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A 75-year-old man presented with acute onset thoracic back pain, progressive leg weakness with numbness and urinary retention. His symptoms started suddenly and progressed overnight. He denied a recent history of trauma. On neurological examination he had complete loss of all sensations below Th10 level and leg paraplegia (American Spinal Injury Association grade A myelitis). Admission lateral spine X-ray and non-contrast CT were performed (figures 1 and 2). Figure 1 Lateral X-ray demonstrating compression fracture of Th12. Figure 2 Non-contrast CT with sagittal view showing burst compression fracture of Th12 with osteosclerosis and remodelling …

Background Spontaneous acute spinal subdural hematoma (SASSDH) is a rare but serious condition. We present diagnostic challenges and serial magnetic resonance imaging (MRI) findings of a patient who developed warfarin-associated thoracic SASSDH that was managed surgically. Case description A 68-year-old male presented with sudden onset left-sided chest and back pain, left leg weakness, and bilateral loss of sensations below T4 level. His symptoms developed after strenuous physical activity. He was taking warfarin for atrial fibrillation. His admission international normalized ratio was 4.25. Deterioration of neurological status 3 days after admission prompted spinal computed tomography (CT) scan that demonstrated nonhomogenous hyperdense intradural mass lesion in the thoracic spine. MRI demonstrated heterogeneous mass lesion on the left side of the spinal canal and thoracic myelopathy. The patient underwent urgent surgical evacuation of subacute subdural hematoma extending from T3 to T6 levels. MRI scan following the surgery showed no signs of the hematoma and thoracic myelopathy. MRI at 3 months follow-up demonstrated myelopathy extending from T3 to T6 levels with deviation of the spinal cord. The patient's motor strength and sensations improved but he retained left leg weakness with sensory deficit below T8 level. Conclusions Spinal subdural hematoma should be suspected in patients presenting with acute onset back pain and myelopathy in the absence of trauma history. Coagulopathy should raise the suspicion for SASSDH. MRI is a valuable imaging modality for initial diagnosis to rule-out other lesions, and to assess postoperative re-bleeding and residual lesions.

Objective A prospective review of a clinical series was performed. The treatment features of atlas fractures with and without associated axis injuries were investigated. Methods Twenty-nine patients were investigated. Results No displaced fractures were treated with a cervical orthosis. Patients with displaced fractures were managed with a halo vest immobilization; 96.4% patients had a solid fusion at their last follow-up evaluations. Conclusions Isolated not displaced or combined with not displaced axis fractures atlas fractures can be treated effectively with a rigid cervical collar alone. Isolated displaced fractures or not displaced but with concurrent displaced axis fractures require immobilization by the halo vest.

Objective: The aim of this study was to evaluate and compare the biomechanical effects of locking plate superior and anteroinferior positioning on the osteosynthesis of the clavicles osteotomized obliquely. Materials and methods: Ten matched pairs of fresh cadaveric clavicles osteotomized through the mid-shaft obliquely were repaired with a titanium 7-hole 3.5-mm reconstruction locking plate in the superior or the anteroinferior position. The maximal failure loads and the displacement of the specimens at 166 N, 183 N, 203 N loads were recorded by the machine in 3-point cantilever bending. Bending failure stiffness was calculated between 10–150 N and 151 N to maximal bending failure loads. Results: The mean maximal failure load was 396.2 N (SD, 117.3) for superior constructs and 220.1 N (SD, 51.1) for anteroinferior one (P &lt, 0.05). There was significant difference in displacement between superior and anteroinferior plated specimens at 183 N (6.3 [SD, 2] vs. 9.9 [SD, 3.6]) and 203 N (6.4 [SD, 0.6] vs. 11.7 [SD, 6.6]) loads, P &lt, 0.05). Mean bending failure stiffness between 151 N and maximal loads was 22.6 N/mm (SD, 13.2) for superior plates and 11 N/mm (SD, 9) for anteroinferior plated clavicles (P &lt, 0.05). Conclusions: The superior plating of obliquely osteotomized clavicles with the titanium 7-hole 3.5-mm locking reconstruction plate had a significantly greater biomechanical stability at fixed loads of 183 N and 203 N than the anteroinferior plating in the inferior directed cantilever bending. The superior plating osteosynthesis exhibited a significantly greater stiffness from 151 N to maximal bending failure loads as well.

