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BACKGROUND: Spinal fractures are among the most common traumatic injuries in elderly patients, with the odontoid process being frequently affected. As this patient group usually has high rates of comorbidity and chronic diseases, a nonoperative approach may offer a reasonable solution for a favorable fracture pattern. OBJECTIVE: We modified the procedure by implanting a bilateral atlantoaxial joint spacer (model DTRAX) into the joint space and review our experience utilizing this technique for the treatment of patients with a fracture of the odontoid process. METHODS: A retrospective evaluation was performed on patients treated surgically for unstable traumatic fractures of the odontoid process. The stabilization was performed using a dorsal rod and screw instrumentation of the lateral mass of the atlas and the pars interarticularis of the axis. The procedure was further modified by implanting a bilateral atlantoaxial joint spacer (DTRAX) into the joint space bilaterally after the removal of the articular cartilage. Patients older than 70 years with a traumatic fracture of the odontoid process were included. Pain was assessed pre- and postoperatively using the visual analog scale (VAS). To verify fusion during follow-up, either x-ray imaging of the cervical spine or magnetic resonance imaging or computed tomography were performed. RESULTS: A total of 5 patients were included in our study. Four patients had an American Society of Anesthesiology score of 3 and 1 had a score of 4. The average duration of surgery was 187 ± 38.1 minutes. The average blood loss during the procedure was 340 ± 270 mL. The average radiological follow-up period was 21.2 ± 17.5 months. Preoperatively, the average VAS pain score was 2.3 ± 3.3. Postoperatively, the mean VAS decreased to 0.6 ± 0.9. The average follow-up period for pain was 27.2 ± 19 months. No patient showed neurological deficits before or after surgery. Follow-up demonstrated solid fusion in all cases. CONCLUSION: The fusion of the atlantoaxial joint with bilateral atlantoaxial joint spacers represents a suitable and feasible option for achieving high fusion rates in elderly patients with odontoid fractures. CLINICAL RELEVANCE: A significant percentage of patients who are treated non-operatively will experience nonunion, which may cause instability of the atlantoaxial joint. Posterior fixation with screws and rods is a treatment option, but it leaves the cartilaginous joint surface in place, which can be an impediment to the fusion process. In other cases, degenerative collapse of the C1/C2 joint can cause compression of the C2 nerve root. LEVEL OF EVIDENCE: 4.

Disk herniations that obstruct the spinal canal by more than 50% are named "giant disk herniations" (GDHs). GDHs are challenging to treat from a surgical perspective because of their size and the risk of iatrogenic manipulation during resection resulting in additional neurological compromise. As a result, the appropriateness of minimally invasive tubular approaches for the treatment of lumbar GDHs remains controversial.To report our experience in treating lumbar GDHs using tubular minimally invasive surgery.A total number of 228 disk herniations were evaluated for the criteria of GDH. In addition, the presence of neurological deficits such as cauda equina syndrome, pain as measured by a visual analog scale, operating time, complications, estimated intraoperative blood loss, and number of surgical revisions were assessed. The standard tubular diskectomy technique was modified to include unilateral laminectomy for bilateral decompression before the diskectomy to create a sufficient working space for removal of the disk fragments.Twenty-three (10%) patients met the criteria for GDH. Clinically significant motor weakness was present in 21 patients (91.3%) before surgery, and 3 patients (13%) presented with cauda equina syndrome. The average mean visual analog scale (±SD) for the preoperative pain score was 8.3 and decreased to 2.4 at follow-up after surgery. All cases of cauda equina syndrome resolved postoperatively.Unilateral tubular minimally invasive surgery diskectomy seems to be a safe and effective treatment alternative for lumbar GDHs, combined with the "over-the-top" decompression, which provides bilateral decompression and working space.

The concrete, pictorial, and abstract methods of this lesson give students access to investigate, isolate, define, and use prime numbers.

Previous work by Diffo Lambo and Moulen [Theory and Decision 53, 313–325 (2002)] and Felsenthal and Machover [The Measurement of Voting Power, Edward Elgar Publishing Limited (1998)], shows that all swap preserving measures of voting power are ordinally equivalent on any swap robust simple voting game. Swap preserving measures include the Banzhaf, the Shapley–Shubik and other commonly used measures of a priori voting power. In this paper, we completely characterize the achievable hierarchies for any such measure on a swap robust simple voting game. Each possible hierarchy can be induced by a weighted voting game and we provide a constructive proof of this result. In particular, the strict hierarchy is always achievable as long as there are at least five players.

This article, a qualitative research project based on grounded theory, illustrates processes used by a group of individuals diagnosed with schizophrenia to create a self-authored community. These individuals were long-term residents (continuous residence for more than 1 year) of a large psychiatric hospital. The results illustrate the challenges people face in forming relationships. The process of venturing forth and connecting begins cautiously, with few expectations. It is closely related to facilitative environments, such as public places and place of residence, and to routines, daily activities, and facilitative objects, such as coffee and cigarettes. These environments have few interactive demands and feature the presence of other people. The process is also related to past experience and current relationships, both real and virtual. We found some disparity from what is reported in the literature concerning the connection between relationships and staying out of hospital. The participants clearly visualized relationships as connecting them to the wider community and providing hope, and not necessarily linked to staying out of hospital. This disparity may be linked to these individuals having short community tenure. It may also be related to the small sample size. We argue that venturing forth and connecting is a useful concept when considering how individuals with long hospitalizations connect to a community. We consider that the actions of people recently discharged from long-term care should be seen as relatively normal and part of the struggle we all face in living in the world together.