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PubMed2000

Clinical considerations in the chiropractic management of the patient with Marfan syndrome.

OBJECTIVE: To describe the chiropractic management of a patient with whiplash-associated disorder and a covert, concomitant dissecting aneurysm of the thoracic aorta caused by Marfan syndrome or a related variant. CLINICAL FEATURES: A 25-year-old man was referred by his family physician for chiropractic assessment and treatment of neck injuries received in a motor vehicle accident. After history, physical examination, and plain film radiographic investigation, a diagnosis of whiplash-associated disorder grade I was generated. INTERVENTION AND OUTCOME: The whiplash-associated disorder grade I was treated conservatively. Therapeutic management involved soft-tissue therapy to the suspensory and paraspinal musculature of the upper back and neck. Rotary, manual-style manipulative therapy of the cervical and compressive manipulative therapy of the thoracic spinal column were implemented to maintain range of motion and decrease pain. The patient achieved full recovery within a 3-week treatment period and was discharged from care. One week after discharge, he underwent a routine evaluation by his family physician, where an aortic murmur was identified. Diagnostic ultrasound revealed a dissecting aneurysm measuring 78 mm at the aortic root. Immediate surgical correction was initiated with a polyethylene terephthalate fiber graft. The pathologic report indicated that aortic features were consistent with an old (healed) aortic dissection. There was no evidence of acute dissection. Six month follow-up revealed that surgical repair was successful in arresting further aortic dissection. CONCLUSION: The patient had an old aortic dissection that pre-dated the chiropractic treatment (which included manipulative therapy) for the whiplash-associated disorder. Manipulative therapy, long considered an absolute contraindication for abdominal and aortic aneurysms, did not provoke the progression of the aortic dissection or other negative sequelae. The cause, histology, clinical features, and management considerations in the treatment of this patient's condition(s) are discussed.

Accidents, Traffic↗
PubMed1998

Cervical spine alignment in immobilized hockey players: radiographic analysis with and without helmets and shoulder pads.

OBJECTIVE: To establish the appropriate technique for cervical immobilization of the hockey player with an acute neck injury, we analyzed the alignment of the cervical spine in healthy volunteers with combinations of applied hockey equipment and assessed the amount of cervical spine motion possible in a secured hockey helmet. Our hypothesis was that there is a significant difference among various positions of the cervical spine with and without equipment and with active motion in a secured helmet. DESIGN: We analyzed lateral cervical spine radiographs of eight healthy male volunteers immobilized on a backboard with the following combinations of hockey equipment: shoulder pads and helmet, shoulder pads only, helmet only, no equipment, and neck flexion and extension with helmet and shoulder pads on and helmet secured to the backboard. SETTING: Large university hospital, tertiary care center. RESULTS: Cervical lordosis without equipment (control) was not significantly different than cervical lordosis with shoulder pads and helmet applied (p=0.31). Subjects with shoulder pads averaged 8.9 degrees more lordosis than did controls (p= 0.0002) and 6.6 degrees more lordosis than did subjects with shoulder pads and helmets (p=0.027). Subjects with shoulder pads and a helmet secured to the backboard were able to flex and extend the cervical spine 12.9 degrees compared with the control position (p =0.009). CONCLUSIONS: In an acute cervical spine injury involving an ice hockey player, we recommend immobilization in both the helmet and the shoulder pads, with removal of both pieces of equipment in a controlled hospital setting and only after initial radiographic examination. We also recommend securing the player's chin to prevent as much head and neck motion as possible during transport and transfers.

Adult↗
PubMed1983

Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management.

Controversy surrounds the management of prostatomembranous urethral injuries. We herein present 38 patients and review the findings of 538 in 19 reported series. Results indicate a high risk of stricture, impotence and incontinence if conventional early urethral realignment techniques are used. Therefore, it is suggested that this approach be reserved for cases demanding immediate intervention (high riding bladder, associated rectal tear, concomitant bladder neck injury or continued bleeding), and that all others be managed by initial suprapubic cystostomy alone and delayed urethroplasty. Urethroplasty selection is discussed.

Erectile Dysfunction↗
PubMed1999

Epidemiology and pathogenesis of posttraumatic headache.

