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Pediatric Disk Herniation

Pediatric disk herniation is a rare condition that should be considered in the differential diagnosis of the child with back pain or radiating leg pain. Because pediatric disk herniation is relatively uncommon, there is typically a delay in diagnosis compared with time to diagnosis of adult disk herniation. Pediatric disk herniations are often recalcitrant to nonsurgical care, but such measures should be attempted in patients who present with isolated pain symptoms and have a normal neurologic examination. Twenty-eight percent of adolescent disk herniations involve apophyseal fractures; this presentation has a higher rate of surgical intervention than do herniations without fracture. Surgical management of pediatric disk herniation involves laminotomy and fragment excision. Short-term data demonstrate excellent pain relief, with 1% of children requiring repeat surgery for lumbar disk pathology in the first year. Long-term data suggest that 20% to 30% of patients will require additional surgery later in life.

Diagnosis and Management of Cervical Radiculopathy: Current Concepts

Cervical radiculopathy is a neurologic condition caused by compression of a nerve root in the cervical spine, most commonly as a result of degenerative cervical spondylosis or intervertebral disk herniation. The disease typically manifests as unilateral neck pain radiating to the arm in a dermatomal pattern. Numbness, tingling, and muscle weakness may also be seen. The most common level of involvement is C5-6, followed by C6-7. Most patients with cervical radiculopathy can be successfully managed with nonsurgical treatment. Surgery can be helpful in patients who do not respond to nonsurgical management or in those with significant weakness in one or more muscle groups. Options for surgical treatment include anterior cervical diskectomy and fusion and posterior laminoforaminotomy. The decision to perform one procedure over the other depends on the location of the compressive pathology, the number of levels involved, and whether the patient has neck pain. Relief of arm pain and improvements in motor and sensory function have been reported in 80% to 90% of patients following cervical nerve root decompression.

Subaxial Cervical and Cervicothoracic Spine Fractures and Dislocations

Fractures and dislocations of the subaxial cervical spine and cervicothoracicjunction are common and potentially devastating injuries. Depending on the severity of injury, outcomes range from full recovery to varying degrees of temporary or permanent incomplete or complete neurologic compromise to death. The most common surgical techniques employed in treating these injuries are anterior cervical diskectomy and instrumented fusion, anterior cervical corpectomy with interbody strut graft placement and instrumented fusion, posterior spinal fusion with or without instrumentation, and anterior or posterior iliac crest bone grafting. Treatment decisions are typically based on an understanding of the injury mechanism, degree of biomechanical instability, neurologic status of the patient, and individual patient factors. A better understanding of the epidemiology, diagnosis, classification, treatment options, and complications of these life-threatening injuries will allow the practicing clinician to maintain a high index of suspicion and appropriately manage patients.

Update on the Management of Trochanteric Fractures of the Hip

The trochanteric area of the femur is the region of the femoral metaphysis between the base of the femoral neck and the most distal level of the lesser trochanter. In elderly persons, this area of the femur, also variously called the extracapsular or pertrochanteric region of the femur, is typically affected by osteoporosis, reducing its structural strength, and in persons older than 65 years is subject to a high incidence of fracture. It is estimated that 238,000 hip fractures occur annually in the United States, and this figure could increase to 512,000 hip fractures per year by the year 2040. Trochanteric fractures represent more than half of these hip fractures, and in the geriatric population are among the most common injuries encountered by orthopaedic surgeons. This article reviews the pathophysiology and clinical presentation of trochanteric proximal femur fractures, and is intended to supplement and extend our previously published OKOJ article, "Trochanteric Proximal Femur Fractures."