Objective. This prospective observational study of the Short-Form Health Survey (SF-36), Oswestry Disability Index, Lithuanian version of the McGill Pain Questionnaire, and Visual Analogue Scale (VAS) for pain was performed to evaluate their effectiveness in the additional preoperative screening of patients with disc herniation disease. Patients and methods. In the present study, we investigated a cohort of 100 patients with lumbar disc herniation causing low back pain and the second one of 100 patients with nonspecific low back pain by applying physical activity, pain scales and Short-Form 36 General Health Questionnaire. Results. The quantitative analysis of SF-36 domain scores showed the substantial differences in both examined (herniated and control) groups. In the present study, we estimated moderate but statistically significant (P&lt, 0.05) correlations between the bodily pain domain scores and assessment of back and leg pain on the VAS, as well as between the physical function and walking/standing ability (Oswestry). According to appropriate pain assessment instruments (Lithuanian version of the McGill Pain Questionnaire), qualitative and quantitative analysis of the preoperative patients was performed. Conclusion. The provided methodology could be used in population-based studies or in clinical samples that focus on specific impairments and seek to control the pain frequency and intensity, for example, follow-up assessments testing the effectiveness of surgical procedures performed, and to elicit the pathways leading to other impairments.

The aim of our study was twofold: firstly, to compare the preoperative and postoperative results at mid-term follow-up periods along with the data of the control group. Secondly, to evaluate the effectiveness among open-discectomy and microdiscectomy surgical groups. In the present study, we investigated a cohort of 100 patients with the lumbar disc herniation causing low back pain compared to 100 subjects of the control group with the non-specific low back pain by applying physical activity, pain scale, Short Form 36 General Health Questionnaire and additional postoperative records of patient's satisfaction and complications level, consumption of analgesics, and return to work status. The quantitative analysis of all questionnaires showed substantial differences in the preoperative and postoperative groups. The best results were achieved at the second year follow-up period. However, there were no statistically significant differences in both the examined surgical subgroups (p > 0.05). In addition, we estimated from moderate to great statistical significance (p < 0.01-0.05) among preoperative and overall postoperative results: PHC and MHC in the SF-36, Oswestry and VAS. The total increased satisfaction, reherniation rate and return to work frequency comprised 40, 9 and 64%, respectively. The analgesics were still indicated for 21% of the patients. The results of the present study suggest of sufficient decompression in both surgical groups, as the health-related quality of life parameters (Oswestry, VAS and SF-36) were defined as clinically improved. Regardless of persisted minor pain in both areas, it remained greater in the low back than in the leg, which should be held for beneficial to decompressive surgery.

Objective. The aim of this study was to investigate the influence of patients’ age on the development of radiologic signs of degeneration of adjacent levels after the anterior fusion for the cervical spine injuries. Material and methods. A total of 45 patients who had compressive flexion and vertical compression injuries of the cervical spine (by Ferguson–Allen mechanistic classification) were included in the study. There were 40 male and 5 female patients with a mean age of 31.5 years (range 15–64). These patients were treated with anterior decompression, iliac bone grafting, and anterior plating. Twenty-two patients aged less than 30 years were in the first group, 23 individuals more than 30 years of age were in the second group. A long-term radiologic followup involved assessment of the fusion and examination of the changes at levels immediately above and below the fused vertebrae. Results. Hypermobility of the disc space above the fused vertebra was found in 9 (40.9%) patients from the first group vs. 3 (13%) from the second one (P&lt, 0.05). Narrowing and osteophytes of the disc space below the fused vertebra was found in 2 (9.1%) patients from the first group vs. 10 (43.5%) from the second one (P&lt, 0.05). Conclusions. Hypermobility of the motion segment above the fused vertebra was found more frequently in patients aged less than 30 years. Narrowing and osteophytes of the disc space below the fused vertebra were found more frequently in older patients.

Objective. The purpose of this article is to present two cases of penetrating gunshot injuries to the lumbar spine with migration of the bullets within the dural sac and to describe the method of removal of the bullet from the dural sac. Material and methods. Two cases of penetrating gunshot injuries to the lumbar spine with migration of the bullets within the dural sac are presented. Clinical course, diagnostic tools, and management of two patients who suffered from these injuries are illustrated. The method of removal of the bullet from the dural sac is described too. Results. The wounds in these two cases healed without infection. The neurological status of our patients improved gradually. Radiographs taken 2 years after the injury did not demonstrate the postoperative instability of the lumbar spine. Conclusions. The bullet in the dural sac at the level of the cauda equina must be removed. The method proposed by us can facilitate this procedure.