This article presents an overview of the epidemiology and pathophysiology of posttraumatic headache. It reviews definitions of mild head injury (MHI), mild traumatic brain injury (MTBI), and concussion, and discusses the confusion that often occurs with these terms. Headache types and their pathophysiology are examined in detail. Just as the exact pathophysiology is unknown for migraine and other types of headache, the exact pathophysiology of headache after trauma is also still unknown in many cases. Possible connections between head or neck injuries and headache are reviewed, as well as hypothesized neurochemical changes that may occur in both migraine and traumatic brain injury (TBI). Psychological and legal factors are also considered.

Brain Injuries↗
PubMed2001

An evaluation of head movement in backboard-immobilized helmeted football, lacrosse, and ice hockey players.

OBJECTIVE: Improper handling of an unstable neck injury in the prehospital setting may result in iatrogenically induced neurologic injury. Due to helmet design, stabilization of the cervical spine in American football does not require routine removal of the helmet and shoulder pads prior to transport. Adequate data is not available evaluating hockey and lacrosse helmets. This study compares the amount of head movement in American football, lacrosse, and ice hockey helmets during head and neck stabilization procedures. STUDY DESIGN: Prospective. PARTICIPANTS: 12 ice hockey, 9 football, and 9 lacrosse athletes from an National Collegiate Athletic Association Division 1 program. SETTING: On-campus biomechanical laboratory with three HiRes cameras, routinely tested for accuracy. METHODS: Athletes were immobilized on backboards as per protocol. Three motion analysis HiRes cameras follow retroreflective markers placed on the helmet and bite mouthplate to measure relative head and helmet motion. MAIN OUTCOME MEASURES: Helical angles determine the relative range of motion of the head inside the helmets. RESULTS: The mean range of head motion for football players was 4.88 degrees (n = 9, SD 2.07), lacrosse players 6.56 degrees (n = 9, SD 1.61), and ice hockey players 5.54 degrees (n = 12, SD 1.19). These results were not significantly different (p > 0.05). CONCLUSIONS: The rotational head motion seen inside standard immobilized lacrosse and ice hockey helmets is similar to that seen in football helmets. This supports the safety of prehospital stabilization of the potential cervical spine-injured ice hockey and lacrosse athletes with in-line stabilization and helmet in place. Extrapolation of data may not be applicable to other helmet designs, and future studies are needed to determine the safety of emergency procedures in all helmet designs.

Adolescent↗
PubMedDate not supplied

Iatrogenic axillary artery injury from humeral neck fracture repair. A rare and unusual event in which and aggressive strategy was mandatory to save a child limb.

Humeral neck fracture is rarely associated with injury of the nearby axillary artery and in the English literature only 29 such cases have been reported. An injury of the distal axillary artery secondary to reduction and fixation of a humeral neck fracture is a very rare and unusual complication, to the best of our knowledge has never been reported in literature. In this paper we report the case of entrapment of the distal axillary artery in the humerus rhyme fracture in a 9-year-old child who suffered a nighttime car-accident with her father. At admission, the child presented a left humeral neck fracture with no other lesions and no neurologic problems in her limb; peripheral pulses present in her left hand at palpation. After closed reduction and pinning of the fracture with 2 K-wires, the left upper limb became ischemic and pulseless and the child was transferred at our Institution for diagnosis and treatment. In this paper we discuss the treatment to be adopted in this very unusual situation.

Axillary Artery↗
PubMed2000

Treatment of chronic cervical-associated headache with botulinum toxin A: a pilot study.

