Journal of Musculoskeletal Research

A total of 116 surgically treated patients with unstable fractures of the thoracic and lumbar spines were subjected to this study on basis of the simple radiographic and CT findings of the injured spinal column and neurological changes at the injured cord and/or roots level. Among them 50 patients were paraplegics and 66 patients were non-paraplegics. Spine fracture patterns shown on axial CT images were classified into five types on the basis of the fracture severity of vertebral body associating the canal compromise by the encroached fracture fragments from middle column and posterior element. Type I: vertical linear fracture through mid-anterior and posterior elements; Type II: retropulsed fragment in the canal with intact posterior element; Type III: retropulsed fragment in the canal with fracture of the posterior element; Type IV: severe comminution of body and disruption of posterior element around the canal; Type V: fracture-dislocation of comminuted vertebral body and neural arch (with or without double margin sign and with or without vacant facet sign). Displacement of vertebral body on lateral plane radiograms showed significant difference ($p$ < 0.001) between the non-paralytics and paralytics, but there were no differences in kyphotic angles and anterior body height loss between the two groups. Neurological injury was highly complicated in cases of the fracture-dislocation (20 out of 22 patients: 90.9%). Unstable fracture which occurred in the thoracic level showed high incidence of neurological injuries [24 out of 28 patients (85.7%)]; complete paralysis in 20 (71.4%) out of 28 patients in comparison with that of the thoracolumbar and lumbar fractures. Anteroposterior (AP) diameter of the compromised neural canal and percentile surface area of the compromised canal showed significant differences between the paralytics and non-paralytics (canal diameter: $p$ < 0.05, canal compromise: $p$ < 0.05). Neural deficit was highly complicated in type IV and V fractures. In conclusion, it was found that clinical neurological assessment and CT-based fracture classification were the valid approaches in managing the fractured spine.

Study design: Assessment of posterior occipitocervical fusions, based on the post-operative (postop) follow-up radiographic findings. Objectives: To investigate an objective radiological evaluation method of the occipitocervical stabilization and fusion. Summary of Background data: For evaluation of the union of the non-instrumented or instrumented stabilization and bony fusion of the occipitocervical segments, only a few studies have been performed by some previous authors. Material and Methods: Occipitocervical fusions were performed in 20 patients from 1995 to 2007. The patients underwent occipitocervical fusions with 4 different surgical methods; autogenous iliac bone grafts and wire fixation (seven cases), loop and sublaminar wire fixation (five cases), Cotrel–Dubousse (CD) occipitocervical rod (two cases), and contoured reconstruction plate and screw systems (six cases). The stability and established union of the fused segment and the instrument failure or loosening were evaluated with flexion/extension lateral radiograms. The stability was evaluated by alignment change in degrees and distances between a point of the occiput and cervical vertebrae on the sagittal plane radiograms, taken at postop three months ago. Angular motion over 2${}^{\circ }$ and 2mm of displacement on radiograms were defined to be unstable and/or ununited. When there was no such motion of the fused segment and the instrument breakage or loosening, the fused segment was judged stable and fused. Results: Diagnosis of nonunion was made in three out of seven patients who have undergone fusion with autogenous bone grafts with wire fixation. In the other patients, we were unable to determine the presence of a solid fusion mass at the fusion site, because of overlapping of the instrument and graft bones. In all rigidly instrumented cases, stability was obtained. Conclusion: The occipitocervical fusion segments were judged clinically to be stabilized rather than fused, if the flexion/extension radiographs, taken at postop three and six months, did not demonstrate motion at the fusion site.

Objectives: The purpose of this study is to assess the role of the Hartshill horseshoe cage for lumbar and lumbosacral interbody fusion through anterior Robinson–Smith construct. Materials: About 25 adults (11 males and 14 females), aged 29 to 56 years were the subject materials. Disease entities were post-traumatic internal derangement, isthmic and degenerative spondylolisthesis and lumbar scoliosis (DLS). The fusion levels were L${}_{4-5}$ in 21 and L₅–S₁ in four patients, braced postoperatively for 2–3 months. Results: Fusion took place at least five months on average (4–7 months). No complications were encountered. In one DLS patient who had multi-segment posterior instrument-aided stabilization (T${}_{11}$–S₁), the lowest pedicle screw became loosened gradually, but cage was maintained intact without loosening. Conclusion: Hartshill horseshoe cage offered a conducive biomechanical environment for anterior interbody fusion.

The erector spinae muscle is categorized as the intermediate layer of the intrinsic back muscles. Textbooks often describe the iliocostalis thoracis as originating superior to the iliocostalis lumborum. Six cadavers were dissected to reveal the iliocostalis thoracis origin and insertion points which show that the iliocostalis thoracis has fascicular attachments to the common erector spinae tendon. After reviewing nine common anatomy textbooks, 66.7% did not describe the iliocostalis thoracis as having fascicular extension into the common erector spinae tendon in both the text and illustrations. Interestingly, 22.2% of these textbooks had text that explained the attachments differently than the illustrations showed. While all cadaver specimens are inherently different, this finding shows that textbooks should reflect the fact that the iliocostalis thoracis originates from the common erector spinae tendon. This outcome could influence the healthcare a patient receives for antalgic compensatory posture associated with low back pain.

Background and objectives: Carpal tunnel syndrome (CTS) is caused by compression of the median nerve as it passes through the wrist. It can be treated with both surgical and non-surgical methods. Botulinum toxin type A has been used in the treatment of spasms, dystonia, migraine relief and myofascial pain. This study is aimed at evaluating the safety and tolerability of botulinum toxin type A in carpal tunnel syndrome. Methods: We conducted an open-label, prospective study using 30 units of onabotulinum Toxin A (Botox${}^{\text{®}}$), injected into the carpal tunnel using the in-plane ultrasound-guided ulnar approach. We used the verbal numeric rating scale (VNRS) to assess changes in pain and paraesthesias both 4 and 12 weeks following the injection. All adverse effects were recorded. Results: A total of 18 patients with 22 mild-moderate idiopathic CTS were included in the study. A total of 14 women and 4 men with a mean of age $60.91\pm 13.30$ years. Botulinum toxin A was well tolerated and only one patient reported temporary subjective weakness in his/her hand muscles. Both at 4 weeks and 3 months following the injection we observed a 63.6% subjective improvement in the patients’ level of pain and paraesthesias, with no statistical significance ($p=0.126$). Conclusion: Our study shows the effects of botulinum toxin in relieving pain and paraesthesias in carpal tunnel syndrome with moderate symptoms. The use of an in-plane ultrasound approach for its injection into the carpal tunnel adds value and safety to the procedure, and, based on our experience, is well tolerated and safe. Further studies are required to confirm these results and define optimal doses of botulinum toxin.

The plantar plate is a fibrocartilaginous structure that lies deep to the metatarsal heads and provides stability to the metatarsophalangeal (MTP) joints. Repetitive motion may lead to irritation, inflammation and tear of the plate. In this case, a 400m hurdler reported metatarsalgia, swelling and misalignment of the secondtoe, in the absence of trauma. Pain was experienced during the toe off phase of hurdling. The patient had a hammer toe and a positive Lachman’s Test on examination. Fluoroscopy guided second MTP joint arthrogram confirmed the diagnosis of plantar plate tear. Complete Plantar Plate Repair and Weil’s Osteotomy were then carried out for definitive management after physiotherapy and analgesia failed to provide relief. Although there are numerous conservative measures to treat this ailment, surgical management remains the most effective.