Traumatic dislocation of the atlanto-occipital joint

We present four patients who had sustained a traumatic dislocation of the atlanto-occipital joint. The diagnosis was initially missed in two patients. One patient, who was neurologically intact, was treated non-operatively. The remaining three recovered neurologically after an occipitocervical fusion. Early recognition of the injury, especially in multiply-injured patients with head injuries, and timely management may improve survival and neurological recovery.

Traumatic dislocation of the atlanto-occipital joint

We present four patients who had sustained a traumatic dislocation of the atlanto-occipital joint. The diagnosis was initially missed in two patients. One patient, who was neurologically intact, was treated non-operatively. The remaining three recovered neurologically after an occipitocervical fusion. Early recognition of the injury, especially in multiply-injured patients with head injuries, and timely management may improve survival and neurological recovery.

Cortical allografts in spinal tuberculosis

One-hundred-twenty-three patients with neurological deficit due to spinal tuberculosis underwent anterior spinal decompression and anterior column reconstruction with fresh-frozen femoral allograft. Fifty-two patients with a follow-up of more than 5 years were evaluated to assess the incorporation and the efficacy of allograft in maintaining correction. The allograft was incorporated in 49 patients at a mean follow-up of 6.5 (5.3-8.2) years. Complete neurological recovery occurred in 39 patients. The mean pre-operative kyphosis of 37 degrees (15 degrees -67 degrees ) was corrected to 18 degrees (5 degrees -45 degrees ). Fresh-frozen allografts are a suitable alternative to autologous rib and iliac crest grafts in the treatment of spinal tuberculosis.

A scalable membrane gradostat reactor for enzyme production using Phanerochaete chrysosporium

This is the first demonstration of process scale-up of a membrane gradostat reactor for continuous enzyme production using Phanerochaete chrysosporium ME446. The fungus was immobilised by reverse filtration on to externally unskinned, ultrafiltration capillary membranes and then nutrient gradients were induced across the biofilm. A 10-fold scale-up from a single capillary bioreactor to a 2.4 l multi-capillary unit resulted in a 7-fold increase in enzyme productivity with a peak at 209 U l(-1) d(-1). Subsequent scale effects on the spore distribution, continuous manganese peroxidase production profile and biofilm development are discussed.

Staged reduction and stabilisation in chronic atlantoaxial rotatory fixation

We present seven children with atlantoaxial rotatory fixation (AARF) of more than three months' duration after an injury to the upper cervical spine. The deformity was irreducible by skull traction. MRI and MR angiography (MRA) of the vertebral arteries were performed in four children. The patients were neurologically intact. Thrombosis of the ipsilateral vertebral artery was noted in two patients. The deformity was gradually corrected and stabilised after transoral release of the atlantoaxial complex, skull traction and posterior atlantoaxial fusion. Soft-tissue interposition and contractures within the atlantoaxial complex prevented closed reduction. MRI and MRA of the vertebral arteries were useful in elucidating the pathology of chronic atlantoaxial rotatory fixation.

Staged reduction and stabilisation in chronic atlantoaxial rotatory fixation

We present seven children with atlantoaxial rotatory fixation (AARF) of more than three months’ duration after an injury to the upper cervical spine. The deformity was irreducible by skull traction. MRI and MR angiography (MRA) of the vertebral arteries were performed in four children. The patients were neurologically intact. Thrombosis of the ipsilateral vertebral artery was noted in two patients. The deformity was gradually corrected and stabilised after transoral release of the atlantoaxial complex, skull traction and posterior atlantoaxial fusion. Soft-tissue interposition and contractures within the atlantoaxial complex prevented closed reduction. MRI and MRA of the vertebral arteries were useful in elucidating the pathology of chronic atlantoaxial rotatory fixation.

Vertebral artery injury in cervical spine trauma

Forty-seven patients with cervical spine trauma were evaluated prospectively with magnetic resonance imaging (MRI) and angiography (MRA) to determine the incidence of vertebral artery injury. Twelve patients (25%) had vertebral artery injuries (one bilateral), and occlusion was identified in nine patients and dissection in four. The vertebral artery injury did not result in neurological dysfunction. No specific treatment was instituted for the vascular injury, and in four patients, MRA showed no evidence of recanalization at follow-up.

