Improvement In Neurological Status Research Articles

Spinal trauma in Tanzania: current management and outcomes.

Spinal trauma is a major cause of disability worldwide. The burden is especially severe in low-income countries, where hospital infrastructure is poor, resources are limited, and the volume of cases is high. Currently, there are no reliable data available on incidence, management, and outcomes of spinal trauma in East Africa. The main objective of this study was to describe, for the first time, the demographics, management, costs of surgery and implants, treatment decision factors, and outcomes of patients with spine trauma in Tanzania. The authors retrospectively reviewed prospectively collected data on spinal trauma patients in the single surgical referral center in Tanzania (Muhimbili Orthopaedic Institute [MOI]) from October 2016 to December 2017. They collected general demographics and the following information: distance from site of trauma to the center, American Spinal Injury Association Impairment Scale (AIS), time to surgery, steroid use, and mechanism of trauma and AOSpine classification and costs. Surgical details and complications were recorded. Primary outcome was neurological status on discharge. The authors analyzed surgical outcome and determined predicting factors for positive outcome. A total of 180 patients were included and analyzed in this study. The mean distance from site of trauma to MOI was 278.0 km, and the time to admission was on average 5.9 days after trauma. Young males were primarily affected (82.8% males, average age 35.7 years). On admission, 47.2% of patients presented with AIS grade A. Most common mechanisms of injury were motor vehicle accidents (28.9%) and falls from height (32.8%). Forty percent of admitted patients underwent surgery. The mean time to surgery was 33.2 days; 21.4% of patients who underwent surgery improved in AIS grade at discharge (p = 0.030). Overall, the only factor associated with improvement in neurological status was undergoing surgery (p = 0.03) and shorter time to surgery (p = 0.02). This is the first study to describe the management and outcomes of spinal trauma in East Africa. Due to the lack of referral hospitals, patients are admitted late after trauma, often with severe neurological deficit. Surgery is performed but generally late in the course of hospital stay. The decision to perform surgery and timing are heavily influenced by the availability of implants and economic factors such as insurance status. Patients with incomplete deficits who may benefit most from surgery are not prioritized. The authors' results suggest that surgery may have a positive impact on patient outcome. Further studies with a larger sample size are needed to confirm our results. These results provide strong support to implement evidence-based protocols for the management of spinal trauma.

Transforaminal Posterior Approach Is Effective for Treatment of Lower Thoracic Spine Spondylodiscitis.

Patients with lower-thoracic spine pathologies that affect anterior column stability and compress the neural tissues need anterior decompression and reconstruction. Anterior approaches result in long-term morbidities. Posterior laminectomy and fixation alone may not be sufficient to maintain spine stability. To evaluate the results of a posterior-only transforaminal thoracic interbody fusion approach for patients with thoracic disc space infection in terms of the improvement in neurologic status, resolution of infection, correction of kyphotic deformity, and assessment of post-operative complications. A prospective study was done on 40 patients with lower thoracic spine spondylodiscitis. All patients were assessed with pre-operative imaging. Neurologic assessment was performed using the American Spinal Injury Association (ASIA) Impairment Scale and functionally by the modified Japanese Orthopedic Association (JOA) scale. Pre-operative and post-operative white blood cell count, erythrocyte sedimentation rate, and C-reactive protein levels were compared. All patients were operated on through a posterior approach using the transforaminal thoracic interbody fusion for decompression, reconstruction, and anterior fusion. Mean age of patients was 49years; mean operative period was 188min; mean blood loss was 611mL. Twelve patients' ASIA scores improved and only two patients' scores declined. One patient died 11months post-operatively due to septicemia. The mean follow-up period was 27.8months. The modified JOA score improved from 6.3 ± 1.6 to 9.5 ± 0.6. The local kyphosis angle was improved from 13.8 to 6.9° post-operatively, with insignificant loss of correction at the end of follow-up. Thirty-eight out of 40 patients had solid anterior fusion at the end of follow-up. The clinical outcomes of this study showed that the transforaminal thoracic interbody approach is effective for both decompression and anterior reconstruction of the lower thoracic spine in patients with spondylodiscitis.

Management of Acute Traumatic Central Cord Syndrome: A Narrative Review.

Study Design:Narrative review.Objectives:To provide an updated overview of the management of acute traumatic central cord syndrome (ATCCS).Methods:A comprehensive narrative review of the literature was done to identify evidence-based treatment strategies for patients diagnosed with ATCCS.Results:ATCCS is the most commonly encountered subtype of incomplete spinal cord injury and is characterized by worse sensory and motor function in the upper extremities compared with the lower extremities. It is most commonly seen in the setting of trauma such as motor vehicles or falls in elderly patients. The operative management of this injury has been historically variable as it can be seen in the setting of mechanical instability or preexisting cervical stenosis alone. While each patient should be evaluated on an individual basis, based on the current literature, the authors’ preferred treatment is to perform early decompression and stabilization in patients that have any instability or significant neurologic deficit. Surgical intervention, in the appropriate patient, is associated with an earlier improvement in neurologic status, shorter hospital stay, and shorter intensive care unit stay.Conclusions:While there is limited evidence regarding management of ATCCS, in the presence of mechanical instability or ongoing cord compression, surgical management is the treatment of choice. Further research needs to be conducted regarding treatment strategies and patient outcomes.

