Chance Of Neurological Recovery Research Articles

Abstract 146: Advanced Age and Neurological Recovery in Elderly Patients With Out-of-Hospital Cardiac Arrest Treated With Targeted Temperature Management: A Nationwide Population-Based Registry Study

Objectives: The chance of neurological recovery after out-of-hospital cardiac arrest (OHCA) can be influenced by advanced age, however further recent evidence will be need in elderly population. The purpose of this study is to evaluate the impact of advanced age on the neurological recovery in elderly OHCA survivors treated with targeted temperature management (TTM). Methods: This retrospective observational study, using a nationwide population-based OHCA registry, was conducted from January 2016 to December 2020. Non-traumatic elderly (≥ 65 years) comatose OHCA survivors treated with TTM were enrolled. The elderly patients were divided into four groups (65-69 years, 70-74 years, 75-79 years, and ≥ 80 years). The primary outcome was good neurological outcome, defined as Cerebral Performance Categories (CPC) of 1 or 2 at hospital discharge. Results: Among 23,336 OHCA patients who admitted to the hospital, 3,398 patients treated with TTM. Excluding 2,033 non-elderly patients, 1,365 patients were analyzed. In four elderly group, the rate of good neurological outcomes were decreased by advanced age (24.2%, 16.1%, 11.4%, and 5.9%). This was also observed after subgroup analysis based on the initial shockable (40.6%, 31.5%, 28.6%, and 14.9%) and non-shockable rhythm (10.6%, 7.2%, 4.1%, and 3.4%). Multivariate analysis showed the adjusted odds ratio (aOR) for good neurological outcome decreased as advanced age (65-69 years: reference, 70-74 years: aOR 0.70, 75-79 years: aOR 0.49, and ≥ 80: aOR 0.25). The optimal age cutoffs for good outcome in elderly OHCA survivors with shockable and non-shockable rhythm were 77 years and 72 years respectively. Conclusions: The neurologic recovery rate in OHCA survivors treated with TTM was gradually decreased with advanced age. However even with ≥ 80 years with shockable rhythm, had a good neurologic outcome of 14.9%, which is higher than 65-69 years of 10.6% in non-shockable rhythm.

Functional outcome of surgically treated patients of ossified posterior longitudinal ligament of cervical and dorsal spine in Indian population - A single center retrospective analysis of 40 patients.

Aims:The aim of the study was to retrospectively evaluate the neurological outcome in operated patients of ossified posterior longitudinal ligament (OPLL) of cervical and/or dorsal spine using modified Japanese orthopedic association (mJOA) score and find out the factors affecting the outcome.Settings and Design:The study design was a retrospective study.Materials and Methods:Forty operated patients of cervical and/or dorsal spine OPLL were included in the study. Neurological examination was conducted and analyzed using mJOA score pre- and postoperatively at 1, 6, and 12 months. Improvement in the mJOA score based on age, sex, type of OPLL, duration of symptoms, type of surgical procedure, and radiological parameters were calculated, analyzed, and compared with previous records of the patient.Results:Significant improvement in mJOA scores with mean preoperative being 12.27 ± 1.95 with 1-year postoperative 13.85 ± 2.02 (P < 0.0001) noted. There is a significant difference in mean mJOA scores in posterior approach with instrumentation (P < 0.0001) as compared with laminoplasty group (P < 0.005). Patients with occupancy ratio <60% had better results (P < 0.0001) as compared to those with occupancy ratio of >60% (P = 0.003). Patients with duration of symptoms >1 year had poorer results compared to those of <1 year duration. Mean ossification kyphosis angle was 19.4° ± 5.73°.Conclusion:OPLL is a progressive disease which causes severe neurological deficit if left untreated. OPLL in a young patient with short duration of symptoms, low occupancy ratio, and low ossification kyphosis had better chances of neurological recovery. Type of OPLL and sex of patient do not affect the recovery. OPLL managed early and surgically has better results irrespective of anterior or posterior approach with significant improvement in mJOA score. Decompression with fusion has better results than decompression alone.

Roy-Camille Type 3 suicidal jumper's fractures: Case series and review of the literature.

