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Study design: Retrospective population-based epidemiological study.Objectives:To assess the nationwide, population-based incidence, causes, age, gender, extent and prevalence of spinal cord injuries (SCIs) in Iceland from 1975 to 2009. Setting: Landspitali University Hospital in Iceland, the single referral center for SCIs in Iceland.Methods:A retrospective review of hospital records on all admissions due to SCIs. Analysis of incidence, causes, age, gender, extent of injury and prevalence. Results: A total of 207 patients with traumatic spinal cord injury (TSCI) were admitted: males 72%, females 28%. The percentage of females with TSCI increased to 37% in 2000-2004. Mean age at injury was 38 years. Average incidence per million population per year was 30 in 1975-1979, 12.5 in 1995-1999 and 33.5 in 2005-2009. Thirty-day mortality was 6.3%. Causes of injury were road traffic accidents (RTA) in 42.5% of the cases; the majority did not use seatbelts. Falls amounted to 30.9%, with an increase of low falls among the elderly causing incomplete cervical lesions. Sport/leisure activities were the cause in 18.8%, of which 54% occurred after 2000. The main single cause of TSCI in sport/leisure were horse-riding accidents, followed by winter sport accidents, especially among women. Other causes constituted 7.7%. The injury was complete in 39%; cervical lesions were 57% and thoracic/lumbar lesions were 43%. In December 2009, the crude prevalence rate was 526 per million population. Conclusions: The findings showed a significant increase of TSCI in 2005-2009, especially in sport/leisure accidents and incomplete cervical lesions due to falls among elderly. Prevention strategies need to focus on these risk groups and on seatbelt use.Spinal Cord advance online publication, 27 September 2011; doi:10.1038/sc.2011.105. Language: en

Altered activity in the axioscapular muscles is considered to be an important feature in patients with neck pain. The activity of the serratus anterior (SA) and trapezius muscles during arm elevation has not been investigated in these patients. The objectives of this study was to investigate whether there is a pattern of altered activity in the SA and trapezius in patients with insidious onset neck pain (IONP) ( n =22) and whiplash associated disorders (WAD) ( n =27). An asymptomatic group was selected for baseline measurements ( n =23). Surface electromyography was used to measure the onset of muscle activation and duration of muscle activity of the SA as well as the upper, middle, and lower trapezius during unilateral arm elevation in the three subject groups. Both arms were tested. With no interaction, the main effect for the onset of muscle activation and duration of muscle activity for serratus anterior was statistically significant among the groups. Post hoc comparison revealed a significantly delayed onset of muscle activation and less duration of muscle activity in the IONP group, and in the WAD group compared to the asymptomatic group. There were no group main effects or interaction effects for upper, middle and lower trapezius. This finding may have implications for scapular stability in these patients because the altered activity in the SA may reflect inconsistent or poorly coordinated muscle activation that may reduce the quality of neuromuscular performance and induce an increased load on the cervical and the thoracic spine.

In 5 patients with advanced breast cancer and spinal metastases MR imaging of the spine was performed before and/or after death. T1-, proton density-, and T2-weighted and “phase contrast” images were obtained in the sagittal plane. Autopsies included histopathologic examination of whole sagittal sections of the vertebral body. The relative signal intensities on the different MR sequences of various tissues identified histologically were evaluated. “Phase contrast” images combined with T1-weighted images were highly sensitive in detecting metastases. All metastatic tumours over 3 mm in size were found with MR imaging. Vertebrae containing connective tissue and reactive bone marrow had an MR appearance similar to that of metastases even though no metastases were found histopathologically.

