“C3, 4, 5 Keeps the Diaphragm Alive.” Is Phrenic Nerve Palsy Part of the Pathophysiological Mechanism in Strangulation and Hanging? Should Diaphragm Paralysis be Excluded in Survived Cases?: A Review of the Literature

Predictors of Early Mortality Following Surgical or Non-surgical Treatment of Subaxial Cervical Spine Fractures: A Retrospective Nationwide Registry Study

BACKGROUND

Traumatic subaxial cervical spine fractures are a significant public health concern due to their association with spinal cord injuries (SCI). Despite being mostly caused by low-energy trauma, these fractures significantly contribute to morbidity and mortality. Currently, research regarding early mortality based on the choice of treatment following these fractures is limited. Identifying predictors of early mortality may aid in postoperative patient monitoring and improve outcomes.

PURPOSE

This study aimed to identify predictors of 30-days, 90-days, and one-year mortality in adults treated for subaxial fractures.

STUDY DESIGN

A retrospective review of the nationwide Swedish Fracture Register (SFR).

PATIENT SAMPLE

All adult patients in the SFR who underwent treatment for a subaxial cervical fracture (n = 1,963).

OUTCOME MEASURES

Analyzed variables included age, sex, injury mechanism, neurological function, fracture characteristics, and treatment type. The primary endpoints were 30-days, 90-days, and one-year mortality.

METHODS

1,963 patients in the SFR, treated for subaxial cervical fractures between 2013 to 2021, were analyzed. Surgical procedures included anterior, posterior, or anteroposterior approaches. Non-surgical treatment included collar treatment or medical examinations without intervention. Stepwise regression and Cox regression analysis were used to determine predictors. Model performance was tested using the area under the receiver operating characteristic curve (AUC).

RESULTS

620 patients underwent surgery and 1,343 received non-surgical treatment. Surgical cases had primarily translation fractures, with 323 (52%) displaying no neurological deficits. Mortality rates at 30 days, 90 days, and one year were 22/620 (3.5%), 35/620 (5.6%), and 53/620 (8.5%), respectively. Age and SCI were predictors of mortality. Non-surgically treated patients mostly had compression fracture, with 1,214 (90%) experiencing no neurological deficits. Mortality rates at 30 days, 90 days, and one year were 41/1,343 (3.1%), 71/1,343 (5.3%), and 118/1,343 (8.7%). Age, male sex, SCI and fractures occurring at the C3 or C6 levels were predictors of mortality. An intact neurological function was a positive predictor of survival among non-surgically treated patients (AUC > 0.78).

CONCLUSIONS

Age and SCI emerged as significant predictors of early mortality in both surgically and non-surgically treated patients. An intact neurological function served as a protective factor against early mortality in non-surgically treated patients. Fractures at C3 or C6 vertebrae may impact mortality.

Can the size of the contact area body-ground influence the presence of acute pulmonary emphysema in cases of incomplete hanging?

In a recently published study, we showed that acute pulmonary emphysema (APE) was present in cases of death by incomplete hanging and absent in cases of complete hanging. This result suggested a possible role of the hanging position on the respiratory distress of these victims. To further investigate this hypothesis, in the present study, we compared cases of incomplete hanging with a small contact area between body and ground (group A) to cases of incomplete hanging with a large contact area (group B). As positive and negative control group, we investigated cases of freshwater drowning (group C) and acute external bleeding (group D) respectively. Pulmonary samples were histologically examined, and the mean alveolar area (MAA) for each group was measured by digital morphometric analysis. MAA was 23,485 μm² for group A and 31,426 μm² for group B (p < 0.05). MAA of group B was similar to MAA of positive control group (33,135 μm²) and MAA of group A was similar to MAA of negative control group (21,991 μm²). These results seem to confirm our hypothesis and suggest that the size of the contact area between body and ground influences the presence of APE. Furthermore, the present study showed that APE can be proposed as a vitality sign in incomplete hanging, but only in cases with a large contact area between body and ground.

Experimental Study of Nerve Transfer to Restore Diaphragm Function

BACKGROUND

Diaphragmatic paralysis after phrenic nerve injury is an infrequent but serious condition. The destruction of respiratory function after unilateral phrenic nerve injury has been the subject of many investigations.

METHODS

In this study, we used a rat model of complete paralysis of the unilateral diaphragm to observe changes in pulmonary function.

RESULTS

We found in young rats with complete paralysis of the unilateral diaphragm, the vital capacity and total lung capacity show compensation after 4 weeks, and contralateral phrenic nerve transfer can enhance pulmonary function. However, in the aged rats, respiratory function parameters do not show compensation until 16 weeks after injury.

CONCLUSIONS

These findings suggest that contralateral phrenic nerve end-to-side anastomosis is a promising therapeutic strategy. In general, our results suggest that this surgical method may hold great potential to be a secure, feasible, and effective technique to rescue diaphragmatic function.

Accidental Strangulation with Cervical Nerve Root Injury Caused by the Entrapment of Clothing in a Soybean Milling Machine

The clothing of a forty-five-year-old man became entrapped by the mixing rotator while he was operating a soybean milling machine. His clothing was wound around the rotator, and tightened around his neck and chest, causing strangulation and a loss of consciousness. He was rescued by his coworkers and transported to our hospital by helicopter. Upon arrival, he regained consciousness. A physiological examination revealed multiple petechiae on his face and strangulation marks with subcutaneous hemorrhage on his neck and upper trunk. In addition, he had motor weakness of the right upper extremity and bilateral paresthesia from C5 to Th1. All radiological studies were negative. He was admitted for observation. After the patient's creatine phosphokinase level peaked and his focal neurological signs improved, he was discharged on foot on the 6^th hospital day. Accidental ligature strangulation with cervical nerve root injury, in which an article of clothing is caught in an electrical machine and strangles the wearer, is very rare. This case is presented for its rarity and the unique pattern of injury.

New Rhizotomy Procedure for Primary Spasmodic Torticollis

OBJECTIVE

Spasmodic torticollis (ST) is an idiopathic neurologic disorder affecting the muscles of the neck. Surgery is a preferred treatment, when conservative treatments or Botulinum neurotoxin injections fail to relieve the symptoms. Our objective here is to report the outcome of a new surgical method for treating ST patients in our department.

METHODS

The new procedure consists of rhizotomy of the spinal accessory nerve (SAN) and C1-C2 nerve roots, coagulation of the distal end of SAN (Group A). The results of this procedure were compared with a group of patients who underwent only rhizotomy of the SAN and anterior C1-C2 nerve roots (Group B). Clinical data were retrospectively collected from 39 patients with laterocollis and rotatory torticollis subtypes of ST from Jun 1, 2014 to Jun 1, 2015. The effect of the surgery was evaluated by the reduction in the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total scores preoperatively and postoperatively. The mean duration of the postoperative follow-up period was 2.57 years, ranging from 2 to 3 years.

RESULTS

The mean preoperative TWSTRS score was 65.89 ± 3.55 and 65.80 ± 3.45 in Groups A and B, respectively. Six months after the surgery, the TWSTRS scores decreased to 40.00 ± 12.14 and 26.04 ± 11.77, respectively. There was a statistically significant improvement preoperatively and postoperatively in both groups (P < 0.05). The decrease in TWSTRS score of Group B was more significant than that of Group A (P < 0.05). The main complications included shoulder numbness, shoulder weakness, and hoarseness.

CONCLUSIONS

The procedure in this study provides a new and effective surgical method for patients with ST. This procedure should be recommended if conservative therapy does not offer satisfactory relief of symptoms.