Background:Roy-Camille reported only three patients in their Type 3 posttraumatic transverse sacral fracture (TSF) classification. A modified Roy-Camille classification has been already proposed by other authors suggesting further categorization of the TSFs as partially displaced or completely displaced to predict the rate of neurological recovery following lumbopelvic fixation.Materials and Methods:We reported three adult cases of surgical fixation of fracture–dislocation (3A and 3B) of the sacrum due to traumatic injuries and submitted to lumbopelvic posterior reconstruction. A case of a 15-year-old male patient affected by Type 3C with vascular pelvic injury was also reported. A comprehensive literature search was performed on evaluation and management of Type 3 TSFs.Results:In Type 3A, there is a minimal anterior dislocation and the reduction is feasible with good chance of recovery. In Type 3B, the anterior dislocation is severe, neurological deficits are present, reduction is difficult, and there is a risk of vascular injury both at the trauma and during the surgical reduction. In Type 3C, the anterior dislocation is massive, and the risk of vascular injury is very high requiring prompt vascular or endovascular treatment. Open reduction and posterior instrumentation are technically feasible in patients affected by Type 3 high TSFs.Conclusions:In our opinion, a modified Roy-Camille classification could be useful in the assessment of prognostic and therapeutic aspects of such fractures, In our opinion, a modified Roy-Camille classification could help assess the prognostic and therapeutic aspects of such fractures, in which the severity of the dislocation affects the surgical technique, the chance of neurological recovery, and the patient's life expectancy.

Factors Associated with High-Quality Cardiopulmonary Resuscitation Performed by Bystander.

Bystander cardiopulmonary dresuscitation (CPR) improves the survival and neurological outcomes of sudden cardiac arrest patients. The rate of bystander CPR is increasing; however, its performance quality has not been evaluated in detail. In this study, emergency medical technicians (EMTs) in the field evaluated bystander CPR quality, and we aimed to investigate the association between bystander information and CPR quality. This retrospective cohort study was based on data included in the Smart Advanced Life Support (SALS) registry between January 2016 and December 2017. We included patients older than 18 years who experienced an out-of-hospital cardiac arrest (OHCA) due to medical causes. Bystander CPR quality was judged to be “high” when the hand positions were appropriate and when compression rates of at least 100/min and compression depths of at least 5 cm were achieved. Among 6,769 eligible patients, 3,799 (58.7%) received bystander CPR, and 6% of bystanders performed high-quality CPR. After adjustment, the occurrence of cardiac arrest at home (adjusted odds ratio (aOR), 95% confidence interval (CI); 0.42, 0.27–0.64), witnessed cardiac arrest (1.45, 1.03–2.06), and younger bystander age all showed associations with one another. High-quality CPR led to a 4.29-fold increase in the chance of neurological recovery. In particular, high-quality CPR in patients aged 60 years showed a significant association compared with other age groups (7.61, 1.41–41.04). The main factor affecting CPR quality in this study was the age of the bystander, and older bystanders found it more difficult to maintain CPR quality. To improve the quality of bystander CPR, training among older bystanders should be the focus.

1447 A Rare but Fatal Case of N-methyl-D-aspartate Receptor Antibody Encephalitis Associated With a Pancreatic Neuroendocrine Tumor

