BACKGROUND CONTEXT: Vertebral column resection (VCR) and pedicle subtraction osteotomies (PSO) are most commonly performed at or below the mid thoracic apex to lower lumbar spine. Evidence regarding three-column osteotomies of the upper thoracic spine and cervicothoracic junction are limited. PURPOSE: This study details and compares complications, radiographic, and clinical outcomes of lower cervical and upper thoracic three-column osteotomies. STUDY DESIGN/SETTING: A retrospective analysis of patients who underwent either a lower cervical (C-6 or C-7) or upper thoracic (T-1 through T-5) 3-column osteotomy (VCR or PSO) for proximal junction kyphosis, fixed cervical sagittal deformity, or posttraumatic kyphosis. PATIENT SAMPLE: Forty-one patients (mean age 60) with average follow- up of 15 months underwent 20 VCRs and 21 PSOs. There were 15 lower cervical and 26 upper thoracic three-column osteotomies. METHODS: Parametric outcomes were analyzed using student t-tests. RESULTS: Average estimated blood loss (1228 vs 1232 cc) and number of fusion levels (10) were similar. Operative time for the lower cervical three-column osteotomies was shorter (251 vs 328 minutes, p=0.013. The lower cervical osteotomy group had longer ICU (5.6 vs 2.3 days) and hospital (14.5 vs 8 days) stays (p=0.99 and 0.175 respectively). For the lower cervical osteotomy group, average preoperative global sagittal vertical axis (SVA), C2-7 SVA, cervical lordosis and pelvic tilt (PT) was 1.1 cm (-6.1 to +11.6), 7.9 cm (4.3-13), 21° of kyphosis (0 to -49) and 23.9° (8-43°). Postoperative global SVA, C2-7 SVA, cervical lordosis and postop PT was 3 cm (-5 to 8.7), 4.7 cm (1.8-7.5), 18° of lordosis (1 to 46) and 21°(7-43) respectively. For the upper thoracic osteotomy group, average preoperative global sagittal vertical axis (SVA), C2-7 SVA, cervical lordosis, and pelvic tilt (PT) was 4.25 cm (-2.7 to 16.6), 5.2 cm (0.5 to 8.4), 20.6° (-16 to 44), and 27° (8-50). Postoperative global SVA, C2-7 SVA, cervical lordosis, and postop PT were 3.9 cm (-1.6 to 19.2), 4 cm (1.2 to 7.2), 18.4° (-43 to 52), and 25° (8-35) respectively. Overall, the lower cervical osteotomies provided greater correction in cervical SVA (p=0.03) and C2-T1 angle (p<0.001) only. Preoperative SF-12 physical component scores (PCS) for the lower cervical and upper thoracic groups were 30.5 and 38 respectively. Postoperative scores were 32.4 and 46.7. The upper thoracic group showed greater improvement, however this was not statistically significant (p=0.5). There were no differences in reoperation rates (20% vs 15%, p=0.7) between the groups. The lower cervical group had 3 (20%) reoperations done for 2 pseudarthroses, 1 infection, and 1 case of distal junctional kyphosis (DJK). Rates of medical complications in the lower cervical osteotomy group were higher (40% vs 8%, p5.034). This included 3 patients with respiratory failure requiring tracheotomy, 1 permanent dysphagia and 2 deep venous thromboses (DVT). In the upper thoracic group, 4 (15%) reoperations were done for 1 pseudoarthrosis, 1 infection, 1 DJK and adjacent segment stenosis. One patient had dysphagia and one had a DVT. Three patients in this group had asymptomatic remote site rod fracture without a subsequent reoperation. CONCLUSIONS: Three-column osteotomies at the cervicothoracic junction and upper thoracic spine restore regional sagittal alignment. Lower cervical osteotomies produce greater correction of C2-C7 SVA and cervical lordosis with shorter operative time. Length of stay and medical complications rates were higher. In this study, upper thoracic 3-column osteotomies did not show significant radiographic changes in cervical or spinopelvic parameters. However, there were less medical complications, shorter stay and trend toward greater improvements in general health status PCS.
Keywords: hexamethonium bromide; thoracic spine; pelvis; parameters; health status; spine; society; osteotomy; lordosis; patient; human; kyphosis; operation duration; pseudarthrosis; dysphagia; reoperation; infection; bleeding; Student t test; fracture; deep vein thrombosis; follow up; lumbar spine; deformity; tracheotomy; respiratory failure; hospital; stenosis; length of stay; surgery

Cerebellar hemorrhage from a delayed cervical spine hardware migration - Chalouhi N.; Chitale A.; Tjoumakaris S.; Gonzalez L.F.; Theofanis T.; Jabbour P. (Clinical Neurology and Neurosurgery, 2013)
Keywords: aged; article; case report; cerebellum hemorrhage; computer assisted tomography; female; human; intensive care unit; magnetic resonance angiography; medical device complication; medical history; nuclear magnetic resonance imaging; posterior fossa; skull defect; spine fusion implant; tracheostomy; vascular lesion

Long-term ventilation in children: Longitudinal trends and outcomes - McDougall C.M.; Adderley R.J.; Wensley D.F.; Seear M.D. (Archives of Disease in Childhood, 2013)
Background Cross-sectional studies have suggested a rapid expansion in paediatric long-term ventilation (LTV) over the last 20 years but information on longitudinal trends is limited. Methods Data were collected prospectively on all patients receiving LTV over a 15-year period (1.1.95-31.12.09) in a single regional referral centre. Results 144 children commenced LTV during the 15- year period. The incidence of LTV increased significantly over time, with an accompanying 10-fold increase in prevalence due to a significant increase in institution of non-invasive ventilation (NIV). There was no significant increase in invasive ventilation. 5-year survival was 94% overall and was significantly higher for patients on NIV (97%) than invasively ventilated patients (84%). 10-year survival was 91% overall. Although some children were able to discontinue respiratory support (21% at 5 years and 42% at 10 years), the number of patients transitioned to adult services increased significantly over time (26% of total cohort). Patients with neuromuscular disease were less likely to discontinue support than other patients. Conclusions The paediatric LTV population has expanded significantly over 15 years. Future planning of paediatric hospital and community services, as well as adult services, must take into account the needs of this growing population.
Keywords: adolescent; adult; article; artificial ventilation; assisted ventilation; cervical spinal cord injury; child; congenital central hypoventilation syndrome; cross-sectional study; diaphragm paralysis; Duchenne muscular dystrophy; female; human; incidence; infant; kyphoscoliosis; Langerhans cell histiocytosis; long term care; long term ventilation; lung hypoplasia; major clinical study; male; mortality; myopathy; neuromuscular disease; noninvasive ventilation; outcome assessment; positive end expiratory pressure; preschool child; prevalence; priority journal; prospective study; school child; sleep disordered breathing; spinal muscular atrophy; spine injury; survival; tracheobronchomalacia; tracheostomy; ventilated patient

Application of a sponaneous ventilation protocol: Experiences from a weaning center for neurological diseases - Oehmichen F.; Zäumer K.; Ragaller M.; Mehrholz J.; Pohl M. (Nervenarzt, 2013)
Objective: The aim of this study was to investigate a novel standardized protocol in this neurological weaning unit in order to optimize the weaning process for patients subjected to prolonged mechanical ventilation. Of primary interest were the frequency of and reasons for deviating from the protocol as well as risk factors for weaning failure and mortality. Patients and methods: All patients admitted to the weaning unit were enrolled in this prospective observational study. The weaning protocol consisted of 22 discrete weaning steps. An individual weaning approach was only begun if the standardized protocol failed. Variables for risk analysis included age, body mass index, APACHE II score, reason for initiating mechanical ventilation, total duration of inpatient stay before admission to the weaning unit, extent of mechanical ventilation period before admission, chronic pulmonary diseases and dialysis. Results: Between October 2007 and December 2008 a total of 644 consecutively admitted patients were enrolled in the study. The mean age was 67.6 ± 12.3 years, the mean inpatient stay before admission was 45.8 ± 34.9 days and the mean duration of mechanical ventilation before admission to the unit was 38.1 ± 28.7 days. The mean APACHE II score was 19.0 ± 7.2, 68 % of the patients were male, 98.6 % had a tracheotomy tube, 30.9 % had a history of chronic pulmonary disease and 13.7 % required dialysis. Reasons for initiating ventilation were cerebral 33.1 %, pulmonary 28.7 %, cardiovascular 31.5 %, neuropathic 2.8 %, myopathic 0.9 %, spinal cord injuries 1.9 % and 1.1 % were unclear. Weaning was successful in 77.3 % (498 patients) of all cases with a mean duration of 22.0 ± 33.9 days. Of those successfully weaned, a total of 85.9 % (n = 428) were weaned according to the standard protocol. The weaning process was also shorter (20.8 ± 35.6 versus 29.0 ± 19.9 days) for those patients weaned according to the protocol compared to those patients where the protocol failed. Protocol failure was normally due to complications during the weaning process. Among the patients where the protocol failed, chronic pulmonary disease (41.4 versus 28.3 %; p < 0.02), a longer duration of ventilation (42.3 ± 22.8 versus 35.9 ± 25.3 days; p < 0.01) and a longer in-hospital stay (52.7 ± 41.4 versus 42.4 ± 30.1 days; p < 0.01) prior to admission were significantly more common. A total of 23.0 % (n = 148) of the patients died and 9.8 % (n = 63) of the patients were discharged into a home care ventilation program. Chronic pulmonary disease and the duration of inpatient stay prior to admission were predictors of weaning failure. The APACHE II score, age and acute renal failure with concomitant need for dialysis were the factors best predicting mortality. Conclusions: The majority of patients receiving prolonged mechanical ventilation can be successfully weaned using a standardized protocol. Failures of standardized weaning per protocol occurred most often in patients with chronic pulmonary disease and following longer inpatient stay. These patients also had a higher risk of final weaning failure. © 2013 Springer-Verlag Berlin Heidelberg.
Keywords: acute kidney failure; age; aged; article; artificial ventilation; body mass; chronic lung disease; dialysis; female; hospital patient; human; major clinical study; male; mortality; myopathy; neuropathy; observational study; risk factor; spinal cord injury; tracheotomy; treatment withdrawal

Effect of ethnicity and insurance type on the outcome of open thoracic aortic aneurysm repair - Murphy E.H.; Stanley G.A.; Arko M.Z.; Davis III C.M.; Modrall J.G.; Arko III F.R. (Annals of Vascular Surgery, 2013)
Objectives: Mortality and complication rates for open thoracic aortic aneurysm repair have declined but remain high. The purpose of this study is to determine the influence of ethnicity and insurance type on procedure selection and outcome after open thoracic aneurysm repair. Methods: Using the Nationwide Inpatient Sample database, ethnicity and insurance type were evaluated against the outcome variables of mortality and major complications associated with open thoracic aneurysm repair. The potential cofounders of age, gender, urgency of operation, and Deyo index of comorbidities were controlled. Results: Between 2001 and 2005, a total of 10,557 patients were identified who underwent elective open thoracic aneurysm repair, with a significantly greater proportion of white patients (n = 8524) compared with black patients (n = 819), Hispanic patients (n = 556), and patients categorized as other (n = 658). Most patients (67%) were male. Almost half (45%) of the procedures were performed for urgent/emergent indications. Overall mortality was 10.7% (n = 1126) and the rate of spinal cord ischemia was 0.4% (n = 43). Univariate analysis revealed significant differences among race with regard to surgery type, income, hospital region, hospital bed size, and insurance type (P < 0.0001). Differences between insurance coverage were significant for gender, surgery type, income, hospital region, and race (P < 0.0001). Bivariate analysis by race revealed differences for death (P < 0.0001), pneumonia (P < 0.0001), renal complications (P = 0.011), implant complications (P < 0.0001), temporary tracheostomy (P = 0.004), transfusion (P < 0.0001), and intubation (P < 0.0001). In terms of payer status, bivariate analysis by insurance coverage revealed differences in death (P < 0.0001), central nervous system complications (P = 0.008), pneumonia (P < 0.0001), myocardial infarction (P = 0.001), infection (P < 0.0001), renal complications (P < 0.0001), malnutrition (P < 0.0001), temporary tracheostomy (P < 0.0001), spinal cord ischemia (P = 0.001), transfusion (P < 0.0001), and intubation (P < 0.0001). Conclusions: A high percentage of open thoracic procedures (45%) are performed urgently or emergently in the United States, which is associated with increased morbidity and mortality. Both ethnicity and payer status were associated with significant differences in surgical outcomes, including mortality and frequency of complications after open thoracic aortic aneurysm repair. © 2013 Elsevier Inc. All rights reserved.
Keywords: article; central nervous system disease; comorbidity; digestive system disease; endovascular aneurysm repair; ethnicity; female; health insurance; heart infarction; Hispanic; hospital bed capacity; human; intubation; kidney disease; major clinical study; male; malnutrition; medicaid; medicare; mortality; peripheral vascular disease; pneumonia; postoperative complication; postoperative infection; priority journal; private health insurance; race difference; respiratory tract disease; spinal cord ischemia; thoracic aorta aneurysm; tracheostomy; transfusion; treatment outcome; vascular disease

Phrenic nerve palsy associated with brachial plexus avulsion in a pediatric patient with multitrauma - Karaoǧlu P.; Yiş U.; Öztura I.; Akdoǧan O.; Bayram E.; Topçu Y.; Hz S. (Pediatric Emergency Care, 2013)
Although brachial plexus injury occurring during multitrauma is frequent in adults, it is rarely observed in childhood. The most common cause of pediatric traumatic brachial palsy is motor vehicle accidents followed by pedestrian struck. Generally, phrenic nerve palsy accompanying brachial plexus trauma is observed in 10% to 20% of cases, but it is overlooked because unilateral injuries are frequently asymptomatic. Severe unilateral phrenic nerve palsy accompanying brachial plexus avulsion is very rare. Here, we present a pediatric case of unilateral phrenic nerve palsy associated with respiratory distress and brachial plexus avulsion due to multitrauma. Copyright © 2013 by Lippincott Williams & Wilkins.
Keywords: inotropic agent; article; brachial plexus injury; bradycardia; case report; cervical spinal cord injury; child; computer assisted tomography; diaphragm paralysis; dyspnea; electromyography; encephalomalacia; female; femur fracture; fluoroscopy; follow up; fracture reduction; Glasgow coma scale; hematoma; human; humerus fracture; hypotension; intensive care unit; laceration; nerve paralysis; nuclear magnetic resonance imaging; phrenic nerve; phrenic nerve paralysis; pneumothorax; postoperative period; preschool child; respiratory distress; resuscitation; skull fracture; tachypnea; thorax radiography; thorax tube; tracheotomy; traffic accident

Characterizing the need for tracheostomy placement and decannulation after cervical spinal cord injury - Nakashima H.; Yukawa Y.; Imagama S.; Ito K.; Hida T.; Machino M.; Kanbara S.; Morita D.; Hamajima N.; Ishiguro N.; Kato F. (European Spine Journal, 2013)
Purpose: There have been few reports on the risk factors for tracheostomy and the possibility of patients for decannulation. The purpose of this study was to identify factors necessitating tracheostomy after cervical spinal cord injury (SCI) and detect features predictive of successful decannulation in tracheostomy patients. Methods: One hundred and sixty four patients with cervical fracture/dislocation were retrospectively reviewed. The patients comprised 142 men and 22 women with a mean age of 44.9 years. The clinical records were reviewed for patients' demographic data, smoking history, level of cervical spine injury, injury patterns, neurological status, evidence of direct thoracic trauma and head injury, tracheostomy placement, and decannulation. Risk factors necessitating tracheostomy and factors predicting decannulation were statistically analysed. Results: Twenty-five patients (15.2 %) required tracheostomy. Twenty-one patients were successfully decannulated. Smoking history (relative risk [RR], 3.05; p = 0.03) and complete SCI irrespective of injury level (C1-4 complete SCI: RR, 67.55; p < 0.001, C5-7 complete SCI: RR, 57.88; p < 0.001) were significant risk factors necessitating tracheostomy. C1-4 complete SCI was more frequent among those who could not be decannulated. However, even in patients with high cervical complete SCI at the time of injury, patients regaining sufficient movement to shrug their shoulders within 3 weeks after injury could later be decannulated. Conclusions: The risk factors for tracheostomy after complete SCI were a history of smoking and complete paralysis irrespective of the level of injury. High cervical level complete SCI was found to be a risk factor for the failure of decannulation in patients without shoulder shrug within 3 weeks after injury. © 2013 Springer-Verlag Berlin Heidelberg.
Keywords: adult; aged; article; cannulation; cervical spinal cord injury; cervical spine; cervical spine dislocation; cervical spine fracture; controlled study; female; human; injury severity; major clinical study; male; medical record review; priority journal; smoking; tracheostomy

Challenges in the surgical management of spine trauma in the morbidly obese patient: A case series - Rosenfeld H.E.; Limb R.; Chan P.; Fitzgerald M.; Bradley W.P.L.; Rosenfeld J.V. (Journal of Neurosurgery: Spine, 2013)
Object. The treatment of morbidly obese individuals with spine trauma presents unique challenges to spine surgeons and trauma staff. This study aims to increase awareness of current limitations in the surgical management of spine trauma in morbidly obese individuals, and to illustrate practical solutions. Methods. Six morbidly obese patients were treated surgically for spine trauma over a 2-year period at a single trauma center in Australia. All patients were involved in high-speed motor vehicle accidents and had multisystem injuries. All weighed in excess of 265 pounds (120 kg) with a body mass index ≥ 40 (range 47.8-67.1). Cases were selected according to the considerable challenges they presented in all aspects of their management. Results. Best medical and surgical care may be compromised and outcome adversely affected in morbidly obese patients with spine trauma. The time taken to perform all aspects of care is usually extended, often by many hours. Customized orthotics may be required. Imaging quality is often compromised and patients may not fit into scanners. Surgical challenges include patient positioning, surgical access, confirmation of the anatomical level, and obtaining adequate instrument length. Postoperative nursing care, wound healing, and venous thromboembolism prophylaxis are also significant issues. Conclusions. Management pathways and hospital guidelines should be developed to optimize the treatment of morbidly obese patients, but innovative solutions may be required for individual cases. © AANS, 2013.
Keywords: pregabalin; warfarin; adult; anterior spine fusion; article; artificial ventilation; atelectasis; body mass; body weight; case study; clinical article; compartment syndrome; computer assisted tomography; deep vein thrombosis; diagnostic imaging; dysphonia; emergency health service; endotracheal intubation; extravasation; fasciotomy; female; flail chest; fluid resuscitation; follow up; fracture dislocation; fracture immobilization; fracture reduction; heart contusion; hematothorax; human; hypotension; hypoxia; image intensifier; image quality; intensive care unit; discectomy; laminectomy; male; medical record review; morbid obesity; myotome; neck pain; neuropathic pain; nuclear magnetic resonance imaging; nursing care; odontoid process fracture; open reduction (procedure); orthotics; osteosynthesis; patient monitoring; patient positioning; patient safety; perioperative period; plate fixation; pneumothorax; posterior spine fusion; postoperative care; practice guideline; quadriplegia; recurrent laryngeal nerve palsy; repeat procedure; residential care; resuscitation; retrospective study; spinal cord injury; spine injury; spine surgery; sternotomy; thorax drainage; thorax pain; tracheostomy; traffic accident; vertebra dislocation; vocal cord paralysis; wound healing

Management of Acute Spinal Cord Injury in the Neurocritical Care Unit - Evans L.T.; Lollis S.S.; Ball P.A. (Neurosurgery Clinics of North America, 2013)
Acute spinal cord injury (SCI) is associated with widespread disturbances not only affecting neurologic function but also leading to hemodynamic instability and respiratory failure. Traumatic SCI rarely occurs in isolation, and frequently is accompanied by trauma to other organ systems. Management of individuals with SCI is complex, requiring aggressive monitoring and prompt treatment when complications arise. Typically this level of care is provided in the neurocritical care unit. This article reviews the pathophysiology of the neurologic, cardiovascular, and pulmonary derangements following traumatic SCI and their management in the critical care setting. © 2013 Elsevier Inc.
Keywords: aminophylline; antiinflammatory agent; atropine; captopril; dopamine; erythropoietin; fludrocortisone; ganglioside GM1; glucocorticoid; glutamate receptor antagonist; heparin; hydralazine; hypertensive agent; inotropic agent; labetalol; low molecular weight heparin; methylprednisolone; midodrine; naloxone; nifedipine; nimodipine; noradrenalin; oxygen; phenylephrine; placebo; prostaglandin E2; tirilazad; warfarin; artificial ventilation; atelectasis; autonomic dysreflexia; B scan; bradycardia; cardiovascular disease; cervical spinal cord injury; deep vein thrombosis; dose response; drug dose comparison; drug effect; drug efficacy; drug fatality; drug megadose; fluid resuscitation; heart arrest; heart arrhythmia; human; hypotension; incidence; induced hypothermia; intensive care unit; intermittent pneumatic compression device; low drug dose; lung embolism; lung ventilation perfusion ratio; neuroprotection; nonhuman; orthostatic hypotension; pathophysiology; phlebography; pneumonia; prevalence; priority journal; respiratory failure; respiratory tract intubation; review; spinal cord injury; spiral computer assisted tomography; therapy effect; tracheostomy; vein thrombosis; venous thromboembolism; ventilator associated pneumonia

An algorithm for the management of posttraumatic cervical spondyloptosis - Dahdaleh N.S.; Dlouhy B.J.; Greenlee J.D.W.; Smoker W.R.K.; Hitchon P.W. (Journal of Clinical Neuroscience, 2013)
Posttraumatic cervical spondyloptosis is the most severe form of fracture dislocation. Since its occurrence is uncommon, there is no consensus on its surgical management. Detailed description of five patients who were successfully managed through one approach (posterior or anterior) is presented, a review of the current literature is reported, and biomechanics is provided. An algorithm for the treatment of cervical spondyloptosis is then proposed. © 2013 Elsevier Ltd. All rights reserved.
Keywords: adult; anterior spine fusion; article; biomechanics; cervical spinal cord injury; cervical spine dislocation; cervical spine radiography; clinical article; computer assisted tomography; disease association; dyspnea; motor evoked potential; somatosensory evoked potential; female; human; intraoperative period; magnetic resonance angiography; male; neck pain; neurologic examination; percutaneous endoscopic gastrostomy; posterior spine fusion; postoperative period; posttraumatic cervical spondyloptosis; preoperative period; priority journal; shoulder dislocation; spinal cord compression; spine stabilization; surgical approach; tracheostomy; traffic accident

Using a reconstruction locking compression plate as external fixator in infected open clavicle fracture - Sirisreetreerux N.; Sa-ngasoongsong P.; Chanplakorn P.; Kulachote N.; Laohajaroensombat S.; Suphachatwong C.; Phiphobmongko V.; Wajanavisit W. (Orthopedic Reviews, 2013)
Open clavicle fracture is an uncommon injury mostly caused by severe direct trauma. It is often associated with multiple organ injuries. Generally, surgical intervention with debridement and fracture repair is always indicated in order to prevent infection, non-union, and malalignment. In situations of bony exposure and significant contamination concomitant with severe soft tissue damage, the external fixation is the treatment of choice because of the possibility it offers of providing stable fixation with minimal local tissue damage resulting in excellent union rates and better soft tissue outcome. Nevertheless, traditional external fixation encountered some potential problems as its bulkiness and sharp edges caused discomfort to the patient. In this study, we present an interesting case of a polytraumatized patient with a gunshot injury with complex open clavicle fracture that was successfully treated with external fixation using reconstruction with a locking compression plate as definitive treatment. © N. Sirisreetreerax et al., 2013.
Keywords: povidone iodine; Acinetobacter baumannii; adult; article; bone infection; case report; clavicle fracture; compression plate; debridement; fracture external fixation; fracture healing; gunshot injury; human; internal fixator; male; range of motion; reconstruction locking compression plate; respiratory distress; soft tissue inflammation; spinal cord injury; tracheostomy; X ray; betadine

Video laryngoscopy added fiberoptic intubation in a patient with difficult airway - Gupta N.; Pandia M.P.; Prabhakar H.; Chauhan M. (Journal of Anaesthesiology Clinical Pharmacology, 2013)
Keywords: fentanyl; propofol; rocuronium; artificial ventilation; atlantoaxial dislocation; bone plate; bone screw; bone transplantation; case report; cervical spine; child; compression fracture; endotracheal intubation; endotracheal tube; epiglottis; fiberoscope; human; intensive care unit; intramedullary nailing; kyphosis; laryngoscopy; letter; lung auscultation; male; nuclear magnetic resonance imaging; oxygen saturation; positive end expiratory pressure; preoperative evaluation; school child; spinal cord compression; spine fracture; spine radiography; spine stabilization; tracheostomy; tracheostomy tube; video laryngoscopy; wound healing

Transoral endoscopic odontoidectomy to decompress the cervicomedullary junction - Zhang Q.; Kong F.; Yan B.; Guo H.; Li M.; Chen G.; Ling F. (Spine, 2013)
Study Design. Clinical study. Objective. To investigate the feasibility of the transoral endoscopic odontoidectomy without occipitocervical fusion. Summary of Background Data. Endoscopic transnasal resection of the odontoid process is less invasive than the conventional transoral odontoidectomy. However, the endonasal approach has a much longer working distance compared with the transoral approach to the craniovertebral junction and usually the endonasal approach needs a previous occipitocervical posterior fusion. Methods. From July 2007 to June 2010, 5 patients (3 males and 2 females, age range, 25-41 yr) with irreducible cervicomedullary junction compression were subjected to endoscopic transoral odontoidectomy without occipitocervical posterior fi xation and bone fusion. Results. A purely endoscopic transoral odontoidectomy for decompression of the cervicomedullary junction without the occipitocervical fusion was achieved successfully in 5 patients. None of the patients underwent tracheotomy and postoperative gastrostomy tube placement. The patients were started on liquids on the third postoperative day and advanced to a regular diet on the fourth postoperative day. There was no postoperative velopharyngeal insuffi ciency, cerebrospinal fluid leakage, regional infection, or meningitis. The patients were discharged in 10 to 12 days after the surgery. There were no evidence of instability at the craniovertebral junction at 12 to 47 months of follow-up and remarkable improvement in neurological function was observed in each patient. Conclusion. The endoscopic transoral approach may be a more direct route to C1 and the odontoid than the endoscopic endonasal approach. This approach allows complete resection odontoid to decompress the cervicomedullary junction without increasing the risk of complications such as wound infection, meningitis, and velopharyngeal insuffi ciency. Usually, the occipitocervical posterior fusion and tracheotomy is less necessary in this approach. Copyright © 2013 Lippincott Williams & Wilkins.
Keywords: adult; article; Babinski reflex; cervicomedullary junction; clinical article; computer assisted tomography; diet; endoscopic surgery; feasibility study; female; fluid intake; follow up; functional status; general condition improvement; Hoffmann reflex; human; male; neck pain; nuclear magnetic resonance imaging; priority journal; spinal cord; spinal cord compression; spinal cord decompression; surgical patient; syringomyelia; transoral endoscopic odontoidectomy; treatment outcome

Severe spinal cord injury in craniocervical dislocation. Case-based update - Martínez-Lage J.F.; Alarcón F.; Alfaro R.; Gilabert A.; Reyes S.B.; Almagro M.-J.; López-Guerrero A.L. (Child's Nervous System, 2013)
Background: Craniocervical distraction injuries, including atlanto-axial dislocation (AAD) and atlanto-ocipital dislocation (AOD), are often associated with severe spinal cord involvement with high morbidity and mortality rates. Many patients with these injuries die at the accident scene, but advances in emergency resuscitation and transport permit that many patients arrive alive to hospitals. Discussion: Children with craniocervical distraction injuries usually present with a severe cranioencephalic traumatism that is the most relevant lesion at admission. After resuscitation and hemodynamic stabilization, the spinal cord damage appears as the main lesion. Apnea and quadriparesis, or quadriplegia, are usually present at the onset. Early diagnosis and management perhaps decrease life-threatening manifestations of the spinal lesion. But even so, the primary spinal cord insult is often irreversible and precludes obtaining a satisfactory functional outcome. Patients and methods: We report the findings of four children with craniocervical distraction injuries (AOD and AAD) who presented with severe spinal cord damage. All patients were admitted with respiratory distress or apnea together with significant brain injuries. The medical records pertaining to these patients are summarized in regard to clinical features, management, and outcome. Conclusions: In spite of timely and aggressive management, craniocervical injuries with spinal cord involvement continue to have a dismal prognosis. Outcome is closely related to the severity of the initial brain and spinal cord damage and is nearly always fatal in cases of complete spinal cord transection. Priority should be given to life-threatening complications. Ethic issues on indications for surgery deserve a detailed discussion with the children's parents. © 2012 Springer-Verlag.
Keywords: acute kidney failure; adolescent; anemia; apnea; article; atlantoaxial dislocation; atlantoocipital dislocation; blood transfusion; brain contusion; brain edema; brain injury; case report; cerebellum infarction; cervical collar; cervical spine dislocation; child; childhood injury; coma; computer assisted tomography; congenital disorder; disease severity; ego development; endotracheal intubation; somatosensory evoked potential; face edema; female; follow up; fracture external fixation; fracture immobilization; Glasgow coma scale; hemodynamics; hospital admission; human; hypercapnia; hypoxemia; infant; intensive care unit; intracranial pressure monitoring; male; mandible fracture; metabolic acidosis; mortality; neuroimaging; nuclear magnetic resonance imaging; osteosynthesis; oxygen desaturation; pneumonia; preschool child; priority journal; prognosis; quadriplegia; respiratory distress; resuscitation; school child; septic shock; skull base; spinal cord injury; spinal cord lesion; spinal cord transsection; spine fusion; spine injury; subarachnoid hemorrhage; survival; tracheostomy; traffic accident; traumatic brain injury

The experience of parents regarding ventilatory support with tracheotomy decision-making for their child with type 1 spinal muscular atrophy - Rul B.; Carnevale F.; Estournet B.; Quijano-Roy S.; Desguerre I.; Hervé C. (Intensive Care Medicine, 2013)
Background: Type 1 Spinal Muscular Atrophy (SMA) (subdivided in France as Type 1 true or bis), is a neuromuscular disorder that progressively paralyzes the child, compromising the child's prognosis as respiratory muscles are affected. The tracheotomy may help prevent death, but entails ethical questions given the severity of the motor disability that will follow. Regardless of whether or not health care professionals (HCP) agree with performing a tracheostomy for this population, they cannot make this decision alone-parents must be included in the decisional process. Considering that HCP teams in France are tending to favor tracheostomy for Type 1 bis SMA, a study was conducted with parents of these children who had been tracheotomised, to better understand how they experienced this decision. Method: Interpretive phenomenological interviews of 13 parents of 7 tracheostomized children with SMA Type 1 bis, recruited from two children's hospitals in France. Results: Initially, parents do not want their children to be tracheostomized. They gradually come to accept the proposed tracheostomy because of a profound feeling of powerlessness regarding the illness and their trust toward the HCP. This decision marked an important turning point, which varied across parents in terms of the difficulties they had to overcome. Conclusion: The pediatric neurologist, the child's referring physician, is the principal interlocutor for such a tracheotomy decision. This decision relies on the treatment discussions that the physician has with the parents.
Keywords: tracheotomy; decision making; child; human; spinal muscular atrophy; society; newborn intensive care; parent; tracheostomy; France; physician; prognosis; powerlessness; neuromuscular disease; population; health care personnel; motor dysfunction; breathing muscle; interview; diseases; neurologist; death; pediatric hospital

An autopsied case of adult-type Alexander disease with S393R mutation in the GFAP gene - Iwasaki Y.; Mori K.; Ito M.; Saito Y.; Tatsumi S.; Mimuro M.; Mizuta I.; Yoshida T.; Nakagawa M.; Yoshida M. (Neuropathology, 2013)
A 50-year-old Japanese man with no remarkable family history noticed diplopia. Gait disturbance, muscle weakness and dysuria gradually progressed. Neurological examination 6 years post onset revealed eye movement disorders with nystagmus, sensory disturbance and orthostatic hypotension. Tongue atrophy with fasciculation was observed. Deep tendon reflex was brisk with positive Babinski sign. MRI showed severe atrophy of the medulla oblongata to cervical cord (tadpole appearance). He progressed to tetraplegia, and tracheostomy and gastrostomy were performed after dysphagia developed. Stable state continued for several years, and he died due to respiratory failure 11 years after onset. The brain weighed 1380 g. Numerous Rosenthal fibers were observed in the medulla oblongata to spinal cord. Myelin loss with relatively preserved axons was extensively observed from the middle of the pons to the spinal cord. A few Rosenthal fibers were also observed in the cerebral white matter, basal ganglia and cerebellum, particularly in the ventricular subependyma. Clinicopathological diagnosis was adult-onset bulbospinal-type Alexander disease. GFAP gene analysis revealed a novel mutation of S393R.
Keywords: myelin; Alexander disease; mutation; gene; Japanese (people); society; neuropathology; adult; spinal cord; fiber; medulla oblongata; atrophy; dysuria; gait; muscle weakness; male; fasciculation; cervical spinal cord; diplopia; orthostatic hypotension; tongue; pons; white matter; tendon reflex; Babinski reflex; human; tadpole; nystagmus; eye movement disorder; respiratory failure; dysphagia; neurologic examination; brain; gastrostomy; tracheostomy; nerve fiber; quadriplegia; basal ganglion; cerebellum; subventricular zone; diagnosis; family history; nuclear magnetic resonance imaging

Eighteen years with spinal muscular atrophy (SMA) type 1 - Valencia B.; Bach J.R. (Tanaffos, 2013)
Keywords: adult; article; assisted ventilation; bi level positive airway pressure; case report; extubation; female; human; mechanically assisted coughing; medical history; respiratory care; tracheotomy; upper respiratory tract infection; vital capacity; Werdnig Hoffmann disease

