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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., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Study Design: Retrospective review of a prospectively collected database., Objective: To examine whether short- and long-term outcomes after surgery for lumbar stenosis (SPS) and degenerative spondylolisthesis (DS) vary across centers., Summary of Background Data: Surgery has been shown to be of benefit for both SPS and DS. For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated., Methods: Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of SPS or DS undergoing surgery were followed from baseline at 6 weeks, 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Baseline characteristics and short- and long-term outcomes were analyzed., Results: A total of 793 patients underwent surgery. Significant differences were found between centers with regard to patient race, body mass index, treatment preference, neurological deficit, stenosis location, severity, and number of stenotic levels. Significant differences were also found in operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and wound infection. When baseline differences were adjusted for, significant differences were still seen between centers in changes in patient functional outcome (Short Form-36 bodily pain and physical function, and Oswestry Disability Index) at 1 year after surgery. In addition, the cumulative adjusted change in the Oswestry Disability Index Score at 4 years significantly differed among centers, with Short Form-36 scores trending toward significance., Conclusion: There is a broad and statistically significant variation in short- and long-term outcomes after surgery for SPS and DS across various academic centers, when statistically significant baseline differences are adjusted for. The findings suggest that the choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important.

Object: Stroke is a leading cause of death and disability. Given that neurologists and neurosurgeons have special expertise in this area, the authors hypothesized that the density of neuroscience providers is associated with reduced mortality rates from stroke across US counties., Methods: This is a retrospective review of the Area Resource File 2009-2010, a national county-level health information database maintained by the US Department of Health and Human Services. The primary outcome variable was the 3-year (2004-2006) average in cerebrovascular disease deaths per million population for each county. The primary independent variable was the combined density of neurosurgeons and neurologists per million population in the year 2006. Multiple regression analysis was performed, adjusting for density of general practitioners (GPs), urbanicity of the county, and socioeconomic status of the residents of the county., Results: In the 3141 counties analyzed, the median number of annual stroke deaths was 586 (interquartile range [IQR] 449-754), the median number of neuroscience providers was 0 (IQR 0-26), and the median number of GPs was 274 (IQR 175-410) per million population. On multivariate adjusted analysis, each increase of 1 neuroscience provider was associated with 0.38 fewer deaths from stroke per year (p < 0.001) per million population. Rural location (p < 0.001) and increased density of GPs (p < 0.001) were associated with increases in stroke-related mortality., Conclusions: Higher density of specialist neuroscience providers is associated with fewer deaths from stroke. This suggests that the availability of specialists is an important factor in survival after stroke, and underlines the importance of promoting specialist education and practice throughout the country.

Background: Lumbar discectomy is the most commonly performed spine procedure. Academic spine centers with potentially differing caseloads and experience may have different outcomes., Objective: To determine whether the choice of center in which surgery is performed affects lumbar discectomy outcomes., Methods: Spine Patient Outcomes Research Trial participants with a confirmed diagnosis of intervertebral disc herniation undergoing standard first-time open discectomy were followed from baseline at 6 weeks, and 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Patient data from this prospective study were reviewed. Enrollment began in March 2000 and ended in November 2004., Results: Seven hundred ninety-two patients underwent first-time lumbar discectomy. Significant differences were found among centers in patient age and race, baseline levels of disability, and treatment preferences. There were no significant differences among the centers in other patient characteristics (eg, sex, body mass index, the prevalence of smoking, diabetes, or hypertension), or disease characteristics (herniation level or type). Some short-term outcomes varied significantly among centers, including operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and reoperation rate. However, there were no differences among the centers in incidence of nerve root injury, postoperative mortality, Short Form 36 scores of body pain or physical function, or Oswestry Disability Index at 4 years., Conclusion: Although mean blood loss, risk of durotomy, length of stay, and rate of reoperation vary among academic spine centers performing lumbar discectomy, there appears to be no difference in long-term functional outcomes.

Object: Motor vehicle accidents (MVAs) are a leading cause of death and disability in young people. Given that a major cause of death from MVAs is traumatic brain injury, and neurosurgeons hold special expertise in this area relative to other members of a trauma team, the authors hypothesized that neurosurgeon population density would be related to reduced mortality from MVAs across US counties., Methods: The Area Resource File (2009-2010), a national health resource information database, was retrospectively analyzed. The primary outcome variable was the 3-year (2004-2006) average in MVA deaths per million population for each county. The primary independent variable was the density of neurosurgeons per million population in the year 2006. Multiple regression analysis was performed, adjusting for population density of general practitioners, urbanicity of the county, and socioeconomic status of the county., Results: The median number of annual MVA deaths per million population, in the 3141 counties analyzed, was 226 (interquartile range [IQR] 151-323). The median number of neurosurgeons per million population was 0 (IQR 0-0), while the median number of general practitioners per million population was 274 (IQR 175-410). Using an unadjusted analysis, each increase of 1 neurosurgeon per million population was associated with 1.90 fewer MVA deaths per million population (p < 0.001). On multivariate adjusted analysis, each increase of 1 neurosurgeon per million population was associated with 1.01 fewer MVA deaths per million population (p < 0.001), with a respective decrease in MVA deaths of 0.03 per million population for an increase in 1 general practitioner (p = 0.007). Rural location, persistent poverty, and low educational level were all associated with significant increases in the rate of MVA deaths., Conclusions: A higher population density of neurosurgeons is associated with a significant reduction in deaths from MVAs, a major cause of death nationally. This suggests that the availability of local neurosurgeons is an important factor in the overall likelihood of survival from an MVA, and therefore indicates the importance of promoting neurosurgical education and practice throughout the country.