INTRODUCTION: N-methyl-D-aspartate receptor antibody (NMDAR-Ab) encephalitis is an autoimmune inflammatory condition of the brain thought to be paraneoplastic given its strong association with malignancy, but such related tumors are rarely detected in older males. To our knowledge, there is only a single case report of NMDAR-Ab encephalitis related to a pancreatic neuroendocrine tumor (NET). Here, we report a case of NMDAR-Ab encephalitis associated with pancreatic NET that was fatal despite early tumor resection. CASE DESCRIPTION/METHODS: A 79-year-old man with hypertension presented with acute onset of confusion, agitation, and urinary and bowel incontinence. He was living independently but had progressive short-term memory loss over the year prior. Electroencephalogram showed diffuse slowing without seizure activity. Magnetic resonance imaging of the brain noted trace sulcal FLAIR hyperintensity in perirolandic regions. Cerebrospinal fluid (CSF) analysis revealed elevated protein (96 mg/dL), low nucleated cell count, no oligoclonal bands, and negative infectious serology and cultures. CSF paraneoplastic panel was positive for anti-NR1 antibody, confirming the diagnosis of NMDAR-Ab encephalitis. Malignancy workup revealed a 1.2 cm mass in the pancreatic tail, and endoscopic ultrasound-guided fine-needle biopsy showed positive staining for synaptophysin and chromogranin A consistent with a well-differentiated NET. The patient rapidly declined from worsening encephalopathy and required percutaneous gastrostomy tube placement. He underwent laparoscopic distal pancreatectomy and splenectomy with intravenous immunoglobulin and glucocorticoids, but a repeat CT abdomen next month showed peritoneal metastases with diffuse uptake on somatostatin receptor scintigraphy and rising serum chromogranin A (603 ng/mL). He had no significant neurologic recovery and eventually died on comfort measures without further interventions. DISCUSSION: Though rare, prior cases of NMDAR-Ab encephalitis associated with NET described the importance of early surgical removal of the underlying tumor to provide the best chance of neurologic recovery. Metastatic disease portends a poor prognosis as it renders encephalitis impossible to resolve. Worldwide experience with NMDAR-Ab encephalitis is limited and further observations are needed to refine current treatment strategies.

Insult - Stroke

A stroke is usually caused by ischaemia, less frequently by an intracerebral hemorrhage. The distinction between hemorrhagic and ischaemic strokes, as well as the identification of patients requiring immediate recanalization therapy, cannot be made by clinical examination but requires CT imaging. In most patients with an ischemic stroke, large parts of the affected brain area are functionless throughout the first hours, but not yet irreversibly damaged (penumbra tissue). These areas can be saved through early vessel recanalization. In the acute phase of ischaemic stroke, a delay of 15 minutes results in a significant worsening of the neurologic prognosis.With modern endovascular techniques, even patients with the most severe ischemic strokes have a fair chance of neurological recovery, if they are admitted to a specialised centre within the first few hours.

Abstract 220: More Patience to the Patient? -The Timing of Initiating Targeted Temperature Management

Introduction: The timing of Targeted Temperature Management (TTM) after Return of spontaneous circulation (ROSC) is controversial. Spontaneous neurological recovery can avoid the resource-wasting and adverse events of TTM. The purpose of this study is to determine the percentage of spontaneous recovery in a three-hour interval post ROSC, and to predict factors of recovery to Glasgow-Coma-Scale (GCS) Motor response 6 (M6). Hypothesis: Some patients may recover to GCS M6 in the early post ROSC period. These patients may also have favorable neurological outcome at discharge. Methods: This was a single center observational study which enrolled 541 patients with ROSC after OHCA. We recorded the motor response post ROSC, the motor response at 3hr, the patients’ characteristics, and resuscitation variables. Predictors of GCS M6 were assessed by multiple logistic regression analysis. Results: Graph 1 showed the number of patients with motor response change in a three-hour interval. All 96 patients with GCS M6 at 3hr had favorable neurological outcome, except 6 died from cardiogenic shock and 7 died from terminal cancer status. GCS M6 at 3hr, instead of GCS M6 post ROSC, was a predictor for favorable neurological outcome (OR, 2.09; 95%CI, 1.80-2.42; P= 0.0001) when adjusted with demographic and resuscitation variables. There were three factors predicting the GCS M6 at 3hr, including the cumulative epinephrine dose (OR, 0.81; 95% CI, 0.70 - 0.93; P=0.003), the CPR duration (OR, 0.957; 95% CI, 0.93 -0.98; P=0.001), and the initial shockable rhythm (OR, 4.41; 95% CI, 2.44 - 7.85; P=0.0001). Conclusions: A significant portion of patients had spontaneous recovery to GCS M6 within 3 hours, and had favorable neurological outcome. Certain factors could be used to predict the recovery in early post ROSC period. The optimal timing of TTM could be re-evaluated. Close monitoring GCS together with appropriate usage of sedation are critical for patients with higher chance of neurological recovery.

