To analyze the characteristics and treatment results of upper cervical injury in elderly patients, 112 cases with upper cervical injury were reviewed in our hospital in the past 20 years. The patients were divided into three groups : non-elderly (age≤64 years), young elderly (age, 65-74 years) and old elderly (age≥75 years). There were 43 non-elderly patients (male, 37 ; female, 6), 28 young elderly patients (male, 15 ; female, 13) and 41 old elderly patients (male, 17 ; female, 24). The groups were compared in terms of the cause of injury, type of injury, treatment methods and treatment results.

  The main cause of injury was traffic accident (63%) in non-elderly patients and fall in both young and old elderly patients (85% and 100%, respectively). The most common type of injury was odontoid type II fracture in the non-elderly group, axis body fracture in the young elderly group, and odontoid type III fracture in the old elderly group. Surgical treatment was performed in 17/43 patients in non-elderly group, 9/28 patients in young elderly group, and 10/41 patients in old elderly group. Three patients in non-elderly group and 4 patients in the old elderly group died during hospital stay following surgery. Ten patients were lost to follow-up. Follow-up data were obtained from the remaining 95 patients. Bony union was achieved in 39/40 patients in the non-elderly group, 23/24 patients in the young elderly group, and 27/31 patients in the old elderly group.

  Elderly patients were more likely to sustain upper cervical injuries even in low-energy trauma such as a simple fall. When choosing a treatment method, it is necessary to consider osteoporosis, co-morbidities, and daily activity.

  Study Design : Retrospective study.

  Purpose : The clinical symptoms of cervical kyphosis are mainly divided in two types. One is dropped head syndrome with a gait disturbance or horizontal gaze palsy, resulting in a chin-on-chest deformity in the standing or sitting position. The other is spondylolisthesis with myelopathy due to focal kyphosis. There is no clear consensus on the optimal surgical strategy for cervical kyphosis, and the long-term surgical outcome has not been sufficiently evaluated. In this study, the authors analyzed the outcomes of surgical treatment for cervical kyphosis.

  Methods : From 2007 to 2017, surgical treatment was performed in 15 patients with a maximum cervical focal kyphosis angle of>15 degrees. To retrospectively analyze their cases, the patients were categorized into three groups (5 patients each) according to the surgical approach adopted : Group A, posterior approach ; Group B, single-stage combined anterior and posterior approach ; Group C, multi-stage combined anterior and posterior approach. The patients’ characteristics, operating time, blood loss, and radiologic parameters were noted.

  Results : The average age of the patients was 75.0 years (range, 47-89 years), and the mean follow-up period was 658 days (range, 34-1,516 days). Almost all posterior fusions were performed using cervical lateral mass screw fixation and a strut iliac bone graft was used for anterior fusion. The cervical focal kyphosis angle, C2-7 Cobb angle, C2-7 sagittal vertical axis, T1 slope, C2-7 range of motion, and improvement in the Japan Orthopaedic Association score were not significantly different between the three groups. The average age, operation time, and blood loss tended to be lower in Group C than in Group B. The lateral mass screw loosened in one patient in Group A, and the anterior plate loosened in one patient in Group C.

  Conclusion : Surgical treatment for cervical kyphosis should be planned on an individual basis, and careful follow-up of instrumentation is important.

  Far-out syndrome is a rare disease in which the L5 nerve root is impinged between the L5 transverse process and the sacral alar in the L5/S1 extraforaminal area. We report two cases of far-out syndrome : one treated with nerve root block and the other treated with surgery. The first case was of a 61-year-old man who presented with a 2-year history of severe right sciatica. Computed tomography and magnetic resonance imaging revealed a lumbosacral transitional vertebra (Castellvi type IIa). An osteophyte was formed in this joint and compressed the right L5 nerve root. The right sciatica was improved with nerve root block. The second case was of an 88-year-old man who presented with intermittent claudication. Magnetic resonance images revealed lumbar canal stenosis. Lumbar laminectomy was performed for the L4/L5 stenosis. Two years later, left sciatica and foot drop appeared. Computed tomography coronal images revealed a lumbosacral transitional vertebra (Castellvi type IIb), and the L5 nerve root was compressed by the osteophyte on the left side. Conservative therapy was ineffective, and posterior decompression was performed with a navigation system. Pain was relieved, but foot drop persisted. Awareness of the pathology at the joint between the transverse process and the sacral alar is essential in patients diagnosed as having lumbosacral transitional vertebrae.

  An 84-year-old man suffered severe low-back pain after falling on a cruise ship. He got ashore in Chile and was admitted to a local hospital 7 days after injury. His diagnosis was L3 vertebral burst fracture. Bone fragment extruded in to the spinal canal about 50%. Posterior spinal fixation surgery was performed 4 days after admission, when he found it difficult to walk due to severe low-back pain. He had an episode of high fever 8 days after surgery, and antibiotic therapy was initiated using ciprofloxacin. Magnetic resonance image (MRI) revealed iliopsoas muscle empyema and pyogenic spondylitis. A drainage tube was inserted into the empyema cavity 17 days after surgery. Salmonella was detected in the culture specimen of the iliopsoas muscle empyema.

  He departed from Chile 20 days after the surgery and, 5 days later, he was admitted to our hospital via a hospital in Mexico. On admission to our hospital, his operative wound was dehisced and his abdominal computed tomography (CT) images revealed increased abscess on both sides of iliopsoas muscles. Removal of the instrument and debridement was performed on the third day at our hospital. Salmonella enteritidis growth was detected in a specimen of the wound. Drip infusion of ciprofloxacin was continued until the 42nd day in our hospital. Ceftriaxone and minocycline were administrated from the 42nd day to the 91st day.

  The exact route of salmonella infection was not determined because he had no abdominal symptoms such as diarrhea during the entire course and salmonella was not cultured from fecal specimen. Two possible routes of infection were considered. The first was infection through the blood stream. A Salmonella colony may have caused bacteremia, which led to the development of pyogenic spondylitis. Second, the surgical site infection may have spread.

  Here, the authors reported the case of a patient who developed surgical site Salmonella enteritidis infection at a foreign hospital.