Objective: To examine electronic records of GP management of chronic kidney disease., Design: Cross-sectional study., Setting: Thirteen general practices., Participants: Fifteen thousand four hundred and fiftteen active patients aged 50 years and over., Main Outcome Measure:   Recorded estimated glomerular filtration rate (eGFR) and diabetes, and rate of prescribing of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACE/ARBs)., Results: Six thousand and fifty-nine (39%) patients had hypertension and 1859 (12%), diabetes. Two thousand six hundred and eighty-nine (17%) patients were recorded with eGFR < 60 mL min(-1) (1.73 m(2) )(-1) , while 3344 (22%) did not have an eGFR result recorded. Hypertension, diabetes and eGFR <60 mL min(-1) (1.73 m(2) )(-1 ) were shown to be significantly related to prescribing of ACE/ARBs; however, 31% of known diabetics and 23% of diabetics with an eGFR < 60 mL min(-1) (1.73 m(2) )(-1 ) are not recorded as receiving ACE or ARB therapy. Forty-two per cent of patients with eGFR < 60 mL min(-1) (1.73 m(2) )(-1) , are also not recorded as receiving ACE or ARB therapy. There was a 23% variation in the rates of prescribing of ACE/ARBs by practice for patients with diabetes and eGFR < 60 mL min(-1) (1.73 m(2) )(-1) ., Conclusion:   The overall recording of eGFR and the recorded prescribing of ACE or ARB therapy in known diabetics and patients with eGFR < 60 mL min(-1) (1.73 m(2) )(-1) appear suboptimal. Also, the variations in prescribing between practices require further investigation., (© 2012 The Authors. Australian Journal of Rural Health © National Rural Health Alliance Inc.)

Postural orthostatic tachycardia syndrome (POTS) has been recognized since at least 1940. A review of the literature identifies differences in the definition for this condition and wide variations in treatment and outcomes. This syndrome appears to describe a group of conditions with differing pathophysiology, which requires treatment tailored to the true underlying disorder. Patients need to be fully evaluated to guide treatment. Further research is required to effectively classify the range of underlying pathophysiology that can produce this syndrome and to guide optimal management.

Background: Incidental durotomy is a familiar encounter during surgery for lumbar spinal stenosis. The impact of durotomy on long-term outcomes remains a matter of debate., Objective: To determine the impact of durotomy on the long-term outcomes of patients in the Spine Patient Outcomes Research Trial (SPORT)., Methods: The SPORT cohort participants with a confirmed diagnosis of spinal stenosis, without associated spondylolisthesis, undergoing standard, first-time, open decompressive laminectomy, with or without fusion, were followed up from baseline at 6 weeks, and 3, 6, and 12 months and yearly thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean follow-up among all analyzed patients was 43.8 months., Results: Four hundred nine patients underwent first-time open laminectomy with or without fusion. Thirty-seven of these patients (9%) had an incidental durotomy. No significant differences were observed with or without durotomy in age; sex; race; body mass index; the prevalence of smoking, diabetes mellitus, and hypertension; decompression level; number of levels decompressed; or whether an additional fusion was performed. The durotomy group had significantly increased operative duration, operative blood loss, and inpatient stay. There were, however, no differences in incidence of nerve root injury, mortality, additional surgeries, or primary outcomes (Short Form-36 Bodily Pain or Physical Function scores or Oswestry Disability Index) at yearly follow-ups to 4 years., Conclusions: Incidental durotomy during first-time lumbar laminectomy for spinal stenosis did not impact long-term outcomes in affected patients.

Object: Incidental durotomy is an infrequent but well-recognized complication during lumbar disc surgery. The effect of a durotomy on long-term outcomes is, however, controversial. The authors sought to examine whether the occurrence of durotomy during surgery impacts long-term clinical outcome., Methods: Spine Patient Outcomes Research Trial (SPORT) participants who had a confirmed diagnosis of intervertebral disc herniation and were undergoing standard first-time open discectomy were followed up at 6 weeks and at 3, 6, and 12 months after surgery and annually thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean (± SD) duration of follow-up among all of the intervertebral disc herniation patients whose data were analyzed was 41.5 ± 14.5 months (41.4 months in those with no durotomy vs 40.2 months in those with durotomy, p < 0.68). The median duration of follow-up among all of these patients was 47 months (range 1-95 months)., Results: A total of 799 patients underwent first-time lumbar discectomy. There was an incidental durotomy in 25 (3.1%) of these cases. There were no significant differences between the durotomy and no-durotomy groups with respect to age, sex, race, body mass index, herniation level or type, or the prevalence of smoking, diabetes, or hypertension. When outcome differences between the groups were analyzed, the durotomy group was found to have significantly increased operative duration, operative blood loss, and length of inpatient stay. However, there were no significant differences in incidence rates for nerve root injury, postoperative mortality, additional surgeries, or SF-36 scores for Bodily Pain or Physical Function, or Oswestry Disability Index scores at 1, 2, 3, or 4 years., Conclusions: Incidental durotomy during first-time lumbar discectomy does not appear to impact long-term outcome in affected patients.

