A scoring system for evaluating symptoms after ankle fractures is presented. It is tested against (1) a linear analogue scale; (2) the limitation in range of motion in loaded dorsal extension; (3) the presence of osteoarthritis; and (4) the presence of dislocations on radiographs. It correlates well with these four parameters, which are considered to summarize the results after this type of injury, and is therefore considered to assess the symptoms in an objective way. The scoring system is recommended for scientific investigations, as even minor subjective differences in disability experienced by the patient are significantly separated. The use of this system will simplify the comparison of results presented by different authors.

The study design includes a prospective, randomised controlled study comparing total disc replacement (TDR) with posterior fusion. The main objective of this study is to compare TDR with lumbar spinal fusion, in terms of clinical outcome, in patients referred to a spine clinic for surgical evaluation. Fusion is effective for treating chronic low back pain (LBP), but has drawbacks, such as stiffness and possibly adjacent level degradation. Motion-preserving options have emerged, of which TDR is frequently used because of these drawbacks. How the results of TDR compare to fusion, however, is uncertain. One hundred and fifty-two patients with a mean age of 40 years (21-55) were included: 90 were women, and 80 underwent TDR. The patients had not responded to a conservative treatment programme and suffered from predominantly LBP, with varying degrees of leg pain. Diagnosis was based on clinical examination, radiographs, MRI, and in unclear cases, diagnostic injections. Outcome measures were global assessment

Thirty-one consecutive patients with ankylosing spondylitis and spinal fractures were reviewed. There were 6 women and 25 men with a mean age of 60 +/- 11 years; 19 had cervical and 12 had thoracolumbar injuries. Of the patients with cervical fracture, two had an additional cervical fracture and one had an additional thoracic fracture. Three trauma mechanisms were identified: high-energy trauma in 13 patients, low-energy trauma in 13 and insufficiency fracture in 5. One-third of the patients suffered immediate neurological impairment, a further one-third developed neurological impairment before coming for treatment and only one-third remained intact. Two patients with thoracolumbar fractures had deteriorated neurologically due to displacements during surgery at other hospitals. All patients were treated operatively except the two patients with two-level cervical fractures, who were managed in halo vests. In the cervical spine both anterior and posterior approaches were employed. In the thoracolumbar spine the majority of the patients were initially treated using a posterior approach only. Complications were common. Of the 27 patients with neurological compromise, 10 had remained unchanged; 12 had improved one Frankel grade; 4 had improved by two Frankel grades; 1 had improved by four Frankel grades. We conclude that even minor trauma can cause fracture in an ankylosed spine. A high proportion of patients with spinal fractures and ankylosing spondylitis have neurological damage. The risk of late neurological deterioration is substantial. As the condition is very rare and the treatment is demanding and associated with a very high risk of complications, the treatment of these patients should be centralised in special spinal trauma units. A combined approach that stabilises the spine from both sides is probably beneficial.

IntroductionFractures of the odontoid process of the axis have been the subject of many investigations, but most articles do not consider the biological impact of age. Few publications cover the subject in the elderly population, although odontoid fractures are the most common fractures of the cervical spine in this age group. There is still a lack of agreement on the best method of treatment among patients over 65 years of age. Conservative treatment carries a high risk of developing non-union [15,19] as does halovest treatment [8]. Posterior C1-C2 fusion according to Gallie has long been the method of choice. The Gallie technique, however, is not biomechanically optimal and has a failure rate of 1/5 [9]. By adding transarticular screws the mechanical situation was improved [14,16]. Recently, the anterior screw technique according to has gained increased popularity. In most reports, younger and older patients have been grouped together. Few publications have examined the results explicitly in the elderly population. Berlemann and Schwarzenbach [5] advocated the anterior screw technique in the elderly.The present study is a review of a consecutive series of odontoid fractures in patients over 65 years of age treated at our department between 1988 and 1994. The results of anterior screw fixation, posterior C1-C2 fusion, and conservative treatment are compared. Materials and methodsThe series consists of 29 consecutive patients (18 women) with a mean age of 78 (66-99) years with odontoid fractures treated at our department between 1988 and 1994. Patient demographics and results are presented in the Table 1. Twenty-four of the fractures were Abstract This study is a retrospective analysis of patients older than 65 years with odontoid fractures. The series consisted of 29 consecutive patients with odontoid fractures (18 women, mean age 78, range 66-99 years). Twenty-six patients were neurologically intact, Frankel E, whereas three had neurological symptoms: two Frankel D and one Frankel C. Eleven patients were treated with anterior screw fixation according to Böhler, seven with a posterior C1-C2 fusion. Ten patients with either minimally displaced fractures or with complicating medical conditions were treated conservatively. At follow-up, 7/7 patients with posterior fusion had healed without any problems, whereas 8/11 patients treated with anterior screw fixation, and 7/10 conservatively treated patients were either failures or had healed, but after a complicated course of events. We conclude that anterior screw fixation according to Böhler is associated with an unacceptably high rate of problems in the elderly. Probable causes may be osteoporosis with comminution at the fracture site, or stiffness of the cervical spine preventing ideal positioning of the screws. As non-operative treatment also often fails, the method of choice seems to be posterior C1-C2 fusion.

This home exercise programme, including training of neck and shoulder ROM, relaxation and general advice seems to be sufficient treatment for acute WAD patients when used on a daily basis. Additionally, patients reporting low self-efficacy and high disability levels may profit from more attention initially, as these psychological factors are significant predictors of pain at long-term follow-up.