Cervical spine fractures in patients with ankylosing spondylitis are serious and potentially lethal injuries with high complication rates.

The results support a correlation between the presence of imaging signs of cerebral microangiopathy, clinically silent MHs, and acute IPHs.

IntroductionPosterior C1-C2 fusion is used to treat fractures and nonunions of the odontoid and in rheumatoid C1-C2 instability. Other rarer indications are traumatic lesions of the transverse ligament [11], ligament laxity in Down or Marfan syndromes [6,21,22] or congenital deformity (i.e. os odon-toideum) [9,13]. The methods used for treatment of odontoid fractures include both nonsurgical methods such as immobilization in a halo vest [27,34,35] or Philadelphia collar [34] and surgical methods such as anterior screw fixation [2,4]. However, disadvantages and complications have been demonstrated with all these treatment methods, especially in elderly patients [3,5,16,24,26,30,33,34,36].Abstract In posterior C1-C2 fusion, traditional wire fixation gives poor stability. The bone quality is often insufficient to provide the competent structural bone graft that is required, and the introduction of sublaminar wires is somewhat dangerous. The stability is markedly improved by adding transarticular screws, but the drawbacks of structural bone graft and sublaminar wires remain. The C1 claw of the Olerud Cervical Fixation System improves C1-C2 fixation without relying on structural bone graft or compromising the spinal canal. The aim of this study was to evaluate radiological healing and possible complications in a consecutive series of C1-C2 fusions from our department operated with the C1 claw device. Twenty-six patients (14 women) with a mean age of 73 (range 37-93) years were included. The diagnoses were odontoid fracture in 18 patients, rheumatoid instability in 6, and odontoid non-union and os odontoideum in 1 each. The patients were followed clinically and with plain radiographs for an average of 15 (range 3-27) months. There were no neurological or vascular complications, and no secondary displacements or reoperations in the series. Twenty patients followed for 6-27 months were radiographically healed. Six patients died from unrelated causes 1-38 months postoperatively. Three of these patients had no radiographs later than the postoperative control, one had a healed odontoid fracture but resorbed bone graft at 8 months, while the remaining two patients were not healed, but showed no signs of healing disturbance at the time of death. On the basis of the findings of this study, posterior C1-C2 fusion with the Olerud Cervical Fixation System seems promising. No serious complications related to the surgical procedure were encountered. The stability of the implant obviates the use of a solid bone block as a graft and still allows a high frequency of fusion healing.

images in clinical medicineT h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 371;14 nejm.org october 2, 2014 1332A 65-year-old woman presented to the hospital with a 4-month history of intermittent low-grade fever, asthenia, anorexia, and weight loss. Her medical history was limited to atrophic gastritis treated with intramuscular vitamin B 12 . Physical examination revealed a large, soft mass protruding from her right flank (Panel A, view from posterior). Blood tests showed a leukocyte count of 17,900 per cubic millimeter (90% neutrophils), a hemoglobin level of 9.8 g per deciliter, a C-reactive protein level of 274 mg per liter, and an erythrocyte sedimentation rate of 104 mm per hour. Blood cultures were negative. Computed tomography of the abdomen with the use of contrast material revealed a large, obstructing calculus in the upper-pole calyx of the right kidney, causing focal atrophy and cortical thinning of the upper pole (Panel B, arrow); there was also a large retroperitoneal abscess (Panel C, white arrows) extending into the chest (Panel C, red arrow) and subcutaneous tissues of the right flank (Panel C, blue arrow). A urine culture was positive for Proteus mirabilis, as was a culture of fluid drained percutaneously from the abscess. A right nephrectomy was performed. Histologic examination revealed an abscess with chronic inflammation and no xanthogranulomatous changes. The patient was doing well 18 months after surgery.

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