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A debilitated 73-year-old white man was diagnosed with back pain secondary to acute hematogenous Eikenella corrodens vertebral osteomyelitis on the basis of history and physical examination, radiographs, computed tomography, magnetic resonance imaging, and open biopsy of the L3 vertebral body. A rare cause of vertebral osteomyelitis, possibly reported only once before in the world literature, E. corrodens is a facultative anaerobic gram-negative bacillus and a normal oral inhabitant. E. corrodens should be considered in the differential diagnosis of vertebral osteomyelitis and can be managed with immobilization and long-term intravenous antibiotics.

Ochronosis, the musculoskeletal manifestation of alkaptonuria, primarily involves the larger joints of the body, including the spine. Ankylosis of the thoracolumbar spine leads to progressive loss of flexibility. The case described is that of a 72-year-old man with ochronosis who suffered a hyperextension injury to his spine in a fall, resulting in a fracture through an ankylosed L2-L3 disk space. To the authors' knowledge, this is the first reported fracture of an ankylosed ochronotic spine.

Anterior ankle dislocations without concomitant malleolar fractures are rare injuries. Review of the English-language literature disclosed only three previously reported cases. A 21-year-old man sustained an isolated anterior ankle dislocation with an associated fracture of the trigonal process, which was reduced without difficulty. At follow-up examination 33 months later, the patient's major complaint was chronic, posttraumatic peroneal tendon dislocation. The proposed mechanism of injury suggested in this case is forced plantar flexion.

Vertebral osteomyelitis due to hematogenous seeding of Streptococcus agalactiae occurred in a 29-year-old farmer. The patient was treated with immobilization and parenteral antibiotics but developed recurrent back pain requiring a posterior spinal fusion. In a review of the literature, Group B streptococcal vertebral osteomyelitis seems not to have been previously reported in an adult.

The true incidence of spinal cord injury as a complication of elective anterior discectomy and interbody fusion is not known. It would appear that the risk of encountering this complication increases if the surgical procedure includes instrumentation within the spinal canal. In 5 of the cases reported herein the cause for spinal cord injury was identifiable; in the remaining 5, the mechanism of injury is either obscure or not reported. All 10 patients reported had their surgery performed using the drill and dowel technique. The role of the posterior osteophyte in spondylosis and the rationale for routinely entering the spinal canal in order to decompress the spinal cord and nerve roots are examined. Since the majority of refractory disk problems that require surgery can be satisfactorily managed by discectomy and interbody fusion alone, routine instrumentation within the spinal canal may be an avoidable hazard in the majority of instances. The pathogenesis and prognosis of the anterior cord syndrome is reviewed, a possible etiology is suggested, and the anatomy, the autonomy and the importance of the anterior spinal artery system are noted. Its vulnerability in the treatment of degenerative disk disease and a possible mechanism for its occult impairment is mentioned.

Fourteen consecutive patients with burst fractures at T12 or L1, partial paralysis, and more than 30% canal compromise were prospectively evaluated pretreatment and posttreatment with roentgenograms to determine the initial fracture pattern, CT scans to determine the percent canal compromise and subsequent improvement, and a quantitative motor trauma index scale and bladder sphincter evaluation to determine neurologic recovery. The follow-up period averaged 32 months (range, 12-50 months). Treatment was as follows: nonoperative (three patients), Harrington rods and fusion (seven patients), and Harrington rods and fusion followed by anterior decompression and fusion (four patients). The initial severity of paralysis did not correlate with the initial fracture roentgenographic pattern or the amount of initial CT canal compromise. Neurologic recovery did not correlate with the treatment method or amount of canal decompression. Subsequent recovery did correlate with the initial fracture pattern. If the patient had a Type I or Type II fracture (both greater than 15 degrees kyphosis), greater than 90% neurologic recovery occurred, regardless of treatment. If the patient had a Type III fracture (less than 15 degrees kyphosis and the maximal canal compromise where bone encircles the canal) less than 50% neurologic recovery occurred. If the patient had a Type IV fracture (less than or equal to 15 degrees kyphosis and the maximal canal compromise at the level of the ligamentum flavum), the neurologic recovery was variable. Prognosis for neurologic recovery can be made based on initial roentgenograms. If greater than 15 degrees kyphosis is present, there is a good prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Of 256 patients with a major spinal cord injury as a result of fracture of the cervical spine, 38 per cent had a laminectomy. Three months after injury, 33 per cent of the patients with laminectomy required fusion for instability compared to 22 per cent of the nonlaminectomy group. There were no cases of late instability in pure flexion or extension fracture groups. Ninety per cent of the late instability cases were in the groups with hyperflexion and flexion compression fractures. Laminectomy should be avoided for these fractures, but early fusion may be necessary to prevent progressive deformity.

