White Cord Syndrome Following Cervical Surgery in a Patient With Klippel-Feil Syndrome: A Case Report

White cord syndrome is a rare entity, as there are very few cases described in the current literature. Postoperative MRI examination reveals cord intrinsic changes, including edema and ischemia. It is also described as a reperfusion injury of the spinal cord. This report depicts a rare case of "white cord syndrome" with tetraplegia after posterior laminectomy and fusion of the cervical spine in a patient with Klippel-Feil syndrome. A 33-year-old male patient with Klippel-Feil syndrome presented to our department with cervical myelopathy, claudication, deteriorating neurological status, imbalance, and lower limb spasticity. Due to kyphotic malformation of the cervical spine, a two-stage surgical intervention was scheduled. The patient first underwent anterior spinal fusion of C4-C6 with corpectomy of C5, where many anatomical and visceral differentiations were signed, so the surgical team was enhanced by a vascular surgeon. The postoperative period was uneventful and the patient was discharged after a week of hospitalization without any neurological deterioration. A second surgical intervention was scheduled after two months where laminectomy of C5-C7 and posterior fusion of C5-T1 were carried out. However, due to intraoperative spinal instability and various anatomical spinal variations, a third surgery, which would be occipitocervical fusion, was decided as the final surgical solution. During the third surgical operation, after the laminectomy of C1 to C5 and the placement of the occipital plate, the screws, and the two rods in situ, complete nullification of the intraoperative neurophysiologic control was signed. The internal fixation was removed immediately, the wake-up test revealed tetraplegia below C5, and the patient was transferred to the ICU. Immediate MRI revealed no spinal cord hematoma; however, spinal cord edema was present. The patient underwent a tracheostomy and remained quadriplegic with a sensory level of T8 and motor level of C5 and was discharged to a rehabilitation center. The possibility of white cord syndrome should be explained by surgeons before any cervical decompression surgery, as well as a thorough neurological examination should be performed postoperatively. The early recognition and prompt management of white cord syndrome is recommended.

Our C-Arm-Free Minimally Invasive Technique for Spinal Surgery: The Thoracolumbar and Lumbar Spine-Based on Our Experiences

Background and Objectives: The implementation of intraoperative imaging in the procedures performed under the guidance of the same finds its history dating back to the early 1990s. This practice was abandoned due to many deficits and practicality. Later, fluoroscopy-dependent techniques were developed and have been used even in the present time, albeit with several disadvantages. With the recent advancement of several complex surgical techniques, which demand higher accuracy and are in conjunction with the existence of radiation exposure hazard, C-arm-free techniques were introduced. In this review study, we aim to demonstrate the various types of these techniques performed in our hospital. Materials and Methods: We have retrospectively analyzed and collected imaging data of C-arm-free, minimally invasive techniques performed in our hospital. The basic steps of the procedures are described, following with a discussion, along with the literature of findings, enlisting the merits and demerits. Results: MIS techniques of the thoracolumbar and lumbar spine that do not require the use of the C-arm can offer excellent results with high precision. However, several disadvantages may prevail in certain circumstances such as the navigation accuracy problem where in the possibility of perioperative complications comes a high morbidity rate. Conclusions: The accustomedness of performing these techniques requires a steep learning curve. The increase in accuracy and the decrease in radiation exposure in complex spinal surgery can overcome the burden hazards and can prove to be cost-effective.

Surgical Site Infection Following the Correction of Adolescent Idiopathic Scoliosis With ApiFix: A Retrospective Study Analyzing Its Incidence and Recurrence

Background and objective ApiFix (OrthoPediatrics, Warsaw, IN) is an internal brace used for the correction of adolescent idiopathic scoliosis (AIS) classified as Lenke 1 or 5 with a Cobb angle of 35-60 degrees that decreases to ≤30 degrees on lateral side-bending radiographs. Since the indications are very specific, it is not a common procedure. Our study aimed to evaluate the incidence of surgical site infection (SSI) and its recurrence following treatment with ApiFix. Materials and methods A retrospective study of 44 cases of AIS treated at our center from 2016 to 2022 with ApifiX was conducted. Two patients who presented with SSI were initially treated with irrigation and debridement (I&D) following antibiotic therapy.  Results A total of 44 patients with a mean age of 15.1 years were evaluated. Two of our patients presented with early-onset infection while one of them presented after the end of treatment with a skin ulcer due to septic screw loosening. The removal of the ApiFix implant revealed a pedicle abscess during the screw removal. Conclusions In this study of 44 patients, we observed two cases of infection and one case of reinfection. Given the limited muscle detachment and short operating time needed for Apifix, statistics suggest that the risk of SSI is always present. Further randomized trials are needed to gather more evidence on this subject.

