A broken epidural catheter with a retained fragment in the spinal canal - first reported in 1957 - is estimated to occur in 0.002% of cases of catheter insertion. A major decision lies between leaving an asymptomatic fragment in situ or surgical exploration/removal; there are also timing considerations. A 37-year-old lady was admitted for routine spontaneous vaginal delivery under epidural anaesthesia given by epidural catheter midline L3/4 space. During catheter removal she extended her spine and probably caught the catheter between kissing spinous processes. It snapped; 12 cm were retained. Ultrasound and MRI scan confirmed part of the residuum was in the spinal canal. Literature was reviewed. We decided on surgical exploration two days later. The residual catheter was located through a 2cm incision and removed by gentle traction without complication. No CSF leak followed. Healing was uncomplicated; no symptoms suggested neurological injury or CSF fistula. If the residual catheter fragment is proven by radiology to lie outside the spinal canal and no residual catheter breaches the skin - providing a portal for infection - conservative management is reasonable. Residual catheter in the canal can migrate, compress a nerve root(s), cause epidural haematoma and form adhesions with the dura within two weeks making subsequent removal difficult and CSF leak practically inevitable. Where at least part of the residual catheter fragment is within the spinal canal we recommend removal within a few days before adhesions form; this is easy, avoids need for follow up and potentially much more difficult surgery later.

laminectomy is an essential surgical procedure in the face of any trauma to the spine with neurological deficit, the burst fracture with recoil of the posterior wall should aroused particular interest; simply performing a laminectomy of the lesion level is insufficient and that for two considerations the first is anatomical in relation to the orientation of the blades which is not strictly horizontal therefore leaving the upper vertebral plate uncovered, and the second is anatomopathological since the maximum of compression is posterior superior therefore has a horse on the two blades, that of the The lesional floor and that of the overlying floor; given that the retro-pulsed fragment is localized in 90% of cases in posterior superior. taking into account these two considerations, to which is added the detailed analysis of the morphological examinations, will certainly allow the surgeon to achieve the most complete decompression possible, the only guarantee of a possibility of neurological recovery

The ideal management of acute spinal cord injuries (ASCI) has been matter of long-lasting debate. While it is agreed that patients with acute injuries and instability need urgent decompression, the ideal timing is not clearly defined The objective of this study was to evaluate the current practice in terms of timing of surgery in ASCI patients among spinal surgeons from Ibero-Latinoamerican countries. A descriptive cross-sectional study design as a a survey was sent to members of SILACO and associated societies. . Sixty-eight (42.0%) considered that ASCI with complete neurology injury should be treated within 12 hours, 54 (33.3%) performed early decompression within 24 hours and 40 (24,7%) until the first 48 hours. Regarding acute SCI with incomplete neurological injury, 115 (71.0 %) would operate in the first12 hours. There was a significant difference in the proportion of surgeons that would operate ASCI within 24 hours or less, regarding the type of injury (complete injury:122 vs incomplete injury:155, p<0.001).In case of central cord syndrome without radiological evidence of instability but with spinal cord compression, 152 surgeons (93.8%) would perform surgical decompression: 1 (0.6%) in the first 12 hours, 63 (38.9%) in the first 24 hours, 4 (2.5%) in the first 48 hours, 66 (40.7%) in the initial hospital stay as soon as possible, 18 (11.1%) after neurologic stabilization. Ten (6.2%) surgeons would not consider the surgical treatment regardless of its timing.
Future studies are needed to identify the ideal timing for decompression of this subset of ASCI patients.

Background: Bilateral cervical facet dislocations are potentially devastating injuries and usually require surgical treatment. There is limited literature on the management of mal-union bilateral cervical facet dislocation. Case presentation: We report a case of a 53-year-old woman who was treated previously in another country for a cervical bilateral facet dislocation with a minerva plaster cast. Two years later the patient was referred to us by her family doctor complaining of neck pain and bilateral extremity paresthesias. Computed tomography and MRI demonstrated a grade 2 anterolisthesis of C4 on C5 and a fused bilateral facet dislocation. We performed a combined 360 degree anterior/posterior fusion with facet osteotomy to restore the normal lordotic cervical curvature. At 24-month follow-up, the patient remains free of pain and with no sensory-motor deficits. Discussion: This is one of the few cases described for a surgical correction of a mal-union cervical bilateral facet dislocation. Current literature does not offer a clear solution to the management of these conditions. With this case report, we wish to highlight the necessity of an anterior and posterior release and subsequent stabilization to address this complex complication.

Odontoid fractures account for 15% of all cervical fractures and up to 50% of all axis fractures. Cervical vertebrae congenital fusions are relatively common. C2-C3 fusion limits mobility at this level and can be asymptomatic, but can also be associated with other clinical features, like myelopathy or Klippel-Feil or Crouzon syndromes. The rare conjunction of an odontoid fracture and a fused C2-C3 level represents an additional challenge in the treatment of this patients. We present a case of a 57-year-old male that suffered a cervical trauma after a fall. The imaging studies revealed an odontoid fracture, Grauer type IIb, and a C2-C3 congenital fusion. Intra-operatively, instead of using the C2-C3 intervertebral space, a guide wire was introduced using C3-C4 disc space as entry level and oriented through the C2-C3 fused vertebral body until the odontoid apex was reached. The radiological control confirmed the satisfactory trajectory of the guide wire, and a 50mm canulated screw was then inserted. A good screw trajectory and fracture reduction were achieved.
The patient had a good post-operative course. He is pain free and shows signs of fracture healing on the 6th month post-operative CT control scan. The rare finding of odontoid type II fracture in a patient with fused C2-C3 level requires a good surgical planning and a surgical hardware adaptation, but does not necessarily mean a contraindication for anterior screw fixation. This technique can still be applied, using the C3-C4 disc space as entry point, with good final outcomes.