Magnetic resonance imaging (MRI) of the spine is a new imaging technique that allows greater visualization of the spinal cord than other imaging modalities. This article reports on two cases of traumatic division of the spinal cord demonstrated by MRI. Both patients had complete transection of the spinal cord and did not have neurologic functional recovery distal to the spinal cord transection. MRI is applicable to diagnosis in acute conditions and to reveal division of the spinal cord, allowing prediction of an unlikely chance of neurologic recovery.

The diagnosis of complete or incomplete quadriplegia and designation of functional levels can be accurately determined during the first 24 hours after injury in virtually all cases of severe traumatic quadriplegia. The prognosis for recovery depends upon an understanding of regeneration of nerve roots following injury and the significance of return of involuntary reflex activity. A realistic prognosis and accurate evaluation of various forms of treatment depend upon accurate documentation of the pattern of sensory and motor deficits.

Three different methods of internal fixation for the flexion-rotation thoracolumbar spinal fractures were tested biomechanically in a cadaver model for strength, mode of failure and ease of application. The compression rod system was clearly superior in strength and rotational stability to the spring device, but it was more difficult to apply than springs. The distraction rod system exhibited an intermediate level of strength with adequate rotational stability. Technically, the method is exacting and requires a clear understanding of its principle of 3 point fixation.

Injuries to the subaxial cervical spine must be suspected in any patient who suffers a head injury or complains of neck pain or neurologic symptoms of the arms or legs following an accident, particularly a motor vehicle or diving accident. Careful neurologic examination and lateral roentgenograms are indicated in all patients with suspected injury. If there is any neurologic deficit, fracture, or dislocation seen on roentgenogram, skull-traction tongs should be applied to provide stability and prevent further damage. If the neurologic examination and roentgenograms are normal, a stretch-test roentgenogram may be indicated to detect an occult ligamentous injury. Muscular strains and first-degree sprains may be treated with a collar and early active exercise. Subluxation and facet dislocations are most reliably treated with a posterior one-level fusion. Comminuted body fractures are best treated with an anterior strut graft. Complex fracture-dislocations of both anterior and posterior columns may be best treated with skull traction followed by combined anterior and posterior stabilization. Halo-jacket immobilization has few indications in subaxial injuries. It does not provide enough stability to maintain reduction of unstable mid- and low-cervical injuries. It may be used for postoperative immobilization in very unstable situations, but its greatest use is in immobilization of C1 and C2 fractures.

Principles of management of long bone fractures in patients with spinal cord injuries vary with the type of fracture and duration of quadriplegia. Class I fractures (acute injuries) are managed by existing principles of long bone fracture management with a tendency to open reduction and internal fixation to dispense with the necessity of plaster casts on insensate skin. Class II fractures (pathologic--osteoporotic) heal well, require minimal specific treatment, and open reduction is usually contraindicated. Class III fractures (acute injuries in chronic paraplegia) are treated with methods least likely to disrupt the patient's life style in a wheelchair. Open reduction should be used whenever there are difficulties with circular casts and traction methods.

Thirty patients with heterotopic ossification following spinal injuries were divided into acutely-injured and post-surgical groups. Patients in the acutely injured group had symptoms of heterotopic ossification within 6 months of injury. The formation and maturation of the heterotopic bone around the affected hip(s) were studied by serial alkaline phosphatase determinations and radiographic examinations. Radionuclide bone scans using 99m Technetium diphosphonate were made in all patients. Treatment consisted of maintaining range of motion. This appears to be a self-limiting process as maturation occurs. Surgery was not necessary in this group. In patients with mature deposits, wedge and segmental resection of the extraosseous bone was necessary to regain enough hip flexion for the patinets to sit. This was followed by vigorous joint ranging. After one year, average range of recovered flexion was 60 degrees.