Pulmonary issues in patients with chronic neuromuscular disease - Benditt J.O.; Boitano L.J. (American Journal of Respiratory and Critical Care Medicine, 2013)
Patients with chronic neuromuscular diseases such as spinal cord injury, amyotrophic lateral sclerosis, and muscular dystrophies experience respiratory complications that are cared for by the respiratory practitioner. An organized anatomical approach for evaluation and treatment is helpful to provide appropriate clinical care. Effective noninvasive strategies for management of hypoventilation, sleep-disordered breathing, and cough insufficiency are available for these patients. Copyright © 2013 by the American Thoracic Society.
Keywords: dystrophin; glycoprotein; amyotrophic lateral sclerosis; atelectasis; autonomic dysfunction; breathing muscle; central nervous system disease; chronic disease; coughing; dermatomyositis; diaphragm paralysis; disease association; human; hypoventilation; interstitial lung disease; lung alveolus hypoventilation; motoneuron; multiple sclerosis; muscle weakness; muscular dystrophy; myasthenia gravis; myopathy; myositis; myotonic dystrophy; neuromuscular disease; noninvasive ventilation; pneumonia; poliomyelitis; priority journal; respiratory failure; respiratory tract disease; review; sleep disordered breathing; spinal cord disease; spinal cord injury; syringomyelia; thorax radiography; tracheostomy; upper respiratory tract obstruction

Conservative management of esophageal perforation after a fall - Delos Reyes A.P.; Clancy C.; Lach J.; Olorunto W.A.; Williams M. (International Journal of Surgery Case Reports, 2013)
INTRODUCTION: Esophageal perforation in the setting of blunt trauma is rare, and diagnosis can be difficult due to atypical signs and symptoms accompanied by distracting injury. PRESENTATION OF CASE: We present a case of esophageal perforation resulting from a fall from height. Unexplained air in the soft tissues planes posterior to the esophagus as well as subcutaneous emphysema in the absence of a pneumothorax on CT aroused clinical suspicions of an injury to the aerodigestive tract. The patient suffered multiple injuries including bilateral first rib fractures, C6 lamina fractures, C4-C6 spinous process fractures, a C7 right transverse process fracture with associated ligamentous injury and cord contusion, multiple comminuted nasal bone fractures, and a right verterbral artery dissection. Esophageal injury was localized using a gastrograffin esophagram to the cervical esophagus and was most likely secondary to cervical spine fractures. Because there were no clinical signs of sepsis and the esophagram demonstrated a contained rupture, the patient was thought to be a good candidate for a trial of conservative management consisting of broad spectrum intravenous antibiotics, oral care with chlorhexadine gluconate, NPO, and total parenteral nutrition. No cervical spine fixation or procedure was performed during this trial of conservative management. The patient was received another gastrograffin esophagram on hospital day 14 and demonstrated no evidence of contrast extravasation. DISCUSSION: Early diagnosis and control of the infectious source are the cornerstones to successful management of esophageal perforation from all etiologies. Traditionally, esophageal perforation relied on a high index of clinical suspicion for early diagnosis, but the use of CT scan for has proved to be highly effective in diagnosing esophageal perforation especially in patients with atypical presentations. While aggressive surgical infection control is paramount in the majority of esophageal perforations, a select subset of patients can be successfully managed non-operatively. CONCLUSION: In the setting of blunt trauma, esophageal perforation is rare and is associated with a high morbidity. In select patients who do not show any clinical signs of sepsis, contained perforations can heal with non-operative management consisting of broad spectrum antibiotics, strict oral hygiene, NPO, and total parenteral nutrition. © 2013 Surgical Associates Ltd.
Keywords: chlorhexidine gluconate; adult; antibiotic therapy; artery dissection; article; bradycardia; breathing rate; case report; cervical spine fracture; comminuted fracture; computed tomographic angiography; computer assisted tomography; conservative treatment; contrast medium extravasation; contusion; early diagnosis; electrocardiography; esophagus injury; esophagus perforation; falling; female; hand grip; heart palpitation; heart rate; human; intensive care; motor dysfunction; mouth hygiene; multiple trauma; nose fracture; nose septum; nuclear magnetic resonance imaging; priority journal; respiratory failure; resuscitation; rib fracture; sepsis; sinus bradycardia; spine stabilization; subcutaneous emphysema; thorax radiography; total parenteral nutrition; tracheostomy

Dysphagia in acute tetraplegia: Diagnosis, incidence, and associated factors - Shem K.; Castillo K.; Wong S.L.; Chang J. (Topics in Spinal Cord Injury Rehabilitation, 2013)
Objective: Identify the incidence and risk factors for dysphagia after spinal cord injury (SCI) and determine the accuracy of bedside swallow evaluation (BSE) as a diagnostic tool. Design: Prospective study. Participants/Methods: Individuals with SCI admitted to an SCI unit underwent a BSE as soon as they were able to participate in BSE, followed by a videofluoroscopy swallow study (VFSS) within 72 hours of the BSE. Subjects were categorized as having dysphagia if they had positive findings in either BSE or VFSS. Results: Seventy-six patients (13 female and 63 male) were enrolled. The average age of the subjects was 41.9 years (SD =17.5). Fifty-six (74%) had high cervical tetraplegia (C4 or higher). Dysphagia was present in 23 subjects (30.3%). The associations between dysphagia and the presence of tracheostomy ( = .014), ventilator use (P = .040), pneumonia (P = .001), and nasogastric tube (P = .012) proved to be statistically significant. Although not statistically significant, a trend was noted between dysphagia and age (P = .056). Positive findings on BSE were different from the findings on VFSS only in 3 cases. Sensitivity of BSE was 100% and specificity of BSE was 84% when VFSS was considered as gold standard for diagnosing dysphagia. Excluding those subjects who still had dysphagia on discharge, average days from initial diagnosis of dysphagia based on BSE to the resolution of dysphagia was 14.1 days (SD = 9.5 days). Conclusion: Nasogastric tube, tracheostomy, and ventilator use are significant risk factors for dysphagia after SCI. When present, dysphagia resolved within 15 days of diagnosis of dysphagia.
Keywords: quadriplegia; dysphagia; spine injury; diagnosis; human; nasogastric tube; ventilator; tracheostomy; risk factor; swallow (bird); spinal cord injury; patient; male; female; pneumonia; gold standard; prospective study

Laryngeal dislocation after ventral fusion of the cervical spine - Krauel J.; Winkler D.; Münscher A.; Tank S. (Indian Journal of Anaesthesia, 2013)
We report on a 70-year-old patient who underwent ventral fusion of the cervical spine (C3/4 and C4/5) for spinal canal stenosis performed by the neurosurgery department. The patient suffered an exceedingly rare complication of the surgery - laryngeal dislocation. Had the deformed laryngeal structures been overlooked and the patient extubated as usual after surgery, reintubation would have been impossible due to the associated swelling, which might have had disastrous consequences. Leftward dislocation of the larynx became apparent post-operatively, but prior to extubation. Extubation was therefore postponed and a subsequent computed tomography (CT) scan revealed entrapment of laryngeal structures within the osteosynthesis. A trial of repositioning using microlaryngoscopy performed by otolaryngology (ears, nose and throat) specialists failed, making open surgical revision necessary. At surgery, the entrapped laryngeal tissue was successfully mobilised. Laryngeal oedema developed despite prompt repositioning; thus, necessitating tracheotomy and long-term ventilation. Laryngeal dislocation may be an unusual cause of post-operative neck swelling after anterior cervical spine surgery and should be considered in the differential diagnosis if surgical site haematoma and other causes have been ruled out. Imaging studies including CT of the neck may be needed before extubation to confirm the suspicion and should be promptly obtained to facilitate specific treatment.
Keywords: contrast medium; dexamethasone; aged; article; case report; cervical spine; computer assisted tomography; consciousness level; edema; extubation; human; hyoid bone; discectomy; intubation; laryngoscopy; larynx disorder; male; microlaryngoscopy; osteosynthesis; pleura effusion; postoperative complication; respiratory failure; sepsis; spine fusion; spine stabilization; swelling; tracheotomy; ventilator associated pneumonia; vertebral canal stenosis

Analysis of the risk factors for early death in acute severe traumatic cervical spinal cord injury - Leng Y.-X.; Nie C.-Y.; Yao Z.-Y.; Zhu X. (Chinese Critical Care Medicine, 2013)
Objective: To survey the risk factors for early death of patients with acute severe traumatic cervical spinal cord injury. Methods: A retrospective analysis of data of consecutive patients with acute severe traumatic cervical spinal cord injury admitted from January 1st 1994 to October 1st 2012 were made. The patients died within 30 days or not were allocated for death group or survival group. The risk factors for early death were analyzed through univariate analysis and logistic analysis. Results: Among 1093 patients with acute traumatic cervical spinal cord injury, 352 patients with severe injury were included, and the early death rate was 14.49% (51/352). The leading causes of spinal cord injury were vehicle accidents (153 cases) and falls (117 cases). The main causes of early death were respiratory failure (16 cases), multiple organ failure (MOF, 14 cases) and gastrointestinal bleeding (11 cases). Combining the results of univariate and logistic analysis, it was found that high acute physiology and chronic health evaluation II (APACHE II) score [>15, odds ratio (OR) = 11.595, P=0.000], high damage level (OR=3.519, P=0.032), hyponatremia (OR=6.316, P=0.000), neurogenic shock (OR=6.209, P=0.000), pulmonary infection (OR=14.627, P=0.000) and tracheostomy (OR=8.983, P=0.000) were risk factors for early death of patients with acute severe traumatic cervical spinal cord injury, however, the impact of gender, age, surgery, fracture and dislocation, high central fever, and administration of steroids on early death of patients with acute severe traumatic cervical spinal cord injury were uncertain. Conclusion: The factors reflecting disease severity and occurrence of related complications were more important in predicting the early death among patients with acute severe traumatic cervical spinal cord injury, while the influence of age, surgical manipulation etc. were minor factors.
Keywords: steroid; APACHE; article; cause of death; cervical spinal cord injury; controlled study; dislocation; falling; fever; fracture; gastrointestinal hemorrhage; health survey; human; hyponatremia; injury severity; lung infection; major clinical study; mortality; multiple organ failure; neurogenic shock; respiratory failure; risk assessment; risk factor; shock; survival; tracheostomy; traffic accident; traumatic brain injury

Survival of patients with spinal muscular atrophy type 1 - Gregoretti C.; Ottonello G.; Testa M.B.C.; Mastella C.; Ravà L.; Bignamini E.; Veljkovic A.; Cutrera R. (Pediatrics, 2013)
BACKGROUND: Spinal muscular atrophy type 1 (SMA1) is a progressive disease and is usually fatal in the first year of life. METHODS: A retrospective chart review was performed of SMA1 patients and their outcomes according to the following choices: letting nature take its course (NT); tracheostomy and invasive mechanical ventilation (TV); continuous noninvasive respiratory muscle aid (NRA), including noninvasive ventilation; and mechanically assisted cough. RESULTS: Of 194 consecutively referred patients enrolled in this study (103 males, 91 females), NT, TV, and NRA were chosen for 121 (62.3%), 42 (21.7%), and 31 (16%) patients, respectively. Survival at ages 24 and 48 months was higher in TV than NRA users: 95% (95% confidence interval: 81.8%-98.8%) and 67.7% (95% confidence interval: 46.7%-82%) at age 24 months (P < .001) and 89.43% and 45% at age 48 months in the TV and NRA groups, respectively (P < .001). The choice of TV decreased from 50% (1992-1998) to 12.7% (2005-2010) (P < .005) with a nonstatistically significant increase for NT from 50% to 65%. The choice of NRA increased from 8.1% (1999-2004) to 22.7% (2005-2010) (P < .001). CONCLUSIONS: Long-term survival outcome is determined by the choice of the treatment. NRA and TV can prolong survival, with NRA showing a lower survival probability at ages 24 and 48 months. Copyright © 2013 by the American Academy of Pediatrics.
Keywords: age distribution; article; artificial ventilation; child; female; human; major clinical study; male; noninvasive respiratory muscle aid; noninvasive ventilation; preschool child; priority journal; prognosis; respiratory failure; retrospective study; spinal muscular atrophy; Werdnig Hoffmann disease; survival; survival rate; tracheostomy; treatment outcome

Spinal subdural hematoma in the setting of atlanto-occipital dislocation: The case for early aggressive management - Tymchak Z.; Kelly M.; Woo A.; Meguro K. (Canadian Journal of Neurological Sciences, 2013)
Background: Traumatic spinal subdural hematomas (SSDH) are rare. Few cases have been reported in the setting of atlanto-occipital dislocation. Methods: We present the case of a 31-year-old gentleman who sustained polytrauma from a motor vehicle accident. He presented with partial loss of brainstem reflexes and hemodynamic instability, yet was able to follow simple commands. Imaging revealed atlanto-occipital subluxation and SSDH extending from the foramen magnum to C4/5. There was little to no supratentorial pathology. The patient was treated with an occiput-C4 decompression and fusion and evacuation of the SSDH. Results: The patient underwent an extended stay in hospital but was eventually weaned from his tracheostomy and has since been transferred to our rehabilitation centre. He was able to communicate verbally and displayed good cognitive capacity. Conclusions: Patients suffering traumatic atlanto-occipital injuries with or without SSDH often die prior to reaching medical care. Our experience suggests that survivors should be managed aggressively regardless of their clinical presentation. This is particularly true in those patients with injuries confined to the cervico-medullary region as they may have better functional outcomes given the relative sparing of the higher cortical centres.
Keywords: spinal hematoma; human; patient; injury; brain stem; subluxation; traffic accident; medical care; foramen magnum; pathology; hospital; decompression; imaging; tracheostomy; rehabilitation; reflex; survivor; multiple trauma

Rehabilitation of cervical spinal cord injury resulting from tissue plasminogen activator treatment for acute ischemic stroke - Vuong N.L.N.; Oleson C.V.; Ditunno J.F. (Topics in Spinal Cord Injury Rehabilitation, 2013)
Objective: To illustrate rehabilitation challenges in autonomic and sensorimotor function specific to patients with dual diagnoses of acute stroke and cervical spinal cord injury (SCI). Design: Case report and review of the literature. Participants/Methods: A 77-yearold man developed C5 complete tetraplegia secondary to epidural hematoma following tissue plasminogen activator (tPA) administration. The latter had been given for acute ischemic stroke. After a prolonged ICU course, including C5-T8 spinal decompression surgery and ventilator-dependent respiratory failure, our patient was transferred to acute inpatient rehabilitation. Autonomic instability from combined cranial and spinal pathologies complicated his rehabilitation course. Results: Extracranial hemorrhage from tPA treatment of ischemic stroke occurs in 2%-13% of patients. Literature review reveals only 2 cases resulting in paraplegia. This is the first reported case involving tetraplegia. A patient with both cervical SCI and stroke presents unique challenges related to blood pressure and pulmonary management. In our patient's case, the possibility of autonomic dysreflexia required tighter blood pressure control and prevention of precipitating events from bladder/bowel origins to differentiate causes of hypertension. Pulmonary management was challenged by motor weakness, dysphagia from bulbar dysfunction, and copious secretions from parasympathetic (vagal) predominance. With tracheostomy placement, insufflator-exsufflator use, and the interdisciplinary care of physiatry, respiratory therapy, speech, occupational and physical therapy, the patient achieved a safe discharge home. Conclusion: The combination of acute stroke and cervical SCI is a rare event for which an interdisciplinary team approach is essential to successful rehabilitation.
Keywords: tissue plasminogen activator; rehabilitation; cervical spinal cord injury; brain ischemia; spine injury; human; patient; cerebrovascular accident; quadriplegia; ventilator; decompression surgery; spinal cord decompression; hypertension; dysphagia; bodily secretions; physical medicine; artificial ventilation; prevention; epidural hematoma; blood pressure regulation; autonomic dysreflexia; blood pressure; case report; paraplegia; bleeding; pathology; diagnosis; respiratory failure; weakness; bulbar paralysis; speech; tracheostomy; male; sensorimotor function; physiotherapy; hospital patient

First case of severe enterovirus 71 infection in Portugal - Venâncio P.; Oliveira M.; Silva R.; Conceição C.; Brito M.J. (Pediatric Infectious Disease Journal, 2013)
Keywords: aciclovir; C reactive protein; ceftriaxone; ciprofloxacin; glucose; immunoglobulin; immunoglobulin G; methylprednisolone; nitric oxide; brain atrophy; case report; central nervous system infection; cervical spinal cord injury; child; coma; disease severity; drug pulse therapy; encephalitis; Enterovirus A71; enterovirus 71 infection; Enterovirus infection; flaccid paralysis; glucose blood level; hand foot and mouth disease; heart arrest; high frequency ventilation; human; hypotension; immunoelectrophoresis; letter; leukocyte count; lung edema; male; newborn intensive care; nuclear magnetic resonance imaging; Portugal; preschool child; priority journal; reverse transcription polymerase chain reaction; spastic paresis; tracheostomy

Current and emerging management options for patients with Morquio A syndrome - Algahim M.F.; Almassi G.H. (Therapeutics and Clinical Risk Management, 2013)
Morquio A syndrome is a lysosomal storage disease associated with mucopolysaccharidosis. It is caused by a deficiency of the lysosomal enzyme, N-acetylgalactosamine--6-sulfate sulfatase, which leads to accumulation of keratan sulfate and condroitin-6 sulfate in multiple organs. Patients present with multisystemic complications involving the musculoskeletal, respiratory, cardiovascular, and digestive systems. Presently, there is no definitive cure, and current management options are palliative. Enzyme replacement therapy and hematopoietic stem cell therapy have been proven effective in certain lysosomal storage diseases, and current investigations are underway to evaluate the effectiveness of these therapies and others for the treatment of Morquio A syndrome. This review discusses the current and emerging treatment options for Morquio A syndrome, citing examples of the treatment of other mucopolysaccharidoses. © 2013 Algahim and Almassi, publisher and licensee Dove Medical Press Ltd.
Keywords: NCT01242111; NCT01275066; NCT01415427; NCT01515956; NCT01609062; NCT01697139; antibiotic agent; chondroitin 6 sulfate; elosulfase alfa; iduronate 2 sulfatase; keratan sulfate; levo iduronidase; lysosome enzyme; n acetylgalactosamine 6 sulfatase; placebo; adenoidectomy; airway obstruction; aortic valve disease; aortic valve replacement; atlantoaxial subluxation; bioaccumulation; cervical myelopathy; conduction deafness; cornea disease; drug efficacy; drug safety; drug tolerability; dwarfism; endotracheal intubation; enzyme deficiency; enzyme replacement; gene therapy; hematopoietic stem cell transplantation; hemiplegia; human; Hunter syndrome; Hurler syndrome; kyphoscoliosis; ligament disease; Maroteaux Lamy syndrome; mitral valve disease; Morquio a syndrome; Morquio syndrome; muscle weakness; neurogenic bladder; neurogenic bowel; neurologic disease; nonhuman; otitis media; perception deafness; photophobia; pigeon thorax; quadriplegia; respiratory tract infection; review; sleep disordered breathing; spinal cord compression; stunting; tonsillectomy; tracheostomy; tympanostomy tube; valgus knee; weakness; bmn 110

[Diaphragm pacemaker: alternative for chronic ventilatory support]. - Hazenberg A.; Hofker S.S.; van der Aa J.G.; Nieuwenhuis J.A.; Kerstjens H.A.; Wijkstra P.J. (Nederlands tijdschrift voor geneeskunde, 2013)
Currently, more than 2200 patients in the Netherlands receive chronic ventilatory support. In the majority of patients this leads to increased survival without any complications. Nevertheless, in case of ventilatory support via a mask, problems such as skin irritation, leakage and claustrophobia can occur. In case of tracheostomy, it can lead to increased pulmonary secretion. Diaphragm pacing with an external pacemaker might be an attractive alternative to prevent these symptoms as it can replace ventilatory support by mask or tracheostomy. Current indications are patients with spinal cord injury or with congenital central hypoventilation syndrome who are chronically respiratory insufficient. In our experience, patients can be completely or partially weaned from mechanical ventilation when using the diaphragm pacer. In the Netherlands, the technique is only performed at the University Medical Center Groningen.
Keywords: article; artificial heart pacemaker; artificial ventilation; diaphragm; human; innervation; pathophysiology; respiratory failure; treatment outcome

Timing of tracheostomy after anterior cervical spine fixation - Babu R.; Owens T.R.; Thomas S.; Karikari I.O.; Grunch B.H.; Moreno J.R.; Lad S.P.; Bagley C.A. (Journal of Trauma and Acute Care Surgery, 2013)
BACKGROUND: Patients with cervical spinal cord injury frequently undergo early anterior cervical spine fixation (ACSF) and tracheostomy procedures to reduce further deterioration, to reduce risk of pulmonary complications, and to improve patient mobilization. However, tracheostomy is often delayed because of the risk of cross contamination as a result of the proximity to the ACSF incision site. Currently, there is a paucity of studies evaluating this outcome to determine the safety of early tracheostomy after ACSF. In this study, we have evaluated the outcomes and complications associated with early tracheostomy placement. METHODS: We performed a retrospective review of all patients who underwent tracheostomy placement and ACSF during the same hospitalization between 2005 and 2010. A variety of patient and procedural data were collected, including demographics, timing of ACSF and tracheostomy, length of hospitalization, indication for surgery, American Spinal Injuries Association and Glasgow Coma Scale scores on admission, reason for tracheostomy, method of tracheostomy, and complications. RESULTS: Of the 1,184 patients who underwent an ACSF, 20 (1.7%) required a postfixation tracheostomy. Tracheostomy was performed at mean (SD) of 6.9 (4.2) days after ACSF, ranging from 0 to 17 days. Although nearly half of all patients underwent postfixation tracheostomy within 6 days, no wound or implant infection was seen to occur in any patient. Ten patients (50%) developed ventilator-associated pneumonia, with most cases occurring before tracheostomy (90% vs. 10%, p < 0.0001). Univariate analysis only revealed late tracheostomy to significantly increase the risk of complications (odds ratio, 9.33; 95% confidence interval, 1.19-73.0; p = 0.033). Analysis of all studies in the literature revealed a 1% cross-infection rate, with no cases involving implant contamination. CONCLUSION: Our findings suggest that early tracheostomy can be performed safely after cervical spine fixation surgery, with no patients developing incisional or implant infections. As the risk of cross contamination is only 1%, early tracheostomy should be strongly considered because of its potential benefits. LEVEL OF EVIDENCE: Therapeutic/care management, level IV. Copyright © 2013 Lippincott Williams &Wilkins.
Keywords: adult; aged; anterior cervical spine fixation; article; cardiopulmonary arrest; female; Glasgow coma scale; hematoma; human; injury scale; length of stay; major clinical study; male; outcome assessment; postoperative complication; priority journal; retrospective study; spine stabilization; tracheostomy; ventilator associated pneumonia

A rare case of a penetrating,life-threatening injury to the oropharynx - Crockett A.; Shah S.; Pickles J. (Journal of Laryngology and Otology, 2013)
Case report A six-year-old child presented to the accident and emergency department after he had been found in the street apnoeic and cyanosed with a broken pencil embedded in his mouth and a Glasgow Coma Score of 3. In the accident and emergency department, the child's Glasgow Coma Score fluctuated between 8 and 13. A penetrating injury of the soft palate was noted, and a provisional diagnosis of penetrating intracranial injury was made. Antibiotics were given and the child was intubated and ventilated. Computed tomography (CT) showed no evidence of brain or spinal cord injury. Examination under anaesthesia revealed a small penetrating wound in the nasopharynx with cerebrospinal fluid (CSF) leakage. The child was transferred, intubated, to Great Ormond Street Hospital. Attempted extubation after 72 hours failed because of a poor gag reflex and aspiration. Magnetic resonance imaging (MRI) and magnetic resonance angiography showed an ill-defined lesion in the right side of the medulla and upper spinal cord. Antibiotics were continued. After 9 days, a tracheostomy was fashioned. The child's level of consciousness subsequently improved, but there was evidence of a partial bulbar palsy together with left facial and upper and lower limb weakness. The CSF leak ceased spontaneously within 72 hours. Further management consisted of nasogastric tube feeding and rehabilitation, including swallowing therapy and physiotherapy. After six months, there was still a mild left-sided limb weakness. Conclusion This unusual penetrating injury of the brain stem was diagnosed on clinical grounds and correct management instituted despite a normal CT scan. Suspicions were subsequently confirmed by MRI scanning, together with the development of focal neurological signs which became apparent following extubation.
Keywords: antibiotic agent; oropharynx; injury; human; child; penetrating trauma; computer assisted tomography; accident; coma; extubation; emergency ward; limb weakness; nuclear magnetic resonance imaging; liquorrhea; aspiration; therapy; reflex; nose feeding; hospital; nasopharynx; rehabilitation; physiotherapy; brain stem; cerebrospinal fluid; diagnosis; soft palate; anesthesia; bulbar paralysis; examination; consciousness; tracheostomy; spinal cord injury; spinal cord; leg; magnetic resonance angiography; swallowing; brain; neurologic disease; case report

Perioperative antibiotic use for spinal surgery procedures in US children's hospitals - Mcleod L.M.; Keren R.; Gerber J.; French B.; Song L.; Sampson N.R.; Flynn J.; Dormans J.P. (Spine, 2013)
STUDY DESIGN.: Retrospective cohort study using the Pediatric Health Information System database. OBJECTIVE.: To describe longitudinal patterns of prophylactic antibiotic use and determinants of antibiotic choice for spinal fusion surgical procedures performed at US children's hospitals. SUMMARY OF BACKGROUND DATA.: Surgical site infections (SSIs) account for a significant proportion of post-spinal surgery complications, particularly among children with complex conditions such as neuromuscular disease. Antimicrobial prophylaxis with intravenous cefazolin or cefuroxime has been a standard practice, but postoperative infections caused by organisms resistant to these antibiotics are increasing in prevalence. Studies describing the choice of antibiotic prophylaxis for pediatric spinal surgery are lacking. METHODS.: We included children 6 months to 18 years of age discharged from 37 US children's hospitals between January 1, 2006, and June 30, 2009, with (1) an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code indicating a spinal fusion and (2) combinations of diagnosis codes indicating adolescent idiopathic scoliosis (AIS) (n = 5617) or neuromuscular scoliosis (NMS) (n = 3633). After identifying antibiotics ordered on the operative day, we described variation in broad-spectrum antibiotic use over time and measured associations between patient/surgery characteristics and antibiotic choice. RESULTS.: Prophylactic antibiotic choice varied across hospitals and over time. Broad-spectrum antibiotics were used in 37% of AIS and 52% of NMS operations. Seven (19%) hospitals used broad-spectrum coverage for more 80% of all cases. For NMS procedures, broad-spectrum antibiotic use was associated with patient characteristics known to be associated with high SSI risk. Use of vancomycin and broad gram-negative agents increased over time. CONCLUSION.: Broad-spectrum antimicrobial prophylaxis varied across hospitals and was often associated with known risk factors for SSI. These results highlight the need for future studies comparing the effectiveness of various prophylaxis strategies, particularly in high-risk subgroups. This research can inform the development of best practice for SSI prevention in spinal fusion procedures. © 2013, Lippincott Williams & Wilkins.
Keywords: aminoglycoside; cefazolin; cephalosporin derivative; clindamycin; vancomycin; adolescent; adolescent idiopathic scoliosis; adult; antibiotic prophylaxis; article; bladder dysfunction; cerebral palsy; child; cohort analysis; comorbidity; female; gastrostomy; Gram negative bacterium; Gram positive bacterium; human; infant; major clinical study; male; medical information system; neuromuscular scoliosis; pediatric surgery; perioperative period; preschool child; priority journal; retrospective study; risk factor; school child; scoliosis; spinal dysraphism; spine fusion; spine surgery; surgical infection; tracheostomy

Ultrasound scanning for percutaneous dilatational tracheostomy: A systematic review - Pugh R.; Slater A. (Critical Care, 2013)
Introduction Percutaneous dilatational tracheostomy (PDT) remains a frequently performed procedure in the ICU. However, there is great variability in the course of blood vessels in the pre-tracheal area. A 5% risk of clinically relevant bleeding was recently reported for patients undergoing PDT [1]. We conducted a systematic review of reports evaluating clinical outcomes following use of ultrasound scanning (US) for PDT. Methods Two investigators performed a search of the literature using the following databases: CENTRAL, Embase, MEDLINE and SCOPUS. The following eligibility criteria were used: population including adults >16 years managed in the ICU; use of ultrasound to guide decision-making pre-PDT or guide PDT performance; report of clinically relevant outcome measures. Nonrandomised controlled trials were classif ed according to Cochrane Non-Randomised Study Methods Group criteria [2] and evaluated for risk of bias. Results An initial search identif ed 2,043 reports, of which 10 studies met eligibility criteria: eight case series, one randomised controlled trial (RCT) and one prospective cohort study, incorporating 488 patients. Two studies specif cally reported data on patients with obesity (n = 29 patients) and one study reported data for a group of patients with spinal cord f xation (n = 6). US was used to guide decision to perform PDT or surgical tracheostomy in f ve studies, with decision to perform surgical tracheostomy ranging from 0 to 27% of cases. US was used to guide insertion point in seven studies, and used real-time in four studies. Times to perform US-guided PDT were reported in four studies (ranging from 8 to 12 minutes). No studies compared time taken with or without US. Data on complications of procedure were reported in nine studies. Minor bleeding was reported for eight cases (1.6% overall). Prolonged bleeding was reported in two cases (0.4%). There were no episodes of catastrophic bleeding among 488 cases. High risk of bias was identif ed in f ve studies in terms of patient selection. An intervention protocol was not defined in three reports. No attempt was made at blinding any aspect of the 10 studies. Conclusion Use of US guidance could theoretically help minimise risk of haemorrhagic complications during PDT and perhaps reduce time taken to perform PDT. However, there is currently inadequate evidence from controlled cohort studies or RCTs to suggest that routine use for PDT in selected or unselected groups improves clinically relevant outcome measure.
Keywords: tracheostomy; systematic review; intensive care; emergency medicine; echography; human; patient; risk; bleeding; cohort analysis; procedures; population; Embase; randomized controlled trial; data base; controlled study; blood vessel; decision making; blindness; ultrasound; patient selection; obesity; spinal cord; adult; case study

Cervical spine arterio venous malformation - Parla G.; Ameh V. (BMJ Case Reports, 2013)
We present an unusual case of a young patient who presented to our emergency department with a history of sudden onset of pain on the left side of the neck and numbness to the left arm after lifting a small weight. Patient continued to work as normal for approximately 30 min after the event and then attended the emergency department as numbness in the left arm was not resolving. On examination there was no sensorymotor deficit in the lower limbs but neurological deficits were found in the upper limbs which made us suspect a diagnosis of cervical spine injury/brachial plexus. The patient then rapidly developed numbness in both upper and lower limbs and eventually became aphasic and developed a rapid, shallow respiration and was unable to maintain the airway. The patient was then intubated and ventilated. The patient was then transferred to a neurosurgical centre after the relevant investigations was found to have an arteriovenous malformation of spinal cord.
Keywords: analgesic agent; article; brachial plexus injury; brain arteriovenous malformation; brain hemorrhage; case report; cervical spinal cord injury; cervical spine injury; clinical feature; conservative treatment; deterioration; differential diagnosis; follow up; human; intubation; mechanical ventilator; medical decision making; neck pain; nuclear magnetic resonance imaging; paresthesia; physical examination; priority journal; rehabilitation care; repeat procedure; resuscitation; sensory dysfunction; tracheostomy; treatment outcome; vascular access

Brachytelephalangic chondrodysplasia punctata with a new hemizygous missense mutation in a neonate - Meyer S.; Löffler G.; Gencik M.; Fries P.; Papanagiotou P.; Oehl-Jaschkowitz B.; Gortner L. (American Journal of Medical Genetics, Part A, 2013)
Keywords: ARSE gene; article; artificial ventilation; case report; chondrodysplasia punctata; diaphragm paralysis; echography; exon; flaccid paralysis; gene; gene identification; hemizygosity; hiccup; human; hydramnios; infant; lung hypoplasia; male; midface hypoplasia; missense mutation; mutational analysis; newborn; nose malformation; nuclear magnetic resonance imaging; pneumothorax; priority journal; quadriplegia; spinal cord compression; spinal cord decompression; thorax radiography; tracheostomy

Maternal vitamin K deficient embryopathy: Association with hyperemesis gravidarum and Crohn disease - Toriello H.V.; Erick M.; Alessandri J.-L.; Bailey D.; Brunetti-Pierri N.; Cox H.; Fryer A.; Marty D.; Mccurdy C.; Mulliken J.B.; Murphy H.; Omlor J.; et al. (American Journal of Medical Genetics, Part A, 2013)
Chondrodysplasia punctata (CDP) is an etiologically heterogeneous disorder characterized by the radiographic finding of stippled epiphyses (punctate calcifications). It is often accompanied by a characteristic facial appearance, known as the Binder phenotype, which is attributed to hypoplasia of the nasal cartilages; abnormal distal phalanges (brachytelephalangy) are a common component manifestation as well. We report eight patients with a Binder phenotype with or without CDP who all shared a known or suspected maternal deficiency of vitamin K. We suspect that this phenotype is probably under recognized, and we hope to increase awareness about the maternal risk factors, especially hyperemesis gravidarum, which lead to nutritional deficiency. © 2013 Wiley Periodicals, Inc.
Keywords: antiemetic agent; azathioprine; metoclopramide; ondansetron; prednisolone; prothrombin; vitamin K group; adolescent; adult; anemia; article; bone radiography; brachydactyly; calcification; calcifying chondrodystrophy; child; chromosome analysis; clinical article; compression therapy; Crohn disease; disease association; disease severity; echography; electrolyte intake; embryopathy; epistaxis; faintness; female; fetus distress; gestation period; heterotopia; human; hyperemesis gravidarum; hypoalbuminemia; hypokalemia; hypomagnesemia; hyponatremia; hypoproteinemia; ketonuria; laboratory test; male; midface hypoplasia; muscle weakness; newborn jaundice; nose obstruction; nuclear magnetic resonance imaging; obesity; phototherapy; physical examination; priority journal; respiratory distress; respiratory failure; school child; sequence analysis; spinal cord compression; spine surgery; subglottic stenosis; tracheostomy; upper respiratory tract infection; vitamin K deficiency; vomiting