Introduction: Little research has been conducted analysing the organisational risks that compound and trigger dispensing and medication errors. This pilot study appraises the attitudes to and behaviours related to the dispensing errors of pharmacists practising in diverse venues and roles in inland Australia., Methods: Twelve pharmacists working in the Riverina (Wiradjuri country) participated in a structured interview consisting of a brief survey and open-ended questions. The interviews were audio-recorded for transcription, then analysed by the interviewer for emerging themes. In this pilot study, the attitudes and actions of pharmacists in response to dispensing errors were explored to determine the nature of organisational strategies implemented to detect and recover 'slips, lapses and mistakes'. The rationale behind investigating attitudes and actions stems from the theory of planned behaviour., Results: While many common themes emerged, the attitudes of each pharmacist were unique. The strategies implemented to prevent errors were venue-specific and purpose-designed to the training level of the staff and physical environment. A diverse mix of attitudes was represented by the sample, with no correlation between worksite, sex, age or role identified. Trends may emerge because, in regard to dispensing errors, subjective norms and perceived behavioural control play a greater role in forming the intention to act, rather than personal attitudes. The majority of examples given by participants was discussion of recorded errors and near misses, which included changes to procedures implemented to prevent the same error occurring. This culture of continuous quality improvement was the overarching common theme. Other common themes were the role of technology in the supply of medicines, privacy implications when drawing staff from a rural or regional centre, workload concerns with regard to management responsibility and the impact of the way error management was demonstrated during the formative early years of practice. Distraction from dispensing, through management roles in pharmacies with moderate prescription volumes, was a common contributor to errors., Conclusion: A culture of continuous quality improvement exists amongst pharmacists in Inland Australia, which would benefit from improved dialogue about the impact of organisational risks on the rate of dispensing errors. The safety culture, and behaviour modelling experienced during the internship program has a profound impact on the perceived behavioural control of young pharmacists. This year instils mores, which may be the result of independent survival in remote and regional settings, rather than compliance with professional practice standards. While many of the pressures and demands of minimising errors are common across the profession; unique, venue specific strategies are commonly implemented in the cycle of continuous quality improvement in regional and remote settings.

Object: The authors sought to determine a cause-specific mortality profile for US neurosurgeons during the period 1979-2005., Methods: Neurosurgeons who died during the study period were identified from the Physician Master File database. Using the National Death Index, the reported cause of death was identified for 93.7% of decedents. Standardized mortality ratios were used to compare mortality risk in the study cohort to that of the US population., Results: There was a marked reduction in mortality from virtually all causes in comparison with the control population. This finding is consistent with prior studies of mortality in physicians. The small number of deaths among female neurosurgeons precluded meaningful analysis for this group. Increased mortality risk for male neurosurgeons was seen from leukemia, nervous system disease (particularly Alzheimer disease), and aircraft accidents. Deaths from viral hepatitis and HIV infection, considered to be occupational hazards for surgeons, were less frequent than in the general population. Suicide, drug-related deaths, and alcohol-related deaths were less frequent than in the general population., Conclusions: Neurosurgeons may be at higher risk for death from leukemia, aircraft accidents, and diseases of the nervous system, particularly Alzheimer disease; however, the mortality profile of neurosurgeons is favorable when compared with the general population.

Background and Objectives: : During ankle block performance, anesthetizing the sural nerve is important for generating complete anesthesia of the lateral aspect of the foot. We hypothesized that an ultrasound-guided perivascular approach, utilizing the lesser saphenous vein as a reference, would prove more successful than a conventional approach based on surface landmarks., Methods: : Eighteen healthy volunteers were prospectively randomized into this controlled and blinded study. Each subject was placed prone and the right ankle was randomized to receive either an ultrasound-guided perivascular sural nerve block (group US) or a traditional landmark-based sural nerve block (group TRAD). The subject's left ankle then received the alternate approach. The ultrasound technique relied on injecting local anesthetic circumferentially around the lesser saphenous vein. All blocks were performed with 5 mL of 3% chloroprocaine. We evaluated sensory block to ice and pinprick. Secondary outcome variables included performance times, number of needle passes, participant satisfaction, and presence of any complications., Results: : At the midfoot position, testing at 10 minutes after block placement revealed a loss of sensation to ice in 94% (complete in 78% and partial in 16%) in the US group versus 56% in the TRAD group (complete in 28%, partial in 28%) (P <.01). Complete loss of sensation to ice persisted in 33% of the US group as compared with 6% in the TRAD group at 60 minutes (P <.05). A similar pattern was observed when the blocks were tested with pinprick. Ultrasound-guided blocks took longer to perform on average than the traditional blocks (mean difference of 102 seconds, P <.001). The ultrasound block was subjectively felt to be denser by 88% of the subjects (P =.001)., Conclusions: : Ultrasound guidance using the lesser saphenous vein as a reference point results in a more complete and longer lasting sural nerve block than does a traditional approach using surface landmarks.