Total hip replacement (THR) is a common and costly procedure. The number of THR is expected to increase over the coming years. Two pathways of postoperative treatment were compared in a randomized study. Fifty patients from two hospitals were randomized into a study group (SG) of 27 patients receiving preoperative and postoperative education programs, as well as home visits from an outpatient team. A control group (CG) of 23 patients received "conventional" rehabilitation augmented by a stay at a rehabilitation center if needed. All costs for the two groups both in hospitals and after discharge were collected and analyzed. On average total costs for the SG were $8,550 and $11,952 for the CG, a 28% cost reduction. Total inpatient costs were $5,225 for the SG and $6,515 for the CG. In a regression analysis the group difference is statistically significant. Adjusting for changes in the Oxford Hip Score gives effective costs (C/E). The ratio of the SGs C/E to the CGs is 0.60. That is a cost-effectiveness gain of 40%. A shorter hospital stay augmented with better preoperative education and home treatment appears to be more effective and costs less than the traditional in hospital pathway of treatment.

The present work is analyzing the general biomechanical aspects of fixation techniques in the upper and lower cervical spine along with clinical implications.The in vitro biomechanical properties of five different posterior atlanto-axial fixation techniques are compared. They provided for either a one, two or three-point fixation between atlas and axes. A new device, the C1 claw was biomechanically tested, which allow for fixation without the need for a structural bone graft. The three-point reconstructions indicated superior biomechanical properties compared to all others.The new C1 claw device was clinically evaluated in a series of 26 patients treated with a posterior C1-C2 fusion. There were no clinical or radiological failures in the series, Twenty-one patients out of twenty-three with any length of follow up either showed a solidly healed fusion or a healed fracture. Distractive flexion (DF) injuries in the lower cervical spine treated with anterior plate alone were analyzed with respect to healing rate and complications in a consecutive series of 36 patients. Results indicated that DF injury stage 1 and 2 according to Allen and Ferguson healed without complication, whereas DF injuries stage 3 had a high frequency of failure, needing an additional posterior fixation. The in vitro biomechanical properties of four different fixation techniques for a distractive flexion injury stage 3 were analyzed. The result indicated that anterior plate alone for fixation of a DF injury stage 3 is insufficient supporting the clinical finding in the previous study.Adjacent level motion was analyzed following a one segment fusion in the lower cervical spine. Motion was found to increase in adjacent levels possibly contributing to accelerated degeneration.

Introduction: The timed ‘Up & Go’ (TUG) is a performance test identifying problems in functional mobility. More knowledge on how the type of chair used in uences test results is needed. Objective: To investigate inter-rater agreement on the time score and to assess if chair type used in uenced the performance of the test. Setting: (1) Inter-rater agreement investigation on the time score was carried out with elderly individuals living in a retirement home (n = 31). (2) Four types of chairs were tested on elderly individuals in three different health care centres (n = 100). Results: The two observers were close in timing (mean difference = 0.04 s). From a reference chair the median time for TUG was 15.7 s compared with 16.9 s from a chair with a low seat (p < 0.001). It was signi cantly more dif cult to stand up from a chair without armrests (p < 0.001), and from the lowest chair (p < 0.001), which was also the only chair dif cult to sit down on (p = 0.02). Conclusion: The inter-rater agreement of the time scoring of the TUG has been con rmed. Test performance is dependent on chair type; chairs with armrests and a seating height of 44-47 cm should be used. Clinicians must follow standard procedures and equipment when using the test or else risk invalidating test findings.

By an anterior approach, six pathologic dens fractures were stabilized with screws and methyl methacrylate cement. All the patients had immediate pain relief and could be mobilized without external support. Using the anterior approach, the tumor can be removed and the instability neutralized at the site of the lesion.