Correction of spine deformity in patients with melnick-needles syndrome: Report of 2 cases and literature review - Lykissas M.G.; Crawford A.H.; Shufflebarger H.L.; Gaines S.; Permal V. (Journal of Pediatric Orthopaedics, 2013)
BACKGROUND:: Melnick-Needles syndrome (MNS) is a rare X-linked dominant disorder affecting the skeletal system and connective tissue. To date, <70 cases with MNS have been documented. Although few reports in the literature have shown that these patients might develop kyphoscoliosis, there is no report regarding long-term follow-up of patients with MNS undergo spine surgery. The aim of this study is to describe 2 unique cases of MNS with long-term follow-up after instrumented posterior spinal fusion, multiple-level Ponte osteotomies, and pedicle subtraction osteotomies. METHODS:: A 17-year-old female patient (patient 1) was evaluated for the first time at our institution. She was diagnosed with MNS, severe kyphoscoliosis, and restrictive lung disease. After pulmonary function improvement, she underwent posterior spinal fusion. Halo-femoral traction with gradual weight increase was used a week before spinal surgery. Surgical correction of her spinal deformity was achieved through a hooks-and-wires construct. The second patient was an 18-year-old female (patient 2) who carried the diagnosis of MNS when she was first seen at our institution. She had a significant thoracolumbar junction kyphosis and gibbous. She also suffered from significant pulmonary disease with a stent in her right main stem bronchus. A posterior procedure consisting of multiple-level Ponte osteotomies and pedicle subtraction osteotomy at L2 was carried out. RESULTS:: Eight- and 5-year follow-up of patients 1 and 2, respectively, demonstrated solid fusion, a well-maintained correction, and no evidence of implant breakage. CONCLUSIONS:: The reported cases add to the literature of excellent long-term results of spinal deformity correction with instrumented posterior spinal fusion in patients with MNS. Patients with this condition should be closely monitored from early childhood for the development of spine deformity so that early referral to a spine surgeon can be made followed by appropriate treatment, if necessary. Copyright © 2013 by Lippincott Williams & Wilkins.
Keywords: adolescent; adult; allograft; article; bone dysplasia; breathing disorder; case report; chronic respiratory failure; Crohn disease; death; disease severity; female; follow up; gastroesophageal reflux; human; hydronephrosis; intubation; kyphoscoliosis; kyphosis; limb deformity; lung disease; melnick- eedles syndrome; osteotomy; physical examination; priority journal; sleep disordered breathing; spine fusion; spine malformation; spine radiography; spine surgery; stone formation; surgery; thoracolumbar spine; thorax deformity; tracheostomy; tracheostomy tube; traction therapy; treatment outcome; treatment response; upper respiratory tract obstruction; valgus knee; ventilator; body weight gain; X chromosome linked disorder

Descending necrotizing mediastinitis associated with spinal cord abscess - Dajer-Fadel W.L.; Borrego-Borrego R.; Flores-Calderón O.; Argüero-Sánchez R.; Navarro-Reynoso F.P.; Ibarra-Pérez C. (Asian Cardiovascular and Thoracic Annals, 2013)
A 58-year-old man with a history of Ludwig's angina was admitted with a spinal cord abscess at the level of C2-T1 and associated osteomyelitic destruction of vertebral bodies, spinal cord compression, and secondary quadriparesis, followed by descending mediastinitis. A right posterolateral thoracotomy and a cervicotomy drained purulent exudates. A tracheostomy was performed, and the patient was discharged after 84 days. © The Author(s) 2012.
Keywords: adult; article; case report; cervicotomy; computer assisted tomography; descending necrotizing mediastinitis; human; Ludwig angina; male; mediastinitis; quadriplegia; spinal cord abscess; spinal cord compression; spinal cord disease; spine surgery; spondylolisthesis; thoracotomy; tracheostomy

West nile virus encephalitis - Prabhakar A.; Coleman R.; Kemp N.; Engel L.S.; DeBoisblanc B. (Journal of Investigative Medicine, 2013)
Case Report: Introduction: The prevalence of West Nile virus (WNV) in the continental United States has greatly increased. Manifestations of the virus range from asymptomatic carriers to rapidly progressive neurological and muscular decline. Case: A 40 year old male with no past medical history presented to a rural emergency department with a 3 day history of acute onset headache, severe neck pain, fever, drowsiness, weakness, and poor PO intake. A lumbar puncture was performed and treatment with vancomycin, ceftriaxone, and acyclovir was begun. Initial cerebrospinal fluid (CSF) studies were significant for an elevated WBC with predominance of segmented neutrophils, elevated protein, and normal glucose. CSF was also sent forWest Nile and EBV studies. The patient was subsequently transferred to another facility for further neurological evaluation. Notable physical exam findings upon presentation were fever of 102 oF, normal sensation throughout, and decreased upper extremity motor strength bilaterally. Magnetic resonance imaging (MRI) of the cervical and thoracic spine was significant for inflammatory myelopathy. MRI of brain was unremarkable. The patient's symptoms progressively worsened over the course of 2 days with continued neuromuscular decline and weakness coupled with symmetric loss of reflexes. The patient was subsequently intubated secondary to impending respiratory failure. EMG findings were consistent with Guillain-Barre syndrome Miller Fisher variant. The patient was initiated on IVIG treatment. Eight days after his initial presentation, his serum IgM was found to be positive for WNV. The patient had a long and protracted hospital course with particular difficulty being weaned from the ventilator. One and a half months after his initial presentation, the patient was discharged with a tracheotomy to an outside center to continue his neuromuscular rehabilitation. Discussion: West Nile virus is a single stranded RNA virus that was first documented in the United States in 1999. Neuroinvasive disease is extremely rare among individuals less than 65 years old. This case illustrates that there remains a certain amount of unpredictability with WNV disease progression and severity and it is important to recognize WNV in a patient's differential diagnosis, particularly in areas with higher prevalence.
Keywords: vancomycin; ceftriaxone; glucose; immunoglobulin M; aciclovir; single stranded RNA; protein; RNA; virus encephalitis; medical research; West Nile virus; human; patient; weakness; prevalence; United States; fever; nuclear magnetic resonance imaging; cerebrospinal fluid; lumbar puncture; drowsiness; arm; thoracic spine; reflex; Guillain Barre syndrome; neck pain; case report; headache; differential diagnosis; neutrophil; emergency ward; sensation; medical history; tracheotomy; ventilator; spinal cord disease; brain; male; respiratory failure; serum; hospital; virus; rehabilitation; RNA virus; disease course; electromyogram

Noninvasive respiratory management and diaphragm and electrophrenic pacing in neuromuscular disease and spinal cord injury - Bach J.R. (Muscle and Nerve, 2013)
The purpose of this monograph is to describe noninvasive management of respiratory muscle weakness/paralysis for patients with neuromuscular disease (NMD) and spinal cord injury (SCI). Noninvasive ventilation (NIV) assists and supports inspiratory muscles, whereas mechanically assisted coughing (MAC) simulates an effective cough. Long-term outcomes will be reviewed as well as the use of NIV, MAC, and electrophrenic pacing (EPP) and diaphragm pacing (DP) to facilitate extubation and decannulation. Although EPP and DP can facilitate decannulation and maintain alveolar ventilation for high-level SCI patients when they cannot use NIV because of lack of access to oral interfaces, there is no evidence that they have any place in the management of NMD. © 2012 Wiley Periodicals, Inc.
Keywords: active circuit ventilation; article; artificial ventilation; assisted ventilation; diaphragm paralysis; electrophrenic pacing; electrotherapy; extubation; human; intensive care; intermittent abdominal pressure ventilator; lung function test; mechanical stimulation; mechanically assisted coughing; neuromuscular disease; non invasive procedure; noninvasive positive pressure mechanical ventilation; noninvasive ventilation; outcome assessment; phrenic nerve pacing; positive end expiratory pressure; pressure control ventilation; priority journal; proportion Assist ventilation; spinal cord injury; synchronized intermittent mandatory ventilation; volume control ventilation

Initiating chemotherapy in the ICU: Beneficence or maleficence? - Maronge G.F.; Zacharia G.; Puligothram S.; Narmala S.K. (Journal of Investigative Medicine, 2013)
Case Report: Case: A thirty-seven year old woman presented to the emergency department (ED) at an outside facility with complaint of shortness of breath and back pain. She reported the back pain had started 6 months ago and also reported 2 weeks of abdominal pain. MRI performed in the ED was concerning for spinal cord compression and she was transferred to University Hospital in New Orleans. On arrival, she quickly decompensated and was intubated for respiratory failure and hypotension. CT of the chest showed a large pericardial effusion and multiple bone metastasis to the vertebra, bilateral humeri and clavicles. Transthoracic echo demonstrated evidence of cardiac tamponade and pericardiocentesis revealed serosanguinous fluid, with cytology positive for ovarian adenocarcinoma. CT of the abdomen confirmed this diagnosis, showing a 16.7cm × 18.7cm mass arising from the left adnexa. The oncology service was consulted by the ICU team to discuss the prognosis with the patient's family. Respiratory failure was her only organ failure at that time and the team elected to start treatment. She received one cycle of chemotherapy and the patient remained intubated and managed by the ICU team. On day 7 after chemo, the medical oncology team noted that an aggressive sedation and ventilation weaning approach was not in place. Though this would normally be employed in a young and healthy patient, this had not been implemented due to an assumed poor prognosis. The patient underwent weaning and did require tracheostomy 1 week later, however this was decannulized approximately nine days after that. The patient was discharged at that time, ambulating independently and performing all ADL's. She received her second cycle of chemo before hospital discharge and followed-up in the clinic three weeks later feeling well except fatigue. Discussion: This case underscores the importance of good communication among specialties, being a patient advocate, and using evidence based medicine and objective measures when available in treatment decisions of cancer patients. This patient was a young healthy person with no prior medical problems and no signs of organ failure except respiratory failure. Due to aggressive treatment in the ICU, she was able to enjoy prolonged survival with preserved quality of life.
Keywords: beneficence; medical research; chemotherapy; human; patient; respiratory failure; normal human; prognosis; backache; weaning; oncology; university hospital; spinal cord compression; emergency ward; bone metastasis; female; ovary adenocarcinoma; vertebra; humerus; clavicle; heart tamponade; case report; pericardial effusion; cancer patient; abdominal pain; thorax; abdomen; diagnosis; hypotension; dyspnea; cytology; air conditioning; liquid; sedation; pericardiocentesis; United States; tracheostomy; hospital discharge; hospital; fatigue; interpersonal communication; evidence based medicine; survival; quality of life; nuclear magnetic resonance imaging

Gaze-controlled, computer-assistedcommunication in Intensive Care Unit: S"peaking through the eyes" - Maringelli F.; Brienza N.; Scorrano F.; Grasso F.; Gregoretti C. (Minerva Anestesiologica, 2013)
Background. The aim of this study was to test the hypothesis that a gaze-controlled communication system (eye tracker, ET) can improve communication processes between completely dysarthric ICU patients and the hospital staff, in three main domains: 1) basic communication processes (i.e., fundamental needs, desire, and wishes); 2) the ability of the medical staff to understand the clinical condition of the patient; and 3) the level of frustration experienced by patient, nurses and physicians. Methods. Fifteen fully conscious medical and surgical patients, 8 physicians, and 15 nurses were included in the study. The experimental procedure was composed by three phases: in phase 1 all groups completed the preintervention questionnaire; in phase 2 the ET was introduced and tested as a communication device; in phase 3 all groups completed the postintervention questionnaire. Results. Patients preintervention questionnaires showed remarkable communication deficits, without any group effect. Answers of physicians and nurses were pretty much similar to the one of patients. Postintervention questionnaires showed in all groups a remarkable and statistically significant improvement in different communication domains, as well as a remarkable decrease of anxiety and disphoric thought. Improvement was also reported by physicians and nurses in their ability to understand patients clinical conditions. Conclusion. Our results show an improvement in the quality of the examined parameters. Better communication processes seem also to lead to improvements in several psychological parameters, namely anxiety and drop-out depression perceived by both patients and medical staff. Further controlled studies are needed to define the ET role in ICU.
Keywords: adult; aged; amyotrophic lateral sclerosis; anxiety; article; artificial ventilation; basic needs; chronic obstructive lung disease; clinical article; comprehension; computer; computer assisted communication; data processing; dysarthria; dysphonia; endotracheal intubation; female; frustration; gaze; hospital patient; human; intensive care unit; interpersonal communication; male; medical staff; nurse; physician; questionnaire; spinal cord injury; tracheostomy

Clinical characteristics and early effective treatment for pulmonary infection after acute cervical spinal cord injury - Xu G.-H.; Zhang Y.; Man Y.; Jia L.-S. (National Medical Journal of China, 2013)
Objective: To explore the clinical characteristics and early effective treatment for pulmonary infection after acute cervical spinal cord injury. Methods: A total of 215 inpatients with acute cervical spinal cord injury were retrospectively analyzed. Their chest radiological films and blood profiles at discharge were analyzed. The fourth generation cephalosporin was used to treat pulmonary infection as soon as admission and the antibiotics switched according to the results of sputum culture and drug sensitive test. Incision of trachea was performed and breath supported by breath machine according to respiratory condition and blood gas analysis. All patients were turned over and slapped on the back in order to excrete phlegm in time. Sometimes bronchial lavage was used to excrete phlegm. The chest radiological examinations and sputum culture were performed twice one week. Once fungal infection was definite, specific antibiotic was used to treat infection. Three-liter bas and nasal-feeding were used to improve the nutrition condition. Incision of trachea was closed as soon as possible. Results: Pulmonary infection of 214 patients was finally cured. Among them, 43 suffered from pulmonary closure. One patient died from severe infection of Klebsiella pneumoniae. Pulmonary infection appeared upon admission and was mostly accompanied with hyperpyrexia. The result of sputum culture revealed baumanii and the pathogen of hemoculture was Pseudomonas aeruginosa. At 3-4 weeks later, mycotic infection appeared. And 17 patients suffered from Klebsiella pneumoniae and one died. Conclusion: Pulmonary infection after acute cervical spinal cord injury is severe and occurs early. Effective antibiotics according to the result of sputum culture, turnover & back-slapping for excreting phlegm in time, expectoration training and strengthening overall nutrition are effective therapeutic measures. Copyright © 2013 by the Chinese Medical Association.
Keywords: antibiotic agent; cephalosporin derivative; antibiotic sensitivity; antibiotic therapy; article; blood gas analysis; blood sampling; cervical spine injury; hospital admission; human; hyperpyrexia; Klebsiella pneumoniae; Klebsiella pneumoniae infection; lung infection; major clinical study; Pseudomonas aeruginosa; retrospective study; sputum culture; thorax radiography; trachea; tracheobronchial toilet; tracheostomy

An update on pediatric diaphragm pacing: What we learned and how diaphragm pacing is an excellent option in pediatric spinal cord injured patients - Elmo M.J. (Topics in Spinal Cord Injury Rehabilitation, 2013)
Diaphragm pacing is a viable breathing option in pediatric SCI. This is an update of pediatric diaphragm pacing at one institution highlighting the differences between children and adults. Background: Diaphragm pacing (DP) has successfully replaced or decreased tracheostomy mechanical ventilation (TMV) in adult SCI. The incidence of cervical cord injuries is disproportionately high in young children. The success of DP in the pediatric patient has been previously described. This report will summarize all pediatric patients implanted at one institution highlighting the differences in surgical implantation and diaphragm condition among the age groups. Methods: Retrospective review of all implanted pediatric DP patients. Results: A total of 11 patients between ages of 27 months and 17 years were implanted between January 2009 and May 2012. Additionally at operative exploration, 2 patients unexpectedly had denervated diaphragms and were not implanted. Four patients were between 2-3 years old, 2 were 5 years old, 4 patients were between 9-10 years, and 1 was 17 years old. The average time spent on TMV was 31.65 months with a range of 11 days to 91 months. Over 50% (6) of patients achieved full time pacing. Three patients are off the ventilator for 12-16 hours daily while the others are still in the conditioning phase. One patient, from the possible neuroplasticity effects of functional electrical stimulation, regained full volitional breathing with easy removal of the wires. No patients had perioperative or postoperative complications. To date, there are no long-term complications. The 2 patients implanted early post injury went directly to full time pacing. Scoliosis and use of a hard shell back brace can affect pacing. Children ages 4-5 and those on TMV greater than 5 years have the most anxiety with pacing. Utilizing the pacer simultaneously with TMV can lead to severe hypocapnia. As little as 15-20 minutes of pacing time daily can significantly improve lung compliance affecting tidal volumes when using pressure control mode. Parents report improvement in freedom, independence, mobility, and activity with pacing. Conclusions: Early diaphragm pacing is the optimal utilization and may help with functional recovery. In the 2- to 3-year-olds, the major obstacle to pacing is habituating to the change in sensation. In the 5- to 10-year-olds, the major obstacle to pacing is fear. Early implantation decreases conditioning times. Pacing improves quality of life.
Keywords: steel; diaphragm; patient; human; spinal cord injury; spinal cord; child; implantation; breathing; adult; conditioning; Tobacco mosaic virus; cervical spinal cord injury; functional electrical stimulation; postoperative complication; injury; nerve cell plasticity; artificial ventilation; ventilator; lung compliance; independence; fear; scoliosis; hypocapnia; anxiety; tidal volume; parent; brace; sensation; quality of life; denervation; groups by age; tracheostomy

Management of spinal trauma in emergency department - Akdemir H.U.; Kati C.; Duran L.; Kuruoǧlu E. (Journal of Experimental and Clinical Medicine (Turkey), 2013)
Spinal cord injuries are traumatic incidents which lead to serious clinical consequences and affect the lives of individuals and their families. Despite all medical and surgical advances, optimal treatment still remains a serious clinical problem. It is mostly not possible to prevent the primary injury arising from trauma exposure in spite of all measures taken. However, some biochemical events developing in spinal cord following the primary injury cause more damage to the cord. This process also defined as the secondary injury increases the importance of emergency department approach to patients with acute spinal trauma. Emergency department practices in spinal cord injuries are extremely important in terms of both primary care and prevention of complications. © 2013 OMU.
Keywords: dobutamine; dopamine; methylprednisolone; oxygen; acute disease; anogenital reflex; anus sphincter; assisted ventilation; bleeding disorder; cervical collar; cervical spinal cord injury; cervical spine; cervical spine radiography; clinical examination; clinical trial (topic); computed tomography scanner; computer assisted tomography; decubitus; disease classification; early diagnosis; echography; emergency care; emergency ward; endotracheal intubation; endotracheal tube; epidural hematoma; human; hypotension; immobilization; nasotracheal intubation; neurologic examination; nuclear magnetic resonance imaging; oropharynx airway; oxygen mask; oxygen nasal cannula; oxygen saturation; oxygenation; patient care; peritoneum lavage; proprioception; pulmonary artery occlusion pressure; pulse oximetry; reflex; respiratory care; respiratory tract disease; review; spinal cord injury; spine radiography; spine stabilization; steroid therapy; subdural hematoma; Swan Ganz catheter; tendon reflex; thoracolumbar spine; thoracolumbar spine radiography; tracheotomy; treatment planning; vibration sense

Benefit, timing, and technique of tracheostomy - Lissauer M.E. (Current Problems in Surgery, 2013)
Keywords: airway obstruction; article; artificial ventilation; brain injury; bronchoscope; cost; endotracheal intubation; guide wire; heart arrest; human; intensive care unit; length of stay; mortality; randomized controlled trial (topic); respiratory failure; risk benefit analysis; spinal cord injury; tracheostomy; tracheotomy

Survey of clinicians experience and attitudes regarding spinal muscular atrophy with respiratory distress syndrome type 1 (SMARD1) - Jerrom T.D.; Majumdar A.; Shah S.; Fraser J. (Developmental Medicine and Child Neurology, 2013)
Objectives: In an attempt to help provide more standardised care for children with SMARD1 we carried out an online survey in April 2012 to investigate clinician's experiences and attitudes regarding treatment of SMARD1. Methods: We distributed our survey to 601 Consultants via four specialist interest groups based in the UK including the BPNA. The survey was broken down into eight questions, including demographic information and then a series of ethical and clinical dilemmas. Results: We received 80 responses (13.3%, n=80/601); 36.3% were Paediatric Neurologists (n=29/80), 25% Paediatric Intensivists (n=20/80, with the remainder working within Neurology, Long Term Ventilation (LTV) or General Paediatrics (total 32.4%, n=26/80). When asked 'What treatment plan they would offer the family of a 3.5 month old child with SMARD1 who is ventilated and has repeatedly failed extubation to mask non-invasive ventilation', 47.9% would offer extubation followed by palliative care, 14.1% would advocate long term tracheostomy home ventilation (LTTHV), and 38% would offer both. Consultants with <10 years of experience and those who had not previously cared for a child with SMARD1 were more likely to recommend extubation followed by palliative care. The most commonly cited reasons for not offering children with SMARD1 LTTHV were: unacceptably poor quality of life on LTTHV (54.9%, n=39/71), the burden of care placed upon carers (42.3%, n=30/71) and assumed short life expectancy despite LTTHV (35.2%, n=25/71). 80% (n=8/10) stated categorically that diaphragm plication did not improve the child's clinical status or ventilator requirements. Conclusion: Our study shows that a minority of clinicians would advocate LTTHV for children with SMARD1. Motivating factors for decisions are different between different specialties. Less experienced clinicians and those with no prior experience of SMARD1 appear to be more likely to only offer a palliative approach. Diaphragmatic plication does not appear help in the majority of children.
Keywords: spinal muscular atrophy; respiratory distress syndrome; neurology; human; child; extubation; consultation; air conditioning; palliative therapy; neurologist; United Kingdom; medical specialist; diaphragm; noninvasive ventilation; pediatrics; tracheostomy; quality of life; life expectancy; ventilator

Paediatric neuromyelitis optica (NMO) presenting with encephalopathy and severe brain lesions - Munasinghe J.; Symmonds M.; Fallon P. (Developmental Medicine and Child Neurology, 2013)
Introduction: Neuromyelitis optica is an uncommon demyelinating central nervous system disease characterised by longitudinally extensive transverse myelitis (LETM), optic neuritis and Aquaporin 4 (AQP4) seropositivity. Encephalopathy and extensive brain lesions are a rare presentation of this disease which usually follows a relapsing and remitting course with significant disability. Case description: An 11-year-old girl presented acutely with airway compromise following 3 weeks of increasing lethargy and required prolonged ventilation. She was quadriparetic and had bulbar involvement. MRI revealed LETM involving cervicothoracic spine, demyelinating lesions in bilateral mesial temporal lobes, left basal ganglia, right thalamus, hypothalamus and dorsal medulla. Cerebrospinal fluid was acellular with negative oligoclonal bands. EEG showed evidence of encephalopathy. AQP4 antibodies were positive. She was initially treated with IV methylprednisolone (IVMP) and intravenous immunoglobulin and subsequently prednisolone for 6 weeks. She recovered well however retained a tracheostomy and required nasogastric feeding. Four months later she relapsed with encephalopathy, bilateral abducens palsy and right upper limb weakness. MRI showed new lesions in bilateral basal ganglia, right internal capsule, right thalamus, midbrain and thoracic spinal cord. She received further IVMP, regular plasma exchange and commenced long term prednisolone and azathioprine. She went into remission and became seronegative for Aquaporin 4 antibodies. There has been no clinical or MRI evidence of optic neuritis and VEP was normal. Discussion: This case illustrates that paediatric neuromyelitis optica can present with encephalopathy and large brain lesions in a similar fashion to acute disseminated encephalomyelitis. Optic neuritis may not be present initially. AQP4 antibody is an important investigation in such cases to confirm the diagnosis of NMO, as its severe clinical sequelae can necessitate timely immunosuppression and plasma exchange in addition to steroids.
Keywords: antibody; prednisolone; methylprednisolone; immunoglobulin; aquaporin 4 antibody; azathioprine; oligoclonal band; steroid; aquaporin 4; myelooptic neuropathy; brain disease; brain damage; neurology; optic neuritis; basal ganglion; plasmapheresis; thalamus; nuclear magnetic resonance imaging; air conditioning; tracheostomy; lethargy; airway; myelitis; human; girl; female; central nervous system disease; acute disseminated encephalomyelitis; remission; disability; nose feeding; cerebrospinal fluid; hypothalamus; capsula interna; limb weakness; arm; abducens nerve paralysis; mesencephalon; thoracic spinal cord; temporal lobe; diagnosis; immunosuppressive treatment; spine; electroencephalogram

Home-based overnight transcutaneous capnography/pulse oximetry for diagnosing nocturnal hypoventilation associated with neuromuscular disorders - Bauman K.A.; Kurili A.; Schmidt S.L.; Rodriguez G.M.; Chiodo A.E.; Sitrin R.G. (Archives of Physical Medicine and Rehabilitation, 2013)
Objective: To determine the utility of home-based, unsupervised transcutaneous partial pressure of carbon dioxide (tc-Pco2) monitoring/oxygen saturation by pulse oximetry (Spo2) for detecting nocturnal hypoventilation (NH) in individuals with neuromuscular disorders. Design: Retrospective case series analyzed consecutively. Setting: Multidisciplinary neuromuscular respiratory failure (NMRF) clinic at an academic institution. Participants: Subjects (N=35, 68.6% men; mean age, 46.9y) with spinal cord injury (45.7%) or other neuromuscular disorders underwent overnight tests with tc-Pco2/Spo2 monitoring. Fifteen (42.9%) were using nocturnal ventilatory support, either bilevel positive airway pressure (BiPAP) or tracheostomy ventilation (TV). Interventions: A respiratory therapist brought a calibrated tc-Pco2/Spo2 monitor to the patient's home and provided instructions for data collection during the subject's normal sleep period. Forced vital capacity (FVC), body mass index (BMI), and exhaled end-tidal Pco2 (ET-Pco2) were recorded at a clinic visit before monitoring. Main Outcome Measures: Detection of NH (tc-Pco2 ≥50mmHg for ≥5% of monitoring time). Data were also analyzed to determine whether nocturnal oxygen desaturation (Spo2 ≤88% for ≥5% of monitoring time), FVC, BMI, or daytime ET-Pco2 could predict the presence of NH. Results: NH was detected in 18 subjects (51.4%), including 53.3% of those using BiPAP or TV. NH was detected in 43.8% of ventilator-independent subjects with normal daytime ET-Pco2 (present for 49.4%±31.5% [mean ± SD] of the study period), and in 75% of subjects with an elevated daytime ET-Pco2 (present for 92.3%±8.7% of the study period). Oxygen desaturation, BMI, and FVC were poor predictors of NH. Only 3 attempted monitoring studies failed to produce acceptable results. Conclusions: Home-based, unsupervised monitoring with tc-Pco2/Spo2 is a useful method for diagnosing NH in NMRF. © 2013 by the American Congress of Rehabilitation Medicine.
Keywords: adult; aged; article; body mass; capnometry; clinical article; female; forced vital capacity; home care; human; hypercapnia; hypoventilation; male; neuromuscular disease; nocturnal hypoventilation; oxygen desaturation; oxygen saturation; positive end expiratory pressure; pulse oximetry; retrospective study; sleep; spinal cord injury; tracheostomy; transcutaneous carbon dioxide monitoring

Management of children with spinal muscular atrophy type 1 in Australia - Tassie B.; Isaacs D.; Kilham H.; Kerridge I. (Journal of Paediatrics and Child Health, 2013)
Aims The study aims to: (i) estimate the prevalence of spinal muscular atrophy type 1 (SMA 1); (ii) describe what practices characterise end-of-life care of patients with SMA 1; and (iii) ascertain whether a consistent approach to the management of these patients exists in Australia. Methods An audit of the Australasian pathology laboratories offering the diagnostic SMN1 deletion test was conducted for patients diagnosed with SMA in Australia for 2010 and 2011. In addition, a retrospective clinical audit was conducted in eight major Australian paediatric hospitals of the end-of-life care provided to children with confirmed SMA 1 from 2005 to 2010. Results Thirty-five children were included in the clinical audit, accounting for an estimated 61% of children diagnosed with SMA 1 from 2005 to 2010. Twenty-six per cent were ventilated invasively, only two of whom were intubated after the diagnosis was confirmed. No children were ventilated long term (>90 days) or had a tracheostomy performed. Nasogastric tube feeding was a common measure to support adequate nutritional intake. Total parenteral nutrition, gastrostomy and fundoplication were not provided for any children. Conflict over end-of-life care decisions was documented in one instance, without the involvement of a guardianship tribunal. Conclusion There appears to be a consistent approach in the management of children with SMA 1 in Australia, which can be characterised as 'actively managed dying'. This study could contribute to the development of Australian consensus guidelines for the management of these children. These results also highlight a number of ethical issues related to the management of children with SMA 1. © 2013 The Authors. Journal of Paediatrics and Child Health.
Keywords: survival motor neuron protein 1; article; Australia; child; child care; clinical practice; dietary intake; human; hydration; infant; major clinical study; clinical audit; medical decision making; nose feeding; pediatric hospital; prevalence; priority journal; spinal muscular atrophy; terminal care; tracheostomy

History of hereditary motor and sensory neuropathy with proximal dominant involvement (HMSN-P) - Takashima H. (Rinshō shinkeigaku = Clinical neurology, 2013)
We established a new disease autosomal dominant hereditary motor and sensory neuropathy with proximal dominant involvement (HMSNP) in 1997, in Okinawa, Japan. This disease is characterized by proximal dominant neurogenic atrophy with fasciculations, painful muscle cramp, obvious sensory nerve involvement, areflexia, high incidence of elevated creatine kinase levels, hyperlipidemia and hyperglycemia. (MIM %604484). HMSNP is so called or HMSNO (HMSN OKINAWA type),. These clinical features resembled those of Kennedy-Alter-Sung syndrome. Most HMSNP patients have severe muscle atrophy and finally the tracheostomy and artificial ventilation are required. Therefore, we initially thought to classify HMSNP into a subtype of motor neuron disease (MND) like familial amyotrophic lateral sclerosis (FALS) or spinal muscular atrophy (SMA). However, the general consensus for MND was no sensory involvement. Therefore, as the disease showed severe sensory involvement, we categorized HMSNP in subtype of HMSN at that time. We also reported the pathology of HMSNP, showing severely decreased anterior horn cells, decreased posterior horn cells, and loss of posterior funiculus in the spinal cord.
Keywords: hereditary motor sensory neuropathy; history; human; Japan

A complete C3-C4 spinal dislocation - Yang H.-L.; Zhang Z.-G.; Luo Z.-P. (JAMA Neurology, 2013)
Keywords: adult; article; case report; cast application; cervical spine dislocation; cervical spine injury; human; incontinence; male; paralysis; priority journal; tracheotomy; traction therapy; traffic accident

Anaesthesia and airway management in mucopolysaccharidosis - Walker R.; Belani K.G.; Braunlin E.A.; Bruce I.A.; Hack H.; Harmatz P.R.; Jones S.; Rowe R.; Solanki G.A.; Valdemarsson B. (Journal of Inherited Metabolic Disease, 2013)
This paper provides a detailed overview and discussion of anaesthesia in patients with mucopolysaccharidosis (MPS), the evaluation of risk factors in these patients and their anaesthetic management, including emergency airway issues. MPS represents a group of rare lysosomal storage disorders associated with an array of clinical manifestations. The high prevalence of airway obstruction and restrictive pulmonary disease in combination with cardiovascular manifestations poses a high anaesthetic risk to these patients. Typical anaesthetic problems include airway obstruction after induction or extubation, intubation difficulties or failure [can't intubate, can't ventilate (CICV)], possible emergency tracheostomy and cardiovascular and cervical spine issues. Because of the high anaesthetic risk, the benefits of a procedure in patients with MPS should always be balanced against the associated risks. Therefore, careful evaluation of anaesthetic risk factors should be made before the procedure, involving evaluation of airways and cardiorespiratory and cervical spine problems. In addition, information on the specific type of MPS, prior history of anaesthesia, presence of cervical instability and range of motion of the temporomandibular joint are important and may be pivotal to prevent complications during anaesthesia. Knowledge of these risk factors allows the anaesthetist to anticipate potential problems that may arise during or after the procedure. Anaesthesia in MPS patients should be preferably done by an experienced (paediatric) anaesthetist, supported by a multidisciplinary team (ear, nose, throat surgeon and intensive care team), with access to all necessary equipment and support. © 2012 The Author(s).
Keywords: airway obstruction; anesthesia induction; article; cardiopulmonary insufficiency; cardiovascular disease; chronic obstructive lung disease; clinical feature; disease association; endotracheal intubation; enzyme replacement; extubation; hematopoietic stem cell transplantation; high risk patient; human; life expectancy; mucopolysaccharidosis; multidetector computed tomography; prevalence; range of motion; respiration control; respiratory failure; risk benefit analysis; spinal cord compression; spine instability; surgical mortality; surgical risk; temporomandibular joint; tracheostomy

