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At least 433 records · Page 24Linked to original sources
PubMed2005

A survey of temporomandibular joint dislocation: aetiology, demographics, risk factors and management in 96 Nigerian cases.

A retrospective study of 96 cases of temporomandibular joint dislocation was undertaken. Patients' ages ranged from 9 to 85 years (mean+/-SD, 35.3+/-17.4 years) and peak incidence was at 20-29 years. Mean duration was 7.9 weeks (range, 1h to 3 years). Acute, chronic and recurrent dislocations were seen in 46 (47.9%), 29 (30.2%) and 21 (21.9%) patients, respectively. Males dominated in all three categories but this was not statistically significant (P = 0.8). Excessive mouth opening while yawning (44 cases) was the commonest cause of dislocation, followed by road traffic accidents (13 cases). Ten patients (10.4%) had an underlying systemic disease, the commonest being epilepsy (four cases); those with acute dislocation recorded the highest incidence of underlying illness. Bilateral anterior (86 cases) dislocations were the most frequent. Of the 96 patients, 89 (92.7%) were available for treatment. Manual reduction with or without anaesthesia proved effective for 38/45 acute, 5/24 chronic and 14/20 recurrent cases. Chronic dislocations were treated mainly by surgical osteotomy (13/24). Vertical subsigmoid and oblique ramus osteotomies were the commonest surgical techniques recorded. Treatment was satisfactory for all patients surgically handled except for one case of anterior open bite postoperatively. This study has shown that excessive mouth opening while yawning is the commonest cause of temporomandibular joint dislocation in Nigerians, and conservative approaches to management remain quite effective irrespective of the duration and clinical subtype. The best choice of surgical technique should be determined by proper clinical evaluation and the need to avoid or minimize postoperative morbidity.

Accidents, Traffic↗
PubMed2004

Talar dislocations.

From 1987-2003, 36 patients were treated for talar dislocation, 27 patients for subtalar, six for total talar, and three patients for peritalar dislocation. Luxatio pedis sub talo: We found 19 medial closed, seven lateral closed and one third degree open subtalar dislocations. Our therapeutic concept provides for immediate reduction, which is possible by closed procedure for the majority of medial dislocations. If there is a tendency to redislocation, we perform talonavicular K-wire transfixation. In the case of irreducibility, open reduction via lateral approach is the rule. The lateral dislocation type is often accompanied by additional fractures of the hindfoot and tarsus, frequently requiring primary open procedures via medial approach. 32 patients were followed-up in whom we found 17 excellent results, ten good, three mediocre and two poor results. With two thirds of the patients, low grade arthrosis at least was observed and two thirds showed a reduced amplitude of motion in one or more talar joints. A definite correlation between arthrosis and reduced function was not established. We did not find talar necroses, persisting instabilities, or redislocations. Luxatio tali totalis: We found three lateral and three medial complete dislocations. The therapeutic concept consists of immediate reduction-only possible by open procedure. A tendency to redislocation requires K-wire transfixation. All patients were followed-up. We found two good and four poor results, with two total and three partial necroses. As a secondary treatment, two lower ankle joint(LAJ) and two upper ankle joint (UAJ) arthrodeses were performed. There were no talectomies, amputations, or infections. Luxatio pedis cum talo: We found three anterolateral UAJ dislocations. Our therapeutic concept provides for immediate reduction. The whole capsular ligament apparatus was reconstructed by primary or secondary treatment, depending on the degree of soft tissue damage. Follow-up showed two excellent results

Adolescent↗
PubMedDate not supplied

Analysis of patient variables affecting neurologic outcome after traumatic cervical facet dislocation.