Study design The authors assessed the clinical and imaging findings and late outcome in 50 patients with whiplash-type neck distortions (17 men, 33 women, mean age 33 years). Summary of background data Early symptoms are neck pain, stiffness, and sometimes radiating pain; later bizarre symptomatology poses intricate clinical and medicolegal problems. Pathoanatomic studies indicate that soft tissue injuries may be overlooked. Methods Repeated clinical and radiographic examinations (plain and flexion-extension radiograms and contrast magnetic resonance imaging evaluated with a new grading system); surgical findings; follow-up were performed after 1 and 5 years by an independent observer neurologist. Results Neck pain persisted in 24 patients; radiating pain developed within 6 weeks in 19 patients. Two patients with segmental instability had posterior fusions and complete pain relief. Eight patients with severe radiating pain and large disc protrusions on magnetic resonance had nine surgically confirmed fresh disc herniations. Discectomy and fusion alleviated pain in these patients, whereas symptoms largely persisted in the conservatively treated patients. Conclusions A high incidence of discoligamentous injuries was found in whiplash-type distortions. Most patients with severe persisting radiating pain had large disc protrusions on MRI that were confirmed as herniations at surgery. Neck and radiating pain were alleviated by early disc excision and fusion.

To study potential risks for complications in posterior articular pillar plate fixation, screw-plate systems of Roy-Camille, Louis, and Magerl were implanted into the cervical spines of cadavers under authentic operation theater conditions and in vitro into isolated spine specimens according to the inaugurators' recommendations with regard to plate and screw positioning. We compared these systems with the method of our preference, using the small AO compression plate and monitoring each screw insertion fluoroscopically. The screws were directed toward the projection of the pedicles, and their length was measured individually. Radiographic analysis of the specimens and cryoplaning after implant removal and casting of the screw-plate cavities showed significant differences of the four systems with respect to effective screw length, possible and desirable screw trajectories, and risk for injuries of the facet joints, foraminal neurovascular elements, and vertebral artery, as well as mechanical conflict of the plate with adjacent facet joints.

We evaluated the peroperative blood loss in 21 patients who were treated with 29 operative procedures for thoracolumbar spinal renal cell carcinoma metastases. Embolization was undertaken prior to 11 operations. At posterior surgery the average blood loss was one third after embolization compared with when embolization had not been performed. The blood loss was also lower during anterior surgery, although this difference was smaller. We recommend that preoperative embolization should precede surgical treatment of spinal metastases of renal cell carcinoma where it can be anticipated that the operation will extend into the pathological tissue.

In a patient with paraparesis resulting from a pathologic fracture of Th9, which was due to a breast cancer metastasis, indirect anterior decompression via posterior reduction was performed. The rationale for the operation technique was the similarity between a pathologic fracture of the thoracolumbar spine and a traumatic burst fracture. The method, which uses a transpedicular reduction and fixation device, is substantially less invasive than a formal anterior decompression.

We report on 12 surgically treated patients with myeloma of the spine. Pain relief was obtained in all the patients. Paraparesis was present in 5 patients. All 12 patients subsequently became ambulatory. The average postoperative survival was 2.3 years. Eight patients, all without symptoms from the treated lesion, survived for more than 1 year. Our experience suggests that surgical treatment of multiple myeloma of the spine may be rewarding.

Two cases of severe neurologic damage after open reduction of locked facet joint dislocations of the cervical spine are described. Both patients had progressive neurologic deterioration after the accident. In both cases, the cause of the neurologic injury was sequestrated disk material compressing the spinal cord. One patient, who was reoperated on as an emergency, recovered after removal of the sequestra, whereas the other patient, who was reoperated on later, remained tetraplegic.

We studied 22 cervical spines from traffic accident victims with fatal craniocerebral injuries (19 male victims and three female victims; mean age, 26 years). Two had parietal fractures, 20 had skull base fractures (seven ring fractures), and 16 had severe polytrauma. The spines with all soft tissues were frozen in situ and removed. Fine-focus specimen radiograms were taken in special views and evaluated by an expert orthopedic radiologist. The specimens were then cryosectioned, and all injuries were recorded at submillimeter intervals on high resolution film. Ten radiological fracture diagnoses were incorrect; six were false positive, and four were false negative. In the upper cervical spine, only one of 10 gross ligamentous disruptions was suspected on the radiograms. In the lower cervical spine, 198 lesions were missed on the radiograms: 77 facet joint and ligamentum flavum injuries, 77 uncovertebral, and 22 disc lesions. In two adolescents, eight cartilaginous end-plate avulsions of the discs were found. At second-look evaluation, only four of the 245 unrecognized bone and discoligamentous lesions were detected on the radiograms. All spines were injured. Multiple-level soft-tissue injuries were common.