OBJECTIVE: To see whether therapy with botulinum toxin A may prove to be an effective treatment for headache of musculoskeletal origin. BACKGROUND: Headache is a common finding associated with neck injury. Cervicogenic headache, which is believed to be attributable to injury of the ligaments, muscles, or joints of the cervical spine, is centered in the occipital region with pain referred to the frontotemporal region. Botulinum toxin A produces prolonged muscle relaxation, which is dose dependent and can be easily targeted to affected muscles. METHODS: This randomized, double-blind, placebo-controlled study compares outcome measures in 26 patients suffering from chronic headache subsequent to a cervical whiplash injury. One half of the patients received botulinum toxin A, 100 units, diluted in 1 mL of saline, while the other half received just saline (1 mL). Five cervical trigger points received 0.2 mL each of injectant via a 30-gauge needle. Outcome measures included subjective head pain based on visual analog scales, as well as range of neck motion. Follow-up assessments were carried out at 2 and 4 weeks after treatment. RESULTS: Fourteen subjects who received botulinum toxin A and 12 who received saline completed the study. At both 2 and 4 weeks post injection, the treatment group showed a significant improvement in pain and range of motion from preinjection levels (P<.01). The placebo group demonstrated no statistically significant changes at any posttreatment time.

Adult↗
PubMed1995

[Traumatic injury of the internal carotid artery in the extracranial segment. Description of a severe late complication].

Blunt traumatic injury to the extracranial internal carotid artery may lead to a dissection with resultant stenosis, occlusion, or a dissecting aneurysm. Delayed clinical presentation weeks, months, and even years after the injury is rare, but has important diagnostic, therapeutic and forensic implications. In the current era, where computed tomography is replacing angiography as the main diagnostic procedure, it is extremely important to keep this diagnosis in mind. We report the case of a 31-years-old male patient, who did well after a motorcycle accident with head and neck injury for six years. Since then he only showed left-side Horner's syndrome, which unfortunately was ignored. In 1993 the patient developed occlusion of central retinal artery, and after a therapy with streptokinase he presented with right-side palsy and complete aphasia. CT-scan revealed a large edematous infarction in the middle cerebral artery territory. Transfemoral digital subtraction angiography however demonstrated a dissecting aneurysm of the left extracranial internal carotid artery as the source of intracranial embolization. Severe sequelae of this kind can only be warded of by early diagnosis and proper surgical therapy of vascular injury. Therefore even minimal symptoms suggesting the possibility of a traumatic injury to the carotid artery are recommending timely angiographic investigation.

Adult↗
PubMed2006

Atlanto-occipital dislocation: case report and discussion.

Atlanto-occipital dislocation (AOD) is a devastating condition that frequently results in prehospital cardiorespiratory arrest and accounts for 15% of fatal spinal trauma. Atlanto-occipital dislocation occurs 5 times more commonly in children than adults, and is believed to be caused by hyperextension. Because of improvements in prehospital resuscitation, more victims with AOD now survive to reach the emergency department. Neurologic injury is usually severe secondary to ligamentous disruption that allows the cranium to move with respect to the cervical spine, and associated facial and head injuries are common. There are, however, reports of survivors without neurologic deficits. We present the case of a 46-year-old woman who suffered an AOD after a motor vehicle crash and we discuss the diagnosis of this condition. The signs of AOD are often subtle, and the possibility of this diagnosis must be kept in mind in all patients with a neck injury, even in the absence of neurologic signs. A systematic approach to assessing the cranio-cervical relationship on the lateral cervical x-ray and the appropriate use of CT scanning is essential to identifying AOD. Through this case report we hope to familiarize clinicians with mechanisms of injury and appropriate imaging interpretation that will assist in the diagnosis of AOD.

Accidents, Traffic↗
PubMedDate not supplied

Traumatic spinal cord injuries (SCI): a study of 104 cases.

BACKGROUND: Management of spinal cord injured patients is an integral part of trauma care. There is need to congregate these patients in spinal units where dedicated experts and facilities exist for better outcome of treatment and rehabilitation. The objective of this study therefore, is to promote improved quality of care in the group of patients by highlighting the deficiencies in our setting. METHODS: This is a retrospective study of all traumatic spinal cord injured (SCI) seen at the National Orthopaedic Hospital, Enugu over a six-year period. Information about the demographics, aetiology, level of injury, associated injuries, time of presentation, referral hospital, state of injury, duration of hospitalization, outcome of treatment were obtained from patients' records. Data were analyzed using commercially available SPSS for windows 9. Descriptive statistics are given. RESULTS: There were 104 patients, 88 males and 16 females, giving a ratio of 5.5:1. Road traffic accident, 60 (57.7%), was the commonest aetiological factor and the cervical spine, 70 (67.3%), was most often involved. Head and neck injuries were common associated injuries, 19 (18.3%) in patients with cervical spine injury. Six (5.8%) of our patients were obtunded. Most patients, 69 (66.4%), were received from private hospitals after a mean duration of 7 days. Hospitalization ranged from 1 week-120 weeks with a mean of 11 weeks. Pressure sore was the commonest complication, 30 (28.8%). Thirty six (34.4%) of patients died mainly from respiratory failure. Most of the discharged wheel bound patients (97%) were lost to follow up. CONCLUSION: For better outcome we re-emphasize the need to establish and congregate these patients into regional spinal units. We also suggest a social legislation, which will be fundamental to social re-integration of these SCI and other severely disabled patients.