Long-term follow-up assessment of vascularized rib pedicle graft for tuberculosis kyphosis

This article reports a long-term follow-up assessment (10-15 years) of eight children treated with a vascularized rib pedicle graft after an anterior spinal decompression for paralysis resulting from tuberculosis. Neurologic recovery, fusion, and hypertrophy of the rib grafts were noted in all patients. The vascularized rib pedicle grafts were superior to autologous rib grafts in supporting and promoting early fusion of the anterior column in children with kyphosis resulting from tuberculosis.

Tuberculosis of the cervicodorsal junction

Sixteen patients had paraplegia due to tuberculosis of the cervicodorsal junction. Spinal decompression was performed through an extended lower cervical approach, and a humeral allograft was used to reconstruct the anterior column. All patients improved neurologically with satisfactory correction of the deformity and successful incorporation of the allograft.

Anterior spinal decompression in HIV-positive patients with tuberculosis. A prospective study

total of 39 HIV-infected adults with spinal tuberculosis underwent anterior spinal decompression for neurological deficit. Fresh-frozen allografts were used in 38 patients. Antituberculous drugs were prescribed for 18 months, but antiretroviral therapy was not used. Six patients died within two years of surgery. Neurological recovery and allograft incorporation were observed at follow-up at a mean of 38 months, although the CD4/CD8 ratios were reversed in all patients. Adequate preoperative nutritional support and compliance with antituberculous treatment are essential in ensuring a satisfactory outcome.

Anterior spinal decompression in HIV-positive patients with tuberculosis

A total of 39 HIV-infected adults with spinal tuberculosis underwent anterior spinal decompression for neurological deficit. Fresh-frozen allografts were used in 38 patients. Antituberculous drugs were prescribed for 18 months, but antiretroviral therapy was not used. Six patients died within two years of surgery. Neurological recovery and allograft incorporation were observed at follow-up at a mean of 38 months, although the CD4/CD8 ratios were reversed in all patients. Adequate preoperative nutritional support and compliance with antituberculous treatment are essential in ensuring a satisfactory outcome.

Aspergillus spondylitis in immunocompetent patients

Four immunocompetent patients with neurological deficit underwent anterior decompression for Aspergillus osteomyelitis of the spine. All patients improved neurologically following anterior spinal decompression and antifungal therapy. This study emphasizes the importance of obtaining a tissue diagnosis as these unusual infections may mimic tuberculosis, which is more common.

Fractures of the odontoid process

We treated 183 patients with fractures of the odontoid process (109 type II, 74 type III) non-operatively. Union was achieved in 59 (54%) with type-II fractures. All type-III fractures united, but in 16 patients union was delayed. There was no correlation between union and the clinical or radiological outcome of the fractures. Selective vertebral angiography, carried out in 18 patients ten with acute fractures and eight with nonunion, showed that the blood supply to the odontoid process was not disrupted. Studies on ten adult axis vertebrae at post-mortem showed that the difference in the surface area between type-II and type-III fractures was statistically significant. Our findings show that an age of more than 40 years, anterior displacement of more than 4 mm, posterior displacement and late presentation contribute towards nonunion of type-II fractures.

Fractures of the odontoid process

We treated 183 patients with fractures of the odontoid process (109 type II, 74 type III) non-operatively. Union was achieved in 59 (54%) with type-II fractures. All type-III fractures united, but in 16 patients union was delayed. There was no correlation between union and the clinical or radiological outcome of the fractures. Selective vertebral angiography, carried out in 18 patients ten with acute fractures and eight with nonunion, showed that the blood supply to the odontoid process was not disrupted. Studies on ten adult axis vertebrae at post-mortem showed that the difference in the surface area between type-II and type-III fractures was statistically significant. Our findings show that an age of more than 40 years, anterior displacement of more than 4 mm, posterior displacement and late presentation contribute towards nonunion of type-II fractures.