Cervical Spine Trauma Management

The incidence of spine injury following accidents are still very high in developing countries. Many problems occur after the accident including primary intervention on the scene, transportation to the public primary hospital, the referral system, and finally, the management at the central hospital.Cervical spinal cord injuries represent 20-33% of total spinal injuries with the prevalence of the subaxial levels. In patients with a preoperative neurological deficit due to spine trauma, in case of spinal cord compression or instability, surgery is often the treatment of choice to grant a chance of neurological recovery, early mobilization, and faster return to usual daily activities compared to the conservative treatment. In the past, many authors suggested a delayed surgical treatment to reduce postoperative complications rate, but recent studies have shown that an early decompression (&lt;72 h) may facilitate a postoperative neurological improvement probably due to the prevention of the secondary mechanisms of damage in acute SCI.In the context of the advanced management of spinal injuries, the main points of the focused assessment, the important waypoints of a full classification of the skeletal and spinal cord injury, the principles of early prioritization and decision making, the outline of the surgical strategy including indications, timing, approaches, technique and post-operative care, and the outline principles of rehabilitation. The authors in this paper try to summarize and create a guideline of management, based on experience in a regional centre.

Cervical Spine Trauma Management

The incidence of spine injury following accidents are still very high in developing countries. Many problems occur after the accident including primary intervention on the scene, transportation to the public primary hospital, the referral system, and finally, the management at the central hospital.Cervical spinal cord injuries represent 20-33% of total spinal injuries with the prevalence of the subaxial levels. In patients with a preoperative neurological deficit due to spine trauma, in case of spinal cord compression or instability, surgery is often the treatment of choice to grant a chance of neurological recovery, early mobilization, and faster return to usual daily activities compared to the conservative treatment. In the past, many authors suggested a delayed surgical treatment to reduce postoperative complications rate, but recent studies have shown that an early decompression (&lt;72 h) may facilitate a postoperative neurological improvement probably due to the prevention of the secondary mechanisms of damage in acute SCI.In the context of the advanced management of spinal injuries, the main points of the focused assessment, the important waypoints of a full classification of the skeletal and spinal cord injury, the principles of early prioritization and decision making, the outline of the surgical strategy including indications, timing, approaches, technique and post-operative care, and the outline principles of rehabilitation. The authors in this paper try to summarize and create a guideline of management, based on experience in a regional centre.

Metastatic epidural spinal cord compression: does timing of surgery influence the chance of neurological recovery? An observational case-control study.

Metastatic epidural spinal cord compression (MESCC) is radiologically defined as an epidural metastatic lesion causing the displacement of the spinal cord from its normal position in the vertebral canal. The purpose of this paper is the evaluation of the influence of timing of surgery on the chance of neurological recovery. This is a retrospective observational case-control study performed on patients with MESCC from solid tumors surgically treated at our institute from January 2010 to December 2016. Patients included were divided in two groups depending on surgery that was performed within or after 24h the admission to the hospital. Neurological status was assessed with American Spine Injury Association (ASIA) Impairment Scale. No statistically significant difference was observed in the variation of ASIA if surgery is performed within or after 24h from the admission to the hospital. A statistically significant difference was observed after surgery in each group in the improvement of neurological status. A statistically significant difference was reported in the early post-operative complications in patients surgically treated within 24h. MESCC management is challenge for spine surgeons and may represent an oncologic emergency and if not promptly diagnosed can lead to a permanent neurological damage. According to this study, there is no difference in the chance of neurological recovery if surgery is performed within or after 24h the admission to hospital, but there is a greater rate of early post-operative complications when surgery is performed within 24h from the admission to the hospital.

Misalignment Between Expected Prognosis and Goals of Care After Cardiac Arrest

Chances of neurological recovery after cardiac arrest vary depending on comorbidities and the circumstances of the arrest. When the perceived prognosis

Encephalitis

Encephalitis is a serious and potentially treatable infection of the central nervous system. A pathogen is identified in less than 50% of cases. The differential diagnosis includes acute infection, immune-mediated causes, and other central nervous system processes. Emergent investigations include blood work, cerebrospinal fluid analysis, and neuroimaging. Empiric acyclovir and antibiotics should be started immediately to maximize the child's chance of neurologic recovery.