Forty consecutive patients with 19 fractures and 21 fracture-dislocations in the lower cervical spine were treated prospectively with open reduction and interbody fusion, using the AO titanium locking screw-plate system. There were 30 men and 10 women with a mean age of 36 years (range 16-90 years). Eight were admitted tetraplegic, 12 tetraparetic, and 6 had nerve root injuries. Eleven of the fractures and 18 of the fracture-dislocations were also plated posteriorly. Complications included two cardiac arrests, two transient neurological impairments, two severe gastrointestinal bleedings, and one esophageal fistula. At 2-year follow-up, three patients had died and one had emigrated. Three out of ten patients who had complete motor loss initially had regained useful muscle function, while incomplete motor loss usually returned to normal. All fusions had healed in a good or acceptable position. Twenty-four of the 60 posterior plates impinged on facet joints and five were loose. Six screws transgressed facet joints below the fusion. Ten posterior fusions extended to adjacent mobile segments by exuberant bony overgrowth. Ancillary posterior plating significantly reduced the range of neck mobility and also caused significantly more pain than anterior plate fixation alone.

Spine specimens infested with breast cancer metastases, ranging from localized seed of small tumor deposits to massive invasion and vertebral collapse, were frozen in situ, removed, examined with both conventional radiography and high resolution computed tomography (CT), and then studied in great detail by serial cryoplaning. The majority of metastases in the total of 53.5 vertebrae were lytic, and most were in close contact with the vertebral wall or the endplates. Depressions and defects of the endplates were associated with compensatory expansion of the intervertebral discs. Although lytic lesions abutting endplate defects had the radiological appearance of metastases, all contained herniated disc material rather than tumor. Only four of the 29 grossly destroyed and collapsed vertebrae showed extrusion of the posterior vertebral wall into the spinal canal. Tumor growth in the epidural space was rare. There were no macroscopical reactive changes of the osseoligamentous or neurovascular spinal elements to the metastases, but abnormalities of the posterior elements (kissing spines, facet joint subluxation, and pars interarticularis failure) were common.

Between October 1984 and January 1988 31 magnetic resonance (MR) imaging studies were performed on 27 patients with metastatic vertebral breast cancer (MVBC). The MR images were reviewed to determine the extent and type of sagittal spinal deformity, and whether spinal canal compromise was present. Adjunct studies were compared to determine the pathogenesis of spinal deformity and the etiology of spinal canal compromise. An analysis of the data revealed that a consistent pattern of sagittal spinal deformity exists with MVBC, and a classification system was developed to describe the stages of vertebral deformity. Criteria are suggested for identifying metastatic spinal instability. A protocol is presented for treating patients with metastatic spinal involvement. By understanding the natural history of metastatic spinal deformity, instability and spinal canal compromise can be recognized and treated early, before the onset of progressive deformity and neurologic sequelae.

Summary The pathomorphology of normal and degenerated human cervical spines that had been subjected to trauma was studied in detail by surface-cryoplaning of frozen autopsy specimens. Four cervical spines that had been surgically fused were also sectioned after removal of the metal. In young individuals, disc ruptures occurred that resulted in compromise of the vertebral canal. In degenerated spines, vertebral endplate ridges were frequently fractured. These injuries resulted in encroachment on the spinal cord as well as on the nerve roots in the foramen. Osteophytes from the uncinate processes also contributed to stenosis at the nerve root exits. These pathoanatomical findings were corroborated by intraoperative observations in patients. The high incidence of compressive lesions anteriorly in the cervical spine underscores the need to consider both anterior and posterior surgery in many of these patients.