Spinal cord injury is one of the most devastating of all traumatic conditions that can be encountered by patients. Over the past years much research has been performed on elucidating the mechanisms of spinal cord injury. Experimental and clinical studies have suggested that acute spinal cord injury is a two-step process involving primary and secondary mechanisms. Primary injury of the spinal cord refers to the initial mechanical damage due to local deformation of the spine. Direct compression and damage of neural elements and blood vessels by fractured and displaced bone fragments or disc material occur after mechanical trauma. The secondary mechanism is initiated by the primary injury. The secondary mechanism includes a cascade of biochemical and cellular processes, such as electrolyte abnormalities, formation free radicals, vascular ischemia, edema, posttraumatic inflammatory reaction, apoptosis or genetically programmed cell death and another processes. This review describes the pathophysiology of acute spinal cord injury. Knowledge of the pathophysiology of the acute spinal cord injury is crucial for successful management of the patients with these injuries.

The upper cervical spine includes the articulations of the occiput with atlas and the atlas with the axis, as well as the bony structures of the base of the skull, axis, and atlas. The unique anatomy of the upper cervical spine and the typical mechanisms of injury yield a predictable variety of injury patterns. Injuries to this area include occipital condyle fractures, occipitoatlantal dislocations, subluxations and dislocations of the atlantoaxial articulation, atlas fractures, odontoid fractures, and fractures of the arch of the axis. Injuries to this region are relatively common and can be easily overlooked because patients with the upper cervical injury may have an associated head injury, which can alter their level of consciousness and complicate obtaining an accurate history and physical examination. The complex regional anatomy and overlying structures make plain radiographic images difficult to interpret. Delayed recognition can result in significant disability. A thorough understanding of the clinical presentation, radiographic assessment, and mechanisms of injury can minimize morbidity and enhance treatment effectiveness for the more common upper cervical ligamentous and bony injuries.

The purpose of this study was to determine the treatment features of odontoid fractures with a significant displacement.Thirty-seven patients with acute odontoid fractures were treated in Kaunas University of Medicine Hospital between 1998 and 2003. Seventeen persons with displacement of fragments less than 5 mm or 5 mm (according to E. A. Seybold and J. C. Bayley method) were in the first group. Twenty patients with displacement of fragments more than 5 mm were in the second group. The attempt of closed reduction of the cervical spine axis was performed for all patients. If successful closed reduction was achieved, patients were placed in halo-vest device for 8 weeks. If closed reduction failed, patient was operated according to W. E. Gallie. Postoperatively, all patients wore a halo-vest device during the first 8 weeks.Demographics including age, sex, neurological condition, and associated spinal fractures were similar in patients from these groups (p0.05). Successful closed reduction of the cervical spine axis was achieved in 11 (64.7%) patients from the first group and in 13 (65%) patients from the second group (p0.05). Six (35.3%) patients from the first group and seven (35%) from the second group were treated with immediate C1-C2 posterior fusion (p0.05). Two (16.7%) from twelve patients from the second group were treated by external immobilization by halo-vest device and had nonunion of fracture 8 weeks after the treatment. All operated patients had a solid fusion.If closed reduction of the odontoid fracture with a significant displacement was achieved then external immobilization by halo-vest device can be used. Posterior fusion is the treatment of choice for irreducible odontoid fractures.

1) to assess neurological status in patients with distractive flexion and compressive extension cervical spine injuries; 2) to determine the relationship between neurological recovery and the patterns of cervical spine injuries.Prospectively collected data on 78 persons with traumatic distractive flexion and compressive extension cervical spine injuries. These patients were treated in Kaunas University of Medicine Hospital between 1998 and 2000. The study included 18 (23.1%) females and 60 (76.9%) males. The age range was 16-80 years, mean age was 46.6 years. Cervical spine injuries in all patients were visualized at using Computed tomography and radiography. The cervical spine injury patterns were recognized by the Ferguson-Allen's classification. We divided these patients into two groups: the first group included patients who had sustained distractive flexion cervical spine injuries; the second group included patients who had sustained compressive extension cervical spine trauma. We assessed neurological status of these patients after admission to hospital in the average of four hours after an accident. Motor and sensory evaluation was conducted using the guidelines established by the American Spinal Cord Injury Association. Forty-nine patients were investigated in the average of four years after trauma and treatment. We assessed their neurological status and determined the relationship between neurological recovery and the patterns of cervical spine injury.Forty-eight (61.5%) patients had distractive flexion cervical spine injuries (the first group) and 30 (38.5%) had compressive extension trauma (the second group). We compared patients from the first and the second groups and did not find any difference among an accident circumstances (p0.05), the level of the cervical spine injury (p0.05) and neurological status at the early period after a trauma (p0.05). Eight (16.7%) patients died from the first group, 5 (16.7%) from the second group due to severe spinal cord injury (p0.05). Thirty patients from the first group, and 19 patients from the second group were investigated in the late posttraumatic period (average four years). We performed statistical analysis of these patients and did not find any difference between the accident circumstance (p0.05), the level of the cervical spine injury (p0.05), displacement of the vertebra body (p0.05), neurological status and did not determine the relationship between neurological recovery and the patterns of cervical spine injuries.Neurological status of the patients with distractive flexion and compressive extension cervical spine injuries did not differ. The relationship between neurological recovery and the patterns of cervical spine injuries did not exist.