Atypical teratoid/rhabdoid tumors (AT/RTs) are rare, malignant brain tumors which occur almost exclusively in infants and young children. There have been only 17 cases of AT/RT in adults reported in the medical literature and the rarity of this tumor makes the diagnosis in adults difficult. We describe a case of an AT/RT of the spinal cord in an adult. A 43-year old woman presented with neck and left upper extremity pain. An MRI demonstrated a mass lesion in the dorsal spinal cord extending from C4 to C6. The patient underwent a C3 through C7 laminectomy. In consultation with senior pathologists at other institutions, the lesion was initially diagnosed as a rhabdoid meningioma. Molecular genetic studies revealed monosomy 22 and loss of expression of the INI1 gene in 22q11.2. Subsequently, immunohistochemical studies revealed the absence of INI1 gene expression in the malignant cells, supporting the diagnosis of AT/RT. The patient underwent three additional surgical procedures for recurrent disease throughout the neuraxis secondary to leptomeningeal spread of the tumor. Despite aggressive surgical resection, adjuvant chemotherapy and radiation therapy, the patient succumbed to the disease two and a half years after her initial presentation. An unrestricted autopsy was performed. To our knowledge, this is the first case of a spinal atypical teratoid/rhabdoid tumor in an adult fully documented with molecular, immunohistochemical, cytogenetic and autopsy findings.

Objective: Children can be a difficult population in which to administer medicines and many parents or caregivers may be inexperienced in the administration of paediatric medicines. The aim of this study was to determine the variations in volumes of doses of reconstituted antibiotic suspension using two calibrated administrative devices., Setting: Measurements were conducted in a Dispensing Laboratory in New Zealand, using locally available commercial, standardized measuring devices., Method: A medicine dropper and a spill-proof measuring spoon were selected and a dose of 3 ml, to be given three times daily for five days (45 ml) was used for the purposes of this study. Doses were weighed and corresponding volumes were calculated using the average weight per ml., Results: The doses measured using the medicine dropper were consistently smaller than the doses measured using the spill-proof measuring spoon., Conclusion: The current method of financial subsidy for the provision of liquid antibiotics in New Zealand should be investigated. Pharmacists must ensure that an appropriate measure and sufficient quantity is provided for optimal duration of treatment. This study contributes to the relatively sparse information available on the administration of children's medicines. It will have relevance for countries where pharmacy practice is determined largely by administrative departments.

Background: The male-specific region of the mouse Y chromosome long arm (MSYq) is comprised largely of repeated DNA, including multiple copies of the spermatid-expressed Ssty gene family. Large deletions of MSYq are associated with sperm head defects for which Ssty deficiency has been presumed to be responsible., Results: In a search for further candidate genes associated with these defects we analyzed changes in the testis transcriptome resulting from MSYq deletions, using testis cDNA microarrays. This approach, aided by accumulating mouse MSYq sequence information, identified transcripts derived from two further spermatid-expressed multicopy MSYq gene families; like Ssty, each of these new MSYq gene families has multicopy relatives on the X chromosome. The Sly family encodes a protein with homology to the chromatin-associated proteins XLR and XMR that are encoded by the X chromosomal relatives. The second MSYq gene family was identified because the transcripts hybridized to a microarrayed X chromosome-encoded testis cDNA. The X loci ('Astx') encoding this cDNA had 92-94% sequence identity to over 100 putative Y loci ('Asty') across exons and introns; only low level Asty transcription was detected. More strongly transcribed recombinant loci were identified that included Asty exons 2-4 preceded by Ssty1 exons 1, 2 and part of exon 3. Transcription from the Ssty1 promotor generated spermatid-specific transcripts that, in addition to the variable inclusion of Ssty1 and Asty exons, included additional exons because of the serendipitous presence of splice sites further downstream., Conclusion: We identified further MSYq-encoded transcripts expressed in spermatids and deriving from multicopy Y genes, deficiency of which may underlie the defects in sperm development associated with MSYq deletions.

A 78-year-old woman presented for evaluation of back pain, urinary dysfunction, leg weakness and progressive equinovarus foot deformity. She reported that shortly after her birth in 1924, she underwent resection of a subcutaneous 'cyst' in the lower lumbar area. Seven years prior to evaluation at our institution, she had undergone bilateral total knee arthroplasty for osteoarthritis. After the procedure, she began to experience severe low back pain that radiated into her legs. Weakness of the foot inverters, urinary dysfunction and worsening bilateral equinovarus foot deformity developed in the years following the surgery. MRI revealed a split cord malformation with a tethered spinal cord. Because of the patient's age and poor medical condition, her symptoms were managed conservatively. This case demonstrates symptomatic deterioration in an elderly patient with a tethered spinal cord after many years of clinical stability.

Purpose of Review: To review pharmaceutical and pharmacological issues relating to the benefits and risks associated with the use of naturally sourced nutraceuticals when administered singly or in combinations., Recent Findings: The application of vegetable extracts or dietary supplementation with selenium or antioxidant vitamins results in positive benefits on immunity and other phenomena associated with chronic diseases, ageing and cancer. However, there appear to be no cardiovascular benefits from vitamin mixtures, which may in fact cause harm. Therefore, although recent publications have increased our understanding of the metabolic actions of nutraceuticals, learning to use them to the best advantage is going to require products with uniform and consistent quality. Unfortunately, a single purified substance will not always have the same antioxidant activity, nor provide the same clinical benefits as nutraceutical mixtures and combinations occurring in natural extracts. In order to perform first-class clinical studies to determine safety and efficacy, the stability, compatibility and other pharmaceutical variables inherent in many of these combination products will have to be better controlled., Summary: Nutraceuticals have potent biological actions. Their use is increasing dramatically, and there is growing evidence of clinical benefits. No medicinal products are completely safe so their risks need to be characterized and controlled. Imposing pharmaceutical levels of control and regulation would increase costs and reduce patient access to new products, but the evidence is compelling that closer monitoring of raw materials, processing and formulation will be required to maximize the benefits and minimize the risks.