The Correlation Between the Strength of the Shoulder and Trunk Muscular Systems in Elite Adolescent Water Polo Athletes

Introduction

Water polo is a competitive team sport played in the water between two teams of seven players each. Water polo players must have swimming speed, strong abdominal and back muscles, and strong shoulder muscles to cope with this sport's special conditions. In this study, we investigate the possible association of shoulder and trunk muscle systems in adolescent water polo athletes of high demands.

Materials and methods

The research included 42 water polo players aged 14-16, who train regularly for at least five years, six times a week, and participate in national championships and national teams. The athletes were evaluated on the strength and torque of these muscular systems using the isokinetic dynamometer Biodex System 4 Pro (Biodex Medical Systems, Inc, Shirley, NY). The correlation of the results was done using the statistical package SPSS 21.

Results

The correlations revealed statistically significant differences in trunk extension in combination with the shoulder external/internal rotation ratio. Also, most of the correlations occurred between the trunk and non-dominant limb of the athletes and, more often, in the female athletes. Furthermore, for the hand grip, the male athletes showed a greater difference in strength between the dominant and the non-dominant member than female athletes. Finally, the evaluation of the trunk extension/flexion ratio and external/internal rotation ratio for the shoulder joint showed that many athletes are outside the normal range and need targeted strengthening.

Conclusion

The negative correlation coefficient between trunk extension/flexion and shoulder external/internal rotation indicates that the trunk extension mechanism helps for better internal rotation of the shoulder. Therefore, water polo players should focus on the training of the stretching mechanism of the trunk and also give weight to achieving a balance between the competing muscular systems of the trunk and the shoulder. Thus, athletes can maximize their skills and, at the same time, protect themselves from injuries.

Cruciate Paralysis Following a Displaced Type II Odontoid Fracture: A Case Report

A 54-year-old male was admitted to our emergency department by air transport after being hit as a pedestrian by a motorcycle. He presented with impaired motor function in the upper extremities bilaterally while sensation was spared. He presented no motor or sensory impairment of the lower extremities. A computed tomography scan revealed a displaced type II odontoid fracture. Treatment consisted of open reduction and internal fixation of the odontoid with a single screw. The patient’s functional outcome was excellent during the two-month follow-up.

Cruciate paralysis is a relatively rare although well-defined neurological condition which results from injury at pyramid decussation. In this case, the presence of a posterior bony spike of the fractured dens was responsible for the development of cruciate paralysis. Early diagnosis and adequate treatment can have successful results.

Anatomical Variations of the Iliohypogastric Nerve: A Systematic Review of the Literature

Several anatomical variations of the iliohypogastric nerve branches have been observed in earlier studies. Knowledge of these variations is useful for the improvement of peripheral nerve blocks and avoidance of iatrogenic nerve injuries during surgeries. The purpose of this study was to perform a systematic review of the literature about the anatomical topography and variations of the iliohypogastric nerve. An extensive search on PubMed, Scopus, and Web of Science electronic databases was conducted by the first author in November 2021, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Anatomical or cadaveric studies about the origin, the course, and the distribution of the iliohypogastric nerve were included in this review. Thirty cadaveric studies were included for qualitative analysis. Several anatomical variations of the iliohypogastric nerve were depicted including its general properties, its origin, its branching patterns, its course, its relation to anatomical landmarks, and its termination. Among them, the absence of the iliohypogastric nerve ranged from 0 to 34%, its origin from L1 ranged from 62.5 to 96.5%, and its isolated emergence from psoas major ranged from 47 to 94.5%. Numerous anatomical variations of the iliohypogastric nerve exist but are not commonly cited in classic anatomical textbooks. The branches of the iliohypogastric nerve may be damaged during spinal anesthesia and surgical procedures in the lower abdominal region. Therefore, a better understanding of the regional anatomy and its variations is of vital importance for the prevention of iliohypogastric nerve injuries.

Traumatic Fracture of the Thoracic Spine With Severe Posterolateral Dislocation: A Case Report

Thoracic spine fracture-dislocation injuries are always associated with high-energy trauma and result in severe neurological symptoms. Surgical reconstruction and stabilization are essential for the early mobilization and rehabilitation of patients with this type of injury. Here, we present a unique case of a 57-year-old Greek male who sustained a posterolateral T3-T4 fracture-dislocation, with a complete spinal cord injury (SCI), after falling from a height. The patient was treated with surgical reduction and internal fixation with screws and rods, with satisfactory subsequent realignment.