To investigate clinical status features of the patient's who died from spinal cord and brain swelling.Retrospectively collected data on 67 persons with severe spinal cord injury. These patients were treated and died in Kaunas University of Medicine Hospital between 1995 and 2003. The death reasons were determined after autopsy. The study included 2 (3%) females and 65 (97%) males. The age range was 16-82 years, mean age was 49.6 years. Cervical spine injuries in all patients were visualized at computed tomography and radiography. The cervical spine injury patterns were determined using Ferguson-Allen's classification. Motor and sensory evaluation after admission to hospital was conducted using the guidelines established by the American Spinal Cord Injury Association. From this group of patients, 48 cases were selected with spinal cord swelling as the reason of death. We divided these patients into two groups; 21 patients with C4-C5 neurological level were in the first group and 27 persons with C6-Th1 neurological level were in the second group.. We compared the patients from the first and the second groups and did not find any difference between their age, the patterns of the accidents, the patterns of the cervical spine injuries (p0.05), clinical status after admission to hospital and six hours before patient's death (p0.05). Patients, who died from spinal cord swelling, had alterations in cardiopulmonary function before their death. The patients from the first group died on average in 80 hours after the accident; the patients from the second group died on average in 146 hours after the trauma (p0.05).Patients, who died from spinal cord swelling, had distinct respiratory failure before their death. Alterations of the clinical status of patients with C4-C5 neurological level were faster.

In the article are described cases, when patients sustained fractures of the first and the second cervical spine vertebrae and were treated with "Halo-vest" device. We performed this investigation in order to establish efficiency of "Halo-vest" immobilization and to establish regression of neurological evaluation, patients feelings and their come back to their usual environment, when 1-2 years passed after fracture and treatment. Investigation was performed in 1999-2001. We performed retrospective analysis of 58 cases. From this group we divided 25 cases. There were patients who sustained fractures of the first and the second cervical spine vertebrae and were treated with "Halo-vest" device. Twenty-two patients were treated with "Halo-vest" immobilization successfully. Three patients were operated, because close fractures repositions failed. We analyzed these patients 1-2 years after fracture and treatment, and after data analysis we made conclusion, that 69% patients after these injuries came back to their usual environment. CONCLUSIONS. Reposition of fractures in the upper cervical spine can be achieved with "Halo-vest" device. If close fractures repositions failed, then spondylodesis must be performed and alignment during operation can be maintained with "Halo-vest" device. After these injuries and treatment with "Halo-vest" device about 69% patients came back to their usual environment.

Objective. For complete assessment of benefits of the surgical intervention, it is essential to provide evidence of the impact on patients in terms of health status and healthrelated quality of life. In the present study, the preoperative 36-item Short Form (SF-36) Health Survey scores were determined in patients before lumbar microdiscectomy due to better preoperative screening likewise in the control group – almost healthy population taken into account any habitual ailments experienced in an appropriate age. Patients and methods. In the present study, we investigated a cohort of 100 patients with disc herniation causing low back pain and another hundred of the control subjects, matched by age and gender. The short form 36 general health questionnaire (SF-36) was applied. Results. Estimation of the SF-36 scores showed that (1) all of the domain values were considerably lower in the preoperative patient group than in the second one (P&lt, 0.01), (2) the bodily pain scores were closely correlated to the social function scores (R=0.7, P&lt, 0.01), whereas the physical function was less related to the bodily pain (R=0.6, P&lt, 0.01). The weakest correlation was observed between bodily pain and mental health and general health (R=0.4, P&lt, 0.01). Conclusion. The present study showed that the generic instrument, SF-36 Health Survey, was optimized paraclinical method for patients predisposed to surgical treatment of the lumbar disc herniation disease likewise for normal population individuals, matched by age and sex, in the assessment of health-related quality of life.