Ideally, minimally invasive surgery (MIS) allows less extensive manipulation of surrounding tissues than a conventional open procedure while accomplishing the same goals and objectives at the target structure. Long-term follow-up combined with appropriate outcome measures are necessary to prove the safety and effectiveness of MIS. For MIS procedures to be widely adopted, they must have an acceptable learning curve. Special skills are needed and are beyond those of traditional open surgery, By definition, as compared with conventional open surgeries, minimally invasive procedures typically involve smaller incisions and less extensive surgical manipulation of the tissues that surround the target structure. Ideally, once the target structure has been reached, the minimally invasive procedure should accomplish the same goals and objectives as its open surgical counterpart. Thus, although minimally invasive surgeries are aimed at reducing the morbidity associated with open surgical approaches, they should not hinder the surgeon's ability to perform a successful operation. In other words, minimal invasion should not equate to minimally effective.

Purpose of Review: The routine use of intravenous in-line filters on infusion lines has been controversial for many years, with strong advocates, detractors and many fence-sitting observers. The purpose of this review was to examine the literature for new developments and to cast the net a little wider than in previous reviews in an attempt to draw useful parallels., Recent Findings: There were recent major policy statements or recommendations from a working party of the British Pharmaceutical Nutrition Group and from the US Centres for Disease Control. The first was focussed on filters and was broadly in favour, the second was not focussed on the subject but made quite a strong statement against, on microbiological issues alone. The major purpose of filters, however, is particulate contamination, and whilst there was little in the literature directly on this subject, useful parallels could be drawn from papers describing the therapeutic use of particles and also from their effects in intravenous drug users., Summary: When all the available information is considered, and the role of filters in particulate contamination, in-line chemical precipitates, identifying problems in parenteral therapy practice, microbial contamination and entrapped air is examined, the case for routine use appears strong.

The objective of this report is to describe a surgical technique used successfully when a flat or paddle type spinal cord stimulator electrode cannot be properly positioned via a single laminotomy. Different and innovative surgical techniques useful in placement of spinal cord stimulators and analgesic infusion pump systems have not been well described. The prevalence of anatomic surgical abnormalities or variations that might present barriers to implantation of these devices is unknown but may be as high as 18% for revisions. A dual laminotomy technique can be useful and successful in positioning a flat spinal cord stimulator electrode that cannot be properly positioned via a single laminotomy approach. We report two patients who have been treated successfully with a dual laminotomy technique.

Objective: We reviewed the literature and examined the issues surrounding the use of glutamine in pediatrics and neonatology., Methods: We reviewed the literature using Medline, Embase, Current Contents, and International Pharmaceutical Abstracts. Additional information was obtained from bibliographic citations and personal communications., Results: Evidence showed that glutamine levels are affected in a number of life stages and conditions. Useful, indicative studies are emerging but many fail to demonstrate significant differences. The problems of researching in this patient population were demonstrated., Conclusion: A need for a great deal of further research in this area, including larger multicenter trials, clearly emerged.

Study Design: Review article., Objectives: To review the pathophysiology and management of the pulmonary and hemodynamic derangements that occur after acute spinal cord injury., Summary of Background Data: Acute spinal cord injury is often associated with alterations in pulmonary and cardiovascular function that require treatment in the intensive care unit., Methods: Review of published reports., Results/conclusion: Careful attention to the support of the pulmonary and cardiovascular systems can reduce the morbidity associated with acute spinal cord injury. Pulmonary function decreases markedly in the immediate postinjury period but improves in the subsequent weeks, allowing most patients with injury levels at C4 and below to be weaned from ventilatory support. Bradycardia and hypotension often accompany acute spinal cord injury, and management strategies are reviewed. The prophylaxis and diagnosis of thromboembolic disease are reviewed.

Objectives: In consideration of a US Federal Drug Administration recommendation that all parenteral nutrition admixtures should be administered through an in-line filtration device, this observational study examined the number, size distribution, and sources of particulate contamination in parenteral nutrition admixture infusion systems., Methods: Samples were drawn from the terminal connection of the infusion tubing before connection to the patient. The particles were sized and counted by optical microscopy and further investigated by electron microscopy and energy disperse spectroscopy., Results: Large numbers of particles were found, and information gained about their possible origin., Conclusions: This study provides further support for the adoption of this Federal Drug Administration recommendation.

Increased use of intravenous in-line filtration for all-in-one admixtures has been one of several recent stimuli to developing methods for assessing the stability of parenteral nutrition regimens. Admixture formulations previously deemed to be 'stable' have caused filter blockage and this requires urgent reconsideration of the definitions of physical emulsion stability. The new technique of acoustic attenuation spectroscopy has been evaluated as another means of assessing physical stability of emulsions, and some of the newer techniques have been further applied to provide additional insight into the effects of light and oxygen. There has also been additional work on trace element contamination and changes in trace element concentrations on storage. Overall this review period has been one of evolution rather than revolution.

