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  • Author or Editor: Andreas Kramer x
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Andreas H. Kramer, Michael Hehir, Bart Nathan, Darryl Gress, Aaron S. Dumont, Neal F. Kassell and Thomas P. Bleck

Object

Delayed cerebral ischemia is a major cause of morbidity and death following aneurysmal subarachnoid hemorrhage and requires timely intervention for a successful outcome to be achieved. In this study the investigators compared the commonly used Fisher scale with 2 newer radiographic scales for the prediction of vasospasm, delayed infarction, and poor outcome.

Methods

This was a single-center, retrospective cohort study involving 271 consecutive patients with a ruptured cerebral aneurysm. Without knowledge of subsequent events, admission CT scans were each assigned scores by using 3 different grading schemes: the Fisher, modified Fisher, and Claassen scales. For each of the scales, the relationship between an increasing score and the risk of later complications was assessed in univariate and multiple logistic regression analyses.

Results

With the Fisher scale, the risk of complications was relatively high when the score was 3, but not for other scores. In contrast, using the other scales, there was a more linear relationship between a rising score and the frequency of complications. This was particularly true for the modified Fisher scale, in which each stepwise increase was associated with an escalating risk of vasospasm, delayed infarction, and poor prognosis. Kappa scores measuring interobserver variability among 4 CT readers were also slightly better with the newer scales.

Conclusions

Although the modified Fisher and Claassen scales have yet to be prospectively validated, the authors' findings suggest that the clinical performance of these systems is superior to that of the Fisher scale.

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Thomas Einsiedel, Andreas Schmelz, Markus Arand, Hans-Joachim Wilke, Florian Gebhard, Erich Hartwig, Michael Kramer, Rainer Neugebauer, Lothar Kinzl and Markus Schultheiss

Object

The cervical spine in a patient with ankylosing spondylitis (AS) (Bechterew disease) is exposed to maximal risk due to physical load. Even minor trauma can cause fractures because of the spine’s poor elasticity (so-called bamboo spine). The authors conducted a study to determine the characteristics of cervical fractures in patients with AS to describe the standard procedures in the treatment of this condition at two trauma centers and to discuss complications of and outcomes after treatment.

Methods

Between 1990 and 2006, 37 patients were surgically treated at two institutions. All patients were examined preoperatively and when being discharged from the hospital for rehabilitation. Single-session (11 cases) and two-session anterior–posterior (13 cases), anterior (11 cases), posterior (two cases), and laminectomy (one case) procedures were performed. The injury pattern, segments involved, the pre- and postoperative neurological status, and complications were analyzed.

Preoperative neurological deficits were present in 36 patients. All patients experienced improvement postoperatively, and there was no case of surgery-related neurological deterioration. In patients in whom treatment was delayed because of late diagnosis, preoperative neurological deficits were more severe and improvement worse than those treated earlier. The causes of three deaths were respiratory distress syndrome due to a rigid thorax and cerebral ischemia due to rupture of the vertebral arteries. There were 12 perioperative complications (32%), three infections, one deep venous thrombosis, five early implant failures, and the three aforementioned fatalities. There were no cases of epidural hematoma. In all five cases in which early implant failure required revision surgery, the initial stabilization procedure had been anterior only. A comparison of complications and the outcomes at the two centers revealed no significant differences.

Conclusions

The standard intervention for these injuries is open reduction, anterior decompression and fusion, and anterior–posterior stabilization; these procedures may be conducted in one or two stages. Based on the early implant failures that occurred exclusively after single-session anterior stabilizations (five of 10—a failure rate of 50%), the authors have performed only posterior and anterior procedures since 1997 at both centers. Diagnostic investigations include computed tomography scanning or magnetic resonance imaging of the whole spine, because additional injuries are common. The causative trauma may be very slight, and diagnosis may be delayed because plain radiographs can be initially misinterpreted. In cases in which diagnosis is delayed, patients present with more severe neurological deficits, and postoperative improvement is less pronounced than that in patients in whom a prompt diagnosis is established. Because of postoperative pulmonary and ischemic complications, the mortality rate is high. In the present series the mortality rate was lower than the mean rate reported in the literature.