BACKGROUND CONTEXT: Traumatic cervical facet dislocation accounts for a disproportionate rate of neurologic disability. The relative importance of patient and management variables, including the timing of spinal reduction, in ultimate neurologic outcome has not been well defined. PURPOSE: To analyze data from a cohort of patients sustaining traumatic cervical facet dislocation to determine the relative importance of several patient and management variables in neurologic recovery after injury. STUDY DESIGN/SETTING: A retrospective study was conducted at a major referral center for spinal-cord-injured patients. PATIENT SAMPLE: Forty-five patients sustaining traumatic cervical facet dislocation. OUTCOME MEASURES: Using improvement in American Spinal Injury Association (ASIA) motor score as the primary outcome measure, patient data were used to construct a statistical model allowing the analysis of several clinically relevant variables. METHODS: The records of patients sustaining a traumatic cervical facet dislocation over a 5-year period were reviewed. Clinical data were collected for all patients with adequate follow-up. The data were used to construct a statistical model designed to analyze the contribution of the variables age, gender, time to reduction of the spine and initial motor score to neurologic improvement (the outcome measure). In addition, the effect of variable interaction was studied. RESULTS: Most patients demonstrated neurologic improvement over the course of follow-up after cervical facet dislocation. For this data set, the variables age and initial motor score were significantly associated with neurologic improvement. However, time to reduction of the spine did not demonstrate a significant independent relationship to neurologic outcome. No significant interaction was found between patient age or gender and the time to reduction with regard to predicting neurologic recovery. CONCLUSION: The present study uses a statistical model to determine the relative importance of clinically relevant variables for a population of patients after traumatic cervical facet dislocation. This model confirms the clinical impression that younger patients with lesser degrees of neurologic injury tend to achieve the best neurologic recovery after a traumatic facet dislocation. Although a strong benefit from earlier spinal column reduction did not emerge from the present data set, additional study is needed to define those patients who would benefit from immediate reduction of the spinal column.

Adult↗
PubMed1987

Congenital elbow dislocations.

Three categories of congenital elbow dislocations are described in the literature: humeroulnar, humeroradial, and dislocation or joint laxity with other congenital anomalies. Congenital humeroulnar dislocation is a well-defined problem that occurs predominantly in small breeds of dogs and causes severe limb deformity and dysfunction. Early reduction and stabilization are simple to achieve and have provided good results. Radial head dislocations occur most often as a result of growth disturbance of the radius and ulna. There is a lack of conclusive information on congenital radial head dislocations. Regardless of the etiology, radial head dislocation causes rather mild deformity and lameness and can be treated by conservative management, surgical correction, or radial head ostectomy. Dislocation of the elbow may occur concurrently with other rare congenital anomalies and has been described with ectrodactyly and polyarthrodysplasia.

Abnormalities, Multiple↗
PubMed2002

Effects of acetabular component orientation on dislocation propensity for small-head-size total hip arthroplasty.

OBJECTIVE: Examine the role of surgical orientation of the acetabular cup on posterior dislocation propensity for small-head-size total hip arthroplasty. DESIGN: A finite element model of a widely used total hip arthroplasty system was examined for peak resisting moment and range-of-motion prior to impingement, as well as prior to onset of posterior dislocation. Acetabular component surgical orientation was varied. BACKGROUND: Dislocation is a leading cause of total hip replacement failure, with an incidence between 2% and 11%. Clinical registries imply acetabular component orientation to be a leading predictor of dislocation. The finite element method permits this complex kinetic behavior to be addressed systematically. METHODS: Twenty-five combinations of cup abduction (five angles) and anteversion (five angles) were studied, with the resultant resisting moment about the cup center being tracked in each case. Key events were benchmarked, and a novel dislocation resistance index was developed for multi-factor comparison. RESULTS: Increasing tilt and/or anteversion resulted in a monotonically increasing range-of-motion prior to impingement, as well as increased peak resisting moment. Range of motion was more sensitive to tilt, while peak resisting moment was more sensitive to anteversion. Peak resisting moment for 22-mm head size was nearly 25% less than that for a 26-mm head. CONCLUSIONS: Increased cup tilt and anteversion discourage posterior dislocations of small-head-size components. RELEVANCE: Pre-existing soft tissue compromise and untoward patient motions/postures are largely beyond surgeon control. However, other factors being equal, especially for small-head-size components, many posterior dislocations that would otherwise occur might be prevented by suitable tilt and anteversion of the acetabular component.

Acetabulum↗
PubMed1999

Prereduction radiographs in clinically evident anterior shoulder dislocation.