Introduction: Isolated apophysis injury in thoracolumbar fractures is rare, particularly infrequent when on several levels. Thoracic spine is superimposed on ribs; additional studies such as computerized tomography (CT) are needed to diagnose fractures. Management of multilevel spinous process fractures is not clear. A 9-level thoracic spinous process fractures case is described. Case report: 72-year-old man, alcoholised with amnesia for the event, enters the emergency room after a tractor accident. Complaining of severe back pain (VAS 8/10), had no past medical history. Physical examination: localized tenderness on thoracic area; no neurological deficits. CT scans revealed spinous process fractures on T4–T12; there was neither compression fracture of vertebral body nor encroaching of vertebral canal. To evaluate posterior column of thoracolumbar vertebrae was evaluated using magnetic resonance imaging (MRI) with integrity of interspinous ligaments. Treated conservatively by thoraco-lumbosacral orthosis for eight weeks. Two-year follow-up patient satisfied with results. Conclusion: Such fractures may occur by direct trauma or shear forces on flexed back, this case originated with a tractor accident. Cases of over 5-level spinous process fractures were rarely described on literature, all were treated conservatively. This case is unique, being multilevel thoracic fractures involving only posterior column and especially 9 contiguous level spinous process fractures (literature only described 1 case with 11 contiguous levels). Thoracic spinous process fractures are difficult to diagnose by X-ray. CT scans and MRI to evaluate morphology and integrity of injury were performed. These injuries are considered stable fractures and can be treated conservatively successfully, as described.

Introduction: Upper cervical spine injuries have the potential to be fatal and debilitating due to injury to multiple components.Treatment decisions is also challenging due to the lack of an unifying algorithm.We present the case of a polytrauma patient with a hangman’s fracture, an unstable tear drop fracture of the axis and a concomitent internal carotid aneurysm.Case presentation:A 26-year-old male was brought into the emergency room with multiple injuries after motor vehicle accident. Computed tomography (CT) scan of the cervical spine revealed a hangman’s fracture and a C2C3 tear drop fracture. No subluxation was noted on initial CT.Neurologic status was difficult to evaluate however the patient reported a change in muscle strength of his upper left limb during his stay in intensive care. A new CT scan showed the displacement of the C2C3 tear drop with recoil of C2 at the canal level. He had C1-C3 fixation. Postoperatively, he complained of headache and visual disturbance. Angio-CT scan and an MRI showed an internal carotid aneurysm. Endovascular occlusion was discussed but not performed and he had only anticoagulant treatment.A 6 month follow-up CT sacn of the spine and of the aneurysm demonstrated stability and intact instrumentation.Discussion: To date, there is no unifying algorithm to guide treatment decisions in many cases of upper cervical spine injuries.Vascular injuries have to be taken into consideration before choosing the approach.In our case going anteriorly would have been a disaster in front of the presence of the aneurysm of the internal carotid artery.

Introduction: The treatment of Gehweiler type III atlas fracture remains controversial and should be analyzed carefully.We present the case of a 31-year-old patient with a Jefferson fracture type IIIA according to Gehweiler classification treated at first conservatively. At 6 weeks follow-up we diagnosed an occipito-cervical subluxation and a displacement of the lateral mass of C1 that needed occipito-cervical fusion.Case presentation: A 31 year-old man,fell from a height of 3m causing head and neck trauma. He had a stiff and painful neck and no sensitive nor motor dysfunction.The CT scan showed a Jefferson fracture with no sign of lesion of the transverse atlantal ligament (TAL). So the fracture was classified IIA of the AO Classification and IIIA of Gehweiler classification, and thus was judged stable. The patient had a treatment with a hard collar. In the follow-up after 45 days, he had another CT scan showing displacement of the lateral mass of the atlas, with subluxation of both C1-C2 and C0-C1. The fracture was then classified again as type IC + Type IIB of the AO Classification, IIIB of Gehweiler classification and Dickman type I. The patient was then operated and had an occipito-C3 fusion. Until the last follow-up, the patient had a stabilized aspect of the fracture, with no neurological signs. Discussion: The TAL plays a crucial role in atlantoaxial stability.In Gehweiler type III fracture this ligament must be carrefully analyzed.Treatment aims to correct the dislocation, restore the stability of the atlantoaxial joint, and retain mobility of the cervical spine.

Epidural anesthesia has proved to be a state of art advancement when it comes to providing postoperative analgesia and early ambulation. However drawbacks like hematoma formation, abscess, accidental dural puncture, radiculopathy and breakage of catheter in situ have reported. I hereby present a case of epidural catheter broken in situ. I will try to make a presentation in favour of surgical removal of retained catheter rather than leaving it in situ. Our patient was posted for PFN surgery at some other hospital and before the surgery could begin the anesthetist noticed that while withdrawing the catheter it broke in situ. The patient was referred to our hospital. After all routine investigation, discussion with the patient’s relatives and lot of research about similar cases in past we decided to go for surgical removal and were successful in doing so.There is no consensus in literature over what is to be done in a case of epidural catheter broken in situ. Almost everyone in literature has advocated that the broken catheter be left in situ as the catheter is of inert material and not supposed to cause any problem in future. We tend to disagree. The catheter being a foreign body may commence the formation of granulation tissue around the catheter and this may become infected. Because of fibrosis removal may become impossible and patient may be left with permanent neuro deficit. We advocate early removal of retained catheter when possible.