Adolescent↗
PubMed1991

A behavioral workshop for training immediate supervisors: the key to neck and back injuries?

This study investigated the short-term effects of a workshop for 22 immediate supervisors designed to reduce musculoskeletal pain injuries. One group of supervisors received training on how to deal with musculoskeletal injuries, while the control group of 14 received no training. 36 male immediate supervisors and 171 male employees within the Swedish railroad system completed questionnaires before and after the intervention. The trained supervisors' ratings showed that they enjoyed the workshop and believed that it improved their skills. Moreover, trained supervisors significantly more often than the controls showed target behaviors and attitudes compatible with course content. Finally, employees of the trained supervisors reported significantly more often than the control group that their supervisor used target behaviors. It is concluded that an educational program for immediate supervisors is viable and may lead to changes in attitude and behavior. Teaching supervisors to work with employees is a rich field for future investigation; the long-term effects of such programs need to be studied.

Accidents, Occupational↗
PubMed2004

Death by chainsaw: fatal kickback injuries to the neck.

Each year over 3 million new chainsaws are sold in the United States. The operation of these newer saws combined with the millions of older chainsaws in circulation results in over 28,000 chainsaw-related injures annually. The majority of the injuries involve the hands and lower extremities with less than 10% involving injuries to the head and neck regions. Deaths while operating a chainsaw are extremely rare. The most common hazards associated with chainsaws are injuries caused by kickback, pushback, and pull-in. Kickback is the most common and poses the greatest hazard. Kickback occurs when the rotating chain is stopped suddenly by contact with a more solid area throwing the saw rapidly backward toward the operator. The cause of most injuries can be traced to improper use of the saw or poor judgment on part of the operator. We present two fatal chainsaw deaths; one with an older style saw, and the other with a modern type. In both cases the victims died from fatal injuries received to the neck region from a chainsaw kickback. The first case involved a 49-year-old white male operating an older style chainsaw with limited safety features. The second case involved a 38-year old white male who was operating a newer model chainsaw equipped with a low kickback chain in an unsafe manner.

Accidents↗
PubMed1984

Penetrating injuries to the neck. Selective management.

The management of penetrating neck trauma remains a controversial subject. Two distinct approaches have been advocated: "mandatory" versus "selective" exploration of all neck wounds. Surgical intervention in our institution is based upon the latter, a selective principle of individualization of the patient and his injury. Obvious early exploration is indicated for patients with evidence of major vascular injury, visceral injury, or with progressive neurologic deficit. In the absence of such signs of injury, the authors used a diagnostic protocol which includes esophagram and arteriography. This retrospective reviews and assesses the results of this selectively conservative policy.

Adolescent↗
PubMed2002

Whiplash injury: cases with a long period of sick leave need biomechanical assessment.

A total of 668 cases of cervical spine disorders (CSD) sustained in automotive collisions were analysed. All cases had a minimum sick leave duration of 4 weeks. To evaluate these cases a scheme was developed that takes into account technical, medical, and biomechanical aspects. For each case, the delta-v value of the underlying collision was estimated, the medical files were analysed, and a QTF (Québec Task Force) grade was assigned. In addition, the medical history of the patient was reviewed. It was found that the QTF grade for patients with pre-existing damage of the neck or pre-existing signs differed significantly from those patients without such a history. The overall assessment, which stated the extent to which the symptoms claimed could be explained by the impact, was also found to be significantly influenced by a history of neck injury. The results of the study showed that in about 50% of the cases where the technical analysis alone would not suggest that the symptoms shown could be explained by the impact, those symptoms could be explained when patient history and the collision circumstances were taken into consideration. It also found that medical evaluation based on a QTF grade alone cannot assess the explicability of claimed CSD without taking into account the collision circumstances. Therefore, the assessment of critical individual relevant biomechanical factors is necessary.