The main study objective was to determine if experienced emergency physicians can accurately identify a subgroup of patients with anterior shoulder dislocation for whom prereduction radiographs do not alter patient management. Our prospective study evaluated 97 patients who presented to 2 ski-hill clinics and to our rural emergency department with possible shoulder dislocation between November 1996 and May 1997. Emergency physicians were certain of shoulder dislocation by clinical examination alone in 40 of 59 cases (67.8%) of possible dislocation. All 40 cases were found to have a dislocation (100%; 95% Cl, 91.19% to 100%), and the prereduction radiograph did not affect management of the injury. Prereduction radiographs added 29.6 +/- 12.68 minutes to treatment. We conclude that shoulder dislocation is often readily apparent from history and physical examination. When the experienced emergency physician is certain of the diagnosis of anterior shoulder dislocation, prereduction radiography delays treatment and does not alter management.

Adolescent↗
PubMed2003

The early dislocation rate in primary total hip arthroplasty following the posterior approach with posterior soft-tissue repair.

Although a posterior approach is frequently used for total hip arthroplasties (THAs), some reports have associated this approach with higher dislocation rates than anterior or lateral approaches. To deter dislocations following primary THAs using the posterior approach, the senior author repairs the posterior capsule and the short external rotators to the greater trochanter with nonabsorbable suture. We retrospectively reviewed the occurrence of dislocations among 945 primary THAs performed with this technique at a mean 6.4-year follow-up (range, 2.0-9.3 years). The average patient age was 62.3 years (range, 36-86 years). Eight patients (0.85%) dislocated. Of these, 3 dislocated within the first postoperative year and were treated without surgery; 3 required revision surgery and placement of a constrained liner; and 2 dislocated after trauma and were treated without surgery. With the correct orientation of components and an enhanced soft-tissue repair, the posterior surgical approach can result in an extremely low dislocation rate.

Adult↗
PubMed1998

Prognosis of dislocation after total hip arthroplasty.

One hundred sixty-one dislocations after cemented total hip arthroplasty, with a mean follow-up period of 8 years after dislocation, were reviewed with the aim of establishing the prognosis. There were 84% single and 16% recurrent dislocations. Closed reduction was successful in 81% of cases. Thirty-seven percent of dislocations were early (within 5 weeks), 36% occurred in patients who had had previous surgery, and in 47% there was nonunion of the trochanter. There was a two-way interaction between these factors, and all factors were significant for recurrent dislocation. Twenty-six (16%) recurrent dislocations required surgery. The most common causes of recurrent dislocation demonstrated at operation were component malposition (58%) and failure of the abductor mechanism (42%). In total, 96% of cases were successfully treated.

Adult↗
PubMed1999

The natural history of a posteriorly dislocated total hip replacement.

A retrospective review was conducted to delineate the natural history of the posteriorly dislocated total hip replacement. A total of 1,036 consecutive total hip replacements were performed between 1989 and 1992. Forty (3.9%) were known to have dislocated posteriorly. Twenty-four of these dislocations occurred after primary replacements, and 16 occurred after revision. Eighty-five percent of the dislocations occurred within 2 months and were reduced closed. No statistical differences were noted between these 2 groups with respect to height, weight, sex, age, and femoral and acetabular anteversion. Nonunion of the greater trochanter, modular femoral neck length, and operative approach appeared to affect hip stability. Twenty-three of the 40 dislocated hips (57.5%) redislocated. Sixteen of the 40 hips (40%) required reoperation for recurrent dislocation. Thirteen of the 16 revisions (81.3%) were successful. A dislocated total hip replacement that has been rendered stable does not preclude one from having a successful total hip replacement, and it does not appear to affect survivorship at intermediate follow-up.

Aged↗
PubMedDate not supplied

"Floating tibia-talus complex"--an ipsilateral dislocation of the knee and the subtalar joint in an elderly patient: a case report and review of the literature.

Knee dislocation is defined as a radiographically confirmed total loss of the tibiofemoral articulation. This rare injury is believed to be the result of a high-impact trauma. Knee dislocations are classified according the direction of tibial displacement with respect to the femur. Subtalar dislocation is the simultaneous dislocation of the distal articulations of the talus at both the talocalcaneal and talonavicular joints. These injuries are also quite rare and are mostly (80%-85%) classified as medial subtalar dislocations with the calcaneus lying medially, the head of the talus being prominent dorsolaterally and the navicular located medial and dorsal to the talar head. The authors report the case of an elderly patient who suffered ipsilateral anterior dislocation of his left knee and medial subtalar dislocation of his left foot. The authors believe this to be the first presentation in the English literature of an ipsilateral combination of these two injuries on the same limb.