Clinical and radiological pictures of two newborn babies with manifestations of chondrodysplasia punctata and review of available literature - Jurkiewicz E.; Marcinska B.; Bothur-Nowacka J.; Dobrzanska A. (Polish Journal of Radiology, 2013)
Background: Chondrodysplasia punctata (CDP) is a rare, heterogeneous congenital skeletal dysplasia, characterized by punctate or dot-like calcium deposits in cartilage observed on neonatal radiograms. A number of inborn metabolic diseases are associated with CDP, including peroxisomal and cholesterol biosynthesis dysfunction and other inborn errors of metabolism such as: mucolipidosis type II, mucopolysacharidosis type III, GM1 gangliosidosis. CDP is also related to disruption of vitamin K-dependent metabolism, causing secondary effects on the embryo, as well as fetal alcohol syndrome (FAS), chromosomal abnormalities that include trisomies 18 and 21, Turner syndrome. Case Report: This article presents clinical data and diagnostic imaging findings of two newborn babies with chondrodysplasia punctata. Children presented with skeletal and cartilage anomalies, dysmorphic facial feature, muscles tone abnormalities, skin changes and breathing difficulties. One of the patients demonstrated critical stenosis of spinal canal with anterior subluxation of C1 vertebra relative to C 2. The aim of this article is to present cases and briefly describe current knowledge on etiopathogenesis as well as radiological and clinical symptoms of diseases coexisting with CDP. Conclusions: Radiological diagnostic imaging allows for visualization of punctate focal mineralization in bone epiphyses during neonatal age and infancy. Determining the etiology of chondrodysplasia punctata requires performing various basic as well as additional examinations, including genetic studies. © Pol J Radiol, 2013.
Keywords: article; asphyxia; bone radiography; breathing disorder; case report; chondrodysplasia punctata; chromosome aberration; computer assisted tomography; craniofacial malformation; differential diagnosis; hearing impairment; human; male; muscle hypotonia; newborn; nuclear magnetic resonance imaging; spinal cord compression; thorax radiography; tracheostomy; Zellweger syndrome

Accumulation of phosphorylated TDP-43 in the CNS of a patient with cockayne syndrome - Sakurai A.; Makioka K.; Fukuda T.; Takatama M.; Okamoto K. (Neuropathology, 2013)
Here, we report a case of Cockayne syndrome (CS) in a Japanese man who displayed a unique pathology of phosphorylated trans-activation response (TAR) DNA-binding protein 43 (pTDP-43) with abundant Rosenthal fibers. Many round pTDP-43-positive structures were detected throughout the CNS; however, most of them were located in two regions that also exhibited neuronal depletion: the cerebellar cortex and the inferior olivary nucleus. To a lesser extent, these aggregates were also present in the cerebellar white matter, around the subependymal regions in the brain stem, and in the spinal cord. Intraneuronal pTDP-43 inclusions were only observed in a small number of neurons in the inferior olivary nucleus. Double-label immunofluorescence revealed that many of the aggregates were localized to astrocytes. The observed distribution and the morphology of the pTDP-43-positive structures were unique and have not yet been reported. Therefore, a pTDP-43-related pathology may be implicated in CS as well as in other neurodegenerative diseases such as frontotemporal lobar degeneration and amyotrophic lateral sclerosis. Whether the pathology of these diseases reflects a primary neurodegenerative process or a secondary reaction is not known. © 2013 Japanese Society of Neuropathology.
Keywords: glial fibrillary acidic protein; microtubule associated protein 2; myelin; protein antibody; TAR DNA binding protein; adult; article; aspiration pneumonia; astrocyte; astrocytosis; ataxia; autopsy; body weight; brain degeneration; brain stem; cachexia; case report; cause of death; cell inclusion; central nervous system; cerebellum cortex; cervical dystonia; Cockayne syndrome; computer assisted tomography; confocal microscopy; convulsion; dental caries; dwarfism; dysarthria; dysphagia; emaciation; enteric feeding; facies; foot malformation; gait disorder; growth disorder; hand malformation; hand tremor; hearing impairment; hospital admission; human; human cell; immunofluorescence; immunohistochemistry; immunoreactivity; inferior olivary nucleus; Japanese (people); joint contracture; lateral brain ventricle; lentigo; male; mental deficiency; neuroimaging; neurologic examination; neuropathology; nystagmus; photosensitivity; physical examination; priority journal; progeria; protein depletion; protein expression; protein localization; protein phosphorylation; protein structure; psychomotor retardation; pyramidal sign; respiratory failure; rosenthal fiber; scoliosis; skin fibroblast; smooth pursuit eye movement; spinal cord atrophy; subventricular zone; survival; tracheal hemorrhage; tracheostomy; ultraviolet irradiation; white matter lesion

Spontaneous spinal epidural abscess presenting in a previously healthy young adult man - McDonald A.M.; Rollins J.L. (Case Reports in Medicine, 2013)
We report a case of spontaneous spinal epidural abscess (SEA) with initial chief complaint of shoulder pain and no appreciable neurologic symptoms. Since outcomes of SEA appear to be related to the degree of neurologic deficit at the time of intervention, we explore opportunities for earlier diagnosis. © 2013 Andrew M. McDonald and Jason L. Rollins.
Keywords: D dimer; doxycycline; hemoglobin; hydrocodone; linezolid; methocarbamol; methylprednisolone; paracetamol; vancomycin; adult; adult respiratory distress syndrome; ambulance; arterial gas; article; barotrauma; blood culture; blood pressure measurement; body temperature; bradycardia; breathing rate; cardiopulmonary arrest; case report; cervical spine; cervicobrachial neuralgia; computed tomographic angiography; contrast enhancement; debridement; density; diaphoresis; emergency ward; epidural abscess; erythrocyte sedimentation rate; fiberoptic bronchoscopy; hospital discharge; human; intubation; lung embolism; male; medical history; methicillin resistant Staphylococcus aureus; methicillin resistant Staphylococcus aureus infection; muscle weakness; nausea and vomiting; nuclear magnetic resonance imaging; outpatient; oxygen saturation; oxygen tension; paresthesia; physical examination; pneumothorax; prescription; priority journal; pulse oximetry; pulse rate; quantitative analysis; respiratory distress; sedation; sensation; shoulder pain; shoulder radiography; spinal cord injury; spinal epidural abscess; surgical wound; tachypnea; tracheobronchial toilet; tracheostomy; transesophageal echocardiography; trapezius muscle; vacuum assisted closure; vagus tone; ventilator; vital sign

Analysis of the risk factors for tracheostomy in traumatic cervical spinal cord injury - Yugué I.; Okada S.; Ueta T.; Maeda T.; Mori E.; Kawano O.; Takao T.; Sakai H.; Masuda M.; Hayashi T.; Morishita Y.; Shiba K. (Spine, 2012)
STUDY DESIGN. A retrospective, consecutive case series. OBJECTIVE. To determine the risk factors that have a statistically significant association with the need of tracheostomy in patients with cervical spinal cord injury (CSCI) at the acute stage. SUMMARY OF BACKGROUND DATA. Respiratory complications remain a major cause of further morbidity and mortality in patients with CSCI. Although several risk factors for tracheostomy have been postulated in these patients, no definitive factors have yet been established according to a multivariate analysis. The use of vital capacity was considered as a single global measure of respiratory function in patients with spinal cord injury, but there are very few studies in which the forced vital capacity was investigated as a risk factor for tracheostomy. METHODS. This study that reviewed the clinical data of 319 patients with CSCI, who were evaluated for their neurological impairment within 2 days after injury, was performed. We analyzed the factors postulated to increase the risk for tracheostomy, including patient's age, neurological impairment scale grade and level, smoking history, pre-existing medical comorbidities, respiratory diseases, Injury Severity Score, forced vital capacity, and percentage of vital capacity to the predicted value (%VC), using a multiple logistic regression model and classification and regression tree analysis. RESULTS. Of 319 patients, 32 patients received tracheostomy (10.03%). The factors identified using a multiple logistic regression model were high age (69 years of age or older), severe neurological impairment scale, low forced vital capacity (≤500 mL), and low percentage of vital capacity to the predicted value (<16.3%). The decision tree analysis demonstrated that forced vital capacity, the severe neurological impairment scale, and high patient age were predictive of need for tracheostomy on 94.4% occasions. CONCLUSION. The measurement of forced vital capacity is indispensable to predict the need for tracheostomy in patients with CSCI at the acute stage. © 2012, Lippincott Williams & Wilkins.
Keywords: acute disease; adolescent; adult; aged; article; cervical spinal cord injury; comorbidity; decision tree; female; forced vital capacity; groups by age; human; injury scale; major clinical study; male; neurologic disease; neurological impairment scale; priority journal; rating scale; respiratory tract disease; risk factor; smoking; tracheostomy

Familial ALS with FUS P525L mutation: Two Japanese sisters with multiple systems involvement - Mochizuki Y.; Isozaki E.; Takao M.; Hashimoto T.; Shibuya M.; Arai M.; Hosokawa M.; Kawata A.; Oyanagi K.; Mihara B.; Mizutani T. (Journal of the Neurological Sciences, 2012)
We evaluated the clinicopathological features of familial amyotrophic lateral sclerosis (ALS) with the fused in sarcoma (FUS) P525L mutation. Two sisters and their mother had a similar clinical course, which was characterized by the development of limb weakness at a young age with rapid disease progression. An elder sister, patient 1, progressed into a totally locked-in state requiring mechanical ventilation and died 26 years after the onset of the disease. In contrast, the younger sister, patient 2, died in the early stages of the disease. The patients had neuropathological findings that indicated a very active degeneration of motor neurons and multiple system degeneration, which led to marked brain and spinal cord atrophy in the long term clinical outcome. The multiple system degeneration included the frontal lobe, the basal ganglia and substantia nigra, cerebellum and related area. Compared with previously reported ALS cases, the severe degeneration of the frontal lobe and the striatum were the characteristic features in the patient 1 in this case study. The degeneration spread over multiple systems might be caused not only by the appearance of the FUS immunoreactive neuronal cytoplasmic inclusions but also by the degeneration of neuronal connections from the primary motor cortex and related areas. © 2012 Elsevier B.V. All rights reserved.
Keywords: RNA binding protein FUS; adolescent; adult; amyotrophic lateral sclerosis; arm weakness; article; artificial ventilation; basal ganglion; bulbar paralysis; case report; cerebellum; comparative study; degeneration; developmental disorder; disease course; dysarthria; dysphagia; dyspnea; familial disease; female; frontal lobe; gene mutation; genetic association; human; human cell; human tissue; Japanese (people); limb weakness; multiple organ failure; neuropathology; ophthalmoplegia; pneumonia; polyneuropathy; primary motor cortex; priority journal; quadriplegia; respiratory failure; spinal cord atrophy; substantia nigra; tracheostomy

Risk factors for respiratory failure in elderly patients with traumatic rib fractures - Ng S.Y.; Seethala R.; Yang Y.; Gonzalez C.; Kappottos M.; Frendl G.; Shempp I.; Rogers S. (Critical Care Medicine, 2012)
Introduction: Elderly patients aged > 65 years have increased mortality and morbidity after sustaining traumatic rib fractures. While the incidence of pulmonary morbidity is increased, the risk factors are unknown. Hypothesis: We hypothesized that advanced elderly age (? 80 years), comorbidities such as cardiovascular and cerebrovascular diseases, smoking and obesity, injury severity and presence of traumatic brain or cervical spine injury may increase the risk for respiratory failure. Methods: The study was a retrospective review over a 10 year period of a prospectively collected trauma registry. Variables and outcomes described above were collected.We used a composite outcome for respiratory failure consisting of unplanned intubation, tracheostomy and / or development of pneumonia. Univariate analysis followed by logistic regression was performed to identify the risk factors for respiratory failure. Results: 449 patients with traumatic rib fractures over a 10 year period were analyzed. The mean age was 78.1 ± 8.0. There were 249 patients aged 65 to 79 and 200 patients aged 80 and above. The mean Injury Severity Score and Abbreviated Injury Score (chest) was 17.5 ± 11.0 and 2.4 ± 1.1 respectively. The mean number of fractured ribs was 4.0 ± 3.1. 142 (31.6%) patients had respiratory failure. 45 (10.0%) patients died in hospital.On univariate analysis, only the presence of cervical spine injury and Abbreviated Injury Score (chest) were associated with respiratory failure. The association remained after logistic regression: the ORs for respiratory failure in the presence of cervical spine injury and AIS (chest) were 3.25 (95% CI: 1.97 -5.35) and 1.56 (95% CI: 1.25 - 1.90) respectively. There was a positive interaction between age group and presence of cervical spine injury for respiratory failure (p = 0.001)Conclusions: The risk factors for respiratory failure in elderly patients with traumatic rib fractures are the presence of cervical spine injury and increased AIS (chest) score. The presence of cervical spine injury may have a greater effect in the advanced elderly age group. This data will be useful in identifying elderly patients at risk of respiratory failure after sustaining traumatic rib fractures.
Keywords: intensive care; aged; human; rib fracture; respiratory failure; society; risk factor; cervical spine injury; patient; injury; morbidity; thorax; risk; logistic regression analysis; groups by age; univariate analysis; pneumonia; cerebrovascular disease; tracheostomy; intubation; register; hypothesis; injury scale; brain; injury severity; rib; obesity; smoking; mortality

Respiratory Complications and Management of Mechanical Ventilation in Cervical Spine Injury - Kearns M.; Shimabukuro D. (ICU Director, 2012)
It is estimated that the annual incidence of spinal cord injury in the United States is 12 000 new cases per year. Victims of spinal cord injury are prone to developing respiratory complications such as atelectasis, pneumonia, and ventilatory failure secondary to physiologic derangements resulting from spinal shock and paralysis. Respiratory complications are the leading cause of death in those who survive the initial injury. The goal in ventilator management of spinal cord injury patients in the intensive care unit setting is to prevent these complications and optimize patients for early transfer to a spinal cord rehabilitation facility. To minimize atelectasis, current guidelines recommend the use of very high tidal volumes (15 mL/kg) or setting high tidal volumes (10 mL/kg) in addition to using positive end-expiratory pressure. In this article, the authors discuss the pulmonary complications that affect the mortality of these patients and review the evidence behind the current high tidal volume ventilation strategy. © 2012 The Author(s).
Keywords: article; artificial ventilation; atelectasis; bronchospasm; cervical spine injury; disease severity; human; incidence; intensive care unit; lung edema; pneumonia; positive end expiratory pressure; practice guideline; priority journal; respiratory failure; respiratory tract disease; risk factor; tidal volume; tracheostomy; ventilated patient; ventilator induced lung injury; vital capacity

Diffusion tensor imaging in pediatric transverse myelitis: A case study - Barakat N.; Mulcahey M.J.; Shah P.; Samdani A.; Krisa L.; Faro S.; Mohamed F.B. (Journal of Pediatric Rehabilitation Medicine, 2012)
Transverse myelitis is diagnosed based on the presence of spinal cord inflammation and the absence of infection to the central nervous system. In support of these criteria, patients undergo lumbar puncture to determine Cerebrospinal Fluid (CSF) pleocytosis and un-enhanced or Gadolinium-enhanced spinal Magnetic Resonance Imaging (MRI). We present the case of an 11~year-old previously healthy male who underwent a series of lab tests and MRI scans before a definite diagnosis of transverse myelitis four years prior to this study. The patient still shows deficits at the C4 cord level according to International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) examination, however, his MRI results are negative, and his Diffusion Tensor Imaging (DTI) results are close to values reported in healthy subjects. © 2012 - IOS Press and the authors. All rights reserved.
Keywords: American Spinal Injury Association impairment scale; article; case report; cerebrospinal fluid analysis; cervical spinal cord; child; diffusion tensor imaging; emergency ward; fever; follow up; headache; human; hydromyelia; injury severity; intensive care; lumbar puncture; male; myelitis; neck pain; neurologic examination; nuclear magnetic resonance imaging; priority journal; prospective study; qualitative analysis; respiratory failure; school child; syringomyelia; thorax radiography; tracheotomy; vertebra body; vertebral canal stenosis

Successful tracheal intubation with the McGrath® MAC video laryngoscope after failure with the Pentax-AWS™ in a patient with cervical spine immobilization - Hyuga S.; Sekiguchi T.; Ishida T.; Yamamoto K.; Sugiyama Y.; Kawamata M. (Canadian Journal of Anesthesia, 2012)
Keywords: oxygen; propofol; remifentanil; rocuronium; adult; anesthesia induction; case report; cervical spine fracture; computer assisted tomography; continuous infusion; endotracheal intubation; endotracheal tube; extubation; general anesthesia; human; jet ventilation; laminoplasty; laryngoscope; laryngoscopy; letter; male; oxygen saturation; preoperative evaluation; priority journal; spine stabilization; tracheostomy; traffic accident; treatment outcome; McGrath MAC; Pentax Airway Scope

Pre-conference workshop - Brun S. (Journal of Science and Medicine in Sport, 2012)
This fully comprehensive short course for the On-field Emergency Care of the seriously injured or ill athlete has been developed and accredited by Sports Doctors Australia. The course is also recognised and accredited by RACGP for category 1 QI & CPD points and rural GPs who are registered in the emergency component of the Rural Procedural Grants program can access this grant for attending this course. Given the more serious nature of sporting events and the greater demand for high quality and competent medical care within sport, the SMECC has been designed for the medical practitioner who has the responsibility for the care of athletes or sporting teams of all levels. The course focuses on the on-field management of the seriously injured and seriously ill athlete and involves the essential theory and will focus on the practical application of immediate emergency medical management and is designed around systems and skills stations, whereby the doctor becomes confident at recognising and managing serious incidents without immediate hospital or medical backup. 1. Each station is sport based, and focuses specifically on the four major systems requiring acute medical intervention. The systems covered and some of the skills learnt will include: Airway problems; a. Recognising and managing the compromised airway or an airway which has the potential of becoming compromised. b. Practicing the basics of establishing and maintaining an airway, including: Cervical spine control, Oxygen Therapy and appropriate delivery systems, Bag and mask resuscitation, inserting an oral/nasal airway, ETT and LMA insertion and needle cricothyroidotomy. 2. Breathing problems; a. Recognising and managing the athlete suffering from both medical and surgical problems of this system including asthma and pneumothorax. 3. Circulatory problems; b. Recognising and managing the shock state and the various types of shock, fluid resuscitation and fracture management and stabilisation. c. Identification and management of life threatening arrhythmias will also be addressed. 4. Head and spinal injuries. d. Recognising and managing the head injured patient including how to assess these patients, such as determining ominous neurological signs and how to immobilise a patient with a spinal injury. Each station will identify compromise and potential compromise of the system covered. It will also focus on essential intervention as well as certain contraindications to management. The stations will also emphasise the basics of emergency management as well as the critical advanced medical skills required to stabilise the seriously injured athlete. The course will then tie together as a complete management model so as the participant will gain the confidence and skills required managing the seriously injured athlete.
Keywords: workshop; human; athlete; airway; skill; patient; physician; sport; emergency; spine injury; disease management; breathing; responsibility; needle; resuscitation; medical care; sporting event; oxygen therapy; Australia; tracheotomy; cervical spine; asthma; emergency care; heart arrhythmia; fracture; hospital; fluid resuscitation; pneumothorax; neurologic disease; model

Workshop - Brun S. (Journal of Science and Medicine in Sport, 2012)
This fully comprehensive short course for the On-field Emergency Care of the seriously injured or ill athlete has been developed and accredited by Sports Doctors Australia. The course is also recognised and accredited by RACGP for category 1 QI & CPD points and rural GPs who are registered in the emergency component of the Rural Procedural Grants program can access this grant for attending this course. Given the more serious nature of sporting events and the greater demand for high quality and competent medical care within sport, the SMECC has been designed for the medical practitioner who has the responsibility for the care of athletes or sporting teams of all levels. The course focuses on the on-field management of the seriously injured and seriously ill athlete and involves the essential theory and will focus on the practical application of immediate emergency medicalmanagementand is designed around systems and skills stations, whereby the doctor becomes confident at recognising and managing serious incidents without immediate hospital or medical backup. Each station is sport based, and focuses specifically on the four major systems requiring acute medical intervention. The systems covered andsomeof the skills learnt will include: Airway problems; Recognising and managing the compromised airway or an airway which has the potential of becoming compromised. Practicing the basics of establishing and maintaining an airway, including: Cervical spine control, Oxygen Therapy and appropriate delivery systems, Bag and mask resuscitation, inserting an oral/nasal airway, ETT andLMAinsertion and needle cricothyroidotomy. Breathing problems; Recognising and managing the athlete suffering from both medical and surgical problems of this system including asthma and pneumothorax. Circulatory problems; Recognising and managing the shock state and the various types of shock, fluid resuscitation and fracture management and stabilisation. Identification and management of life threatening arrhythmias will also be addressed. Head and spinal injuries. Recognising and managing the head injured patient including how to assess these patients, such as determining ominous neurological signs and how to immobilise a patient with a spinal injury. Each station will identify compromise and potential compromise of the system covered. It will also focus on essential intervention as well as certain contraindications to management. The stations will also emphasise the basics of emergency management as well as the critical advanced medical skills required to stabilise the seriously injured athlete. The course will then tie together as a complete management model so as the participant will gain the confidence and skills required managing the seriously injured athlete.
Keywords: workshop; human; athlete; airway; skill; physician; emergency; sport; patient; spine injury; asthma; responsibility; tracheotomy; resuscitation; medical care; sporting event; needle; oxygen therapy; breathing; cervical spine; Australia; pneumothorax; fracture; fluid resuscitation; heart arrhythmia; hospital; emergency care; neurologic disease; model

Functional electrical stimulation: Restoration of respiratory function - Onders R.P. (Handbook of Clinical Neurology, 2012)
Tetraplegia can lead to chronic respiratory failure. The need for tracheostomy mechanical ventilation significantly increases the cost of care, decreases the quality of life of the patient, and decreases life expectancy in spinal cord injury (SCI) because of pneumonias. Phrenic nerve stimulation was initially developed in the 1960s and diaphragm pacing was developed in the 1990s; both have the ability to remove a patient from positive pressure ventilation and allow them to breathe with their own diaphragm, decreasing posterior lung lobe atelectasis and pneumonia risk. This chapter summarizes the current surgical techniques, ventilator weaning options, and long-term results of functional electrical stimulation in restoring respiratory function. © 2012 Elsevier B.V.
Keywords: animal; article; convalescence; diaphragm; diaphragm paralysis; electrotherapy; human; phrenic nerve; physiology; spinal cord injury

Surgical treatment of the lower cervical spine in patients with spinal cord injury - Vastmans J.; Maier D.; Vogel M.; Bühren V.; Högel F. (European Spine Journal, 2012)
Introduction: Aim of this retrospective and case controlled investgation was to examine the treatment strategies after injuries of the cervical spine (C3 bis T1) in patients with spinal cord injuries concerning stability of different stabilization techniques. Our hypothesis was that only anterior stabilization with cages and non-angular stable plates is sufficient regarding postoperative stability. Material and Methods: All patients with spinal cord injury and fractures of the cervical spine (C3-Th1) treated operatively (n= 116, mean age: 48,8 Jahre), from 01/2008 - 12/2010 were examined clinically and by CT scan regarding bony union and stability after 3 and 12 months postoperatively. Results: 54 patients were treated initially in our clinic. 43 of these recieved anterior stabilization after discectomy/corpoectomy and reduction using cages and non angular stable plates. 7 patients sent from other hospitals were revised, 4 patients suffering of Bechterews'disease were treated with addiional stabilization from posterior. The 7 revisions were performed in he technique described above and 4 were treated by posterior stabilization while having an instable anterior stabilization and additional tracheostomy. 62 patients sent from other clinics were treated as following: 6 with cages and 4 with tricortical spill, 49 with anterior angular stable plates - 25 with cages and 24 with tricortical spill, 12 patients with additional posterior stabilization and 3 only by dorsal fixation. In the postopertively performed examinations after 3 and 12 months all of our patients were bony healed in good axial alignment. In 13 patients sent from other hospitals who were treated with a tricortical spill we found one non union; in 10 patients treated with angular stable plates the axis was unchanged and in 4 patients (1 non-angular stable plate, 3 gliding plate) a kyphotic kinking was found. The alignment of the patients treated by anterior and additional posterior stabilization, as well as those patients who were treated by single posterior stabilization no malalignment was observed. Conclusion: Anterior stabilization with discectomy or corporectomy, correct reduction and stabilization with cages and non-angular plates leads to good stability. In certain cases and additional posterior stabilization is requiered. The use of tricortical spill sometimes leads to non-unions.
Keywords: spine; cervical spine; human; spinal cord injury; patient; society; surgery; hospital; pseudarthrosis; computer assisted tomography; fracture; discectomy; examination; hypothesis; tracheostomy; injury

Phrenic nerve stimulation as an alternative to prolonged mechanical ventilation - Stanley E.; Broderick J.; Synnott K.; McCarthy J.; Smith E.; Reid V.; Colreavy F.; Carton E. (Irish Journal of Medical Science, 2012)
A 60 year old previously well male patient sustained a C2 traumatic spinal cord injury after a fall from a horse. He remained on full time ventilatory support via tracheostomy tube. After the integrity of the phrenic nerve was confirmed, internal components of the phrenic nerve stimulator (PNS) were surgically implanted. The duration of PNS breathing was gradually increased with the tracheostomy tube capped to facilitate normal humidification of inspired room air and normal voice during passive exhalation. He could operate his motorised wheelchair with his chin, tolerated normal diet by mouth and had a prolonged period free of lower respiratory tract infections..
Keywords: phrenic nerve; nerve stimulation; artificial ventilation; society; tracheostomy tube; male; spinal cord injury; exhalation; horse; human; nerve stimulator; breathing; humidifier; ambient air; voice; patient; wheelchair; chin; diet; lower respiratory tract infection

Cervical spine trauma in diffuse idiopathic skeletal hyperostosis: Injury characteristics and outcome with surgical treatment - Bransford R.J.; Koller H.; Caron T.; Zenner J.; Hitzl W.; Tomasino A.; Mayer M. (Spine, 2012)
STUDY DESIGN.: Retrospective study of a consecutive series of operatively managed patients with cervical fractures with diffuse idiopathic skeletal hyperostosis (DISH) presenting to 3 institutions over an 8 year period. OBJECTIVE.: Assess demographics, fracture characteristics, outcome and complications in patients managed surgically. SUMMARY OF BACKGROUND DATA.: Cervical spine injuries related to DISH represent a difficult subgroup of trauma patients to treat. This subset is fraught with potential complications related to the injury of the ankylosed spine, high rate of co-morbidities, and older demographics. The data in the literature on treatment, outcomes and complications is largely comprised of case reports and small case series. METHODS.: All patients with cervical fractures in the setting of DISH between January 2001 and December 2008 were reviewed retrospectively. Charts and radiographs were reviewed assessing demographics, injury characteristics and short-term outcomes. Statistical analysis was performed analyzing the impact of distinct parameters on the incidence of medical and surgical complications. RESULTS.: Thirty-three patients with age 73.8 ± 11years were identified. DISH-affected segments numbered 5.5 ± 2.1. Injury severity as assessed by the Subaxial-Injury-Classification scoring-system (SLIC) averaged 7.2 ± 1.4points. 7 patients (20.6%) were ASIA-A on admission, 4 (11.8%) ASIA-B, 4 (11.8%) ASIA-C, 10 (29.4%) ASIA-D, and 7 (20.6%) ASIA-E. All but 2 patients (6%) had medical co-morbidities.Inpatient stay was 26.6 ± 23.4 days. 16 patients (47%) had anterior, 12 patients (35.3%) had posterior, and 5 patients (14.7%) had combined anterior-posterior instrumented fusion. 25 patients (73.5%) had medical/surgical complications. 20 patients (58.8%) suffered serious pulmonary complications not related to the neurologic injury (p < 0.05). Nine patients (26.5%) had died. Seven patients (20.6%) showed improved ASIA-scores, 18 patients (52.9%) had no improvement and 2 patients (5.9%) deteriorated. CONCLUSION.: The current findings pinpoint the potential for medical and surgical complications in this high risk subgroup. Surgeons should be aware of the unique aspects associated with treatment of these injuries. © 2012, Lippincott Williams & Wilkins.
Keywords: adult; aged; anterior spine fusion; artificial ventilation; cervical spine fracture; cervical spine radiography; clinical article; clinical feature; comorbidity; decubitus; deep vein thrombosis; delirium; deterioration; diffuse idiopathic skeletal hyperostosis; dysphagia; female; hospital admission; human; hyperostosis; idiopathic disease; injury severity; intubation; length of stay; lung complication; male; medical record review; mortality; neurological complication; outcome assessment; pneumonia; posterior spine fusion; postoperative complication; priority journal; retrospective study; review; scoring system; surgical infection; tracheostomy; urinary tract infection

Risk factors for heterotopic ossification in patients with spinal cord injury: A case-control study of 264 patients - Citak M.; Suero E.M.; Backhaus M.; Aach M.; Godry H.; Meindl R.; Schildhauer T.A. (Spine, 2012)
STUDY DESIGN.: Case-control study. OBJECTIVE.: We designed a case-control study to analyze the risk factors associated with the development of heterotopic ossification (HO) in patients with traumatic spinal cord injury. SUMMARY OF BACKGROUND DATA.: Patients with spinal cord injury have a high risk of developing HO, although the exact etiopathogenesis is still unknown. Several factors are known to be potential risk factors. However, we are not aware of any large clinical studies evaluating the risk factors for HO. METHODS.: Patients who were treated for a traumatic spinal cord injury in our hospital, and who subsequently developed HO, were identified by querying the electronic database at our hospital from 2002 to 2010. One hundred thirty-two patients and 132 controls were included. Our primary outcome measures were the risk of developing HO according to whether the patient had experienced a complete spinal cord lesion according to American Spinal Injury Association Impairment Scale; tetraplegia or paraplegia; cervical, thoracic, or lumbar injury; severe chest trauma; and the time interval between injury and surgery. Secondary risk factors explored were patient age; sex; presence and number of comorbidities; length of hospital and intensive care unit stay; associated traumatic injuries; presence of spasticity, pressure ulcers, deep venous thrombosis, and urinary tract infection; and pulmonary complications, such as pneumonia and necessity of tracheostomy. RESULTS.: Patients with associated spasticity and thoracic trauma, complete lesion, pneumonia, presence of tracheostomy, and urinary tract infection had a higher risk of developing HO. CONCLUSION.: Adequate management of potential risk factors could help reduce the overall incidence of HO and outcome in patients with traumatic spinal cord injury. © 2012, Lippincott Williams & Wilkins.
Keywords: abdominal injury; adult; age; article; brain injury; case control study; cervical spine injury; comorbidity; controlled study; decubitus; female; gender; head injury; heterotopic ossification; human; intensive care unit; length of stay; limb injury; lumbar spine; lung complication; major clinical study; male; outcome assessment; paraplegia; pelvis injury; pneumonia; priority journal; quadriplegia; risk assessment; risk factor; spasticity; spinal cord injury; thoracic spine; thorax injury; tracheostomy; urinary tract infection

Nonaneurysmal cerebellar subarachnoid haemorrhage as rare complication of lumbar disc surgery - Knoop M.; Allen C. (European Spine Journal, 2012)
Introduction: The rates of intraoperative dural tear range from 3.5 % for primary lumbar discectomy to over 10 % for lumbar revision discectomy. Most of the reported cases of intracranial haemorrhage after spinal surgery involved intraoperative dural tearing or cerebrospinal fluid (CSF) leakage. We report a case in which nonaneurysmal cerebellar subarachnoid haemorrhage after occurred lumbar revision discectomy and review the literature. Material and Methods: A 70-year-old man with a history of smoking and adipositas presented clinical signs and symptoms and MR imaging studies consistent with a reherniated nucleus pulposus at the L4-L5 disc space. He underwent a lumbar revision discectomy. Intraoperatively, an incidental durotomy occurred and was repaired uneventfully. One closed suction drain was placed subfascial. Shortly after extubation the patient had a reduced level of consciousness. Two hours postoperatively, the drain had drawn 250 ml clear fluid tinged with blood, consistent with CSF. The man developed severe headache, and lost consciousness. The emergency computed tomographic scan showed an atypical cerebellar subarachnoid haemorrhage in the sulci as well as haematom of cortex of both cerebellar hemispheres. Haemorrhage and edema led to compression of the fourth ventricle and subsequent non-communicating hydrocephalus. The subfascial wound drain was removed. The patient was immediately transferred to the operation room for external ventricular drain and suboccipital decompression. Angiography did not reveal the focus of bleeding. Tracheotomy was performed. Concomitantly, the patient developed pneumonia, Clostridium difficile associated diarrhea, meningitis and epileptic seizures as well as a coagulation disorder. Over the next weeks the patients state of consciousness improved. Five weeks postoperatively, the man was transferred to a rehabilitation department, two months later he died there. Conclusion: The reported case adds to the literature on complication in lumbar disc surgery. Nonaneurysmal cerebellar subarachnoid haemorrhage is a rare but potentially lethal complication of lumbar disc surgery. The postoperative CSF loss as a possible mechanism for this cerebellar subarachnoid haemorrhage. Preventing dural injury during spinal surgery, dural repair and minimizing CSF loss after intraoperative dural tearing, especially during suction drain, would be helpful to prevent cerebellar subarachnoid haemorrhage.
Keywords: spine; subarachnoid hemorrhage; lumbar disk; surgery; society; human; discectomy; patient; consciousness; male; spine surgery; bleeding; cerebrospinal fluid; suction drainage; nucleus pulposus; operating room; tracheotomy; nuclear magnetic resonance imaging; brain hemorrhage; brain fourth ventricle; edema; hemisphere; physical disease by body function; obesity; computer assisted tomography; emergency; smoking; headache; blood; compression; communicating hydrocephalus; wound drain; lacrimal fluid; decompression; angiography; pneumonia; liquid; injury; rehabilitation center; blood clotting disorder; seizure; meningitis; Clostridium difficile infection; extubation; liquorrhea

Diaphragmatic pacing stimulation in spinal cord injury: Anesthetic and perioperative management - Tedde M.L.; Filho P.V.; Hajjar L.A.; de Almeida J.P.; Flora G.F.; Okumura E.M.; Osawa E.A.; Fukushima J.T.; Teixeira M.J.; Galas F.R.B.G.; Jatene F.B.; Auler Jr. J.O.C. (Clinics, 2012)
OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilatordependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov: NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results. © 2012 CLINICS.
Keywords: NCT01385384; adolescent; adult; anesthesia; article; artificial heart pacemaker; artificial ventilation; controlled clinical trial; controlled study; diaphragm; electrotherapy; female; human; implantation; laparoscopy; male; methodology; perioperative period; quadriplegia; spinal cord injury; time; treatment outcome