Effectiveness of 3 Surgical Decompression Strategies for Treatment of Multilevel Cervical Myelopathy in 3 Spinal Centers in China

Retrospective multicenter study. To compare clinical outcomes and surgical-related adverse events in patients with multilevel cervical myelopathy (MCM) undergoing simple anterior, simple posterior, or 1-stage posterior-anterior surgical decompression strategies. Simple anterior, simple posterior, and 1-stage posterior-anterior surgical decompression strategies have been advocated for MCM treatment in both Western and Chinese populations. However, there is limited evidence on whether 1-stage posterior-anterior strategy may offer equal or more advantages than the other 2 strategies for patients with MCM. A retrospective review of medical records was conducted for 255 patients with MCM who had undergone surgical decompression in 3 Chinese spinal centers from 1999 to 2010. Neurological status, perioperative variables, and surgical complications were assessed. Multiple linear regression was used to evaluate factors associated with the outcomes of each strategy. Analyses were conducted on a total of 229 patients with MCM undergoing surgical decompression via 1-stage posterior-anterior (68 patients), simple anterior (102 patients), and simple posterior approaches (59 patients). One-stage posterior-anterior approach had the highest Japanese Orthopaedic Association recovery rate after adjusted for age and sex (adjusted mean ± SD: 50.0 ± 3.2, P < 0.001) and additionally adjusted for smoking, duration from onset of symptoms to surgery, comorbidities, preoperative Japanese Orthopaedic Association score, Ishihara's curvature index and Pavlov ratio, operative blood loss, operating time, anterior operated disc levels, and posterior operated levels (adjusted mean ± SD: 51.6 ± 11.6, P < 0.01). Anterior approach had the largest difference between the pre- and postoperative Ishihara's curvature indexes after adjusted for age and sex (adjusted mean ± SD: 5.3 ± 1.0, P < 0.01) and after multivariable adjustment (adjusted mean ± SD: 6.5 ± 2.8, P = 0.003). One-stage posterior-anterior strategy can be a reliable and effective treatment strategy for MCM in a subgroup of patients with anterior and posterior compression on spinal cord simultaneously.

Mitochondrial DNA haplogroup R in the Han population and recovery from septic encephalopathy

To determine whether the main mitochondrial DNA (mtDNA) haplogroups of the Han people are associated with neurological recovery from septic encephalopathy. We studied 137 individuals with septic encephalopathy who were sequentially admitted to the intensive care unit or the emergency intensive care unit at the First Affiliated Hospital, College of Medicine, Zhejiang University, and the People's Hospital of Zhejiang Province. Demographic and clinical data were recorded along with clinical outcome over 28days. The Glasgow coma scale (GCS) score was calculated daily until it reached 15 or until the patient died during the 28-day period. Follow-up was completed for all study participants. We then determined the mtDNA haplogroups of the patients by analyzing sequences of hypervariable mtDNA segments and testing diagnostic polymorphisms in the mtDNA coding region with DNA probes. MtDNA haplogroup R, one of the main mtDNA haplogroups of the Han people, was a strong independent predictor of outcome following septic encephalopathy, conferring a 4.053-fold (95% CI 1.803-9.110, p=0.001) increased chance of neurological recovery within 28days compared with those with a non-R mtDNA haplogroup. In the Han population, mtDNA haplogroup R is a strong independent predictor of the outcome of septic encephalopathy, conferring an increased chance of neurological recovery compared with individuals with a non-R haplogroup. Our results provide potential insights into the mechanisms involved in septic encephalopathy, and reveal that the mtDNA haplogroup R is an independent predictor of the outcome of septic encephalopathy.