Aged↗
PubMed2004

Differences between the wear couples metal-on-polyethylene and ceramic-on-ceramic in the stability against dislocation of total hip replacement.

After total hip replacement an insufficient range of motion (ROM) can lead to contact between femoral neck and rim of the cup (= impingement) causing dislocation and consecutive material failure. The purpose of this study was to analyse the influence of different wear couples on the ROM and stability against dislocation. By means of a special testing device the ROM until impingement, the ROM until dislocation as well as the resisting moment against levering the head out of the cup were experimentally determined. Various total hip systems with cup inserts made of ceramic and polyethylene were comparatively examined in different implant positions. Maximum resisting moment as well as the ROM until impingement and dislocation were clearly influenced by the implant position. Furthermore, the stability against dislocation was affected by design parameters, whereas in the case of appropriate implant position differing wear couples (metal-on-polyethylene vs. ceramic-on-ceramic) had a minor impact. However, as shown by tests under lubricant conditions, ceramic-on-ceramic couples provided less dislocation stability in unfavourable implant position in comparison to metal-on-polyethylene. Therefore, ceramic-on-ceramic couples should only be applied in the case of optimised implant orientation preventing impingement and dislocation with subsequent material failure like chipping off or breakage.

Ceramics↗
PubMedDate not supplied

Peritalar dislocations: a retrospective study of 18 cases.

The purpose of this study is to retrospectively evaluate 18 consecutive cases of peritalar dislocations referred to our department during a period of 25 years and to delineate the factors influencing long-term prognosis. There were 13 (73%) medial and 5 (27%) lateral dislocations. Six patients (33%) suffered an open injury, including 2 of 13 (15%) medial and 4 of 5 (80%) lateral dislocations. Associated fractures involving the hindfoot or forefoot were noted in 7 feet, including 3 of 5 lateral dislocation cases. Reduction was accomplished under general anesthesia; in no case was open reduction necessary. In 4 of 6 open injuries with associated fractures, temporary fixation with Kirschner wires was performed. Patients were immobilized in a plaster cast for 4 weeks, or for 6 weeks in the presence of fracture, followed by weightbearing as tolerated. At a mean follow-up of 10.2 years (range, 4 to 26 years), 10 patients (56%) showed excellent results; all had sustained a closed medial low-energy dislocation. There were 3 cases (17%) with fair results and 5 cases (28%) with poor results. Forty-five percent of patients showed a restriction of activity, a reduction of subtalar range of motion, and moderate or severe radiographic signs of hindfoot degenerative arthritis. There were no cases of talar avascular necrosis, and in no case was secondary surgery necessary. Lateral dislocation and open medial dislocations with concomitant fractures showed a greater potential for poor prognosis. The results were independent from period of cast immobilization, suggesting that 4 to 6 weeks of immobilization provides acceptable long-term results.

Adolescent↗
PubMedDate not supplied

Bilateral traumatic dislocation of the distal radioulnar joint, ulna dorsal: case report and review of the literature.

Bilateral dislocation of the distal radioulnar joint seems not to have been reported in the literature. This is a report of a 22-year-old man successfully treated with closed reduction and immobilization in long arm casts. Limited forearm rotation and wrist pain after a twisting injury are typical findings. In ulna dorsal dislocation the patient's forearm is locked in pronation. In ulna volar dislocation the wrist appears narrow and the forearm is locked in supination. The mechanism of injury for dorsal dislocations is hyperpronation; for volar dislocations it is hypersupination. Dislocation of the distal radioulnar joint injures the triangular disk and/or fractures the ulnar styloid. Suspicion is important in making the diagnosis. Fifty per cent of unilateral cases reported in the literature were missed initially or were diagnosed late. The acute case is easily treated by closed reduction under local anesthesia and immobilization in a long arm cast. Treatment of the chronic dislocation includes various soft tissue reconstructions or resection of the distal ulna depending on the degree of arthrosis.

Adult↗
PubMed2002

Surgical approach, abductor function, and total hip arthroplasty dislocation.