Background and Objectives: Frequency of epidural steroid injections (ESI) and characteristics of patients receiving them are unknown or poorly described. Patients believed to respond better to ESI include young or middle-aged individuals, those with recent onset or a radicular pattern of pain, and patients without previous spinal surgery. The aim of this study is to estimate the frequency of ESI, to examine the characteristics of patients who have them recommended, and to determine if clinical practice reflects published data pertaining to indications for ESI., Methods: Descriptive data from 25,479 selected patients with spinal and radicular pain were reviewed. Patients were grouped according to whether or not ESI was recommended, scheduled, prescribed, or continued. Prevalence of ESI use and patient characteristics were compared using standard statistical tests., Results: Overall, ESI were recommended to 2,022 (7.9%) patients. Patients with lumbar pain had ESI proposed 12.6% of the time. Those with cervical and thoracic symptoms had ESI recommended 3.7% and 1.8% of the time, respectively. Patients in whom ESI was recommended were more likely to have pain radiation (P <.001), dermatomal pain distribution (P <.001), and neurologic signs (P <.001). They also had a greater incidence of comorbidities (P <.001) and were older (P <.001). There was no difference in the frequency of prior surgery (P =.169) nor was there a difference based on gender (P =.548) in patients not recommended to have ESI. Patients with symptom duration between 1 month and 1 year were more likely to have ESI recommended., Conclusions: ESI are commonly used to treat patients with spinal and radicular pain. There is some consistency between clinical practice and published recommendations for ESI use.

Nucleus pulposus herniations are far less common in the thoracic spine than at the cervical and lumbar regions. Traditionally, diagnosis of thoracic disc herniations has been challenging because the signs and symptoms are often subtle early in their course. As a result, delays in diagnoses are common. Because they are uncommon as well as difficult to diagnosis, the neurosurgical community has sparse data on which to base good clinical decision making for the treatment of these herniations. In this review the authors seek to place the phenomenon of thoracic disc disease into the context of its pathophysiology. After a careful evaluation of the available clinical, pathological, and basic science data, a case is made that the cause of nucleus pulposus herniations in the thoracic spine is similar to those occurring in the lumbar and cervical regions. The lower incidence of herniations is ascribed primarily to the reduced allowable flexion at the thoracic level compared with the lumbar and cervical levels. To a lesser extent, the contribution of the ribs to weight-bearing may also play a role. Further review of clinical data suggests that thoracic disc herniations, like herniated cervical and lumbar discs, may be asymptomatic and may respond to conservative therapy. Similarly, good surgery-related results have been reported for herniated thoracic discs, despite the more challenging nature of the surgical procedure. The authors conclude that treatment strategies for thoracic disc herniations may logically and appropriately follow those commonly used for the cervical and lumbar levels.

Desk-top microcomputers and total parenteral nutrition grew up together, and in their early days there was considerable progress in both camps. Since that time, the power of computing devices has increased dramatically, as has their ability to share information both between individual systems and worldwide through facilities such as the Internet and e-mail. Although there are some signs of continuing progress, to date there appears to be little evidence in peer-reviewed journals that this increased power is being utilized or that the vision of the pioneers in this area has been realized.

Object: The authors conducted a study to assess the anatomical appropriateness of using the S-2 dorsal neuroforamina as a hook fixation point, and they present the results of their clinical experience of using a nonscrew alternative for the surgical management of low lumbar (L-4 or L-5) burst fractures., Methods: The technique used involves lumbar laminar fixation, rod contouring (to preserve lordosis), S- sublaminar wire fixation, S-2 dorsal neuroforaminal hook fixation, cross-fixation, and distraction. Because the S-2 dorsal neuroforamina was used as a unique fixation point, anatomical data obtained in 10 cadavers supporting the technique's utility are provided. Surgery was performed in six patients by using this technique, and solid fusion was achieved in all., Conclusions: The reestablished lordotic posture was preserved in all but one patient. From an anatomical perspective, the findings corroborate the use of the S-2 dorsal foramina as a hook fixation point. This technique provides a viable adjunct or alternative to sacral screw and ilial fixation techniques.

William Jason Mixter was born in 1880 and graduated from the Harvard Medical School class of 1906. Like his father, Mixter was a prominent surgeon at the Massachusetts General Hospital, and in 1911 the two shared the job of overseeing all neurosurgery at that institution. By the early 1930s, W. J. Mixter was considered to be one of the nation's leading experts in spinal surgery, and he went on to become the first chief of the neurosurgery department at Massachusetts General Hospital. He served in the U. S. Army in both world wars and was actively involved in his local church community in Boston for many years. In 1934, at the age of 54, Mixter and Joseph S. Barr published an article on the intervertebral disc lesion in the New England Journal of Medicine. That article fundamentally changed the popular understanding of sciatica at that time, and for this work Mixter is generally credited by his contemporaries as being the man who best clarified the relation between the intervertebral disc and sciatica. Mixter and Barr's landmark report helped to establish surgery's prominent role in the management of sciatica at the time. Over the next few decades, discectomy surgery increased in popularity tremendously, and some refer to that period as the "dynasty of the disc."