Computed tomography perfusion–based selection of patients for endovascular recanalization

Intravenous and intraarterial recombinant tissue plasminogen activator remains underutilized in the treatment of acute ischemic stroke, largely due to strict adherence to the concept of the therapeutic time window for administration. Recent efforts to expand the number of patients eligible for thrombolysis have been mirrored by an evolution in endovascular recanalization technology and techniques. As a result, there is a growing need to establish efficient and reliable means by which to select candidates for endovascular intervention beyond the traditional criteria of time from symptom onset. Perfusion imaging techniques, particularly CT perfusion used in combination with CT angiography, represent an increasingly recognized means by which to identify those patients who stand to benefit most from endovascular recanalization. Additionally, CT perfusion and CT angiography appear to provide sufficient data by which to exclude patients in whom there is little chance of neurological recovery or a substantial risk of postprocedure symptomatic intracranial hemorrhage. The authors review the current literature as it pertains to the limitations of time-based selection of patients for intervention, the increasing utilization of endovascular therapy, and the development of a CT perfusion-based selection of acute stroke patients for endovascular recanalization. Future endeavors must prospectively evaluate the utility and safety of CT perfusion-based selection of candidates for endovascular intervention.

Time perception is distorted during responses to medical emergencies

An accurate perception of time is critical for responders to cardiac arrests and other medical emergencies. Interventions such as medications or defibrillation are meant to be given at particular times. External chest compressions and bag-valve mask ventilations should be done at a particular rate. Accurate timing of the length of pulselessness may have implications for post-emergency management. Additionally, reported timing of pulselessness may alter clinicians' perception of the patient's chances for neurological recovery. Prior research indicates that stressful situations may impair subjects' time perception. It is hypothesized that this is true for responders to medical emergencies. Although there are many competing factors, responders to medical emergencies most likely feel that time passes more slowly than it actually does. This could have important implications for patient management both during and after medical emergencies.

Rigid Equinovarus Deformity Corrected With a Multiplanar External Fixator

Over the years, I have found treating patients with rigid equinovarus deformities to be quite a challenge.” “ R igid equinovarus deformities are uncommon, yet when they present, they can be challenging for the foot and ankle surgeon to treat. Often, these deformities occur because of the lack of posttraumatic immobilization or orthosis following head trauma, cerebral vascular accident, or neurologic injury. Patients involved in highlevel traumas can have life-threatening injuries, and initially, a neurologic condition affecting the lower extremities may be unknown. If they are fortunate to survive, patients with lower extremity deformities will have difficulty ambulating, which may be necessary for their continued longevity. Over time, the deformities can progress to a fixed position, making it difficult for nonsurgical options such as physical therapy, dynamic splinting, and serial casting to be successful. Custom bracing for rigid equinovarus deformities can be challenging and has a high rate of skin ulceration over the lateral ankle due to increased contact pressure. Surgical options for patients with fixed equinovarus deformity include Achilles tendon lengthening, medial ankle tendon release or lengthening, posterior capsule release, tendon transfer, osteotomy, and fusion. Redfern and Thordarson recently reported the results of Achilles lengthening and posterior tibial tenotomy with immediate weight bearing in patients with fixed equinovarus deformity. Nine of 10 patients had significant improvement in deformity and ambulatory status. However, rapid restoration of a neutral ankle position surgically can increase skin and neurologic complications. I have encountered wound complications and neurologic insult as a result of rapid correction to a plantigrade foot in patients with rigid equinovarus. These complications caused me to rethink how I approach this patient population. The goal of surgery is to achieve a plantigrade foot, improve ambulatory status, balance the foot and ankle, and allow weight bearing with the fixator once the ankle has become more neutral. The multiplanar external fixator allows the surgeon to correct the deformity in a controlled manner, helping to prevent skin and neurologic complications. The key preoperative decision-making elements include short-term goals, longterm goals, and assessing the need to add tendon transfers to balance the foot. The major long-term goal is for the patient to ambulate on the affected extremity. Patients who have no chance of neurologic recovery (ie, sciatic nerve injury following knee dislocation) and no muscle function may not be candidates for tendon transfer after correction of the deformity. They will benefit by having an extremity that is braceable. Patients who have some neurologic recovery and would be amendable to a tendon transfer if their deformity had not been rigid will benefit by correcting the deformity and doing the tendon transfer as a staged procedure. I believe there is merit in correcting the deformity gradually and then staging a tendon transfer, such as a bridle procedure, to help provide balance to the foot and ankle. I have treated several patients who have had previous neurologic injury to their

Rigid equinovarus deformity corrected with a multiplanar external fixator.