Dislocation is a leading early complication of total hip arthroplasty. The effect of surgical approach on instability and abductor function is a controversial topic. A comprehensive literature review was done to evaluate the correlation of surgical approach and primary total hip arthroplasty dislocation. Two hundred sixty clinical studies were identified between 1970 and 2001. Four prospective studies were identified but individually they contained insufficient power or control groups to reach statistical significance regarding surgical approach and dislocation. Fourteen studies involving 13,203 primary total hip arthroplasties met the inclusion criteria based on variables previously shown to affect stability. These studies were evaluated with respect to surgical approach and dislocation. The combined dislocation rate for these studies was 1.27% for the transtrochanteric approach, 3.23% for the posterior approach (3.95% without posterior repair and 2.03% with posterior repair), 2.18% for the anterolateral approach, and 0.55% for the direct lateral approach. Eight studies involving 2455 primary total hip arthroplasties evaluated postoperative limp. The incidence of postoperative limp was 4% to 20% for patients who had the lateral approach and 0% to 16% for patients who had the posterior approach. The quality of the literature regarding surgical approach, dislocation rates, and abductor function is limited. Larger controlled prospective studies are needed to investigate the potential benefits of the posterior approach in lieu of a dislocation rate six times higher than the direct lateral approach for primary total hip arthroplasty.

Arthroplasty, Replacement, Hip↗
PubMed1997

Knee dislocation: initial assessment and implications for treatment.

OBJECTIVE: To evaluate bicruciate knee injuries and determine whether they should be treated as knee dislocations, especially with regard to vascular injuries. DESIGN: Retrospective. SETTING: University hospital, level 1 trauma center. PATIENTS: Fifty patients admitted between 1987 and 1994 who had sustained knee dislocations or bicruciate ligament injuries. MAIN OUTCOME MEASURES: Mechanism of injury, direction of dislocation, knee ligament injury pattern, presence or absence of periarticular fracture, presence of vascular and nerve injuries, and location of associated trauma were measured. RESULTS: Twenty-two knees had classic knee dislocations. Twenty-eight knees presented as "reduced" bicruciate ligament injuries. Vascular injury occurred just as frequently in bicruciate ligament injuries as in knee dislocations. The direction of the knee dislocation did not predict ligament injury pattern or the presence of arterial injury. CONCLUSION: Bicruciate ligament injuries are equivalent to knee dislocations with regard to mechanism of injury, severity of ligamentous injury, and frequency of major arterial injuries.

Adolescent↗
PubMed1999

Fracture and dislocation of snowboarder's elbow.

BACKGROUND: This study focuses on the analysis of snowboarding versus skiing injuries, especially fracture, dislocation, or both, of the elbow, based on 7 years of medical records and roentgenograms of patients injured at a ski-snowboard area, Mt. Zao National Park, and demonstrates the precise characteristics of snowboard injury in the elbow region. METHODS: A retrospective study of 1,445 injured snowboarders and 10,152 injured skiers was undertaken to assess both snowboarding and skiing injuries. Sixty-four cases of snowboarding injuries and 152 cases of skiing injuries were available for precise analysis of fracture, dislocation, or both, in the elbow region. RESULTS: Fractures, dislocations, or both, in the elbow were more frequently observed for snowboarders (30 of 64 cases, 46.9%) when compared with that for skiers (26 of 152 cases, 17.1%) (p < 0.001). The rate of dislocation with or without fracture of the elbow was also significantly higher for snowboarders (17 of 64 cases, 26.6%) than for skiers (8 of 152 cases, 5.3%, p < 0.001). Seventeen cases of elbow dislocation in snowboarding were all of the posterior type, which accompanied two coronoid process fractures and two radial neck fractures. Fractures of the coronoid process (five cases), radial head (one case), radial neck (five cases), olecranon (one case), proximal ulnar shaft (one case), and extension-type fracture of distal humerus (four cases) were the fracture types observed in the analysis. CONCLUSION: Posterior dislocation; fractures of coronoid process, radial neck, and radial head; and extension-type fracture of the distal humerus characterize the particular and frequent injury mechanism responsible for snowboarding trauma in the elbow region. Thus, snowboarding injury of the elbow is recognized as a severe injury and is characterized by a frequent risk of posterior dislocation, fracture, or both. The severity of elbow injuries in snowboarding mainly seems to be due to direct mechanical force on the elbow, receiving the full impact of falling down, combined with an outstretched hand and elbow extension, or with an outstretched hand and longitudinal thrust force, to the proximal radius and ulna and distal humerus.

Adolescent↗
PubMed2002

Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study.