Accidents, Traffic↗
PubMed1993

Biochemical indicators of hazardous shoulder-neck loads in light industry.

Prolonged, repetitive handling of light material is known to increase the risk of shoulder-neck disorders. Biological risk indicators related to musculoskeletal exposure, applicable by the general practitioner in the workplace, could provide an instrument for early intervention and rehabilitation. Eight women were studied, all full-time workers performing assembly tasks associated with a high prevalence of shoulder-neck complaints. All subjects were more tender in the shoulder region than young women in low-risk occupations. Heart rate recordings indicated a low general metabolic load during work. Concentrations in antecubital venous blood of several markers for metabolic stress and cellular damage (lactate, ammonia, hypoxanthine, urate, malondialdehyde, potassium, creatine kinase) were normal for all subjects, and showed no increase during 3 consecutive working days. Thus, the blood markers did not reflect hazardous shoulder-neck exposure.

Adult↗
PubMed1997

[A case of a surgically treated extracranial internal carotid artery saccular aneurysm].

Extracranial internal carotid artery aneurysm is rare. Most cases are due to spontaneous or traumatic dissection of the cervical internal carotid artery. Here we report a case of surgically treated extracranial internal carotid artery (ICA) aneurysm. A 74-year-old man noticed a pulsatile mass just below the left mandibular angle. Intravenous digital subtraction angiography revealed multiple aneurysms in the systemic arteries, including the aortic arch, abdominal aorta and left extracranial ICA. It was decided to treat the aneurysms of the aortic arch and of the abdominal aorta conservatively. Cerebral angiography, however, showed a saccular aneurysm which projected latero-posteriorly at the C2 level of the left extracranial ICA. Although the patient had no previous ischemic event, we decided to treat this aneurysm surgically in view of the risk of cerebral ischemia caused by intraaneurysmal thrombus formation or rupture of the aneurysm by neck injury. The operation was performed under mild hypothermal general anesthesia. Electroencephalography was carried out during the operation. A skin incison was made from the anterior border of the sternocleidomastoid muscle to the pretragal region to expose the parotid gland. This skin incision, elevation of the parotid gland and division of the digastric muscle were useful for exposing the distal portion of the extracranial ICA. After trapping of the aneurysm, it was punctured and collapsed by aspiration and the dome was excised at its neck. The ICA was then reconstructed by suturing the cut neck of the aneurysm. Patency of the ICA was confirmed by postoperative angiography. The postoperative course was smooth except for hoarseness, which was caused by damage to a minor branch of the vagus nerve during exposure of the aneurysmal dome.

Aged↗
PubMed1990

Scalene muscle abnormalities in traumatic thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is not a single disorder but a collection of abnormalities in the same anatomic area that elicit similar symptoms. The many causes of TOS are best classified into one of three groups: osseous, traumatic, and nontraumatic. Although patients with traumatic TOS constituted 86% of our last 600 patients with TOS who underwent surgical treatment, the precise mechanism underlying the condition remains obscure. To determine if there was microscopic abnormalities, 45 anterior and middle scalene muscles from patients with traumatic TOS were studied by means of histochemical stains applied after freezing of the muscles. The results revealed a consistent abnormal histologic pattern in patients with traumatic TOS: type II fibers were atrophied; there was an increase in the average number of type I fibers (78% versus 53% in muscles from control patients); and there was a significant increase (mean: 36%) in connective tissue (muscles from control patients averaged less than 15%). Although type II fiber atrophy and type I fiber predominance are seen in a variety of other conditions, their association with fibrosis is rare. Following neck injuries, the changes in the anterior and middle scalene muscles are compatible with trauma, suggesting that fibrotic scalene muscles are an important cause of symptoms in traumatic TOS.

Adult↗