A prevertebral soft tissue measurement exceeding 4 to 5 mm at C3 on a lateral spine radiograph is considered to be evidence of cervical spine injury. The objective of this study was to determine the sensitivity of the prevertebral soft tissue measurement at C3 in patients with proven cervical spine fractures or dislocations and to determine if this measurement correlates with the location or mechanism of injury. Consecutive patients 16 years of age or older who were admitted from July 1988 to June 1995 to a tertiary referral hospital with a discharge diagnosis of cervical spine fracture or dislocation were retrospectively studied. Patients were excluded if an interpretable lateral cervical radiograph taken within 24 hours of the injury was unavailable, medical records were unavailable or incomplete, the injury was caused by penetrating trauma or attempted hanging, or retropharyngeal air was present on the lateral radiograph. For each study patient, the earliest available lateral radiograph was obtained, and the prevertebral soft tissue measurement at the inferior aspect of C3 was recorded. All medical records and reports of imaging studies were reviewed. Two hundred thirty-two patients were identified and 21 were excluded, leaving 212 study patients. Injuries were classified as high (C1 to C2), low (C3 to C7), anterior, or posterior. For each patient the mechanism of injury was inferred from the fracture pattern according to established criteria. For all patients the sensitivity of a prevertebral soft tissue measurement at C3 of > 4 mm was 66% (95% confidence interval [CI] 59, 72). For C1 to C2 (n = 71) and C3 to C7 (n = 138) injuries, the sensitivities were 64% (95% CI 56, 78) and 64% (95% CI 56, 72), respectively. For anterior (n = 95) and posterior (n = 70) injuries the sensitivities were 64% (95% CI 54, 74) and 64% (95% CI 52, 75), respectively. There was no statistically significant difference in the prevertebral soft tissue measurement at C3 for high versus low injury, anterior versus posterior injury, or mechanism of injury. These results show that the prevertebral soft tissue measurement at C3 is an insensitive marker of cervical spine fracture or dislocation and does not correlate with the location or mechanism of injury.

BACKGROUND: In order to determine the type and incidence of pulmonary complications associated with the placement of narrow-bore enteral feeding tubes we conducted a prospective, descriptive study in the multidisciplinary intensive care unit (ICU) of a university hospital. All patients that had narrow-bore enteral feeding tubes inserted over a 2-year period (1993-1995) were included. The study required no clinical interventions. RESULTS: Seven hundred and forty feeding tubes were inserted during the study period. In 14 cases (2%), the feeding tube was inserted into the tracheopulmonary system. Five patients (0.7%) suffered a major complication, including two (0.3%) who died from complications directly related to the feeding tube placement. All patients had altered consciousness and 13 of the 14 had endotracheal tubes in place. Malposition of the feeding tube was not predictable from clinical signs and auscultation, but was detectable by chest roentgenogram. CONCLUSIONS: Inadvertent insertion of enteral feeding tubes into the tracheopulmonary system during placement is associated with significant morbidity and mortality. Clinical signs at the time of insertion are not useful in identifying feeding tubes which are malpositioned. In the ICU patient, a chest roentgenogram is required after all feeding tube insertions prior to the initiation of enteral feeding. In the high-risk patient, alternatives to blind feeding tube insertion should be considered.

Because it is often difficult to diagnose accurately the structurally intact cervical spine after acute trauma, a series of patients was evaluated with magnetic resonance (MR) imaging to assess its efficacy for the evaluation and clearance of the cervical spine in a trauma victim in the early posttrauma period. Ultralow-field MR imaging was used to evaluate 174 posttraumatic patients in whom physical findings indicated the potential for spine injury or minor radiographic findings indicated injury. This series includes only those patients who did not appear to harbor disruption of spinal integrity on the basis of a routine x-ray film. None had clinically obvious injury. Of the 174 patients, 62 (36%) had soft-tissue abnormalities identified by MR imaging, including disc interspace disruption in 27 patients (four with ventral and dorsal ligamentous injury, three with ventral ligamentous injury alone, 18 with dorsal ligamentous injury alone, and two without ventral or dorsal ligamentous injury). Isolated ligamentous injury was observed in 35 patients (eight with ventral and dorsal ligamentous injury, five with ventral ligamentous injury alone, and 22 with dorsal ligamentous injury alone). One patient underwent a surgical fusion procedure, 35 patients (including the one treated surgically) were placed in a cervical collar for at least 1 month, and 27 patients were placed in a thermoplastic Minerva jacket for at least 2 months. All had a satisfactory outcome without evidence of instability. The T2-weighted sagittal images were most useful in defining acute soft-tissue injury; axial images were of minimal assistance. Posttraumatic soft-tissue cervical spine injuries and disc herniations (most likely proexisting the trauma) are more common than expected. A negative MR image should be considered as confirmation of a negative or "cleared" subaxial cervical spine. Diagnostic and patient management algorithms may be appropriately tailored by this information. Thus, MR imaging is useful for early acute posttrauma assessment in a very select group of patients.

