Transoral digital reduction of complete anterior odontoid dislocation followed by fiducial-based navigated transcondylar screw fixation: illustrative case

BACKGROUND Posterior atlantoaxial dislocations (i.e., complete anterior odontoid dislocation) without C1 arch fractures are a rare hyperextension injury most often found in high-velocity trauma patients. Treatment options include either closed or open reduction and optional spinal fusion to address atlantoaxial instability due to ligamentous injury. OBSERVATIONS A 60-year-old male was struck while on his bicycle by a truck and sustained an odontoid dislocation without C1 arch fracture. Imaging findings additionally delineated a high suspicion for craniocervical instability. The patient had neurological issues due to both a head injury and ischemia secondary to an injured vertebral artery. He was stabilized and transferred to our facility for definitive neurosurgical care. LESSONS The patient underwent a successful transoral digital closed reduction and posterior occipital spinal fusion via a fiducial-based transcondylar, C1 lateral mass, C2 pedicle, and C3 lateral mass construct. This unique reduction technique has not been recorded in the literature before and avoided potential complications of overdistraction and the need for odontoidectomy. Furthermore, the use of bone fiducials for navigated screw fixation at the craniocervical junction is a novel technique and recommended particularly for placement of technically demanding transcondylar screws and C2 pedicle screws where pars anatomy is potentially unfavorable.

Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study

Background Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria. Methods Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients. Results Median numeric pain rating was 8.0 (7.0–8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed. Conclusion In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.

Profile of ocular injuries amongst various trauma patients presenting to tertiary care centre of Punjab

To study the epidemiology and clinical profile of ocular trauma patients presenting to tertiary care centre. Prospective study. All patients of ocular trauma in OPD/Emergency were assessed for detail between 1/1/17 to 31/6/18 and data on demographic profile was established as per guidelines of Ocular Trauma Society of India. Patients were categorized in different segments and assessed/followed for visual impairment in particular. A total of 246 cases were examined out of which 87% were males. The most common mode of ocular injury was Road Traffic Accidents. Pediatric eye trauma constituted 16.7% of the total cases. 26.8% cases arrived to our centre between 4-24 hours and 62.6% cases presented after 24 hours. Amongst 131 cases of Road Traffic Accidents, none of them were using protective measures like helmets or goggles. Of these, 17.1% were under the influence of alcohol. 28.5% were involved in medicolegal proceedings. Majority of the cases comprised of monocular trauma (78.1%). Closed globe injuries constituted 88.94% of the total cases of which most cases presented with lid edema and ecchymosis. Chemical injuries were reported in 4.5% cases. 9 patients lost vision completely and 71 cases had vision from light perception to 6/18. Ocular trauma is one of the common causes of ocular morbidity. It has been seen predominantly in male population. Public needs to be educated about safety measurements and education about prompt need to specialised care to reduce ocular trauma related visual morbidity.