Congenital paediatric atlantoaxial dislocation: Clinico-radiological profile and surgical outcome - Mehrotra A.; Nair A.P.; Das K.; Chunnilal J.S.; Srivastava A.K.; Sahu R.; Kumar R. (Child's Nervous System, 2012)
Introduction Congenital atlantoaxial dislocation (AAD) is the most common bony abnormality affecting the craniovertebral junction. The paediatric population has specific problems like preoperative diagnostic difficulties, precise neurological examination, radiological diagnosis, surgical problems including physical fitness to tolerate surgery (including problems of anaesthesia), technical difficulties in surgery and problems related to immobilization Material and methods A total of 229 consecutive paediatric (≤18 years) patients of AAD visited our centre from the period of January 1997 to August 2011. Twenty-nine cases were excluded from the study as these cases were diagnosed as CVJ tuberculosis, 31 cases were excluded as they were traumatic and the remaining 169 cases were retrospectively analysed. These patients were operated by a single experienced surgeon (the senior author) at the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow. The preoperative and the postoperative clinical evaluation of the patient was done by the Kumar and Kalra myelopathic scoring system. The score was recorded in the preoperative period, at the time of discharge, at 3 months follow-up and at 6 months follow-up. Results Ninety-four were males and 75 were females. The age range was 4 to 18 years with mean age 9.96±3.78 years. The follow-up ranged from 3 to 120 months with mean follow-up being 39.03±13.38 months. One hundred five cases were of fixed/irreducible AAD, and 64 were cases of mobile/reducible AAD. Majority of these cases presented with features of pyramidal tract involvement, and 108 cases had compromised pulmonary function test. One hundred thirty-seven cases had improved outcome, and 18 cases were in the same grade in the postoperative period with only 14 cases either deteriorated or died. Conclusions Congenital paediatric AAD are a different subset of abnormalities and have a satisfactory outcome. Preoperative evaluation must also include identification of various syndromes associated with paediatric AAD and respiratory reserve. Cormack-Lehane grade can be helpful in selecting borderline cases for postoperative need of tracheostomy. Majority of the cases have a good outcome, and therefore, surgery should be offered even in severe grade. © Springer-Verlag 2012.
Keywords: adolescent; adult; article; atlantoaxial dislocation; child; clinical feature; female; follow up; human; immobilization; Kumar and Kalra myelopathic scoring system; lung function test; major clinical study; male; postoperative period; preoperative period; preschool child; priority journal; retrospective study; school child; scoring system; treatment outcome

Mechanical airway obstruction due to dislodged spinal hardware - Petrovic M.A.; Kretzer R.; Simon B.A.; Berkow L.C. (Journal of Clinical Anesthesia, 2012)
A difficult airway caused by mechanical obstruction from dislodged spinal hardware in a patient undergoing revision surgery for a cervical chordoma is presented. Due to the logical, sequential multidisciplinary airway and patient management by the anesthesiology, neurosurgery, and otolaryngology teams working together in an environment of clear communication, a potential life-threatening crisis was averted with successful outcome for the patient. © 2012 Elsevier Inc.
Keywords: ketamine; midazolam; adult; airway obstruction; article; case report; cervical hardware; chordoma; computer assisted tomography; fiberoptic intubation; human; intubation; male; medical device; neurosurgery; priority journal; prosthesis complication; spine radiography; spine tumor; tracheostomy

Endoscopic endonasal odontoidectomy in a child with chronic type 3 atlantoaxial rotatory fixation: Case report and literature review - Patel A.J.; Boatey J.; Muns J.; Bollo R.J.; Whitehead W.E.; Giannoni C.M.; Jea A. (Child's Nervous System, 2012)
Introduction Although the transoral transpharyngeal approach has been the standard approach to decompress the odontoid process, it bears some disadvantages including risk of infection, prolonged intubation or tracheostomy, need for nasogastric tube feeding, extended hospitalization, and possible effects of phonation. The endoscopic transnasal approach is a viable alternative, managing to avoid some of the pitfalls of the more accepted transoral transpharyngeal approach. However, there have only been a handful of adult cases and only three pediatric cases Case report We present the case of a 10-year-old girl with a chronic type 3 atlantoaxial rotator fixation and significant spinal cord compression from basilar invagination and a displaced odontoid process. We performed an endoscopic endonasal odontoidectomy prior to posterior occiptocervical fusion on the patient. She was neurologically intact with a well-healed wound at 7-month follow-up. © Springer-Verlag 2012.
Keywords: atlantoaxial rotatory fixation; atlantoaxial subluxation; bone radiography; case report; child; chronic disease; computer assisted tomography; decompression surgery; endoscopic endonasal odontoidectomy; endoscopic surgery; motor evoked potential; somatosensory evoked potential; female; fluoroscopy; follow up; fracture fixation; human; laminectomy; open reduction (procedure); pediatric surgery; priority journal; review; school child; spinal cord compression; spine fusion; surgical approach

Predicting the need for tracheostomy in patients with cervical spinal cord injury - Leelapattana P.; Fleming J.C.; Gurr K.R.; Bailey S.I.; Parry N.; Bailey C.S. (Journal of Trauma and Acute Care Surgery, 2012)
BACKGROUND: Approximately 75% of hospitalized patients with a cervical spinal cord injury (CSCI) will require intubation and mechanical ventilation (MV) because of compromised respiratory function. It is difficult to predict those CSCI patients who will require prolonged ventilation and therefore will most benefit from early tracheostomy. This study intended to show the benefits of tracheostomy, particularly early, and to identify predictors of prolonged MV after CSCI. METHODS: A retrospective review of patients aged 16 years and older with acute CSCI admitted to London Health Science Center from 1991 to 2010 was performed. Demographic data and clinical parameters were extracted from medical records and the trauma registry. Regression analysis was used to identify predictors of prolonged MV. RESULTS: There were 66 eligible patients of which 42 (62%) had a tracheostomy performed. Five patients (7.6%) remained ventilator dependent and seven (10.6%) died more than 7 days after injury secondary to sepsis. After adjusting for the number of ventilator days after injury, patients who had a tracheostomy had fewer pulmonary complications than those who did not have a tracheostomy (p = 0.001). Early tracheostomy resulted in fewer days on the ventilator and a shorter hospital stay. Clinical parameters that predicted MV to be required longer than 7 days were Injury Severity Score > 32, complete SCI, and a PAO2/FIO2 ratio < 300 3 days after MV was initiated. CONCLUSION: We recommend early tracheostomy if the Injury Severity Score is >32, the patient has a complete SCI, and the PAO2/FIO2 ratio is <300 3 days after MV was initiated. LEVEL OF EVIDENCE: Prognostic study, level III. © 2012 Lippincott Williams & Wilkins.
Keywords: adolescent; adult; aged; article; artificial ventilation; cervical spinal cord injury; controlled study; disease registry; female; hospitalization; human; injury scale; lung complication; major clinical study; male; medical record review; prediction; priority journal; scoring system; sepsis; tracheostomy; ventilator

Benefits of performing early tracheostomy in the intensive care unit of a secondary level hospital of north india, our two years experiences - Dhanda D.; Dhanda N.C. (Intensive Care Medicine, 2012)
INTRODUCTION. In most of the intensive care units tracheostomy is being performed on many patients who needs long term ventilatory support. The patients always do get benefited after the tracheostomy. Though there is always debate about the timing of tracheostomy and technique of procedure. OBJECTIVES. To find out the benefits of performing early tracheostomy in the intensive care unit on the patients requiring long term ventilatory support. METHODS. The study was conducted in 14 bedded intensive care unit of secondary level hospital in India over a period of 2 years (from April 2010 to March 2012). Total of 64 tracheostomies were performed over this period on the patients who needed long term ventilatory supports. Out of which 52 were male patients and 12 were females. Age of the patients were between 22 and 70 years. After the procedure weaning time from the ventilator was noted. Most of the procedures were performed by percutaneous technique. RESULTS. The common diagnosis of the patients were brain injuries extradural and subdural hemorrhages 65 %, stroke 25 %, spinal injuries and other diagnosis 10 %.We performed tracheostomy within 7 days of the start of ventilation in most of the patients. After tracheostomy most of the patients (56 %) were able to be weaned off from the ventilatory support within next 2 days and subsequently were shifted out of the intensive care unit to wards. The patients who expired in the intensive care unit were around 24 % and patients who were shifted to other centers for further management were around 20 %. Most frequent complications of the procedures were bleeding and endotracheal tube cuff perforation. CONCLUSIONS. The early performing of tracheostomy (within 5 days) resulted in decrease in peak air way pressure of the ventilator, decrease in requirement of the sedatives to the patients, helping in early weaning from the ventilator, increasing effectiveness of chest physiotherapy in removing the retained secretions. Here in our institute we have been performing the early tracheostomy in the patients who need long term ventilatory support or who we find difficult to wean from ventilator early.
Keywords: sedative agent; intensive care unit; hospital; India; society; intensive care; tracheostomy; human; patient; ventilator; procedures; weaning; diagnosis; spine injury; cerebrovascular accident; subdural hematoma; breathing exercise; brain injury; endotracheal tube cuff; air conditioning; bleeding; ward; perforation; bodily secretions; male; female

Cervicothoracic spinal cord and pontomedullary injury secondary to high-voltage electrocution: A case report - Johl H.K.; Olshansky A.; Beydoun S.R.; Rison R.A. (Journal of Medical Case Reports, 2012)
Introduction: High-voltage electrical injuries are uncommonly reported and may predispose to both immediate and delayed neurologic complications. Case presentation: We report the case of a 43-year-old Caucasian man who experienced a high-voltage electrocution injury resulting in ischemic myelopathy and secondary paraparesis. Conclusion: High-voltage electrocution injuries are a serious problem with potential for both immediate and delayed neurologic sequelae. The existing literature regarding effective treatment of neurologic complications is limited. Long-term follow-up and multidisciplinary management of these patients is required. © 2012 Johl et al.; licensee BioMed Central Ltd.
Keywords: adult; article; brain infarction; brain injury; clinical article; electric burn; electrolyte intake; flaccid paralysis; fluid resuscitation; gastrostomy; human; male; medulla oblongata; neurologic examination; nuclear magnetic resonance imaging; nutritional support; paraplegia; priority journal; spinal cord injury; tracheostomy; wound care

Expulsion of a screw by cough subsequent to anterior cervical spinal fusion: A case report - Shamim F.; Formal C.S.; Shamim R.S. (PM and R, 2012)
Case Description: A 37-year-old man presented to the emergency department reporting that he “coughed up a screw.” He had noticed difficulty swallowing and coughing while eating. History included anterior cervical discectomy and fusion (ACDF) 11 years prior. A radiograph of the cervical spine demonstrated C3-C7 instrumentation held in place by 3 screws, in contrast to a chest radiograph for dysphagia evaluation 4 months prior demonstrating 3 intact screws and 1 loose screw. We believe that the loose screw penetrated the esophagus and trachea, producing esophageal perforation with dysphagia, tracheo-esophageal (T-E) fistula formation, and aspiration. The screw was then expelled by the patient via a cough mechanism. Program Description: ACDF can cause acute complications including dysphagia, esophageal perforation, and worsening of preexisting myelopathy. Late complications include screw loosen-ing and development of a fistulous tract into the esophagus with esophageal perforation by a loose screw. T-E fistula formation is not a described complication of ACDF. Setting: Tertiary care hospital. Results or Clinical Course: Direct laryngoscopy and esophagoscopy demonstrated a T-E fistula and posterior esophageal perforation. The patient received a tracheostomy for airway protection, as well as a gastrostomy-jejunostomy (G-J) tube to minimize the risk of aspiration. The patient was placed on clindamycin for prevention of aspiration pneumonia. Two months after presentation, the patient underwent a T-E fistula repair without complication. After the T-E fistula was healed and closed, the spine hardware was removed. Discussion: While there have been numerous case reports describing esophageal perforation of screws that have migrated away from an anterior cervical plate and passed through the GI tract without morbidity, there is no literature documenting T-E fistula formation and expulsion of a screw by cough. Conclusions: This complication was associated with significant morbidity and caused this patient to undergo 3 secondary surgeries. Hardware complications should be considered in the differential diagnosis for evaluating dysphagia and aspiration in patients with a history of anterior cervical fusion. Recognition and treatment of dysphagia due to hardware dysfunction 4 months prior may have prevented T-E fistula formation and 3 secondary surgeries.
Keywords: clindamycin; spine fusion; human; case report; physical medicine; rehabilitation; coughing; fistula; patient; esophagus perforation; dysphagia; computer; aspiration; morbidity; esophagus; surgery; X ray film; male; spine; aspiration pneumonia; differential diagnosis; trachea; discectomy; tube; gastrostomy; thorax radiography; tracheostomy; esophagoscopy; airway; protection; eating; jejunostomy; risk; laryngoscopy; prevention; disease course; hospital; devices; tertiary health care; spinal cord disease; cervical spine; swallowing; emergency ward

Post-critical care rehabilitation units: An essential link after intensive care units? - Luauté J.; Tell L. (Annals of Physical and Rehabilitation Medicine, 2012)
The concept of post-critical care rehabilitation units emerged in France at the end of the twentieth century when progress in acute neurological care allowed brain or spinal injured patients to survive, but with severe impairments. Brain injured patients who have suffered a coma, and patients with tetraplegia, require important medical supervision with a dedicated program of rehabilitation and are the most likely to benefit from this type of environment. As opposed to critical care, patients should not be in a life-threatening condition. They may have a tracheotomy and/or a gastrostomy but fractures should have been treated before admission. A specific organisational structure is necessary in regard to the number of caregivers and rehabilitation professionals in order to manage medical events still frequent at this stage (e.g., agitation, neurovegetative crisis, complications of immobility), technical cares (e.g., tracheotomy, gastrostomy, intermittent bladder irrigation) and high dependency. Besides minimising the consequences of immobility, especially respiratory complications, the functional assessment and rehabilitation of impairments are central at this point as these are often not investigated sufficiently in intensive care units. Evaluation of awareness may be a specific goal for patients with chronic conscious disorders before the orientation toward units dedicated for vegetative and minimally conscious states. An increased number of post-acute rehabilitation units have been created in recent years but the status and the funding of this type of organisation is still not clear within the French care system.
Keywords: intensive care; rehabilitation; intensive care unit; adaptation; human; patient; tracheotomy; immobilization; brain; gastrostomy; minimally conscious state; functional assessment; environment; quadriplegia; coma; bladder irrigation; agitation; caregiver; fracture; diseases; funding; France

Postoperative emergence in patients undergoing cardiac surgery with cardiopulmonary bypass-a retrospective study - Uehara K. (Journal of Neurosurgical Anesthesiology, 2012)
Introduction: Neurologic deficits after cardiac surgery with cardiopulmonary bypass (CPB) are serious complications. Accelerated recovery is recommended for detecting neurologic complications. Remifentanil has become one of the most widely used anesthetic agents for early emergence, but there is limited information about recovery. In this study, clinical recovery of patients undergoing cardiac surgery was evaluated. Methods: We consecutively conducted a retrospective analysis of adult patients who underwent cardiac surgery with CPB at the Hiroshima City Hospital between January and June 2011. Seven patients who underwent descending thoracic aortic graft replacement were excluded because of the risk of spinal cord ischemia. Emergence was defined as nodding the head or making a grip in response to a verbal command. Results: There were 42 males and 25 females with a mean age of 67.2 years (SD, 13.8 y). Anesthesia was maintained with sevoflurane-remifentanil (pre-CPB) or propofol-remifentanil (during and post-CPB) except for 1 case. The mean operation time was 373 minutes (SD, 134 min). Eighteen patients who received propofol sedation recovered on postoperative day (POD) 0 or 1. Propofol was discontinued in 49 patients on POD 0 (n=15), POD 1 (n=32), POD 2 (n=1), or POD 3 (n=1). The mean time to emergence from propofol was 138 minutes (132 min). Neurologic complications were detected in 3 (4.5%) of the 67 patients. The first patient presented with anisocoria and the second patient presented with right upper extremity paralysis after recovery of consciousness. Computed tomography (CT) revealed ischemic stroke in both cases. The third patient recovered on POD 1. However, she did not fully recover after resedation followed by tracheotomy. CT showed no new lesion. Conclusions: Sixty-seven patients undergoing cardiac surgery with CPB emerged from remifentanil-based anesthesia on POD 0 (n=14), POD 1 (n=49), POD 2 (n=3), or POD 3 (n=1). The mean time to recovery of consciousness after propofol sedation was 138 minutes. The incidence of neurologic complications was 4.5% (n=3). CT revealed ischemic stroke in 2 patients and no finding in 1 patient.
Keywords: propofol; remifentanil; sevoflurane; anesthetic agent; nitrogen 15; human; cardiopulmonary bypass; heart surgery; intensive care; retrospective study; society; Japanese (people); anesthesia; patient; neurological complication; brain ischemia; consciousness; sedation; spinal cord ischemia; tracheotomy; risk; computer assisted tomography; aortic graft; paralysis; arm; anisocoria; hospital; city; operation duration; adult; male; female

Open repair of chronic distal aortic dissection in the endovascular era: Implications for disease management - Pujara A.C.; Roselli E.E.; Hernandez A.V.; Vargas Abello L.M.; Burke J.M.; Svensson L.G.; Greenberg R.K. (Journal of Thoracic and Cardiovascular Surgery, 2012)
Objective: Controversy surrounds the treatment of chronic aortic dissection. Open surgical and endovascular experiences include mixed populations treated with evolving strategies and limited follow-up. We establish a standard against which endovascular repair can be compared by assessing outcomes after open repair of chronic distal aortic dissections anatomically suitable to stent-grafting. Methods: From 2000 to 2008, 169 patients underwent open repair of the descending thoracic artery only (n = 88) or thoracoabdominal (n = 81) chronic aortic dissection (elective in 98, urgent/emergency in 71). Chart review and 3-dimensional assessment of computed tomography were performed. Poor outcome included all-cause mortality or vascular reintervention. Results: Thirty-day mortality was 8% (n = 14). Serious complications included neurologic (n = 12 [spinal cord n = 4, 2.4%]), respiratory (n = 32), and renal failure (n = 1 descending thoracic artery only vs 17 thoracoabdominal, P < .001). Chronic obstructive pulmonary disease predicted early mortality (hazard ratio 8.0, P = .005). Survival at 1, 2, and 5 years was 76%, 69%, and 55%, respectively; 23 patients (14%) required reintervention. Event-free survival at 5 years was 51% and 47% after descending thoracic artery only or thoracoabdominal repair, respectively. Greater maximum aortic diameter (hazard ratio 1.9, P = .03) and greater diameter at the diaphragm (hazard ratio 3.7, P = .01) or renal segment (hazard ratio 4.3, P = .03) predicted poor outcome. Conclusions: Early outcomes are good and late outcomes are less than desirable after open repair of chronic distal aortic dissection, regardless of the extent of repair. High-risk and late-stage patients with larger and more extensive aneurysmal degeneration warrant further investigation, including the use of newer, less-invasive techniques. Select patients at risk for aneurysmal degeneration should undergo a more aggressive initial approach with aortic dissection repair.
Keywords: adult; aged; aortic dissection; artery diameter; article; chronic obstructive lung disease; computer assisted tomography; diaphragm; endovascular surgery; event free survival; female; follow up; human; kidney disease; kidney failure; length of stay; major clinical study; male; medical record review; neurological complication; paralysis; paraplegia; priority journal; respiratory failure; respiratory tract disease; retrospective study; thoracic aortic surgery; tracheostomy

Evaluation of the activity in the rehabilitation and post-intensive care departments in the Toulouse university hospital - Montaut C.; Terracol C.; De Boissezon X.; Marque P.; Labrunee M.; Castel-Lacanal E. (Annals of Physical and Rehabilitation Medicine, 2012)
Introduction and objectives.- In the Service of Physical Medicine and Rehabilitation Toulouse University Hospital, 6-bed rehabilitation postreanimation (RPR) were opened in August 2008. After more than three years, we review this new activity. Method.-We analyzed the epidemiological data (age, sex), the original service, the primary pathology, duration of stay and mode of exit. Results.- Hundred and eight patients (73 men 68% and 35 women 32%) aged 49.6 ± 16.4 years stayed in our unit RPR, for an average of 64.5 ± 66 days. The reason for these hospitalizations was the consequences of a “reanimation” in 37 patients (34%), 22 (20%) were tracheostomized and four (4%) under controlled ventilation, nine were in the process of awakening (8%) and nine (8%) with behavioral disorders that require monitoring. The original service was neurology for 25 patients (23%), neurosurgery in 24 patients (22%), the unit of organ transplantation in 10 patients (9%) and the intensive care unit for nine patients (8%). The main pathology was stroke in 28 patients (26%), spinal cord injury in 19 patients (18%), multiple sclerosis in nine patients (8%) and transplantation in eight patients (7%). Forty-three patients (40%) went in our area of traditional hospitalization, 15 (14%) went to another department follow-up care and 26 (24%) returned home, including four hospitalization at home. One died in the service Conclusion.- This activity rehabilitation post-reanimation corresponds to a real need for public health, and patients may benefit from specific rehabilitation associated with appropriate and specialized medical care. The duration of stay is long and we must improve our collaboration with other post-acute unit, in particular the early learning centers.
Keywords: intensive care unit; rehabilitation; adaptation; university hospital; epidemiology; human; patient; hospitalization; resuscitation; pathology; spinal cord injury; cerebrovascular accident; epidemiological data; neurosurgery; monitoring; male; physical medicine; behavior disorder; neurology; medical care; organ transplantation; arousal; artificial ventilation; follow up; transplantation; multiple sclerosis; public health; learning; female

Neck Neoplastic Conditions in the Emergency Setting: Role of Multidetector Computed Tomography - Caranci F.; Brunese L.; Reginelli A.; Napoli M.; Fonio P.; Briganti F. (Seminars in Ultrasound, CT and MRI, 2012)
Emergent conditions resulting from head and neck neoplasms and their treatment include acute airway obstruction, hemorrhage, spinal cord compression, bilateral vocal cord paralysis, and septic thrombophlebitis. These conditions require accurate diagnosis and rapid intervention to avoid severe permanent damage or death. Successful treatment requires a coordinated response by emergency medicine physicians, otolaryngologists, vascular surgeons, and radiologists. We review these head and neck oncological conditions, whichpresent emergently, with a focus on radiological evaluation and interpretation.© 2012 Elsevier Inc.
Keywords: antibiotic agent; dexamethasone; steroid; acute airway obstruction; acute neck soft tissue hemorrhage; airway obstruction; anaplastic carcinoma; article; cancer radiotherapy; conventional angiography; diagnostic value; drug megadose; dyspnea; emergency medicine; head and neck disease; head and neck squamous cell carcinoma; head and neck tumor; hemoptysis; human; laryngoscopy; larynx disorder; multidetector computed tomography; nuclear magnetic resonance imaging; perfusion weighted imaging; predictive value; priority journal; respiratory distress; septic thrombophlebitis; septic thrombophlebitis; spinal cord compression; stridor; supralaryngeal obstruction; supralaryngeal obstruction; thrombophlebitis; tracheostomy; vocal cord paralysis

The prevalence of malnutrition in spinal cord injuries patients: A UK multicentre study - Wong S.; Derry F.; Jamous A.; Hirani S.P.; Grimble G.; Forbes A. (British Journal of Nutrition, 2012)
Data on the prevalence of malnutrition among patients with spinal cord injuries (SCI) are lacking. The aim of the present study was to assess nutritional risk at admission, and the status of nutritional support in the UK SCI Centres (SCIC); a cross-sectional, multicentre study in four SCIC. A standardised questionnaire was used and distributed to the participating SCIC. After obtaining informed consent, baseline demographic data, nutritional risk score by the 'Malnutrition Universal Screening Tool', BMI and routine blood biochemistry were collected from every patient admitted to an SCIC. The four SCIC, comprising 48·2 % of the total UK SCI beds, contributed data from 150 patients. On admission, 44·3 % of patients were malnourished or at risk of undernutrition. Nutritional risk was more common in patients with acute high cervical SCI than those with lower SCI (60·7 v. 34·5 %), and nutritional risk was more common in those with additional complications including ventilatory support (with tracheostomy, 56·3 v. 38·7 %). Also, 45 % of patients were at risk of overnutrition (BMI ≥ 25 kg/m 2). The prevalence of malnutrition in SCI patients admitted to SCIC is higher than national figures focused on general hospitalised patients, indicating that SCI patients are particularly vulnerable to malnutrition. Patients with SCI who have a tracheostomy may need additional attention. Given the potential negative impact of malnutrition on clinical outcomes, an emphasis on mandatory nutrition screening, followed by detailed assessment for at-risk individuals should be in place in the SCIC. © 2011 The Authors.
Keywords: albumin; creatinine; hemoglobin; magnesium; adult; age distribution; aged; albumin blood level; article; artificial ventilation; body mass; cervical spinal cord injury; controlled study; creatinine blood level; cross-sectional study; decreased appetite; disease association; disease predisposition; female; hemoglobin blood level; high risk patient; human; length of stay; magnesium blood level; major clinical study; male; malnutrition; nutritional assessment; nutritional status; nutritional support; overnutrition; prevalence; risk assessment; spinal cord injury; tracheostomy; vulnerable population

Percutaneous tracheostomy in patients with cervical spine immobilization - Haque A.; Rajajee V.; Fletcher J. (Neurocritical Care, 2012)
Introduction: Cervical Spine Immobilization (CSI) is a relative contraindication for percutaneous dilatational tracheostomy (PDT) because of the inability to extend the neck, making tracheal puncture at the correct level more challenging. Patients with CSI routinely undergo PDT at our institution, however, with both traditional bronchoscopic as well as with real-time ultrasound (RTU) guidance. Our objective was to review the incidence of complications related to PDT in patients with CSI versus patients without CSI. Methods: We reviewed the records of consecutive patients who underwent PDT performed by a single operator at our neurocritical care unit between 6/2008-5/2012. All patients requiring tracheostomy are screened for eligibility for PDT by the attending neurointensivist on service. We recorded the percentage of patients who successfully underwent PDT vs requiring conversion to surgical tracheostomy, the specific guidance used (bronchoscopy, RTU) and all short- and long-term complications including placement of the tube above the first tracheal ring. Results: A total of 112 patients underwent PDT performed by a single neurointensivist. All patients screened by the operator underwent an attempt at PDT, and all patients successfully completed the procedure without conversion to surgical tracheostomy. Ninety-eight of 112 (87%) did not require CSI and 14 (13%) required CSI. In the CSI group, bronchoscopy alone was used in 6/14 (43%) and bronchoscopy plus RTU in 8/14 (57%). No complications occurred in the CSI group. In the no-CSI group, there were 3 (3%) complications (one tracheal granuloma and two tube dislodgments within 7 days). No other short or long term complications were recorded. All tubes were placed below the first tracheal ring. Conclusions: It is feasible to safely perform PDT in patients with Cervical Spine Immobilization using bronchoscopic and real-time ultrasound guidance.
Keywords: patient; human; cervical spine; immobilization; society; tracheostomy; bronchoscopy; tube; real time echography; granuloma; procedures; puncture; neck

A single instituitional experience of 42 cases of pediatric cervical spine trauma from India : Are they different from adult cervical trauma - Gupta D.; Prasad G.L.; Dash C.; Mahapatra A.K.; Agrawal D. (Child's Nervous System, 2012)
Introduction: Pediatric cervical spine injuries are relatively uncommon . Falls are themost common cause. Children have relatively high incidence of upper cervical injuries and their management includes conservative and surgical methods. Objectives: This study was carried out to analyse the epidemiologic profile of pediatric cervical spine injuries and to evaluate the clinico-radiological characteristics of cervical spine injuries in children, to correlate the outcome with the clinico-radiological features. Methodology: Prospective cum retrospective data analysis ( 2008- 2011) at JPN apex trauma centre, New Delhi, India. 42 children (0-18 yrs) were operated during this period. Fall from height was noted in 27 cases, upper cervical spine injuries in 12/42 cases( odontoid fractures in 6 cases). Associated injuries were noted in 8 cases, preop ASIAAscore was noted in 16 cases. Two cases had preop systemic hypotension and required ventilator support. Anterior only approach was used in 26 cases( 61 %). Postoperative VAP was noted in 28 % cases, 38 % required tracheostomy, perioperativemortality noted in 2 cases. Implant failure on long term follow up seen in 2 cases.. 13 of 16 children who came for follow up had become independent for ADL( 81 %) at a follow up range of 4-40 months. Conclusions: Ligamentous injuries are commoner in pediatric patients, fall from height most commonly noted in Indian population, subaxial trauma more common than upper cervical trauma. 81 % had good outcome at last follow up. Such observation warrants aggressive surgical approach in pediatric population to give them better neurological outcome.
Keywords: cervical spine injury; society; adult; neurosurgery; India; human; injury; follow up; child; height; population; odontoid process fracture; patient; implant; data analysis; tracheostomy; ventilator; hypotension; Indian; surgical approach; methodology

Dysphagia and associated respiratory considerations in cervical spinal cord injury - Chaw E.; Shem K.; Castillo K.; Wong S.; Chang J. (Topics in Spinal Cord Injury Rehabilitation, 2012)
Background: Dysphagia is a relatively common secondary complication that occurs after acute cervical spinal cord injury (SCI). The detrimental consequences of dysphagia in SCI include transient hypoxemia, chemical pneumonitis, atelectasis, bronchospasm, and pneumonia. The expedient diagnosis of dysphagia is imperative to reduce the risk of the development of life-threatening complications. Objective: The objective of this study was to identify risk factors for dysphagia after SCI and associated respiratory considerations in acute cervical SCI. Methods: Bedside swallow evaluation (BSE) was conducted in 68 individuals with acute cervical SCI who were admitted to an SCI specialty unit. Videofluroscopy swallow study was conducted within 72 hours of BSE when possible. Results: This prospective study found dysphagia in 30.9% (21 out of 68) of individuals with acute cervical SCI. Tracheostomy (P =.028), ventilator use (P =.012), and nasogastric tube (P =.049) were found to be significant associated factors for dysphagia. Furthermore, individuals with dysphagia had statistically higher occurrences of pneumonia when compared with persons without dysphagia (P <.001). There was also a trend for individuals with dysphagia to have longer length of stay (P =.087). Conclusion: The role of respiratory care practitioners in the care of individuals with SCI who have dysphagia needs to be recognized. Aggressive respiratory care enables individuals with potential dysphagia to be evaluated by a speech pathologist in a timely manner. Early evaluation and intervention for dysphagia could decrease morbidity and improve overall clinical outcomes. © 2012 Thomas Land Publishers, Inc.
Keywords: abnormal respiratory sound; acute disease; adult; article; cervical spinal cord injury; clinical evaluation; controlled study; disease association; dysphagia; female; human; length of stay; major clinical study; male; nasogastric tube; physician; pneumonia; postoperative complication; prospective study; respiratory care; risk factor; speech therapy; spine surgery; swallowing; tracheostomy; ventilator

A retrospective review of the spinal fusion outcomes and complications for a pediatric cohort receiving long-term mechanical ventilation in the pre-operative period - Amin R.; Chowdhury F.; Zeller R. (American Journal of Respiratory and Critical Care Medicine, 2012)
Rationale To determine the spinal fusion outcomes and complications of pediatric patients maintained on pre-operative long-term non-invasive positive pressure ventilation (NiPPV). Methods A retrospective chart review was conducted on patients receiving pre-operative long-term NiPPV who underwent spinal fusion surgery between January 2002 and June 2010, at SickKids hospital, Toronto. Neuromuscular patients not receiving pre-operative NiPPV matched for age, sex and Cobb angle (±20° up to 80° or ≥80°) served as the controls. Outcome measures included Cobb angle, duration of stay in hospital and the intensive care unit, pulmonary and other complications, mortality rate and need for tracheostomy. Results Sixteen patients (6 male) receiving pre-operative long term NiPPV underwent spinal fusion during the study period; 32 patients (12 male) served as controls. The median age at surgery for the ventilated patients (VP) and control patients (CP) was 13 years (range 8-16) and 14 years (range 9-18), respectively. The median pre-operative Forced Vital Capacity (FVC) was 0.50L (range 0.29-1.82) and 1.57L (range 0.62-3.28), respectively for the VP and CP (p=0.001). Four of the VP but none of the CP had FVC less than 500ml preoperatively. The median preoperative Cobb angle was 81° (range 38-116) for the VP and 79° (range 31-120) for the CP. This changed to 34° (range 23-71.7) and 39° (range 30-54) after spinal fusion. The improvement in Cobb angle was not different between groups. All the VP underwent posterior fusion. The surgical approach for the CP was posterior for 26 patients, anterior for 1 patient, staged for three and non-staged anterior release and posterior fusion for one. The median hospital stay for VP was 8.5 days (range 6-29) and 11.0 days (6-57) for CP (p=0.4). The median intensive care unit stay for the VP was 6.1 days (range 1-24) and 1.5 days (1-8) for the CP (p=0.01). Five of the CP required short term NiPPV post-operatively. The median supplemental oxygen usage for VP was 2.0 days (range 0-7) and 4.1 days (range 0-27 ) for the CP (p=0.1). Twelve (75%) VP developed pulmonary complications as compared to 16 (50%) CP. Lower limb paralysis which resolved occurred in 1 VP. There were no mortalities or tracheostomy insertions in either group. Conclusions Patients with pre-operative long term NiPPV can be safely operated on for correction of their deformity. Therefore, the option of surgical correction should be offered to these patients to maximize function and quality of life despite the cardiorespiratory risks.
Keywords: oxygen; spine fusion; artificial ventilation; American; society; human; patient; Cobb angle; surgery; tracheostomy; hospital; male; mortality; intensive care unit; quality of life; deformity; paralysis; hospitalization; medical record review; surgical approach; forced vital capacity; positive end expiratory pressure; ventilated patient; leg; risk