Over the years, I have found treating patients with rigid equinovarus deformities to be quite a challenge.” “ R igid equinovarus deformities are uncommon, yet when they present, they can be challenging for the foot and ankle surgeon to treat. Often, these deformities occur because of the lack of posttraumatic immobilization or orthosis following head trauma, cerebral vascular accident, or neurologic injury. Patients involved in highlevel traumas can have life-threatening injuries, and initially, a neurologic condition affecting the lower extremities may be unknown. If they are fortunate to survive, patients with lower extremity deformities will have difficulty ambulating, which may be necessary for their continued longevity. Over time, the deformities can progress to a fixed position, making it difficult for nonsurgical options such as physical therapy, dynamic splinting, and serial casting to be successful. Custom bracing for rigid equinovarus deformities can be challenging and has a high rate of skin ulceration over the lateral ankle due to increased contact pressure. Surgical options for patients with fixed equinovarus deformity include Achilles tendon lengthening, medial ankle tendon release or lengthening, posterior capsule release, tendon transfer, osteotomy, and fusion. Redfern and Thordarson recently reported the results of Achilles lengthening and posterior tibial tenotomy with immediate weight bearing in patients with fixed equinovarus deformity. Nine of 10 patients had significant improvement in deformity and ambulatory status. However, rapid restoration of a neutral ankle position surgically can increase skin and neurologic complications. I have encountered wound complications and neurologic insult as a result of rapid correction to a plantigrade foot in patients with rigid equinovarus. These complications caused me to rethink how I approach this patient population. The goal of surgery is to achieve a plantigrade foot, improve ambulatory status, balance the foot and ankle, and allow weight bearing with the fixator once the ankle has become more neutral. The multiplanar external fixator allows the surgeon to correct the deformity in a controlled manner, helping to prevent skin and neurologic complications. The key preoperative decision-making elements include short-term goals, longterm goals, and assessing the need to add tendon transfers to balance the foot. The major long-term goal is for the patient to ambulate on the affected extremity. Patients who have no chance of neurologic recovery (ie, sciatic nerve injury following knee dislocation) and no muscle function may not be candidates for tendon transfer after correction of the deformity. They will benefit by having an extremity that is braceable. Patients who have some neurologic recovery and would be amendable to a tendon transfer if their deformity had not been rigid will benefit by correcting the deformity and doing the tendon transfer as a staged procedure. I believe there is merit in correcting the deformity gradually and then staging a tendon transfer, such as a bridle procedure, to help provide balance to the foot and ankle. I have treated several patients who have had previous neurologic injury to their

Predicting neurological outcome following cardiac arrest

Because a large number of patients will suffer cardiac arrest each year, physicians must place attention on improving care for patients in the post-resuscitative setting. Part of this effort requires setting realistic goals based on patients' potential for recovery. Recovery from cardiac arrest often depends on the extent of anoxic brain injury, and for this reason primary teams consult neurologists to offer insight into potential for awakening from post-arrest coma. In doing so, neurologists inform a decision with legal, social and ethical implications. Though inapplicable without preparation at the time of cardiac arrest, the four principles of medical ethics have a direct impact on decision making during the post-resuscitative period. A review of the literature reveals that physical examination, electrophysiology, radiology, and biochemical markers can prove useful in estimating a patient's chances for neurological recovery from cardiac arrest. These factors most reliably predict poor outcome, but do so with high specificity. However, the role of the neurology consultant must change to include guidance on strategies of neuroprotection. Aggressive efforts directed towards neuroprotection may change predictions for outcomes after cardiac arrest in the future.

Rapid traction for reduction of cervical spine dislocations

There is still some controversy about the reduction of unilateral and bilateral facet dislocations in the cervical spine. We have reviewed the notes and radiographs of 210 such patients; reduction was attempted by manipulation under anaesthesia (MUA) in 91, and by rapid traction under sedation in 119, using weights up to 150 lb (68 kg). Our results suggest that early reduction in patients with neurological deficit gives the best chance of neurological recovery, that rapid traction is more often successful than MUA, and that traction is safer than MUA. We found that the use of heavy weights with close monitoring was safe and brought about reduction in an average time of 21 minutes. We recommend this technique for the reduction of all cervical facet dislocations.