Spinal tuberculosis in HIV positive and negative patients: immunological response and clinical outcome

We measured cytokine secretion patterns in peripheral blood and granulation tissue by flow cytometry in 16 human immunodeficiency virus (HIV) positive and 26 HIV negative patients with spinal tuberculosis. Anti-retroviral therapy was not prescribed. There were no significant differences in the postoperative morbidity and neurological recovery between the two groups.

Salmonella typhi spondylitis

We report on five patients with Salmonella typhi spondylitis who were immunologically normal and had no prodromal gastrointestinal illness. The diagnosis was confirmed on blood cultures, Widal test, and needle biopsy of the spine. Appropriate antibiotic treatment resulted in a favorable outcome.

The role of magnetic resonance imaging on spinal trauma

Spinal MR has an increasingly important role in the assessment of spinal trauma. The ability to visualise clearly the spinal cord, nerve roots, ligaments, intervertebral discs and adjacent vascular structures allow a more accurate assessment of the extent of injury, and necessity for further management and provide a prognosis for recovery.

Pyogenic spondylitis

Twenty-nine patients with pyogenic vertebral osteomyelitis were reviewed retrospectively after an average follow-up of 3.7 years. We identified 17 patients with predisposing factors (10 diabetes, 4 urinary tract infection, 2 HIV-positive, 1 rheumatoid arthritis). No patient presented with a febrile illness. The lumbar spine was involved in 15 patients. Eighteen patients had neurological impairment at presentation. Eleven patients who were neurologically intact had needle biopsies and the remaining 18 patients who were neurologically compromised had an open decompression. Staphylococcus aureus was cultured in 14 patients. Although spinal tuberculosis is relatively common in our environment it is important to obtain a tissue diagnosis in order to exclude pyogenic vertebral osteitis.

Osteochondroma with compression of the spinal cord

We report two cases of vertebral osteochondroma. In one patient a solitary cervical lesion presented as entrapment neuropathy of the ulnar nerve and in the other as a thoracic tumour associated with hereditary multiple exostoses producing paraplegia. We highlight the importance of an adequate preoperative evaluation in such patients.

Osteochondroma with compression of the spinal cord. A report of two cases

We report two cases of vertebral osteochondroma. In one patient a solitary cervical lesion presented as entrapment neuropathy of the ulnar nerve and in the other as a thoracic tumour associated with hereditary multiple exostoses producing paraplegia. We highlight the importance of an adequate preoperative evaluation in such patients.

Cryptococcal osteomyelitis of the spine

We have treated seven patients with cryptococcal spondylitis. Five presented with a neurological deficit and one was HIV-positive. Amphotericin-B and 5-flucytosine were used in five patients and ketoconazole was given orally in the remaining two. Three patients made a complete neurological recovery. Since these lesions mimic spinal tuberculosis, which is commonly seen in our environment, we draw attention to the importance of obtaining a tissue diagnosis.

Cryptococcal osteomyelitis of the spine

We have treated seven patients with cryptococcal spondylitis. Five presented with a neurological deficit and one was HIV-positive. Amphotericin-B and 5-flucytosine were used in five patients and ketoconazole was given orally in the remaining two. Three patients made a complete neurological recovery. Since these lesions mimic spinal tuberculosis, which is commonly seen in our environment, we draw attention to the importance of obtaining a tissue diagnosis.

Support of the anterior column with allografts in tuberculosis of the spine

Fresh-frozen allografts from the humerus were used to help to stabilise the spine after anterior decompression for tuberculosis in 47 children with a mean age of 4.2 years (2 to 9). The average angle of the gibbus, before operation, was 53 degrees; at follow-up, two years later, it was 15 degrees. Rejection of the graft or deep sepsis was not seen. Cross trabeculation between the allograft and the vertebral body was observed at six months, with remodelling occurring at approximately 30 months.

Support of the anterior column with allografts in tuberculosis of the spine

Fresh-frozen allografts from the humerus were used to help to stabilise the spine after anterior decompression for tuberculosis in 47 children with a mean age of 4.2 years (2 to 9). The average angle of the gibbus, before operation, was 53°; at follow-up, two years later, it was 15°. Rejection of the graft or deep sepsis was not seen. Cross trabeculation between the allograft and the vertebral body was observed at six months, with remodelling occurring at approximately 30 months.