Ultrasound-guided continuous paravertebral block in isolated thoracic trauma-providing sufficient analgesia for weaning and non-invasive-ventilation (NIV) on ICU for a 46 year old patient after high-speed trauma - Reisig F.; Buettner J. (Ultraschall in der Medizin, Supplement, 2012)
Purpose: After acute high-velocity injury it is desirable to avoid thoracic epidural analgesia to povide neurological examination of the spinal cord function. Systemic analgesia is often insufficient to tolerante non-invasive ventilation (NIV) in massive thoracic trauma and often leads to reintubation and subsequent dilation tracheotomy. Patient and Methods: A 46 year old Pat. (ASA I) suffered from a high speed injury with prolonged extrincation, during which he required intubation and a thoracic drain. Following the standard trauma diagnostic in our institution (FAST & whole-body-trauma-CT) only a massive left sided thoraxtrauma (Rib fractures I - XI, haematopneumothorax and dorsal lung consolidation) could be revealed. The patient was scheduled for extubation and NIV. After reaching normothermia on ICU and good blood gas values in prone position (left side up) a continuous paravertebral block (cPVB) was placed in the 5th intercostalspace using ultrasound-guided (LAX - in-plane) technique (1) under sterile conditions and tunneling (2). Results: After a bolus of 10mlRopivacaine 0,375% the patient was turned on his back and successfully extubated 45 Minutes later and NIV could be supplied immediately (VAS <4). The spread of hypaesthesia covered the segments Th2- Th7. The continous infusion of Ropivacain 0,33% (8ml/h) was gradually reduced. After 5 days extensive NIV on ICU the catheter was paused and on the sixth day removed. The patient was then transfered to a normal ward. A second patient was subsequently treated according to the same regime two month later, which provide again a profund analgetic quality. Conclusion: The placement of a cPVB provided good analgesia for an acute isolated throax trauma. This finding is comparable to results derived from elective thoracic surgery (3). The spread of analgesia was comparable to recent findings in cadaver studies (4) and in preliminary clinicalsudies (5) as well. Ultrasound guided continous paravetebral analgesia in the hands of the experienced sonographer is an excellent alternative for cases where thoracic epiduralshould be avoided.
Keywords: analgesic agent; thorax injury; analgesia; weaning; noninvasive ventilation; patient; human; velocity; injury; ultrasound; neurologic examination; body temperature; blood gas; spinal cord function; extubation; epidural anesthesia; hematopneumothorax; rib fracture; lung; cadaver; diagnosis; thorax surgery; body position; infusion; catheter; ward; intubation; tracheotomy

Influence of personal preferences for life-sustaining treatment on medical decision making among pediatric intensivists - Needle J.S.; Mularski R.A.; Nguyen T.; Fromme E.K. (Critical Care Medicine, 2012)
OBJECTIVES: Withholding and withdrawal of life-sustaining treatment by physicians is influenced by a variety of factors; the role of physicians' personal preferences for life-sustaining treatments has not previously been explored. We sought to examine the relationship between personal preferences for life-sustaining treatment and medical decision making among pediatric intensivists. DESIGN: Cross-sectional national anonymous mail survey. SUBJECTS: All board-certified/eligible pediatric intensivists identified by the American Medical Association Masterfile. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 471 (30%) surveys were returned. A Personal Preference Score was calculated from responses to personal-preference questions for life-sustaining treatments adapted from "Your Life, Your Choices," by Pearlman et al. Physicians were asked to consider the "acceptability" of offering and recommending treatment options involving life-sustaining treatments in a hypothetical scenario of a 2-yr old with a high cervical spinal-cord transection. Logistic regression controlling for sociodemographic characteristics found significant relationships (p < .01) between physicians' own preferences modeled as a one standard deviation change in their own Personal Preference Score (preference for life-sustaining treatment) and whether they offered more or less aggressive care (OR [95%CI]). Physicians who had a higher Personal Preference Score (higher preference for their own life-sustaining treatment) were more likely to recommend a tracheostomy (1.38 [1.35-1.41]) and reintubation if the patient failed extubation (1.87 [1.81-1.94]). Pediatric intensivists who had a lower Personal Preference Score (lower preference for life-sustaining treatment) were more likely to recommend that the patient not be reintubated if extubation failed (1.42 [1.39-1.46]) and to recommend Do Not Resuscitate status (1.34 [1.31-1.37]). CONCLUSIONS: Among pediatric intensivists, personal preferences for life-sustaining treatment were significantly associated with scenario-based responses to acceptability of withholding and withdrawal of life-sustaining treatment. Physicians should be aware of the potential for personal preferences to influence practice recommendations, and endeavor to elicit and respect family preferences in collaborative decision making. Copyright © 2012 by the Society of Critical Care.
Keywords: adult; article; critically ill patient; cross-sectional study; female; health survey; human; intubation; life sustaining treatment; male; medical decision making; medical expert; personal preference; personal preference Score; priority journal; scoring system; spinal cord transsection; tracheostomy; treatment failure

Electrical stimulation of accessory muscles of respiration: Is there a role for enhancing weaning from mechanical ventilatory support in long term acute care? - Gerstenhaber B.; Rosenblum D.; Kowalsky D.; Rochester C.; Palermo F.; Costigan-Humes C.; Tall L. (American Journal of Respiratory and Critical Care Medicine, 2012)
We conducted a pilot study to determine whether transcutaneous Patterned Electrical Stimulation (PENS) of the accessory muscles of respiration could be tolerated and/or enhance the weaning process in patients on long-term mechanical ventilator support at Gaylord Hospital, a Long Term Acute Care Hospital (LTACH). We studied 6 patients: 1 with post-surgical respiratory failure, 4 with COPD and hypercarbic respiratory failure and 1 with adult respiratory distress. The PENS was applied to the following muscle groups: scalenes, upper trapezius and abdominal muscles. PENS was delivered using an Omnistim FX2 stimulator which delivered a train of asymmetrical biphasic square waves with pulse durations of 70 - 100 microseconds and current amplitudes of 25 to 100 milliamps. Pulses were delivered once every 1.5 seconds. Unlike conventional electrical stimulation protocols that produce sustained tetanic muscle contractions, the PENS produced moderate intensity twitch contractions which are better tolerated than sustained contractions. Patients received 20 minutes of PENS to each area simultaneously, three times/week, until weaning success, or a maximum of 6 weeks. Stimulation was adjusted at each session, on an individual basis, to tolerance. Patients with electrical devices (pacemakers, TENS units), massive obesity and neuro-muscular (Spinal Cord Injury, Amyotrophic Lateral Sclerosis and Guillain-Barre syndrome) co-morbidities were excluded. The general weaning process included progressive tolerance of tracheostomy collar, in conjunction with standard physical, occupational and speech therapy. There was no evidence that the use of PENS in conjunction with our weaning program shortened weaning time, decreased the rate of hospital-acquired pneumonia or shortened length of stay compared with historical patients with similar conditions in our institution. However, patient tolerance of the PENS was excellent without complaint of pain or muscle soreness; there were no complications or adverse effects. Thus, while PENS of the accessory muscles of respiration is feasible in patients with respiratory failure, we believe that a larger study is necessary to further evaluate the potential efficacy of PENS in facilitating weaning from mechanical ventilation and to identify subpopulations of patients with respiratory failure who might benefit most from the use of this muscle training technique.
Keywords: muscle; weaning; emergency care; human; American; society; electrostimulation; patient; respiratory failure; pulse rate; hospital; pacemaker; devices; mechanical ventilator; muscle twitch; muscle tetanic contraction; Guillain Barre syndrome; morbidity; tracheostomy; stimulation; speech therapy; abdominal wall musculature; amyotrophic lateral sclerosis; trapezius muscle; adult respiratory distress syndrome; spinal cord injury; artificial ventilation; adverse drug reaction; pain; hospital acquired pneumonia; length of stay; obesity; pilot study; muscle training

Succinylcholine-induced hyperkalemia in a patient with multiple sclerosis - Levine M.; Brown D.F.M. (Journal of Emergency Medicine, 2012)
Background: Succinylcholine administration is associated with hyperkalemia in patients with a variety of medical conditions, including many neuromuscular disorders. Nonetheless, there is a paucity of literature describing hyperkalemia after the administration of succinylcholine to patients with multiple sclerosis. Case Report: This case report describes a 38-year-old woman with multiple sclerosis who developed life-threatening hyperkalemia after the administration of succinylcholine during rapid sequence intubation. Conclusion: This case highlights the potential for iatrogenic hyperkalemia after succinylcholine in patients with neurologic diseases, including multiple sclerosis.
Keywords: baclofen; beta1 interferon; bicarbonate; calcium chloride; cyclophosphamide; docusate sodium; etomidate; glucose; heparin; hydroxychloroquine sulfate; insulin; polystyrenesulfonate sodium; potassium; prednisone; ranitidine; steroid; suxamethonium; topiramate; adult; ambient air; anemia; arm; arterial gas; article; artificial ventilation; auscultation; blood cell count; blood pressure fluctuation; carotid artery pulse; case report; cervical spinal cord injury; dermatome; disease exacerbation; drug dose reduction; dyspnea; electrocardiogram; end tidal carbon dioxide tension; extensor muscle; feces incontinence; female; forced vital capacity; heart arrhythmia; hematocrit; hemiparesis; hospitalization; human; hyperkalemia; hyporeflexia; hypoxia; intensive care unit; limb weakness; lumbar puncture; methicillin resistant Staphylococcus aureus infection; multiple sclerosis; muscle strength; nuclear magnetic resonance imaging; oxygen mask; oxygen saturation; oxygenation; paraplegia; percutaneous endoscopic gastrostomy; pH; plasmapheresis; pneumonia; potassium blood level; priority journal; QRS complex; respiratory acidosis; respiratory tract intubation; sensory dysfunction; sinus rhythm; tachypnea; tracheostomy; urine incontinence; colace; kayexalate; suxamethonium

Annual Scientific Meeting of the Neuroanaesthesia Society of Great Britain and Ireland 2012 (Journal of Neurosurgical Anesthesiology, 2012)
The proceedings contain 28 papers. The topics discussed include: interhemispheric EEG variability measured using a bilateral bispectral index (BIS) sensor; a full audit cycle of preoperative fluid fasting at the Wessex Neurological Center; estimating weight in neurosurgical patients with a raised BMI: a recipe for drug delivery errors; targeting of preoperative clotting studies for elective and emergency intracranial surgery; family satisfaction in a neurosciences intensive care unit; tracheostomies in patients with neurological disease: the first 10 years; a national survey on the use of bispectral index for sedation management in adult patients with traumatic brain injury; spinal clearance in unconscious children with traumatic brain injury: a survey of current practice in paediatric intensive care units of great Britain and Ireland; and bilateral bispectral index (BiBIS): recordings from a patient with vasospasm following clipping of a cerebral aneurysm.
Keywords: United Kingdom; Ireland; society; human; patient; bispectral index; traumatic brain injury; intensive care unit; diet restriction; tracheostomy; liquid; emergency; clinical audit; prescription; brain surgery; satisfaction; brain artery aneurysm; neurosurgery; neurologic disease; sedation; ego development; weight; adult; child; recording; vasospasm; sensor; drug delivery system; electroencephalogram

A single institutional experience of 42 cases of pediatric cervical spine trauma from India: Are they different from adult cervical trauma - Gupta D.; Prasad G.L.; Mahapatra A.K. (Journal of Neurotrauma, 2012)
Introduction Pediatric cervical spine injuries are relatively uncommon and are associated with significant morbidity and mortality. Pediatric anatomy and physiology predispose to upper cervical spine injury and spinal cord injury without radiologic abnormality in contrast to lower cervical spine injury seen in adults. Falls are the most common cause of spinal trauma in Indian pediatric population. Children have relatively high incidence of upper cervical injuries due to their mobile anatomy, ligamentous laxity and cephalocervical disproportion. Methods Objectives: This study was carried out to analyse the epidemiologic profile of pediatric cervical spine injuries and to evaluate the clinicoradiological characteristics of cervical spine injuries in children, to correlate the outcome with the clinico-radiological features. Methodology: Prospective cum retrospective data analysis (2008-2011) at JPN apex trauma centre, New Delhi, India. 42 children (0-18 yrs) were operated during this period. Fall from height was noted in 27 cases, upper cervical spine injuries in 12/42 cases (odontoid fractures in 6 cases). Associated injuries were noted in 8 cases, preop ASIA A score was noted in 16 cases. Two cases had prep systemic hypotension and required ventilator support. Methylprednisolone was not given in this series. All patients had CT of whole spine (as protocol) and MRI imaging study. Patients with whiplash/sciwora were excluded. Results Postoperative VAP was noted in 28 cases, 38 required tracheostomy, perioperative mortality noted in 2 cases. Implant failure on long term follow up seen in 2 cases requiring refixation in one patient. 13 of 16 children who came for follow up had become independent for ADL (81) at a follow up range of 4-40 months thereby showing significant neurological recovery in these group of patients. Conclusions Ligamentous injuries are commoner in pediatric patients, fall from height most commonly noted in Indian population, sub axial trauma more common than upper cervical trauma. 81 had good outcome at last follow up. Such observation warrants aggressive surgical approach in pediatric population to give them better neurological outcome.
Keywords: methylprednisolone; cervical spine injury; nervous system injury; adult; India; human; patient; injury; follow up; child; population; mortality; Indian; height; spine injury; odontoid process fracture; spinal cord injury; data analysis; morbidity; methodology; tracheostomy; imaging; spine; ventilator; implant; hypotension; surgical approach; physiology; nuclear magnetic resonance imaging

Ethics: End-of-life decision-making in a pediatric patient with SMA type 2: The influence of the media - Drake M.; Cox P. (Neurology, 2012)
Objective: Spinal muscular atrophy (SMA) is a group of progressive and fatal neurodegenerative disorders that are characterized by destruction of the anterior horn cells of the spinal cord. In this case report we outline the medical and ethical issues involved in a 7-year-old boy with SMA type 2 who experienced acute respiratory failure. Methods: A review of the literature was conducted focusing particularly on the pathology, presentation, and outcomes of SMA and end-of-life decision-making in pediatrics. Results: In a world where 40%-60% of deaths in pediatric intensive care units are a result of withdrawal or limitation of life-sustaining treatment, end-of-life decision-making has become an integral and difficult part of pediatric practice. Conclusion: Limitation or withdrawal of life-sustaining treatment in a cognitively normal child with SMA poses a significant medical and ethical dilemma. This difficult decision is influenced by confluence of parental, doctor, social, cultural, moral, religious, legal, and economic factors and more recently the media. Copyright © 2012 by AAN Enterprises, Inc.
Keywords: article; artificial ventilation; bradycardia; case report; child; coughing; drowsiness; dyspnea; end of life decision making; endotracheal intubation; ethics; feeding disorder; general condition deterioration; human; hypercapnia; hypopnea index; hypoventilation; lethargy; life sustaining treatment; limb weakness; male; medical decision making; priority journal; respiratory distress; resuscitation; school child; social media; spinal muscular atrophy; tachypnea; terminal care; tracheostomy; treatment withdrawal

Ultrasound-guided continuous paravertebral block in isolated thoracic trauma-providing sufficient analgesia for weaning and non-invasive-ventilation (NIV) on ICU for a 46 year old patient after high-speed trauma - Reisig F.; Lehner C.; Perras J.; Buettner J. (European Journal of Anaesthesiology, 2012)
Background: After acute high-velocity injury it is desirable to avoid thoracic epidural analgesia to povide neurological examination of the spinal cord function. Systemic analgesia is often insufficient to tolerante non-invasive ventilation (NIV) in massive thoracic trauma and often leads to reintubation and subsequent dilation tracheotomy. Case report: A 46 year old Pat. (ASA I) suffered from a high speed injury with prolonged extrincation, during which he required intubation and a thoracic drain. Following the standard trauma diagnostic in our institution (FAST & hole-body-trauma-CT) only a massive left sided thoraxtrauma (Rib fractures I - XI, haematopneumothorax and dorsal lung consolidation) could be revealed. The patient was scheduled for extubation and NIV. After reaching normothermia on ICU and good blood gas values in prone position (left side up) a continuous paravertebral block (cPVB) was placed in the 5th intercostal space using ultrasound-guided (LAX - in-plane) technique (1) under sterile conditions and tunneling (2). After a bolus of 10ml Ropivacaine 0,375% the patient was turned on his back and successfully extubated 45 Minutes later and NIV could be supplied immediately (VAS < 4). The spread of hypaesthesia covered the segments Th2 - Th7. The continous infusion of Ropivacain 0,33% (8ml/h) was gradually reduced. After 5 days extensive NIV on ICU the catheter was paused and on the sixth day removed. The patient was then transfered to a normal ward. Discussion: The placement of a cPVB provided good analgesia for an acute isolated throax trauma. This finding is comparable to results derived from elective thoracic surgery (3). The spread of analgesia was comparable to recent findings in cadaver studies (4) and in preliminary clinical sudies (5) as well.
Keywords: ropivacaine; thorax injury; analgesia; weaning; noninvasive ventilation; patient; human; velocity; injury; anesthesiology; ultrasound; neurologic examination; body temperature; blood gas; spinal cord function; extubation; lung; epidural anesthesia; rib fracture; diagnosis; hematopneumothorax; cadaver; intubation; ward; catheter; body position; infusion; case report; tracheotomy; thorax surgery

International survey of physician recommendation for tracheostomy for spinal muscular atrophy Type i - Benson R.C.; Hardy K.A.; Gildengorin G.; Hsia D. (Pediatric Pulmonology, 2012)
The ethics of invasive mechanical ventilation for children with the neurodegenerative disease Spinal Muscular Atrophy Type I (SMA I) is highly debated, and wide variability in clinical outcomes exists internationally. We conducted this international survey to identify physician characteristics associated with recommendation for tracheostomy and ventilation for SMA I. A cross-sectional online survey was distributed to 1,772 pediatric pulmonologists and pediatric intensivists from online membership directories of American Thoracic Society, American College of Chest Physicians, and European Respiratory Society. 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. A logistic regression model assessed the independent effects of physician variables on the recommendation for invasive ventilation for SMA I. A total of 367 (21%) physicians completed the survey; 82% were pediatric pulmonologists; and 16% pediatric intensivists. Seventy percent of respondents were from the U.S. Fifty percent of physicians were aware of SMA consensus guidelines. Physicians from Commonwealth countries (U.K., Canada, Australia, etc.) were less likely to recommend tracheostomy/ventilation than U.S. physicians (7% vs. 25%, P=0.005). Logistic regression modeling identified years of experience, pediatric pulmonology specialty, agreement with a pro-life statement, and recommendation for non-invasive ventilation as predictive of recommendation for long-term invasive ventilation for SMA I. In the largest international survey on this topic, we identified regional differences in physician recommendation for invasive ventilation for children with SMA I. Our data demonstrate a need for increased awareness of consensus guidelines and further dialog about the physician role in variability of care for children with SMA I. Copyright © 2011 Wiley Periodicals, Inc.
Keywords: adult; article; artificial ventilation; Australia; Canada; child care; consensus; cross-sectional study; demography; female; geographic origin; health care survey; human; logistic regression analysis; long term care; male; medical specialist; normal human; physician attitude; practice guideline; priority journal; respiratory care; spinal muscular atrophy; Werdnig Hoffmann disease; terminal care; tracheostomy; United Kingdom; United States; work experience

Use of Glidescope® As a first-choice technique in Klippel-Feil syndrome airway management - Marques J.; Henriques A.R.; Bettencourt M.; Figueiredo J.N.; Chaló D. (European Journal of Anaesthesiology, 2012)
Background: Klippel-Feil syndrome (KFS) is characterized by the presence of a congenital synostosis of some or all of the cervical vertebrae[1] and a severe restriction of cervical motion that predicts difficult airway. Even minor distraction of the neck can be responsible for neurologic or cervical spine injury, so regional techniques, awake fiberoptic intubation or awake tracheostomy are recommended anesthetic approaches[1-2]. Case report: We report a case of periprosthetic femur fracture in a 23-year-old woman with KFS, ASA III, right congenital deafness, history of encephalocele complicated with meningitis after birth and dilated cardiomyopathy, due to high dose of doxorubicin for an osteossarcoma. Weighed 65 kg and 1,50m in tall. Cervical mobility limited to 15 degrees of head turn to the left, 15 to right, and 10 of extension. Normal dentition, interincisive distance< 3 cm, sternomental distance< 12 cm, Mallampati impossible to evaluate due to limited mouth opening. After institution of standard ASA monitoring, BIS and TOF, awake intubation was performed with remifentanil infusion (0,01-0,1ug/kg/min) and spontaneous ventilation maintained with FiO2=100% face mask. We use 10% lidocaine spray and then Glidescope® lamina 2 was inserted and glottis perfectly visualised and a 6 mm tube inserted once confirmed position. Anaesthesia was induced with propofol 50 mg, rocuronium 20 mg. Maintenance with oxygen and sevoflurane (1 MAC). Femoral and cutaneous femoral nerve block using neurostimulator, 15 ml and 5 ml of Ropivacaine 0,5%, respectively. Discussion: The unavailability of a fiberscope and unique circumctances posed a challenge to convencional rubric of difficult airway algorithm and forced an alternative management using videolaringoscopy (Glidescope®) as first-choice technique, followed by periferic nerve block.
Keywords: anesthetic agent; doxorubicin; propofol; remifentanil; lidocaine; rocuronium; oxygen; sevoflurane; ropivacaine; Klippel Feil syndrome; respiration control; anesthesiology; nerve block; intubation; human; airway; cervical spine; case report; synostosis; drug megadose; tracheostomy; meningitis; monitoring; femur fracture; fiber optics; cervical spine injury; encephalocele; femoral nerve; congestive cardiomyopathy; congenital deafness; dentition; neck; infusion; breathing; face mask; female; glottis; aerosol; tube; anesthesia; fiberoscope; algorithm

A case of myofibrillary myopathy associated with rigid spine syndrome - Liew W.K.; Chai J. (Clinical Neurophysiology, 2012)
Introduction: This is a case of an 11-month-old Cambodian boy, third child born to nonconsanguionous parents, who was previously well. He developed an acute onset of respiratory distress with lethargy following an upper respiratory illness, requiring intubation and ventilatory support. At presentation, he was noted to have marked spine and abdominal muscle rigidity with mild peripheral hypotonia of his limbs. He was initially treated empirically for meningoencephalitis and subsequently tetanus with no improvement of his symptoms. Objectives: To describe the clinical presentation of myofibrillar myopathy. Results: Brain magnetic resonance imaging was normal. His serum creatine kinase was mildly raised at 1000. Echocardiography showed mild septal hypertrophy of the heart. Needle electromyography (EMG) showed myopathic features and his muscle biopsy showed the presence of eosinophilic hyaline bodies on hematoxylin and eosin staining with suggestion of inter-myofibrillary disruption on modified Gomori-Trichrome and Verhoff-Van Gieson stains. He remained dependent on ventilator support and underwent a tracheostomy during his admission. Conclusion: This is a case of myofibrillar myopathy associated with rigid spine syndrome, respiratory insufficiency, and mild cardiomyopathy. Diagnosis was made with muscle biopsy and needle EMG findings.
Keywords: hyalin; hematoxylin; eosin; myopathy; spine; human; muscle biopsy; needle; boy; respiratory distress; lethargy; male; meningoencephalitis; parent; Cambodian; limb; muscle hypotonia; echocardiography; electromyography; muscle rigidity; respiratory tract disease; child; nuclear magnetic resonance imaging; abdominal wall musculature; creatine kinase blood level; brain; hypertrophy; heart; tetanus; intubation; staining; stain; ventilator; tracheostomy; respiratory failure; cardiomyopathy; diagnosis; electromyogram

Vital capacity in spinal muscular atrophy. - Bach J.R.; Tuccio M.C.; Khan U.; Saporito L.R. (American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 2012)
This work describes and correlates plateau/maximum observed vital capacity (VC) with spinal muscular atrophy (SMA) severity and prognosis for autonomous breathing. SMA severity was correlated with VC, onset, paradoxical breathing, age at definitive dependence on continuous mechanical ventilation (DDCV), and age at first respiratory hospitalization and gastrostomy. Ten severe SMA 1A patients with DDCV before 6 mos of age had maximum observed and plateau VC of 100 ml or less, with plateaus for six at 10.3 (range, 3-48) mos. Another 120 had typical SMA 1B defined by any three of the following: acute respiratory failure before 12 mos of age, gastrostomy before 12 mos of age, DDCV before 10 yrs of age, and VC not exceeding 200 ml, with plateaus for 15 at 26.4 (6-138) mos. Fifteen were with mild type 1C defined by three of the following: VC exceeding 200 ml, acute respiratory failure after 1 yr of age, gastrostomy after 1 yr of age, and no DDCV before 10 yrs of age and had a plateau/maximum observed mean VC of 409 (range, 200-1175) ml at 8.9 (range, 7-10) yrs of age. Of 88 patients with SMA 2 and paradoxical breathing (2A), 16 had a mean plateau/maximum observed VC of 758 (range, 460-2100) ml. DDCV with no autonomous breathing always followed plateauing of VC. Types 2B, 3, and 4 patients attained normal VC. Intergroup VC differences were significant (P < 0.05) for 1A, 1B, 1C, 2A, and 2B-4. When intubated and "unweanable," 50-ml VC signaled the ability for autonomous breathing 1 to 21 days after extubation. VC should be monitored from birth. It correlates with prognosis with SMA 1A VCs not exceeding 100 ml or 1B 200 ml. Patients who attained 200 ml at any time (milder 1C) retain some ability to breathe after 10 yrs of age.
Keywords: age; article; artificial ventilation; cause of death; child; comparative study; disease course; female; hereditary spinal muscular atrophy; hospitalization; human; infant; longitudinal study; lung function test; male; methodology; mortality; multimodality cancer therapy; nonparametric test; physiology; preschool child; prognosis; retrospective study; statistics; survival; tracheostomy; vital capacity

Airway Management in Neuroanesthesiology - Aziz M. (Anesthesiology Clinics, 2012)
Airway management for neuroanesthesiology brings together some key principles that are shared throughout neuroanesthesiology. This article appropriately targets the cervical spine with associated injury and the challenges surrounding airway management. The primary focus of this article is on the unique airway management obstacles encountered with cervical spine injury or cervical spine surgery, and unique considerations regarding functional neurosurgery are addressed. Furthermore, topics related to difficult airway management for those with rheumatoid arthritis or pituitary surgery are reviewed. © 2012 Elsevier Inc.
Keywords: acromegaly; airway obstruction; anesthesia; anesthesist; blunt trauma; breathing; cervical spine radiography; clinical practice; computer assisted tomography; endotracheal intubation; extubation; fluoroscopy; general anesthesia; glottis; head injury; human; hypophysis; laryngoscopy; neurosurgery; oxygen saturation; patient positioning; respiration control; review; rheumatoid arthritis; spinal cord; spine surgery; stereotaxic surgery; surgical patient; surgical technique; tracheostomy; treatment contraindication; Airtraq; AWS; Bullard; GlideScope; GlideScope; WuScope

Electrophrenic pacing and decannulation for high-level spinal cord injury: A case series - Bolikal P.; Bach J.R.; Goncalves M. (Journal of Spinal Cord Medicine, 2012)
Background: In 1997, guidelines were developed for the management of high-level ventilator-dependent patients with spinal cord injury who had little or no ventilator-free breathing ability (VFBA). This article describes the three categories of patients, the decannulation criteria, and the successful decannulation of four patients with no VFBA and electrophrenic/diaphragm pacing, using these criteria. Method: Case series. Conclusion: Lack of VFBA in patients with high-level spinal cord injury does not mandate tracheostomy or electrophrenic/diaphragm pacing. © The Academy of Spinal Cord Injury Professionals, Inc. 2012.
Keywords: adult; article; breathing; case report; chronic bronchitis; coughing; diaphragm; female; glossopharyngeal nerve; human; lung compliance; male; quadriplegia; respiratory arrest; spinal cord injury; tracheostomy; ventilator; ventilator free breathing ability; vital capacity; Lipseal

Tracheotomy and children with spinal muscular atrophy type 1: Ethical considerations in the French context - Rul B.; Carnevale F.; Estournet B.; Rudler M.; Hervé C. (Nursing Ethics, 2012)
Spinal muscular atrophy (SMA) type 1 is a genetic neuromuscular disease in children that leads to degeneration of spinal cord motor neurons. This sometimes results in severe muscular paralysis requiring mechanical ventilation to sustain the child's life. The onset of SMA type 1, the most severe form of the disease, is during the first year of life. These children become severely paralysed, but retain their intellectual capacity. Ethical concerns arise when mechanical ventilation becomes necessary for survival. When professionals assess the resulting life for the child and family, they sometimes fear it will result in unreasonably excessive care. The aim of this article is to present an analysis of ethical arguments that could support or oppose the provision of invasive ventilation in this population. This examination is particularly relevant as France is one of the few countries performing tracheotomies and mechanical ventilation for this condition. © The Author(s) 2012.
Keywords: article; classification; ethics; France; hereditary spinal muscular atrophy; hospitalization; human; human relation; infant; informed consent; legal aspect; morality; mortality; newborn; nursing care; onset age; pathology; patient care; personal autonomy; practice guideline; preschool child; standard; tracheostomy

Childhood spinal muscular atrophy: Controversies and challenges - Mercuri E.; Bertini E.; Iannaccone S.T. (The Lancet Neurology, 2012)
Spinal muscular atrophy is an autosomal recessive disorder characterised by degeneration of motor neurons in the spinal cord and is caused by mutations of the survival of motor neuron 1 gene SMN1. The severity of spinal muscular atrophy is highly variable and no cure is available at present. Consensus has been reached on several aspects of care, the availability of which can have a substantial effect on prognosis, but controversies remain. The development of standards of care for children with the disorder and the identification of promising treatment strategies have changed the natural history of spinal muscular atrophy, and the prospects are good for further improvements in function, quality of life, and survival. A long-term benefit for patients will be the development of effective interventions (such as antisense oligonucleotides), some of which are in clinical trials. The need to be prepared for clinical trials has been the impetus for a remarkable and unprecedented cooperation between clinicians, scientists, industry, government, and volunteer organisations on an international scale. © 2012 Elsevier Ltd.
Keywords: survival motor neuron protein 1; artificial ventilation; childbirth; childhood disease; creatine kinase blood level; diagnostic test; disease classification; early diagnosis; electromyography; family counseling; gene deletion; gene insertion; gene mutation; gene sequence; genetic counseling; genetic screening; health care cost; health care quality; human; hypoventilation; incidence; life sustaining treatment; nerve conduction; nutrition; osteoporosis; outcome assessment; oximetry; palliative therapy; parenteral nutrition; patient assessment; physical examination; pregnancy; priority journal; quality of life; respiratory function; review; scoliosis; sensitivity and specificity; sequence analysis; spinal muscular atrophy; spine fusion; tracheostomy; translational research; vital capacity

Total arch and descending thoracic aortic replacement by left thoracotomy - Corvera J.S.; Fehrenbacher J.W. (Annals of Thoracic Surgery, 2012)
Background: The hybrid treatment of transverse aortic arch pathologies with supraaortic debranching and endovascular repair is associated with significant morbidity and death and lacks long-term follow-up. The traditional two-stage open surgical approach to extensive arch and descending thoracic aneurysms carries a significant interval mortality rate. We report the results of a single-stage technique of total arch and descending thoracic aortic replacement by a left thoracotomy. Methods: From January 1995 to February 2011, 426 patients underwent thoracic or thoracoabdominal aneurysm repair, of which a highly selected group of 27 patients underwent total arch replacement with descending thoracic or thoracoabdominal aortic replacement. All procedures were performed with hypothermic circulatory arrest and selective antegrade cerebral perfusion. Two patients required transverse division of the sternum. Two patients had emergency or urgent operations. Five patients had concomitant coronary artery bypass, and 1 had concomitant mitral valve replacement. Results: There were no hospital deaths, no cerebrovascular accidents, and one instance of transient spinal cord ischemia. Three patients had acute renal failure not requiring hemodialysis. Intubation in 5 patients exceeded 48 hours, and 1 patient needed tracheostomy. Two patients required reexploration for postoperative bleeding. Survival at 1, 3, and 5 years was 95%, 78%, and 73%, respectively. Conclusions: Replacement of the total arch and descending thoracic aorta by a left thoracotomy provides excellent short-term and long-term results for the treatment of extensive arch and thoracic aortic pathology, without the need for a second-stage operation. Other cardiac pathologies, such as left-sided coronary disease and mitral valve disease, can be addressed concurrently. © 2012 The Society of Thoracic Surgeons.
Keywords: acute kidney failure; adult; aged; aortic arch surgery; article; brain perfusion; coronary artery bypass graft; deep hypothermic circulatory arrest; descending aortic surgery; female; human; major clinical study; male; mitral valve replacement; mortality; postoperative hemorrhage; priority journal; spinal cord ischemia; sternum; thoracic aorta aneurysm; thoracotomy; tracheostomy

Spinal muscular atrophy type 1: Are proactive respiratory interventions associated with longer survival? - Lemoine T.J.; Swoboda K.J.; Bratton S.L.; Holubkov R.; Mundorff M.; Srivastava R. (Pediatric Critical Care Medicine, 2012)
CONTEXT: Spinal muscular atrophy type 1, an autosomal recessive motor neuron disease, is a leading genetic cause of death in infancy and early childhood. OBJECTIVE: To determine whether the early initiation of noninvasive respiratory interventions is associated with longer survival. DESIGN: Single-institution retrospective cohort study identified children with spinal muscular atrophy type 1 from January 1, 2002 to May 1, 2009 who were followed for 2.3 mean yrs. SETTING: Tertiary care children's hospital and outpatient clinics in a vertically integrated healthcare system. PATIENTS OR OTHER PARTICIPANTS: Forty-nine children with spinal muscular atrophy type 1 were grouped according to the level of respiratory support their caregivers chose within the first 3 months after diagnosis: proactive respiratory care (n = 26) and supportive care (n = 23). INTERVENTIONS: Proactive respiratory care included bilevel noninvasive ventilation during sleep and twice a day cough assist while supportive respiratory care included suctioning, with or without supplemental oxygen. MEASUREMENTS AND MAIN RESULTS: Kaplan-Meier survival curves were assessed based on intention to treat. Children treated with early proactive respiratory support had statistically longer survival compared to supportive care (log rank 0.047); however, the adjusted hazard ratio for survival was not statistically different (2.44 [95% confidence interval 0.84-7.1]). Children in the proactive group were more likely to be hospitalized for respiratory insufficiency (83% vs. 46%) and had shortened time after diagnosis until first hospital admission for respiratory insufficiency (median 118 vs. 979 days). CONCLUSION: Longer survival time with spinal muscular atrophy type 1 is associated with early, noninvasive respiratory care interventions after diagnosis. Copyright © 2012 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Keywords: article; artificial ventilation; caregiver; childhood disease; clinical article; cohort analysis; female; follow up; health care cost; hospital admission; hospital care; human; infant; male; oxygen therapy; priority journal; respiratory care; respiratory failure; retrospective study; spinal muscular atrophy; survival; tracheostomy

