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Gabriel A. Smith, Arshneel S. Kochar, Sunil Manjila, Kaine Onwuzulike, Robert T. Geertman, James S. Anderson, and Michael P. Steinmetz

Despite the increasing prevalence of spinal infections, the subcategory of holospinal epidural abscesses (HEAs) is extremely infrequent and requires unique management. Panspinal imaging (preferably MRI), modern aggressive antibiotic therapy, and prompt surgical intervention remain the standard of care for all spinal axis infections including HEAs; however, the surgical decision making on timing and extent of the procedure still remain ill defined for HEAs. Decompression including skip laminectomies or laminoplasties is described, with varied clinical outcomes. In this review the authors present the illustrative cases of 2 patients with HEAs who were treated using skip laminectomies and epidural catheter irrigation techniques. The discussion highlights different management strategies including the role of conservative (nonsurgical) management in these lesions, especially with an already identified pathogen and the absence of mass effect on MRI or significant neurological defects.

Among fewer than 25 case reports of HEA published in the past 25 years, the most important aspect in deciding a role for surgery is the neurological examination. Nearly 20% were treated successfully with medical therapy alone if neurologically intact. None of the reported cases had an associated cranial infection with HEA, because the dural adhesion around the foramen magnum prevented rostral spread of infection. Traditionally a posterior approach to the epidural space with irrigation is performed, unless an extensive focal ventral collection is causing cord compression. Surgical intervention for HEA should be an adjuvant treatment strategy for all acutely deteriorating patients, whereas aspiration of other infected sites like a psoas abscess can determine an infective pathogen, and appropriate antibiotic treatment may avoid surgical intervention in the neurologically intact patient.

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Michael P. Steinmetz, Roseanna M. Lechner, and James S. Anderson

Atlantooccipital dislocation (AOD) injuries are highly unstable, and usually result in significant neurological injury and death. Recently the postinjury survival period has increased. In a review of the literature the authors found 41 cases in which survival was greater than 48 hours. This is likely due to improved on-scene resuscitation, spinal immobilization, transportation, new diagnostic techniques, and a higher index of suspicion.

Diagnosis is usually made with plain cervical radiographs, but there are shortcomings associated with this modality in the pediatric population. Diagnosis is aided by high-resolution computerized tomography and magnetic resonance imaging. Infants and toddlers may undergo orthotic immobilization alone, whereas older children usually undergo early occipital cervical fusion. Those with incomplete AOD may be managed successfully with orthotic immobilization.

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Michael P. Steinmetz, Meg Verrees, James S. Anderson, and Roseanna M. Lechner

✓ Two children who were 13 months and 3 years old and who had suffered traumatic atlantooccipital dislocation were each treated by being placed in a halo orthosis for 10 weeks. Because of a continued loss of reduction due to the poor fit of the halo vest, a dual-strap augmentation was developed. This strap augmentation allowed consistent reduction to be maintained. Both children were therefore successfully treated nonsurgically with a halo vest. One child remained neurologically intact and the other had improvement in motor strength. There were no complications from the use of strap augmentation for halo vest fixation.