Neurosurgical care is limited in many parts of the world to one or two hospitals serving a large geographic area. The quality of neurosurgical response to emergencies depends on the reliability and completeness of the information received from referral hospitals. The aim of this study is to show how application of guidelines for head injury management in an entire area can be usefully combined with transmission of images from the peripheral to the central hospital. From January 1998 to December 2000, 1665 CT examinations were sent via image transfer to the Neurosurgical Unit; 637 first examinations (47%) and 206 second examinations (70%) were related to acute trauma cases. Out of 637 first examinations, 150 patients were actually transferred to the Neurosurgery Unit (23%), whereas of 206 second examinations, only 10 patients were secondarily transferred (5%). In the absence of the outcomes of patients located outside the Neurosurgical Unit, we studied in detail these 10 patients. They are, in fact, the only way for us to partially measure the impact of our system. Only in a single case could the death be attributed to a delay in transferring the patient. We then studied the factors influencing the decision of patient transfer. Mean GCS was 11 both for transferred and non transferred cases. The mean age of all patients was 52 years (median 48, SD 20.5 years); mean age of non-transferred patients was 54 years and for transferred patients it was 41 years (p < 0.01). The same statistically significant difference concerning age applied to any type of pathology sent via image link. In conclusion our data show that it is feasible to co-ordinate in an entire area the treatment of head injured patients. Available systems for CT images link are reliable and mostly useful. Unnecessary transfers can be avoided and the neurosurgeons can evaluate the images of a number of patients who have always been treated outside our Units. This results in more work for the neurosurgeons on duty, but also in a better quality service for the whole area. The lack of follow-up for patients not admitted to Neurosurgery is the limitation on a quality assessment of the system.

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Functional outcome of elderly patients treated for odontoid fracture. A multicenter study.

This report describes a case of delayed post-traumatic glossopharyngeal and vagus nerves palsy (i.e. dysphonia and swallowing dysfunction). A high resolution CT study of the cranial base detected a fracture rim encroaching on the left jugular foramen. Treatment consisted in supportive measures with incomplete recovery during a one-year follow-up period. Lower cranial nerves palsies after head trauma are rare and, should they occur, a thorough investigation in search of posterior cranial base and cranio-cervical lesions is warranted. The presumptive mechanism in our case is a fracture-related oedema and ischemic damage to the nerves leading to the delayed occurrence of the palsy.

Purpose: Analysis of functional outcome of elderly patients with type II odontoid fractures treated conservatively in relation to their radiological outcome. Methods: 50 geriatric patients with type II odontoid fractures were treated with Aspen/Vista collars. On admission, each patient was assessed assigning ASA score, modified Rankin scale (mRS-pre) and Charlson Comorbidity Index (CCI). 12-15 months after treatment, functional evaluations were performed employing a second modified Rankin scale (mRS-post) together with Neck Disability Index (NDI) and Smiley Webster Pain Scale (SWPS). Radiological outcome was evaluated through dynamic cervical spine x-rays at 3 months and cervical spine CT scans 6 months after treatment. Three different conditions were identified: stable union, stable nonunion, unstable nonunion. Results: Among the 50 patients, 24 reached a stable union while 26 a stable nonunion. Comparing the two groups, no differences of ASA (p=0.60), CCI (p=0.85) and mRS-pre (p=0.14) were noted. Similarly, no differences of mRS-post (p=0.96), SWPS (p=0.85)

The integration of adequate mastery of traditional approaches together with a greater confidence through unfamiliar surgical corridors can improve the development of combined mini-invasive procedures, which seem promising for future targeted LDH excisions.

Study Design: Retrospective multicenter. Objectives: diffuse idiopathic skeletal hyperostosis (DISH) involving the cervical spine is a rare condition determining disabling aero-digestive symptoms. We analyzed impact of preoperative settings and intraoperative techniques on outcome of patients undergoing surgery for DISH. Methods: Patients with DISH needing for anterior cervical osteophytectomy were collected. Swallow studies and endoscopy supported imaging in targeting bone decompression. Patients characteristics, clinico-radiological presentation, outcome and surgical strategies were recorded. Impact on clinical outcome of duration and time to surgery and different surgical techniques was evaluated through ANOVA. Results: 24 patients underwent surgery. No correlation was noted between specific spinal levels affected by DISH and severity of pre-operative dysphagia. A trend toward a full clinical improvement was noted preferring the chisel ( P = 0.12) to the burr ( P = 0.65), and whenever C2-C3 was decompressed, whether hyperostosis included that level ( P = 0.15). Use of curved chisel reduced the surgical times ( P = 0.02) and, together with the nasogastric tube, the risk of complications, while bone removal involving 3 levels or more ( P = 0.04) and shorter waiting times for surgery ( P < 0.001) positively influenced a complete swallowing recovery. Early decompressions were preferred, resulting in 66.6% of patients reporting disappearance of symptoms within 7 days. One and two recurrences respectively at clinical and radiological follow-up were registered 18-30 months after surgery. Conclusion: The “age of DISH” counts more than patients’ age with timeliness of decompression being crucial in determining clinical outcome even with a preoperative mild dysphagia. Targeted bone resections could be reasonable in elderly patients, while in younger ones more extended decompressions should be preferred.

Vertebral artery injury (VAI) is a potential catastrophic complication of Goel and Harms C1–C2 posterior arthrodesis. Meticulous study of preoperative spinal CT angiography together with neuronavigation plays a fundamental role in avoiding VAI. Doppler ultrasonography may be an additional intraoperative tool, providing real-time identification of the vertebral artery (VA) and thus helping its preservation.Thirty-three consecutive patients with unstable odontoid fractures underwent Goel and Harms C1–C2 posterior arthrodesis. Surgery was performed with the aid of lateral fluoroscopic control in 16 cases (control group) that was supplemented by Doppler ultrasonography in 17 cases (Doppler group). Two patients in each group had a C1 ponticulus posticus. In the Doppler group, Doppler probing was performed during lateral subperiosteal muscle dissection, stepwise drilling, and tapping. Blood flow velocity in the V3 segment of the VA was recorded before and after posterior arthrodesis. All patients had a 12-month outpatient follow-up, and outcome was assessed using the Smiley-Webster Pain Scale. Neither VAI nor postoperative neurological impairments were observed in the Doppler group. In the control group, VAIs occurred in the 2 patients with C1 ponticulus posticus. In the Doppler group, 1 patient needed intra- and postoperative blood transfusions, and no difference in terms of Doppler signal or VA blood flow velocity was detected before and after C1–C2 posterior arthrodesis. In the control group, 3 patients needed intra- and postoperative blood transfusions.Useful in supporting fluoroscopy-assisted procedures, intraoperative Doppler may play a significant role even during surgeries in which neuronavigation is used, reducing the chance of a mismatch between the view on the neuronavigation screen and the actual course of the VA in the operative field and supplying the additional data of blood flow velocity.