Noninvasive respiratory management for patients with spinal cord injury and neuromuscular disease - Bach J.R.; Bakshiyev R.; Hon A. (Tanaffos, 2012)
The purpose of this article is to describe noninvasive respiratory management for patients with neuromuscular respiratory muscle dysfunction (NMD) and spinal cord injury (SCI) and the role of electrophrenic pacing (EPP) and diaphragm pacing (DP) in this respect. Long term outcomes will be reviewed and the use of noninvasive intermittent positive pressure ventilation (NIV), MAC, and EPP/DP to prevent pneumonia and acute respiratory failure, to facilitate extubation, and to avoid tracheotomy will be evaluated. Although ventilator dependent patients with most NMDs and high level SCI can be indefinitely managed noninvasively, most ALS patients can be managed for a limited time by continuous NIV before tracheostomy is necessary for survival. Glossopharyngeal breathing (GPB) can be learned by patients without any autonomous breathing ability and used by them in the event of ventilator/EPP/DP failure or loss of interface access. EPP/DP can maintain alveolar ventilation for high level SCI patients when they cannot grab a mouth piece to use NIV. © 2012 NRITLD, National Research Institute of Tuberculosis and Lung Disease, Iran.
Keywords: assisted ventilation; breathing pattern; diphragm pacing; electrophrenic pacing; electrostimulation; glossopharyngeal breathing; human; intermittent positive pressure ventilation; long term care; lung ventilation; mechanically assisted coughing; neuromuscular disease; neuromuscular respiratory muscle dysfunction; non invasive procedure; outcome assessment; oximetry; oxygen saturation; phrenic nerve pacing; phrenic pacing; positive end expiratory pressure; review; spinal cord injury; spirometry; ventilator; Exsufflation Belt

Acute treatment options for spinal cord injury - Markandaya M.; Stein D.M.; Menaker J. (Current Treatment Options in Neurology, 2012)
Most treatment options for acute traumatic spinal cord injury (SCI) are directed at minimizing progression of the initial injury and preventing secondary injury. Failure to adhere to certain guiding principles can be detrimental to the long-term neurologic and functional outcome of these patients. Therapy for the hyperacute phase of traumatic SCI focuses on stabilizing vital signs and follows the Advanced Trauma Life Support (ATLS) algorithm for ensuring stability of airway, breathing and circulation, and disability (neurologic evaluation)-with spinal stabilization-and exposure. Spinal stabilization, with cervical collars and long backboards, is used to prevent movement of a potentially unstable spinal column injury to prevent further injury to the spinal cord and nerve roots, especially during prehospital transport. Surgery to stabilize the spine is undertaken after life-threatening injuries (hemorrhage, evacuation of intracranial hemorrhage, acute vascular compromise) are addressed. Intensive care unit (ICU) admission is to be considered for all patients with high SCI or hemodynamic instability, as well as those with other injuries that independently warrant ICU admission. Avoidance of hypotension and hypoxia may minimize secondary neurologic injury. Elevating the mean arterial pressure above 85 mmHg for 7 days should be considered, to allow for spinal cord perfusion. The use of intravenous steroids (methylprednisolone) is controversial. Early tracheostomy in patients with lesions above C5 may reduce the number of ventilator days and the incidence of ventilator-associated pneumonia. Select patients may benefit from the placement of a diaphragmatic pacer. Aggressive measures, including CoughAssist and Intermittent Positive Pressure Breaths (IPPB), should be used to maintain lung recruitment and aid in the mobilization of secretions. Some patients with high SCI who are dependent onmechanical ventilation can eventually be liberated fromthe ventilator with consistent efforts from both the patient and the caregiver, along with some patience. Intermittent catheterization by the patient or a caregiver may be associated with a lower incidence of urinary tract infections, compared with an in-dwelling urinary catheter. Early mobilization of patients and a multidisciplinary approach (including respiratory therapists, nutritional experts, physical therapists, and occupational therapists) can streamline care and may improve long-term outcomes. A number of investigational drugs and therapies offer hope of neurologic recovery for some patients. © Springer Science+Business Media, LLC 2012.
Keywords: atropine; baclofen; benzodiazepine derivative; corticosteroid; enoxaparin; gabapentin; glycopyrronium; heparin; hypertensive factor; low molecular weight heparin; methylprednisolone; midodrine; minocycline; nonsteroid antiinflammatory agent; noradrenalin; phenylephrine; pregabalin; riluzole; salbutamol; sodium chloride; vasodilator agent; artery catheter; article; artificial ventilation; assistive technology device; autonomic dysreflexia; bleeding disorder; bradycardia; computed tomographic angiography; cost effectiveness analysis; deep vein thrombosis; diaphragmatic pacer; diet therapy; drug cost; exercise; gastrointestinal hemorrhage; hospital admission; human; hyperglycemia; hypotension; indwelling catheter; infection; intensive care unit; intermittent catheterization; lifestyle modification; lung embolism; mobilization; myelography; neuropathic pain; occupational therapy; physiotherapist; physiotherapy; psychosis; spinal cord decompression; spinal cord injury; spinal hematoma; spine stabilization; spine surgery; tracheostomy; urinary tract infection; vena cava filter; ventilator; ventilator associated pneumonia; CoughAssist; Intermittent Positive Pressure Breaths

Safety of recurrent laryngeal nerve (RLN) and spinal accessory nerve (SAN) dissections - Romanchishen A.F.; Romanchishen F.A.; Karpatsky I.V. (European Archives of Oto-Rhino-Laryngology, 2012)
Background: The RLN and SAN are the most frequently damaged vital structures in thyroid cancer (TC) surgery. Methods: 20,113 patients underwent surgery during the period between 1973 and 2005. Postoperative unilateral RLN injury took place in 1.18%, bilateral injures in 0.42% of cases. Most often, this complication was observed in patients with recurrent toxic goiter (1.70%) and diffuse toxic goiter (1.56%). In 2,390 TC patients, RLN injury was observed only in 0.31% due to accurate dissection of this nerve. That motivated us to perform RLN dissection in every thyroid operation. There are about 30 variants of anatomic relations between RLN and inferior thyroid artery, and three most common points of RLN visualization. They are: (a) subclavial point known as Lore's triangle, (b) RLN “cross point” with the inferior thyroid artery, and (c) RLN laryngeal entry point. To improve our knowledge of RLN surgical anatomy, we investigated autopsy material; video documented 937 RLNs, and used the Nerve Integrity Monitoring during thyroid surgery (2001-2005). Results: It was found that RLNs in 3rd point (entry point) were crossed by blood vessels in 94.9% of cases. In every fourth observation vessels crossed the RLN from below. Ligation and transsection of those vessels was very important, because thyroid tissue removal became more convenient. The diameter (1-3 mm) of the vessels increasing from nodular euthyroid goitre to TC and Graves's disease. We preferred to find RLN and started to dissect it from below. Since RLN and ITA crossing became visually controlled, branches of the ITA were accessible for ligation and the parathyroid glands could be dissected and saved easily. Our technique of thyroidectomy allowed finding and saving of 15 nonrecurrent laryngeal nerves among 4,070 thyroid patients. Surgical tactics in case of RLN injury assumed: revision, restoration of RLN, and tracheostomy through the lower flap of the wound in bilateral laryngeal palsy cases. In 11 cases, RLN was restored with suturing under the EMG control. Of six patients followed up for 1-2 years postoperatively, four demonstrated vocal cord function improvement. To protect SAN during MRND, its surgical separation was performed. For safety reasons, the best place for the first nerve visualization was the upper third level of sternocleidomastoid muscle's (SCMM) where it accompanied the internal jugular vein (IJV). In 85.2% SAN laid laterally and in front of the vein, in 11.1%-behind, and in 3.7%-medially to IJV. Then in 88.9% SAN perforated the SCMM and in 11.1% passed adjacent to it. The most common site of SAN exit out from the SCMM was approximately on the border of the upper and middle third of the SCMM (74.1%), in 20.4% it was in the SCMM upper third, and in 5.6% it was in the lower one. Our technique assumes dissection of SAN from the above with separating and saving of nervous branches to SCMM, C3 and. During the dissection, the nerve integrity and function was confirmed using electromyography monitoring. We also used a zigzag shaped incision for that kind of surgery. Conclusions: As a result of regular use of suggested RLN and SAN dissection techniques, the postoperative morbidity rate was significantly reduced.
Keywords: recurrent laryngeal nerve; accessory nerve; dissection; neck; oncology; safety; human; patient; thyroid gland; nerve; injury; surgery; monitoring; thyroid surgery; ligation; toxic goiter; artery; tissues; blood vessel; thyroid cancer; videorecording; morbidity; incision; autopsy; surgical anatomy; electromyography; vein; internal jugular vein; vocal cord; paralysis; wound; tracheostomy; laryngeal nerve; sternocleidomastoid muscle; thyroidectomy; parathyroid gland; goiter; electromyogram; Graves disease; cancer surgery

A pain in the neck: An uncommon cause for sepsis - Baiduc B.Y.; Bhat S.; Arabelo H.; Matti-Orozco B. (Journal of the American Geriatrics Society, 2012)
The elderly are more susceptible to infection and sepsis with a higher risk of morbidity and mortality. This is a case of an 86-year-old man who presented with 3-4 days of deteriorating mentation, fevers and generalized weakness. He was independent and ambulatory at baseline. As per his daughter, he had been bedbound a few days prior to admission. On presentation he was febrile, delirious, A&Ox1, and with neck stiffness without focal neurological findings. Chest X-Ray showed patchy infiltrates. CT head was negative. A lumbar puncture was refused by his family. Empiric treatment was started for pneumonia and possible meningitis. Blood cultures revealed MSSA bacteremia. Despite broad antibiotic coverage his fever and leukocytosis persisted and on hospital day 3 he was found quadriplegic. Concerns about epidural abscess and cord compression prompted an urgent cspine MRI which showed a ventral epidural abscess in the retroodontoid region with severe spinal canal compromise. Neurosurgery and Ortho Spine consults recommended non-operative medical treatment due to its location and the unlikelihood of reversing any deficits given the duration of symptoms. The patient continued to deteriorate, got intubated due to respiratory failure, and eventually, was discharged with a tracheostomy and a PEG tube. He was only able to “twitch” his left shoulder, fingers and toes. Epidural abscesses are rare and most commonly occur in the true epidural space located posterior and lateral to the spinal cord. The dura mater is adherent to the vertebral body anteriorly and the potential space in this area is unlikely for abscesses to form. Also, epidural abscesses occur more frequently in the thoraco-lumbar area due to the larger space. Diagnosing this patient was challenging due to the very atypical location of his abscess. I addition, pneumonia and delirium confounded the clinical picture giving a plausible explanation for the presentation. Treatment is preferably surgical or interventional; however, the location of his abscess made this difficult to perform. Furthermore, any intervention should be done within the first 24 hours of hospitalization. If paralysis is seen for 36-48 hours then medical therapy is fully acceptable. In conclusion, the clinical presentation of epidural abscesses is often non-specific and should be investigated in atypical scenarios.
Keywords: antibiotic agent; neck; sepsis; geriatrics; society; pain; epidural abscess; human; abscess; pneumonia; fever; therapy; patient; thinking; meningitis; male; respiratory failure; vertebral canal; lumbar puncture; mortality; spine; tracheostomy; tube; thorax radiography; morbidity; leukocytosis; rigidity; hospital; bacteremia; aged; risk; compression; infection; neurosurgery; blood culture; hospitalization; delirium; shoulder; toe; epidural space; spinal cord; dura mater; vertebra body; weakness; daughter; paralysis; nuclear magnetic resonance imaging; methicillin susceptible Staphylococcus aureus

Perfluorodecalin lavage of a longstanding lung atelectasis in a child with spinal muscle atrophy - Henrichsen T.; Lindenskov P.H.H.; Shaffer T.H.; Loekke R.J.V.; Fugelseth D.; Lindemann R. (Pediatric Pulmonology, 2012)
Objective Persistent lung atelectasis is difficult to treat and perfluorochemical (PFC) liquid may be an option for bronchioalveolar lavage (BAL). Case report A 4-year-old girl with spinal muscle atrophy was admitted in respiratory failure. On admission, the X-ray confirmed the persistence of total right-sided lung atelectasis, which had been present for 14 months. She was endotracheally intubated and ventilated from the day of admission. BAL with normal saline was performed twice without improvement. Following failed extubation and being dependent on continuous respiratory support, a trial of BAL using PFC liquid (Perfluorodecalin HP) was carried out. The PFC was delivered through the endotracheal tube on three consecutive days. A loading dose of 3 ml/kg was administered, followed by a varying dose in order to more effectively lavage the lungs. She tolerated the procedure well the first 2 days, although there were no clinical signs of improvement in the atelectasis. Intentionally, higher inflation pressures were applied after PFC instillation on day 3. Chest X-ray then showed hazy infiltrates on her left lung and she required more ventilatory support. However, lung infiltrates cleared over the next 3 days. A tracheotomy was done 6 days after the last PFC instillation. She had a slow recovery and was successfully decanulated. Clinical improvement of lung function was seen including less need of BiPAP and oxygen. A chest CT scan showed then functional lung tissue appearing in the previous total atelectatic right lung. Conclusion Lavage with PFC can safely be performed with a therapeutic effect in a child with unilateral total lung atelectasis. Pediatr Pulmonol. 2012; 47:415-419. © 2011 Wiley Periodicals, Inc.
Keywords: antibiotic agent; cefotaxime; oxygen; perfluorodecalin; airway pressure; arterial carbon dioxide tension; arterial pressure; article; artificial ventilation; atelectasis; bronchoscopy; carbon dioxide tension; case report; child; computer assisted tomography; disease duration; disease severity; endotracheal intubation; extubation; female; hospital admission; human; lung function; lung infiltrate; lung inflation; lung lavage; oxygen saturation; positive end expiratory pressure; priority journal; respiratory failure; Human respiratory syncytial virus; spinal muscular atrophy; Staphylococcus hominis; thorax radiography; tracheotomy

Surgical tracheostomy in morbidly obese patients: Technical considerations and a two-flap technique for access - Khoo S.G.; Rajaretnam N. (Journal of Laryngology and Otology, 2012)
Objective: In an era in which percutaneous tracheostomies are frequently performed in 'suitable' necks, more technically complex cases are referred to the otolaryngologist. We describe the surgical technique used and close cooperation required in securing the airway of a morbidly obese patient. Case report: A 52-year-old, morbidly obese man with significant comorbidities was referred for surgical tracheostomy following spinal fractures. This was complicated by a previous percutaneous dilatational tracheostomy scar. Tension-free skin advancement was not possible with a deeply plunging trachea; a vertical skin incision was dropped inferiorly to the sternum for access. A size 8 Shiley XLT Proximal Extension cuffed tracheostomy tube was inserted successfully. Conclusion: We describe safe airway surgery in a morbidly obese man, and outline requirements including the use of a specially designed operating table, the need for an elongated proximal limb tracheostomy tube, and the use of a distal two-flap technique for access to a deeply plunging trachea. © JLO (1984) Limited 2012.
Keywords: corticosteroid; adult; article; case report; chronic obstructive lung disease; coronary artery disease; corticosteroid therapy; endotracheal intubation; human; hypertension; long term care; lumbar vertebra; male; morbid obesity; non insulin dependent diabetes mellitus; obesity hypoventilation syndrome; respiratory arrest; respiratory failure; skin incision; skin scar; sleep disordered breathing; smoking; spine fracture; surgical technique; tracheostomy; vertebra

Massive hematomyelia following intramedullary spinal cord tumor surgery - Shofty B.; Roth J.; Ben-Sira L.; Brotchi J.; Korn A.; Constantini S. (Acta Neurochirurgica, 2012)
Keywords: adult; backache; case report; collapse; human; intramedullary spinal cord tumor; letter; lung sarcoidosis; male; motor dysfunction; nuclear magnetic resonance imaging; paraplegia; priority journal; quadriplegia; spinal cord surgery; spinal cord tumor; spinal hematoma; tracheostomy

Regional anesthesia with a single spinal anesthesia using hyperbaric bupivacaine in a child with arthroglyposis multiplex congenita - Borazan H.; Okesli S.; Uluer M.S.; Sahin O. (Journal of Anesthesia, 2012)
Arthrogryposis multiplex congenita (AMC) consists of complex congenital anomalies characterized by multiple contractures. Anesthetic management of these patients requires special care: as this disease often progresses until dysfunction of multiple organ systems occur, it may have an impact on the anesthetic management. Here, we report a case of AMC undergoing urgent surgery for open tibia fracture who had difficult airway management because of limited mouth opening. The anesthetic management of this patient is represented in light of the literature. © 2011 Japanese Society of Anesthesiologists.
Keywords: acetic acid plus dipotassium hydrogen phosphate plus glucose plus magnesium chloride plus potassium chloride; atropine; bupivacaine; ephedrine; fentanyl; ketamine; lidocaine; midazolam; paracetamol; airway obstruction; arthrogryposis; article; case report; child; endotracheal intubation; human; hyperbaric oxygen therapy; hyperbarism; jaw malformation; joint contracture; laryngoscopy; male; oxygen saturation; postoperative pain; preschool child; regional anesthesia; respiratory tract intubation; scoliosis; spinal anesthesia; tibia fracture; tracheostomy; treatment failure; marcaine

Dysfunction of the diaphragm - McCool F.D.; Tzelepis G.E. (New England Journal of Medicine, 2012)
Keywords: atelectasis; breathing pattern; clinical feature; diaphragm disease; diaphragm paralysis; disease association; dyspnea; echography; electromyography; endotracheal intubation; fluoroscopy; functional electrical stimulation; hemidiaphragm; human; hyperinflation; inspiratory capacity; nerve injury; phrenic nerve; priority journal; prognosis; respiratory failure; review; sleep disordered breathing; spinal cord injury; surgical approach; thorax radiography; tracheostomy

Resolution of tracheostomy complications by decanulation and conversion to noninvasive management for a patient with high-level tetraplegia - Toki A.; Hanayama K.; Ishikawa Y. (Topics in Spinal Cord Injury Rehabilitation, 2012)
Objectives: To report conversion from tracheostomy (TIV) to noninvasive intermittente positive pressure ventilation (NIV) for a continuously ventilator-dependent patient with high-level spinal cord injury (SCI) with no measurable vital capacity (VC = 0 mL) to resolve tracheostomy-associated complications. Methods: A case report of a 38-year-old female in a chronic care facility in Japan with a 10-year history of ventilator-dependent tetraplegia (C1 ASIA-A) presented for increasing difficulty vocalizing. She had been using a fenestrated cuffed tracheostomy tube to produce speech with the cuff defiated. Speech was increasingly hypophonic, because of tracheostoma enlargement, tube migration, and tracheal granulation. Results: The NIV was provided via nasal and oral interfaces, the ostomy was surgically closed, and vocalization resumed. Airway secretions were expulsed using manually assisted coughing. The patient returned to the community. Conclusion: Conversion to NIV should be considered for ventilator-dependent patients with SCI who have adequate bulbar-innervated muscle function to permit effective speech and assisted coughing. © 2012 Thomas Land Publishers, Inc.
Keywords: adult; artificial ventilation; case report; conference paper; diaphragm paralysis; female; human; intermittent positive pressure ventilation; Japan; quadriplegia; tracheostomy; tracheotomy; ventilated patient; vital capacity

Noninvasive respiratory management of high level spinal cord injury - Bach J.R. (Journal of Spinal Cord Medicine, 2012)
This article describes noninvasive acute and long-term management of the respiratory muscle paralysis of high spinal cord injury (SCI). This includes full-setting, continuous ventilatory support by noninvasive intermittent positive pressure ventilation (NIV) to support inspiratory muscles and mechanically assisted coughing (MAC) to support inspiratory and expiratory muscles. The NIV and MAC can also be used to extubate or decannulate 'unweanable' patients with SCI, to prevent intercurrent respiratory tract infections from developing into pneumonia and acute respiratory failure (ARF), and to eliminate tracheostomy and resort to costly electrophrenic/diaphragm pacing (EPP/DP) for most ventilator users, while permitting glossopharyngeal breathing (GPB) for security in the event of ventilator failure. © The Academy of Spinal Cord Injury Professionals, Inc. 2012.
Keywords: oxygen; acute respiratory failure; breathing; breathing muscle; coughing; glossopharyngeal breathing; high level spinal cord injury; human; hypercapnia; mechanically assisted coughing; noninvasive intermittent positive pressure ventilation; oximetry; oxygen therapy; pathophysiology; pneumonia; positive end expiratory pressure; respiratory tract infection; review; spinal cord injury; tracheotomy; traumatic brain injury

Respiratory care of patients with cervical spinal cord injury: a review. - Arora S.; Flower O.; Murray N.P.; Lee B.B. (Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2012)
Respiratory complications following cervical spinal cord injury are common and are the leading cause of morbidity and mortality after this type of injury. Impaired mechanics of ventilation, poor cough, increased secretions and bronchospasm predispose to atelectasis, pneumonia and exacerbations of respiratory failure. Prolonged mechanical ventilation and tracheostomy are often required. This review discusses the relevant pathophysiology, various ventilatory strategies and timing of tracheostomy, and examines the evidence surrounding physiotherapeutic and pharmacological treatment options.
Keywords: artificial ventilation; breathing disorder; human; review; spinal cord injury; tracheostomy

Anterior approach to cervical spine - Cheung K.M.C.; Mak K.C.; Luk K.D.K. (Spine, 2012)
Study Design: Review of surgical technique. Objective: To provide accounts of the authors' preferred methods for performing anterior cervical surgery with personal tips and pearls. Summary of Background Data: Many have described the various anterior surgical approaches to the cervical spine, and in this review, we hope to describe our preferences, highlighted with some tips and pearls. Methods: Various accounts of the transoral, the anterolateral (Smith-Robinson), and the split manubrium approaches were reviewed and used as the basis of the review. Additional notes with regard to the authors' preferences were noted to provide further guidance. The descriptions were delineated from the most cephalad to the most caudal. Results: The transoral, the anterolateral (Smith-Robinson), and the manubriotomy approaches were described. Each account starts with the basic preoperative considerations, then describes the incision and the main anatomical landmarks, and finally concludes with closure and main complications to monitor for. A brief description of the main pathologies that each approach may address is also provided. Conclusion: The 3 anterior approaches to the cervical spine are direct and elegant solutions to pathologies arising from the anterior column. They supplement the more commonly used posterior approaches, which provide stronger multilevel fixation, and thus provide an essential tool in the armamentarium of spine surgeons. Copyright © 2012 Lippincott Williams & Wilkins.
Keywords: antibiotic agent; anterior cervical surgery; anterolateral surgery; aspiration; bone graft; cervical spine; decompression; endotracheal intubation; endotracheal tube; human; iliac crest; incision; liquorrhea; manubriotomy; nasotracheal intubation; osteotomy; postoperative care; postoperative complication; postoperative infection; priority journal; radiography; retropharyngeal abscess; review; skin incision; spine surgery; sternum; surgeon; surgical approach; tongue swelling; tracheostomy; transoral surgery; wound infection; X ray

A dance of empowerment - lessons for the NHI? - Bateman C. (South African Medical Journal, 2012)
Keywords: article; child hospitalization; dancing; home care; hospital care; human; kyphoscoliosis; lung ventilation; musculoskeletal disease; outpatient; patient care; pediatric nurse practitioner; primary health care; spinal cord injury; tracheostomy

Are urological procedures in tetraplegic patients safely performed without anesthesia? A report of three cases - Vaidyanathan S.; Soni B.; Selmi F.; Singh G.; Esanu C.; Hughes P.; Oo T.; Pulya K. (Patient Safety in Surgery, 2012)
Background: Some tetraplegic patients may wish to undergo urological procedures without anaesthesia, but these patients can develop autonomic dysreflexia if cystoscopy and vesical lithotripsy are performed without anaesthesia.Case presentation: We describe three tetraplegic patients, who developed autonomic dysreflexia when cystoscopy and laser lithotripsy were carried out without anesthesia.In two patients, who declined anaesthesia, blood pressure increased to more than 200/110 mmHg during cystoscopy. One of these patients developed severe bleeding from bladder mucosa and lithotripsy was abandoned. Laser lithotripsy was carried out under subarachnoid block a week later in this patient, and this patient did not develop autonomic dysreflexia.The third patient with C-3 tetraplegia had undergone correction of kyphoscoliotic deformity of spine with spinal rods and pedicular screws from the level of T-2 to S-2. Pulmonary function test revealed moderate to severe restricted curve. This patient developed vesical calculus and did not wish to have general anaesthesia because of possible need for respiratory support post-operatively. Subarachnoid block was not considered in view of previous spinal fixation. When cystoscopy and laser lithotripsy were carried out under sedation, blood pressure increased from 110/50 mmHg to 160/80 mmHg.Conclusion: These cases show that tetraplegic patients are likely to develop autonomic dysreflexia during cystoscopy and vesical lithotripsy, performed without anaesthesia. Health professionals should educate spinal cord injury patients regarding risks of autonomic dysreflexia, when urological procedures are carried out without anaesthesia. If spinal cord injury patients are made aware of potentially life-threatening complications of autonomic dysreflexia, they are less likely to decline anaesthesia for urological procedures. Subrachnoid block or epidural meperidine blocks nociceptive impulses from urinary bladder and prevents occurrence of autonomic dysreflexia. If spinal cord injury patients with lesions above T-6 decline anaesthesia, nifedipine 10 mg should be given sublingually prior to cystoscopy to prevent increase in blood pressure due to autonomic dysreflexia. © 2012 Vaidyanathan et al; licensee BioMed Central Ltd.
Keywords: labetalol; risedronic acid; adult; article; assisted ventilation; autonomic dysreflexia; bladder stone; blood pressure measurement; bone density; bone graft; bone scintiscanning; case report; child; cystoscopy; dose response; female; forced vital capacity; human; hypertension; intervertebral disk hernia; discectomy; kyphoscoliosis; laser lithotripsy; lung function test; male; mucosal bleeding; open reduction (procedure); patient safety; peak expiratory flow; pedicle screw; plate fixation; quadriplegia; repeated drug dose; school child; spinal anesthesia; spinal cord compression; tracheostomy; urological procedure

Unusual case of relapsing and remitting rash with progressive motor sensory neuropathy and spinal cord atrophy - Blackburn J.S.; Kuntz N.L.; Grimason M.; Wainwright M.S. (Journal of Child Neurology, 2012)
The authors report a case of a 7-year-old girl with a progressive sensorimotor peripheral neuropathy with acute relapses associated with a desquamating purpuric rash, alopecia, and spinal cord atrophy. Distinctive features include systemic involvement with alopecia and rash, peripheral nervous system involvement with relapsing and remitting sensorimotor neuropathy, and central nervous system involvement with episodes of dystonic posturing and spinal cord atrophy. Extensive diagnostic evaluation for known causes of skin manifestations associated with peripheral neuropathy has failed to identify a cause for this patient's condition. The authors discuss the case as an approach to the differential diagnosis and to highlight unusual features of this yet to be identified clinical entity. © SAGE Publications 2012.
Keywords: immunoglobulin; steroid; alopecia; aminoaciduria; areflexia; article; artificial ventilation; bulbar paralysis; case report; child; disease course; dystonia; electromyography; erythrocyte sedimentation rate; auditory evoked potential; evoked response; female; hearing impairment; Hoffmann reflex; human; human tissue; limb weakness; motor nerve conduction; motor unit potential; muscle biopsy; nerve biopsy; pain; plasmapheresis; polyneuropathy; priority journal; proprioception; purpuric rash; quadriplegia; relapse; respiratory failure; school child; sensorimotor neuropathy; sensory dysfunction; spinal cord atrophy; temperature sense; touch; tracheostomy; vaginal delivery; vibration sense

A significant cervical spine fracture: Think of the airway - Cleiman P.; Nemeth J.; Vetere P. (Journal of Emergency Medicine, 2012)
Background: Airway compromise is a potential complication of significant cervical spine injury. Objectives: To alert emergency physicians to be aware of possible airway collapse after serious cervical spine injury. Case Report: We report a case of an 87-year-old man who presented to the emergency department with an unstable cervical spine fracture after a fall. He subsequently developed complete upper airway obstruction from prevertebral soft tissue swelling, requiring a cricothyrotomy after a failed intubation attempt. Conclusion: Patients with significant blunt cervical spine trauma can be at high risk for upper airway compromise. © 2012 Elsevier Inc.
Keywords: aged; ankylosing spondylitis; article; case report; cervical spine fracture; emergency physician; emergency ward; face injury; human; male; priority journal; tracheotomy; upper respiratory tract obstruction

Do personal preferences for life-sustaining therapy influence medical decision making among pediatric intensivists? - Needle J.; Mularski R.; Nguyen T.; Fromme E. (Journal of Pain and Symptom Management, 2012)
Objectives 1. Measure the personal preferences for lifesustaining treatment among pediatric intensivists. 2. Examine the relationship between pediatric intensivists' personal preferences for life-sustaining treatment and medical decision making. Background. Withholding and withdrawal of lifesustaining treatments in the pediatric intensive care unit is influenced by physician characteristics. Research objectives. To examine the relationship between pediatric intensivists' personal preferences for life-sustaining therapies and medical decision making. Method. Cross-sectional national anonymous mail survey of pediatric intensivists identified by the American Medical Association Masterfile. A Personal Preference Score (PPS) was calculated from responses to questions of personal preferences for life-sustaining treatments adapted from “Your Life, Your Choices,” by Pearlman and colleagues. Physicians were asked to consider the “acceptability” of treatment options in a hypothetical scenario of a child with a spinal cord transection. Logistic regression controlling for socio-demographic characteristics computed odds ratios that represent the association between finding an option “acceptable” to a one standard deviation decrease in the PPS (lower preference for life-sustaining therapy). Result. A total of 471 (30%) surveys were returned. Intensivists with lower PPS were significantly less likely to consider it acceptable to offer (OR = 0.64; 95% CI, 0.62-0.66; p≤ 0.01) and recommend (OR = 0.73; 95% CI, 0.71- 0.74; p≤ 0.01) performing a tracheostomy, less likely to offer (OR = 0.34; 95% CI, 0.28-0.34; p = 0.02) and recommend (OR = 0.53; 95% CI, 0.52-0.55; p≤ 0.01) reintubation if the patient failed extubation, and were more likely to consider it acceptable to offer (OR = 1.58; 95% CI, 1.55-1.62; p≤ 0.01) and recommend (OR = 1.42; 95% CI, 1.39-1.46; p≤ 0.01) that the patient not be reintubated if extubation failed and to recommend DNR status (OR 1.34; 95% CI, 1.31-1.37; p = <0.01). Conclusion. Personal preferences for life-sustaining therapy were significantly associated with scenario-based responses to acceptability of withholding/withdrawal of life-sustaining therapies. Implications for research, policy, or practice. Physicians should ensure that family preferences are elicited and incorporated into medical decision making.
Keywords: human; life sustaining treatment; hospice; medical decision making; nurse; palliative therapy; physician; patient; extubation; demography; risk; tracheostomy; policy; intensive care unit; medical society; child; spinal cord transsection; logistic regression analysis

Double trouble: Spinal muscular atrophy type II and seropositive myasthenia gravis in the same patient - Jokela M.; Udd B.; Päivärinta M. (Neuromuscular Disorders, 2012)
Autosomal recessive proximal spinal muscular atrophy is caused by deletions in the survival of motor neuron (SMN1) gene, while autoimmune myasthenia gravis is an acquired disorder. An association between these two diseases has not been reported. Our patient with intermediate spinal muscular atrophy (SMA type II) did not need alimentary or respiratory aid until age 51 when he suddenly developed bulbar weakness and respiratory insufficiency. Seropositive myasthenia gravis was confirmed and the corresponding symptoms resolved on treatment. © 2011 Elsevier B.V.
Keywords: azathioprine; cholinergic receptor antibody; immunoglobulin; prednisone; pyridostigmine; adult; article; bulbar paralysis; case report; deterioration; drug dose reduction; dysphagia; electromyogram; face muscle; gene; gene deletion; genetic screening; homozygote; human; lip reading; male; masticatory muscle; motor unit potential; muscle weakness; myasthenia gravis; ophthalmoplegia; priority journal; ptosis (eyelid); respiratory tract infection; scoliosis; SMN1 gene; spinal muscular atrophy; tracheostomy; feeding tube

Pulmonary rehabilitation using modified threshold inspiratory muscle trainer (IMT) in patients with tetraplegia - Yasar F.; Tasci C.; Savci S.; Tozkoparan E.; Deniz O.; Balkan A.; Bilgic H. (Case Reports in Medicine, 2012)
It is aimed to present the usefulness of inspiratory muscle trainer (IMT) in treatment of a 20-year-old male patient with diaphragmatic paralysis and tetraplegia due to spinal cord injury (SCI), and supporting effect of IMT in recovering from respiratory failure by rendering his diaphragm functions. The treatment was applied through the tracheostomy cannula by a modified IMT device. After applying IMT for three weeks, it was observed that the diaphragm recovered its functions in electromyography (EMG) test. As a result, in this study, we present a case where a patient could live without any respiratory device for the rest of his life with the help of modified IMT. © Copyright 2012 Funda Yasar et al.
Keywords: adult; article; cannula; case report; devices; diaphragm paralysis; electromyography; human; respiratory exerciser; male; priority journal; pulmonary rehabilitation; quadriplegia; respiratory failure; spinal cord injury; tracheostomy; treatment outcome; Threshold Inspiratory Muscle Trainer