The rural CGW population has not yet undergone the metamorphosis experienced by its urban counterparts. Reminiscent of a past era, suicides far outweight homicides. Although many rural firearm injuries involve hunting accidents, these comprise only a small fraction of CGW at best. Similarly, although many rural firearm injuries involve shotguns or rifles, few CGW result from these weapons. Although the number of patients is small, those with shotgun or rifle injuries manifest lower mortality rates. The authors have confirmed the notion that caliber of civilian weapons is difficult to correlate with outcome. The geographic size of the rural catchment area is an important consideration because it must select a population able to withstand transfer. The authors noted an inverse relationship between length of time before arrival at the facility and mortality. The selection phenomenon probably accounts for the reduced mortality found in the authors series versus most others. Prognostic features of individual gunshot wounds are likely to be similar among varied populations when circumstances of the injury are matched. Thus, one expects similar features on initial examination and CT scan to have similar predictive value. The authors confirmed that CGS and specific deficits were strong predictors of outcome. No patient with a GCS score of 5 or less on admission survived. Absent pupillary response, absent brain stem function, presence of respiratory drive or cough only, and posturing were strong indicators of impending death. The authors confirmed the prognostic value associated with CT evidence of intraventricular hemorrhage, transventricular trajectory, transtentorial herniation, massive edema, and bihemispheric injury. Interestingly, presence of extensive facial fractures, an indicator of trajectory, suggested better outcome. Subarachnoid hemorrhage did not reach prognostic significance. Roughly half of the authors' patients had positive serum ethanol levels, although the test was unable to discern prognosis. Abnormality of any coagulation parameter and frank disseminated intravascular coagulation were correlated with poor outcome. Likewise, thrombocytopenia occurring within the first 24 hours was an indicator of poor prognosis. Although prophylactic antibiotics were not used in all cases, the authors encountered no deep or superficial infections in surviving patients. The prevalence of seizures in the authors' series despite prophylactic AED is unusually high. This feature merits further study.

Vertical C-2 body fractures are presented in 15 patients with clinical and imaging correlations that suggest the existence of a variety of mechanisms of injury. In these patients, clinical and imaging correlations were derived by: 1) defining the point of impact by clinical examination; 2) defining the point of impact by soft-tissue changes on cranial magnetic resonance (MR) imaging or computerized tomography (CT); 3) obtaining an accurate history of the mechanism of injury; and 4) spine imaging (x-ray studies, CT, and MR imaging) of the C-2 body fracture and surrounding bone and soft tissue. The cases presented involve the region located between the dens and the pars interarticularis of the axis. Although these fractures are rarely reported, they are not uncommon. An elucidation of their pathological anatomy helps to further the understanding of the mechanistic etiology of upper cervical spine trauma. A spectrum of mechanisms of injury causing upper cervical spine fractures was observed. The type of injury incurred is determined predominantly by the force vector applied during impact and the intrinsic strength and anatomy of C-2 and its surrounding spinal elements. From this clinical experience, two types of vertical C-2 body fractures are defined and presented: coronally oriented (Type 1) and sagittally oriented (Type 2). A third type of C-2 body fracture, the horizontal rostral C-2 fracture (Type 3), is added for completeness; this Type 3 fracture is the previously described Type III odontoid process fracture described by Anderson and D'Alonzo.

The use of bone plate instrumentation with screw fixation has proved to be a useful adjunctive measure in anterior cervical spine fusion surgery. Proper fitting, positioning, and attachment of this instrumentation have been shown to be frequently suboptimal if done without radiographic guidance. The most commonly used method of radiographic assistance for placement of this instrumentation is fluoroscopy. While this gives satisfactory technical results, it is expensive and time-consuming, and exposes the patient and the operating room personnel to ionizing radiation. The authors present a simple technique to ensure screw placement and plate fitting using Kirschner wires and a single lateral radiograph. This technique saves time, reduces exposure to radiation, and has led to satisfactory results in over 20 operative cases.

A new technique of universal spine instrumentation insertion for the management of thoracic and lumbar spine instability is presented and the results in 10 patients are described. The technique involves the sequential insertion of Texas Scottish Rite Hospital (TSRH) central-post hooks, followed by hook fixation to the rod; force is then applied with correction of deformity, if needed. This allows for methodical, safe, and rapid instrumentation insertion. The new TSRH central-post hook configuration permits manipulation of the hook/rod relationships to the advantage of the surgeon (and patient) by providing more room for both hook insertion and hook/rod fixation. This technique has reduced operative time, facilitated ease of deformity correction, and provided uniformly acceptable early postsurgical results.

The aim of this study was to assess the frequency and importance of biochemical abnormality related to parenteral nutrition (PN) in a group of infants, and to devise an appropriate policy for routine biochemical surveillance. A standard monitoring protocol based on widely published guidelines was applied to 30 consecutive patients (age 3 days-3 years) referred to a children's hospital nutritional care team for PN. No serious biochemical abnormalities were observed to arise simply as a consequence of PN. Electrolyte disturbance most commonly occurred before starting PN. Biochemical abnormality was most likely to be found in patients with abnormal fluid and electrolyte losses. Protocols for biochemical surveillance during PN err on the side of caution and often suggest frequent and comprehensive testing. In stable patients such as the surgical newborn, this is both expensive and unnecessary, and simpler monitoring regimes may be used with safety.

An interesting case of benign nasal polyposis with intracranial extension and subsequent abscess formation is described. Its diagnosis and treatment are presented and the pathology is demonstrated. The literature related to this rare disease process is discussed in detail.

The complications of the administration of parenteral nutrition by central venous catheter were reviewed retrospectively in 71 neonates and infants under the age of nine months. The performance of central catheters inserted by a standard surgical method was compared with that of central catheters introduced by a percutaneous insertion technique using peripheral veins and carried out on the ward. The incidence of catheter related sepsis in percutaneously inserted lines was significantly less (p less than 0.05) than in surgically inserted lines, but in all other respects, there were no significant differences in performance. These findings demonstrate that percutaneous insertion is a simple, safe and cost-effective alternative to surgical placement of feeding catheters in neonates and infants.