BACKGROUND: Knee dislocation, which poses a significant risk for injury of the popliteal artery, prompts many surgeons to evaluate these patients with arteriography routinely. Our hypothesis was that physical examination alone (without arteriography) accurately confirms or excludes surgically significant vascular injuries associated with knee dislocation. METHODS: All patients diagnosed with a knee dislocation by an attending orthopedic surgeon between January 1990 and January 2000 were prospectively managed by protocol at our Level I trauma center according to their physical examination. Those with hard signs (active hemorrhage, expanding hematoma, absent pulse, distal ischemia, bruit/thrill) underwent arteriography followed immediately by surgical repair if indicated. Patients with no hard signs (negative physical examination) were admitted for 23 hours, underwent serial physical examination, and then followed as outpatients. RESULTS: There were 35 knee dislocations in 35 patients during this 10-year period. The average age was 31 years; 18 dislocations were on the right knee and 17 were on the left. Two patients died from closed head injuries and multisystem trauma. Eight patients were found to have hard signs (positive physical examination) either at presentation (six patients) or during their hospitalization after reduction of their dislocation (two patients). All eight patients demonstrated a loss of pulses only. Six of these patients showed occlusion of the popliteal artery on arteriography and underwent surgical repair without complication (five vein grafts, one primary repair), one demonstrated spasm of the popliteal artery, and one showed a normal artery that required no treatment. None of the 27 patients with negative physical examination during their hospitalization ever developed limb ischemia, needed an operation for vascular injury, or experienced limb loss. Sixteen patients were available for follow-up (46%). Twelve patients with negative physical examination (44%) were contacted (mean, 13 months; range, 2-35 months), and four of the eight patients with positive physical examination (50%) and surgical repair were contacted (mean, 19 months; range, 6-49 months). None of the patients in either group developed any vascular-related symptoms or suffered from a vascular repair complication over the follow-up interval. CONCLUSION: This limited series suggests that the presence or absence of an injury of the popliteal artery after knee dislocation can be safely and reliably predicted, with a 94.3% positive predictive value and 100% negative predictive value. Arteriography appears to be unnecessary when physical examination is negative but may avert negative vascular exploration when physical examination is positive. This approach substantially reduces cost and resource use without adverse impact on the patient.

Angiography↗
PubMed1998

Reduction technique for uni- and biarticular dislocations of the lower cervical spine.

STUDY DESIGN: A technical report concerning the methods of reduction of dislocations of the lower cervical spine used in 168 consecutive cases (77 unilateral and 91 bilateral dislocations). OBJECTIVES: To evaluate the efficacy of a reduction protocol comprising three successive phases: reduction by traction, reduction by closed maneuvers with the patient under general anesthesia, and open reduction. SUMMARY OF BACKGROUND DATA: Management of cervical dislocations varies greatly among spine treatment centers, especially concerning the upper limit of traction, the safety of closed manipulations in anesthetized patients, and the approach preferred when surgical reduction is necessary. METHODS: Reduction by gradual traction without anesthesia was attempted first. In case of failure, specific closed manipulations were used with the patient under general anesthesia just before anterior arthrodesis was performed. If this failed, anterior surgical reduction was attempted. Anterior fusion was performed in every patient, even when closed reduction was successful, because of the lasting instability produced by attending ligamentous lesions. RESULTS: Of the patients in 168 cases of dislocation, the protocol failed in 5, all of whom had longstanding unilateral dislocation. Of the 91 with bilateral dislocation, reduction was achieved by simple traction in 39 (43%), by maneuvers with the patient under general anesthesia in 27 (30%), and by anterior surgery in 25 (27%). Among the patients in 77 cases of unilateral dislocation, reduction was achieved by traction in 18 (23%), by external maneuvers in 28 (36%), and by anterior surgery in 26 (34%). In 7 patients, discal herniation engendering neurologic signs was resected during anterior surgery. No neurologic deterioration during or immediately after reduction by this protocol was observed. CONCLUSIONS: This protocol consists of application of rapidly progressive traction, followed if necessary by one or two reduction maneuvers with the patient under general anesthesia. If both methods fail, specific surgical procedures using an anterior exposure seem to be reliable, in that anatomic reduction was obtained in 163 of 168 patients without neurologic deterioration.

Adolescent↗