Dysphagia and respiratory care in individuals with tetraplegia: Incidence, associated factors, and preventable complications - Shem K.; Castillo K.; Wong S.; Chang J.; Kolakowsky-Hayner S. (Topics in Spinal Cord Injury Rehabilitation, 2012)
Dysphagia occurs in a significant number of individuals with spinal cord injury (SCI) presenting to acute care and inpatient rehabilitation. This prospective study has found dysphagia in nearly 40% of individuals with tetraplegia. Tracheostomy, mechanical ventilation, nasogastric tube, and age are significant risk factors. The detrimental complications of dysphagia in SCI can cause significant morbidity and delays in rehabilitation. Thus, early and accurate diagnosis of dysphagia is imperative to reduce the risk of developing life-threatening complications. Incidence and risk factors of dysphagia and the use of the bedside swallow evaluation (BSE) and videofluoroscopy swallow study (VFSS) to diagnose dysphagia are presented. The often underappreciated role of respiratory therapists, including assist cough, high tidal volume ventilation, and the use of Passy-Muir valve, in the care of individuals with SCI who have dysphagia is discussed. Improved secretion management and respiratory stabilization enable the individuals with dysphagia to be evaluated sooner and safely by a speech pathologist. Early evaluation and intervention could improve upon morbidity and delayed rehabilitation, thus improving overall clinical outcomes. © 2012 Thomas Land Publishers, Inc.
Keywords: adult; age; aged; article; artificial ventilation; bedside swallow evaluation; clinical article; diagnostic test; dysphagia; female; human; male; nasogastric tube; quadriplegia; respiratory care; risk factor; spinal cord injury; tracheostomy; videofluoroscopy swallow study

Tracheotomy outcomes and complications: A national perspective - Shah R.K.; Lander L.; Berry J.G.; Nussenbaum B.; Merati A.; Roberson D.W. (Laryngoscope, 2012)
Objectives/Hypothesis: To provide national level data on frequency of tracheotomy and complication rate and in-hospital mortality following tracheotomy. Study Design: Retrospective cohort study. Methods: Retrospective cohort study using a public national database, the Nationwide Inpatient Sample, 2006. Results: There were 113,653 tracheotomies performed in patients 18 years or older in 2006. The overall complication rate was 3.2%, and the in-hospital mortality rate was 19.2%. The data suggest that in-hospital mortality is usually due to the underlying illness rather than the tracheotomy. Mortality was higher in patients older than 50 years, those with cardiac conditions, particularly congestive heart failure, those with public insurance, and patients in Northeast hospitals. Patients with neurologic conditions, trauma, and upper airway infection are more likely to survive to discharge. In-hospital mortality is slightly higher in nonteaching hospitals. Conclusions: This database study determined baseline data for the rate of complications (3.2%) for patients undergoing tracheotomy; it showed that only 80% of adult patients who underwent tracheotomy in the United States survived to discharge. Patients located in the Northeast, patients more than 50 years old, and patients with cardiac conditions were at particularly high risk for mortality. This study provides normative data for these outcomes for patient counseling and planning future quality improvement initiatives in this patient population. © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.
Keywords: adult; aged; asthma; brain injury; cardiomyopathy; cerebral palsy; cerebrovascular accident; chronic obstructive lung disease; congestive heart failure; dementia; epilepsy; heart infarction; human; major clinical study; mortality; muscular dystrophy; myocarditis; obesity; outcome assessment; paralysis; pneumonia; postoperative complication; priority journal; review; risk factor; skull fracture; spinal cord injury; tracheotomy; upper respiratory tract infection

Inadvertent insertion of nasogastric tube into the brain stem and spinal cord after endoscopic skull base surgery - Hanna A.S.; Grindle C.R.; Patel A.A.; Rosen M.R.; Evans J.J. (American Journal of Otolaryngology - Head and Neck Medicine and Surgery, 2012)
A significant number of neurosurgical patients require feeding tube placement via a nasogastric route. It is used as a temporary access for enteral feeding until patients are able to swallow or receive permanent access. Despite how commonly feeding tubes are used, they are not without potential complications. We report a case of inadvertent placement of small-bore feeding tube into the brain stem and spinal cord in a patient with a history of previous endoscopic transnasal resection of clival chordoma. We discuss the management of this complication and the strategies that have been developed to avoid this complication in the future. © 2012 Elsevier Inc. All rights reserved.
Keywords: fibrin glue; abdominal radiography; adult; article; brain decompression; brain stem; cancer radiotherapy; case report; cerebrospinal fluid otorrhea; chordoma; clival chordoma; computer assisted tomography; craniotomy; endoscopic surgery; esophagogastrostomy; gait disorder; gastrostomy; headache; hemostasis; human; hyperlipidemia; hypertension; interstitial pneumonia; male; meningitis; nasogastric tube; nuclear magnetic resonance imaging; obesity; ophthalmoplegia; osteoarthritis; pneumonia; priority journal; quadriplegia; sepsis; sleep disordered breathing; spinal cord; spinal cord disease; surgical risk; thoracotomy; tracheostomy; wedge resection

Prone positioning: Is it safe and effective? - Dirkes S.; Dickinson S.; Havey R.; O'Brien D. (Critical Care Nursing Quarterly, 2012)
Prone positioning has been used as a treatment option for patients with acute lung injury or acute respiratory distress syndrome (ARDS) since the early 1970s. Prone position and extended prone position ventilation have been shown to increase end-expiratory lung volume, alveolar recruitment, and oxygenation in patients with severe hypoxemic and acute respiratory failure. Prone positioning is not a benign procedure, and there are potential risks (complications) that can occur to both the patient and the health care worker. Notable complications that can arise include: unplanned extubation, lines pulled, tubes kinked, and back and other injuries to personnel. Prone positioning is a viable, inexpensive therapy for the treatment of severe ARDS. This maneuver consistently improves systemic oxygenation in 70% to 80% of patients with ARDS. With the utilization of a standardized protocol and a trained and dedicated critical care staff, prone positioning can be performed safely. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Keywords: abdominal surgery; adult respiratory distress syndrome; aortic balloon; article; asthma; bleeding; body position; cardiopulmonary arrest; clinical effectiveness; decubitus; device removal; extubation; face edema; fracture fixation; head injury; heart arrhythmia; human; hypotension; intensive care; intracranial pressure; intraocular pressure; kyphoscoliosis; lung hemodynamics; mean arterial pressure; multiple trauma; osteoarthritis; oxygenation; pelvis fracture; pregnancy; rheumatoid arthritis; rib fracture; safety; seizure; spinal cord injury; systolic blood pressure; thorax surgery; trachea obstruction; tracheostomy; traction therapy; treatment contraindication; vomiting

Factors associated with early mortality after cervical spinal cord injury - Shao J.; Zhu W.; Chen X.; Jia L.; Song D.; Zhou X.; Yan W.; Zhang Y. (Journal of Spinal Cord Medicine, 2011)
Background: A relatively high early mortality rate (<30 days post-injury) for cervical spinal cord injury (SCI) has been observed. Objective: To investigate this early mortality rate observed after cervical SCI and analyze the associated influential factors. Methods: Medical records for 1163 patients with cervical SCI were reviewed, and the number of patients with early mortality was documented. Through logistic regression analysis, the effects of age, gender, occupation, cause of injury, severity of injury, highest involved spinal cord segment, nutritional condition during hospitalization, surgical treatment, tracheotomy, etc., on early mortality were assessed. Implementation of early treatment (i.e. surgery, tracheotomy, and nutritional support) and its effect on patient prognosis were also analyzed. Results: Early mortality occurred in 109 of 1163 patients (9.4%). Four factors affected the early mortality rate, including level and severity of SCI, whether or not surgery was performed, the time interval between SCI and surgery, malnutrition, and tracheotomy. Patients with an American Spinal Injury Association grade of A, a high cervical SCI (C1-C3), and/or no surgical intervention were statistically more likely to have early mortality (P < 0.001). Conclusion: Severe cervical SCI, upper-level cervical cord injury, malnutrition, and inappropriate tracheotomy are risk factors for early mortality in patients with cervical SCI. Surgery can reduce early mortality. Early tracheotomy should be performed in patients with complete upper-level cervical SCI, but patients with incomplete cervical SCI or complete low-level cervical SCI should initially be treated surgically to maintain smooth airway flow. © The Academy of Spinal Cord Injury Professionals, Inc. 2011.
Keywords: albumin; adolescent; adult; age; aged; albumin blood level; article; cervical spinal cord injury; controlled study; early intervention; falling; female; gender; human; injury severity; major clinical study; male; malnutrition; medical record review; mortality; nutritional assessment; nutritional status; nutritional support; occupation; prognosis; spine surgery; survival time; tracheotomy; traffic accident

Malignant hyperpyrexia in cervical spine injury - Arumugam S.K.; Balakrishnan S.; Parchani A. (Qatar Medical Journal, 2011)
Pyrexia is an elevation of body temperature above the normal range due to an increase in the hypothalamic thermoregulatory set point. Hyperpyrexia is an extreme elevation of body temperature equal to or greater than 41.5°C (106.7°F).(1) Malignant hyperpyrexia is a rare and idiopathic extreme elevation of core body temperature above 42°C characterized by the acute onset of hyperthermia, coagulopathy and shock.(2) It is potentially life-threatening and can rapidly progress to severe liver and renal impairment, acidosis and encephalopathy. Reported here is a case of malignant hyperpyrexia in a patient with injury of the cervical spine.
Keywords: analgesic agent; D dimer; fluconazole; heart enzyme; infusion fluid; kidney enzyme; liver enzyme; meropenem; methylprednisolone; myoglobin; piperacillin plus tazobactam; vancomycin; acute kidney failure; adult; article; atelectasis; body temperature; brain edema; bronchoscopy; case report; cervical spine injury; chest tube; clinical article; comminuted fracture; computer assisted tomography; deep vein thrombosis; electroencephalography; falling; Glasgow coma scale; gray matter; headache; hematoma; hematothorax; hemodialysis; hepatitis; hospital admission; human; hypotension; immobilization; intensive care; intubation; limb weakness; long term care; male; malignant hyperthermia; neck pain; nuclear magnetic resonance imaging; paraplegia; patient transport; physical examination; prophylaxis; rhabdomyolysis; rib fracture; spirometry; sputum examination; Staphylococcus aureus; thorax radiography; tracheostomy; white matter

Spinal cord injury: Outcomes of ventilatory weaning and extubation - Call M.S.; Kutcher M.E.; Izenberg R.A.; Singh T.; Cohen M.J. (Journal of Trauma - Injury, Infection and Critical Care, 2011)
Background:: Spinal cord injury (SCI) carries potentially devastating respiratory implications depending on injury level. Optimal strategies for mechanical ventilation in this setting remain poorly described. We reviewed our experience of ventilatory weaning and extubation outcomes in this patient population. Methods:: Eighty mechanically ventilated SCI patients over a 5-year period at a major Level I trauma center were assessed. Injury, clinical, and outcome data were extracted using our ICU database, chart, and registry data. Result:: We identified 80 patients with SCI, classified by anatomic injury and motor functional level. There were no differences in injury severity between patients who were successfully extubated and those who failed (all p = NS). Seventy-four percent were extubated at the time of discharge; successful extubation was associated with lower level of cord injury (p = 0.001) and higher arrival Glasgow Coma Scale score (13.7 ± 2.6 vs. 10.8 ± 5.0, p = 0.021). Of extubation failures, 80% were due to pulmonary mechanical insufficiency, 22% inadequate pulmonary toilet, and 5% sedation or neurologic issues. Patients with weaning or extubation failures had longer ICU (29.9 days ± 24.5 days vs. 8.5 days ± 9.3 days; p < 0.001) and hospital stays (45.8 days ± 45.8 days vs. 26.6 days ± 23.9 days; p = 0.009), and higher rates of ventilator-associated pneumonia (83% vs. 15%, p < 0.001). CONCLUSION:: Higher level of SCI correlates strongly with failure to wean and extubate; despite this, a subset of patients with high cord injury who can be safely weaned and extubated exists. A multicenter study is warranted to specifically identify patients with high SCI who merit weaning and extubation trials.Copyright © 2011 by Lippincott Williams & Wilkins.
Keywords: adult; aged; artificial ventilation; clinical assessment; clinical examination; controlled study; disease registry; emergency health service; extubation; female; Glasgow coma scale; hospital discharge; hospitalization; human; injury severity; intensive care unit; length of stay; lung insufficiency; major clinical study; male; medical record review; motor performance; neuroanatomy; neurologic disease; priority journal; review; sedation; spinal cord injury; tracheobronchial toilet; tracheostomy; traumatic brain injury; treatment failure; treatment outcome; ventilator associated pneumonia

Selective intrabronchial air insufflation for acute lobar collapse in the surgical intensive care unit - Wohlauer M.V.; Moore E.E.; Haenel J.B.; Burlew C.C.; Barnett C.C. (Journal of Surgical Radiology, 2011)
Keywords: adult; airway pressure; article; artificial ventilation; case report; cervical spine dislocation; clinical feature; disease association; female; fever; fiberoptic bronchoscopy; human; hypoxemia; intensive care unit; atelectasis; medical history; osteosynthesis; outcome assessment; oxygen therapy; respiratory airflow; respiratory failure; spinal cord injury; thorax radiography; tracheostomy; treatment indication

Portrait of an artist: A final study - Pinsky K.M. (Ochsner Journal, 2011)
The life of an accomplished, independent 53-year-old woman is completely changed after surgery for a large, invasive spinal cord tumor. A lengthy, unsuccessful attempt at recovery and rehabilitation, compromised by multiple complications and hospitalizations, led to the patient's choice to come off the ventilator. Her end-of-life decision allowed her to die peacefully, surrounded by family and friends, all of whom were profoundly affected by the experience. © Academic Division of Ochsner Clinic Foundation.
Keywords: adult; article; assisted ventilation; attitude to death; balance disorder; tumor invasion; case report; clinical feature; computer assisted tomography; convalescence; female; general condition deterioration; hand paresthesia; human; human dignity; intensive care unit; neck pain; nuclear magnetic resonance imaging; outcome assessment; patient decision making; postoperative period; psychosocial care; quadriplegia; quality of life; respiratory failure; spinal cord surgery; spinal cord tumor; surgical risk; terminal care; tracheotomy

Significance of early tracheotomy in treatment for patients with acute cervical spinal cord injury - Sun Y.-F.; Li Y.-P.; Liu P. (Journal of Jilin University Medicine Edition, 2011)
Keywords: acute disease; article; cervical spinal cord injury; early intervention; human; spinal cord injury; tracheotomy

Methicillin-resistant Staphylococcus aureus (MRSA) is an underestimated problem in traumatic vertebral column fractures and spinal cord injury. A prevalence and riskanalysis from 1996-2008 - Eichler M.; Akbar M.; Wiedenhöfer B.; Bruckner T. (European Spine Journal, 2011)
Intoduction: Patients with traumatic spinal column fractures are faced with a high re-hospitalisation rate and are therefore at risk for a MRSA-colonisation. Methods: Retrospective database analysis between 1996-2008. Results: The total number of all treated was 3527. Isolation mean time was 67.4 days. The MRSA-prevalence was 11.8%. MRSA Patients age was 58.9 (vs.55.1 y.; p=0.0018). Male Patients were more often colonizised then female (15% vs. 6%; p<.0001). Cumulative time of hospital stays and ICU-time was significantly higher (229.7 vs. 93.6 days and 25.6 vs. 4.2 days). The number of re-hospitalization was higher for MRSA patients (2.5 vs.1.6). Patients with cervical injury showed a 14.5% MRSA-rate. Every additional year of age elevates the risk for MRSA 1.2 %. Male had a 2.8 times higher risk for MRSA. The risk of MRSA colonization increased per day of hospital stay about 3.5% %. The risk for MRSA colonization increases with the number of hospital stay ( 3: 13%; 4: 25%. Pressure sores causes a 7 times higher MRSA-risk. Patients with tracheotomy showed a 1.9% higher risk of MRSA-colonization. Diabetes mellitus is associated w/ a 2.4 higher risk of MRSA. Patients from nurseryhomes have a 17 times elevated MRSA-acquisition risk. The eradication rate was 70%. The mortality-rate was significantly higher (20%). Conclusion: This study emphasizes the high MRSA-prevalence and elevated risk in patients with vertebral column fractures with SCI. Clinical work-up of these patients should include a standardized MRSA-screening and initial isolation.
Keywords: spine; fracture; prevalence; spinal cord injury; methicillin resistant Staphylococcus aureus; society; risk; human; patient; hospitalization; male; tracheotomy; decubitus; injury; female; data base; diabetes mellitus; screening; mortality

Paediatric spinal cord injury: Review of patients treated in a tertiary level pediatric hospital - Vinhas Da Silva A.; Vieira M.; Rios J.; Camilo C.; Abecasis F.; Correia M. (Intensive Care Medicine, 2011)
Background and aims: Spinal cord injury (SCI) is rare in children but is often associated with significant morbidity and prolonged stay in PICU. The main objective of this review was to determine the epidemiology, clinical presentation, imaging studies, treatment and outcome of these patients. Patients and methods: Retrospective review of patients with SCI admitted to our PICU between 2003 and 2011. Results: We included 14 patients, 10 were male (71.4%); the mean age was 10 years (3-17). Motor vehicle accidents were the most common cause (42.8%), followed by diving accidents (30.8%). Head trauma was present in 7 patients (50%). Cervical injury represented 78.6% of SCI. Eight patients (57.1%) had complete spinal injury on admission. Vertebral fractures were the most common radiological findings (64.3%). Nine patients (64.3%) were treated surgically, 8 received steroids (57.1%) and five (28.6%) needed vasoactive drugs. Nine patients (64.3%) needed mechanical ventilation (average: 8.2 days; 1-24), none was tracheostomized. Respiratory rehabilitation comprehended daily chest physiotherapy and cough assist. Main complications were urinary (28.6%) and respiratory (50.0%) infections. The average length of PICU stay was 19.2 days (4-46). Nine patients were transferred to the ward and five directly to a rehabilitation centre. At discharge, six patients were tetraplegic and four paraplegic. No patient died. Conclusions: Most children had cervical injury, as expected due to their anatomical specificities. Very good respiratory rehabilitation care avoided tracheostomies in this series. Multidisciplinary approach maximizes recovery.
Keywords: steroid; vasoactive agent; human; patient; pediatric hospital; spinal cord injury; society; newborn intensive care; injury; child; rehabilitation; paraplegia; rehabilitation care; tracheostomy; morbidity; epidemiology; imaging; traffic accident; diving; accident; head injury; male; spine injury; spine fracture; artificial ventilation; breathing exercise; coughing; infection; ward

Surgical treatment of a traumatic C 5/ 6 transdiscal luxation with symptomatic spinal cord injury in a 13 month old child - Stier R.; Gösling T.; Otte D.; Krettek C.; Christian M. (European Spine Journal, 2011)
Background: With around 0.2 % of all fractures in childhood, spine injuries are rare in the pediatric population. There are 83% fractures, 30% with neurological symptoms. Pediatric cases of cervical spine injury account for less then 10 % of all such injuries and approximately 40 to 60 % of all pediatric spine injuries occur in the cervical region. In most of the cases, injuries of the cervical spine can be treat conservative. If a surcigal treatment is indicated, the reposition of flexion/ distraction injury in the close way is just in rare cases possible. Because ligamentous or discal injuries in the lower cervical spine are not stabile, surcigal treatment is indicated, preverably with a ventral spondylodesis. Because of few number of cases , there exist no common management treating lower cervical spine injuries in child. History: This 13-month-old girl was riding in a foreward-facing booster seat anchored next to the driver seat by a lap belt. It was raining, the road was slippery. The car breaked, left the road in the ditch nearby and hit a stone wall with 70 km/ h. At the scene, the responders found the child in the car sitting in the booster seat, she was awake, cried and moved legs and arms. There were no signs of injury. On arrival in the clinic she got tiered, the pupils were isocor. Flaccid paralysis oft he legs, no abdominal skin reflex, no reflex of pain under the mamils. She moved both arms, the babinski was positiv on the right site. Head and cervical spine MRI scans were obtained. It showed an C 5/6 transdiscal luxation with a break of the intervertebral disc of C 6 and oft he dorsal structures C5/6 and an oedemic swalling oft he spinal cord C5/6. The girl got intubated, got a stiffneck and 30 mg Dexamethason. A CT-scan oft he cervical spine showed a distraction injury at the C5-6 level with a 9 mm gap. She got right away in the OR. Therapy: Because the intervertebral disc seamed to be intact, we decided for a halo-fixation and a ventral stabilisation C5/6 without spondylodesis. In between we placed the halo-fixateur the injury showed up as instabil, so we decided to do a spondylodesis with a 4-hole 2,5 mm APTUS-plate and two angle stable screws at C 5 on C 6. Afterwards the halo west could placed. We fixed the head in a reclination position. After two days we made an MRI controll scan, which still showed the cord compression with a parenchymal bleeding. There was still a flaccid paralysis of the legs, no muscle reflexes. Arms and hands could be moved, also for drinking and eating with the spoon. After 3 weeks the patient got respiratory insufficient, so she got a tracheostoma. At the same time we removed the halo-fixateur and fixed the spine with a Miami-J- Collar. Further examinations schowed an anhidrosis and an uninhibited neurogenic bladder, but a functional anal shincter tonus. 4 weeks after trauma the patient went to a rehabilitation. The X-ray showed no dislocation of the osteosynthesis, so we removed the implants one year after trauma. After 24 and 36 month the girl was in good development but she had still paraparesis of her legs. There was no pain at the cercival spine, the extension/ flexion and rotation was free.
Keywords: hexamethonium bromide; dexamethasone; spine; dislocation; spinal cord injury; human; child; society; surgery; injury; leg; cervical spine; girl; spondylodesis; arm; female; intervertebral disk; fracture; cervical spine injury; child restraint system; pain; spine injury; car; flaccid paralysis; reflex; patient; computer assisted tomography; childhood; spinal cord; nuclear magnetic resonance imaging; paraplegia; therapy; skin; osteosynthesis; X ray; rehabilitation; muscle tone; hospital; neurologic disease; population; neurogenic bladder; anhidrosis; examination; sitting; trachea stoma; eating; drinking; muscle reflex; implant; bleeding; compression

Artificial external glottic device for passive lung insufflation - Kim D.H.; Kang S.-W.; Park Y.G.; Choi W.A.; Lee H.R. (Yonsei Medical Journal, 2011)
Purpose: For patients with neuromuscular disease, air stacking, which inflates the lungs to deep volumes, is important for many reasons. However, neuromuscular patients with severe glottic dysfunction or indwelling tracheostomy tubes cannot air stack effectively. For these patients, we developed a device that permits deep lung insufflations substituting for glottic function. Materials and Methods: Thirty-seven patients with bulbar-innervated muscle weakness and/or tracheostomies were recruited. Twenty-three had amyotrophic lateral sclerosis, and 14 were tetraplegic patients due to cervical spinal cord injury. An artificial external glottic device (AEGD) was used to permit passive deep lung insufflation. In order to confirm the utility of AEGD, vital capacity, maximum insufflation capacity (MIC), and lung insufflation capacity (LIC) with AEGD (LICA) were measured. Results: For 30 patients, MICs were initially zero. However, with the use of the AEGD, LICA was measurable for all patients. The mean LICA was 1,622.7±526.8 mL. Although MIC was measurable for the remaining 7 patients without utilizing the AEGD, it was significantly less than LICA, which was 1,084.3±259.9 mL and 1,862.9±248 mL, respectively (p<0.05). Conclusion: The AEGD permits lung insufflation by providing deeper lung volumes than possible by air stacking. © Yonsei University College of Medicine 2011.
Keywords: adult; aeration; aged; amyotrophic lateral sclerosis; article; artificial external glottic device; bulbar paralysis; cervical spinal cord injury; clinical article; female; human; larynx disorder; lung function; lung function test; lung hemodynamics; lung insufflation; male; medical device; quadriplegia; tracheostomy; vital capacity

Vitamin B12 deficiency as a cause of delirium in a patient with spinal cord injury - Harrington A.L.; Dixon T.M.; Ho C.H. (Archives of Physical Medicine and Rehabilitation, 2011)
A man with spinal cord injury (SCI) and multiple medical comorbidities had new-onset delirium during his 14th month of hospitalization. Diagnostic workup did not elicit an obvious etiology for mental status changes. Delirium persisted despite psychiatry intervention, and he was unable to be weaned from the ventilator because of prolonged agitation. Routine anemia workup revealed a possible untreated vitamin B12 deficiency, although laboratory values were inconclusive. Empiric treatment with cyanocobalamin injections was initiated, and his delirium remarkably resolved after 3 weeks of treatment. We provide a concise review of the etiologies and varied clinical presentations of vitamin B12 deficiency. As illustrated in this case, classic laboratory findings may not appear, and neurologic impairments from SCI can obscure the physical signs of deficiency, making diagnosis difficult. Empiric treatment may be indicated in cases of neuropsychiatric abnormalities not explained by other causes. © 2011 American Congress of Rehabilitation Medicine.
Keywords: albumin; bilirubin; calcium; clonazepam; creatinine; cyanocobalamin; ferritin; folic acid; haloperidol; haptoglobin; hemoglobin; homocysteine; iron; lactate dehydrogenase; methylmalonic acid; olanzapine; transferrin; urea; abdominal aortic aneurysm; adult; agitation; albumin blood level; anemia; anxiety disorder; article; artificial ventilation; assisted ventilation; bilirubin blood level; calcium blood level; case report; Clostridium difficile infection; colitis; comorbidity; creatinine blood level; cyanocobalamin deficiency; decubitus; delirium; depression; disorientation; drug substitution; drug withdrawal; erythrocyte count; ferritin blood level; folic acid blood level; hallucination; hematocrit; hemodialysis; hemoglobin blood level; hospital readmission; human; intensive care; intestine ischemia; intestine surgery; iron binding capacity; iron blood level; kidney infarction; lactate dehydrogenase blood level; length of stay; leukocyte count; male; mean corpuscular volume; mental health; paraplegia; pneumonia; psychotherapy; recurrent infection; rehabilitation care; respiratory failure; reticulocyte count; septicemia; somnolence; spinal cord injury; platelet count; tracheostomy; transferrin blood level; urea nitrogen blood level; urinary tract infection; vitamin blood level; wound healing

Cervical spine fracture. Tracheotomy? - Díaz de Cerio Canduela P.; López J.A.P.; Barrutia V.G. (Acta Otorrinolaringologica Espanola, 2011)
Keywords: article; cervical spine fracture; tracheotomy

Prompt restoration of airway along with rapid neurological recovery following ultrasonography-guided needle aspiration of a tubercular retropharyngeal abscess causing airway obstruction - Borgohain B. (Singapore Medical Journal, 2011)
Upper respiratory obstruction in cervical spine tuberculosis rarely occurs due to retropharyngeal cold abscess or secondarily from its rupture. Options for securing the airway are intubation, tracheostomy and needle aspiration or surgical drainage. A young boy presented with neck pain, quadriparesis and stridor, suggesting subacute airway obstruction in advanced tubercular spondylodiscitis of cervical spine C3-C4 (cervical 3rd and 4th level) with extradural compressive myelopathy (C3-C5) and a large retropharyngeal cold abscess. An urgent ultrasonography-guided needle aspiration with a head low position through the left posterior triangle was performed with adequate precautions and back-up for advanced airway management. Needle aspiration yielded 200 ml of pus. Stridor and hoarseness of voice decreased immediately. Within two-and-a-half hours, the patient improved neurologically. Although guided needle aspiration is one of the treatment options, there is a strong tendency to undermine this technique in favour of other options, especially surgery.
Keywords: ciprofloxacin; isoniazid; rifampicin; streptomycin; adult; airway obstruction; article; body position; bone graft; bronchial aspiration procedure; case report; clinical effectiveness; clinical feature; disease association; disease duration; echography; general condition improvement; hoarseness; human; human tissue; male; neurologic examination; nuclear magnetic resonance imaging; oxygen therapy; retropharyngeal abscess; spinal cord disease; spine radiography; spondylitis; stridor; therapy effect; traction therapy; tuberculous osteomyelitis

In reference to acute airway obstruction in cervical spinal procedures with bone morphogenetic proteins - Buchowski J.M.; Riew K.D.; Nussenbaum B. (Laryngoscope, 2011)
Keywords: bone morphogenetic protein; acute disease; airway obstruction; dysphagia; dyspnea; hematoma; hospitalization; human; incidence; intubation; letter; mortality; perioperative period; postoperative period; priority journal; respiratory failure; spine surgery; swelling; tracheostomy

Diffuse idiopathic skeletal hyperostosis of the cervical spine: An underestimated cause of dysphagia and airway obstruction - Verlaan J.-J.; Boswijk P.F.E.; De Ru J.A.; Dhert W.J.A.; Oner F.C. (Spine Journal, 2011)
BACKGROUND CONTEXT: Diffuse idiopathic skeletal hyperostosis (DISH) is a common but underdiagnosed condition relating to ossification of spinal ligaments that can cause compression of the esophagus and trachea. According to case reports, dysphagia or airway obstruction resulting from DISH is a rare occurrence. PURPOSE: This study was intended to identify all published cases of dysphagia and/or airway obstruction resulting from DISH to increase the epidemiologic/clinical knowledge of these related conditions. STUDY DESIGN: A systematic review of the literature was performed. METHODS: The articles resulting from the systematic PubMed/EMBASE search of the literature were closely read, and predefined parameters were scored. RESULTS: The search yielded a total of 118 articles (95 case reports and 23 case series) describing 204 patients with dysphagia and/or airway obstruction resulting from DISH. The number of cases demonstrated a steady increase from 1980 to 2009. This might be a real effect not ascribable to publication bias or expansion of the medical literature alone. CONCLUSIONS: Diffuse idiopathic skeletal hyperostosis as a cause of dysphagia and/or airway obstruction may be an increasing and underappreciated phenomenon. Diffuse idiopathic skeletal hyperostosis should be included in the differential diagnosis of dysphagia and airway obstruction. ©2011 Elsevier Inc. All rights reserved.
Keywords: airway obstruction; alcohol abuse; aspiration pneumonia; backache; cerebrovascular accident; cervical spine; chronic obstructive lung disease; comorbidity; conservative treatment; coronary artery disease; differential diagnosis; diffuse idiopathic skeletal hyperostosis; dysphagia; dysphonia; dyspnea; endotracheal intubation; esophagus function disorder; gastroesophageal reflux; general condition deterioration; heart arrhythmia; heart infarction; human; hyperlipidemia; hyperostosis; hypertension; idiopathic disease; laryngeal nerve injury; ligament; neck pain; non insulin dependent diabetes mellitus; obesity; odynophagia; ossification; osteoarthritis; peripheral occlusive artery disease; pneumonia; priority journal; pulmonary aspiration; radiculopathy; range of motion; respiratory failure; retinol intoxication; review; sleep disordered breathing; spinal cord disease; stridor; cerebrovascular accident; systematic review; thorax outlet syndrome; tracheostomy; body weight loss

Managing high-level cervical spinal cord injuries: Intensivist's point of view - Pease S. (Annals of Physical and Rehabilitation Medicine, 2011)
Incidence of spinal cord injury in France is estimated at 1000 to 2000 patients per year. The diaphragm is innerved by the phrenic nerves that are formed from the cervical nerves C3, C4, C5. High tetraplegia is defined as a spinal cord injury for a level set from C1 to C4. More and more patients suffering such high level are now being admitted alive to trauma centres because of major progress made in pre-hospital management. Optimal pre-hospital management lies on direct admission to dedicated trauma centre, cautious cervical spine immobilisation, and maintenance of adequate mean arterial blood pressure to improve spinal cord perfusion, mechanical ventilation in the case of respiratory insufficiency or coma. In hospital, time of surgery is decided as a collegiate decision between the neurological surgeons and the intensivist after managing first all lifethreatening injuries.Weaning from mechanical ventilation must be envisaged as soon as possible after surgery, in the absence of any lung complication (infection, contusion). Ethical discussion are regularly held during ICU stay. Tracheotomy is frequently performed for comfort of weaning. Opportunity of implanting a phrenic-nerve pacemaker must be considered whenever possible.Weaning time goes from months to years. Early admission to spinal cord injury rehabilitation centres capable of managing ventilator weaning is therefore mandatory if aiming at early discharge from ICU.
Keywords: spinal cord injury; adaptation; artificial ventilation; injury; cervical spinal cord injury; human; hospital management; surgery; phrenic nerve; patient; pacemaker; rehabilitation; France; diaphragm; nerve; quadriplegia; cervical spine; immobilization; spinal cord; perfusion; respiratory failure; coma; hospital; surgeon; lung complication; infection; contusion; tracheotomy; weaning; mean arterial pressure

[Anterior cervical spine hyperostosis--a rare cause of difficult intubation in emergency]. - Stefan M.; Ciupilan C.; Mella C.; Scutariu M.D. (Revista medico-chirurgicalǎ̌ a Societǎ̌ţaii de Medici ş̧i Naturaliş̧ti din Iaş̧i, 2011)
DISH (Diffuse idiopathic skeletal hyperostosis) of cervical spine is a rare condition which causes dysphagia in 23% of cases and occasionally dyspnea. The authors report the case of a 74 years old male, known with progressive dysphagia and recurrent episodes of dysphonia and dyspnea, who suffered a sudden episode of respiratory distress that need finaly tracheotomy after ineffective attempts of orotracheal intubation.
Keywords: adult respiratory distress syndrome; aged; ankylosing hyperostosis; article; case report; cervical spine; dysphagia; dysphonia; dyspnea; emergency health service; endotracheal intubation; human; male; methodology; non insulin dependent diabetes mellitus; radiography; risk factor; tracheotomy; treatment outcome