Surgical Resection of a Cervical Dumbbell Tumor: 2-Dimensional Operative Video.

We demonstrate the surgical resection of a cervical dumbbell tumor in a patient who presented with progressive weakness over 3 mo. He was found to have a large C2-C3 dumbbell-shaped lesion with bony destruction on preoperative imaging. The patient subsequently underwent successful gross total resection of the tumor and had dramatic improvement in neurological status following surgery. Pathology confirmed the diagnosis of a World Health Organization grade I schwannoma. Detailed surgical techniques of the tumor resection and posterior fusion are presented in high-definition video with narration.Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy033 {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Surgical Resection of a Cervical Dumbbell Tumor: 2-Dimensional Operative Video","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_cil69l26"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} There is no identifying information in this video. A patient consent was obtained for publishing of the material included in the video Disclosures Dr Traynelis is a consultant and patent holder for Medtronic and receives fellowship funding from Globus. Dr Fontes is a consultant for Stryker and Medtronic. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Fluktuujący zespół Guillaina-Barré w przebiegu systemowej amyloidozy AL — zwiastun progresji?

Primary systemic light-chain amyloidosis (AL) that accounts for 4/5 of all cases can be manifested as a neuropathy. In some cases, neuropathy is a prodromal symptom, present even before the diagnosis or preceding the progression of the disease. Typically, it is symmetrical and progressive, involving the sensitive rather than motor function in the distal parts of the extremities. It can be accompanied by the paresis and autonomic dysfunction. Some atypical presentations of amyloid neuropathy are also mentioned in the literature including asymmetric polyradiculopathy, cranial nerve (III, V, VII) palsies or multiple mononeuropathies. We present a case study of a 58-year-old male patient with AL kappa-light chain amyloidosis of the kidneys, bone marrow and heart, treated in frontline with VD (bortezmib, dexamethasone) and CyBorD (cyclophosphamide, bortezomib, dexamethasone) and with high-dose melphalan followed by autologous hematopoietic stem cell transplantation (auto-HSCT), who developed Guillain-Barré syndrome not responding to standard treatment (intravenous immunoglobulin and plasmapheresis). Severe symptoms of axonal demyelination proceeded the progression of amyloidosis. The improvement in neurological status was obtained by high dose intravenously corticosteroid therapy. Currently, the patient takes dexamethasone as monotherapy – until now without both hematological and neurological progression. Considering the overall clinical picture, the fluctuating Guillain-Barré syndrome may be a prodromal symptom of the amyloidosis progression.

Hypothermic treatment after computer-controlled compression in minipig: A preliminary report on the effect of epidural vs. direct spinal cord cooling.

The aim of the present study was to investigate the therapeutic efficacy of local hypothermia (beginning 30 min post-injury persisting for 5 h) on tissue preservation along the rostro-caudal axis of the spinal cord (3 cm cranially and caudally from the lesion site), and the prevention of injury-induced functional loss in a newly developed computer-controlled compression model in minipig (force of impact 18N at L3 level), which mimics severe spinal cord injury (SCI). Minipigs underwent SCI with two post-injury modifications (durotomy vs. intact dura mater) followed by hypothermia through a perfusion chamber with cold (epidural t≈15°C) saline, DMEM/F12 or enriched DMEM/F12 (SCI/durotomy group) and with room temperature (t≈24°C) saline (SCI-only group). Minipigs treated with post-SCI durotomy demonstrated slower development of spontaneous neurological improvement at the early postinjury time points, although the outcome at 9 weeks of survival did not differ significantly between the two SCI groups. Hypothermia with saline (t≈15°C) applied after SCI-durotomy improved white matter integrity in the dorsal and lateral columns in almost all rostro-caudal segments, whereas treatment with medium/enriched medium affected white matter integrity only in the rostral segments. Furthermore, regeneration of neurofilaments in the spinal cord after SCI-durotomy and hypothermic treatments indicated an important role of local saline hypothermia in the functional outcome. Although saline hypothermia (24°C) in the SCI-only group exhibited a profound histological outcome (regarding the gray and white matter integrity and the number of motoneurons) and neurofilament protection in general, none of the tested treatments resulted in significant improvement of neurological status. The findings suggest that clinically-proven medical treatments for SCI combined with early 5 h-long saline hypothermia treatment without opening the dural sac could be more beneficial for tissue preservation and neurological outcome compared with hypothermia applied after durotomy.

The rationale of surgical treatment in pediatric spine tuberculosis

Introduction: Extrapulmonary TB in pediatric patient affects the quality of life and must be considered seriously. Early surgical treatment is needed to eradicate infection, preserve the physis, and simultaneously correct the deformity. The aim of this study is to assess the efficacy of conservative treatment compared to early surgical treatment regarding neurological improvement, kyphotic correction, and pain relieve. Method: This is a retrospective case series. We reviewed 28 pediatric spine tuberculosis in Dr. Soetomo General Hospital Surabaya, Indonesia during year 2010-2012. All patients have received TB drugs and indicated for surgical treatment, yet the 15 patients did not provide parental consent. These were selected as non-surgical group. Thirteen patients obtained surgical treatment including bone graft, w/o instrumentation (surgical group). All clinical data were collected at the time of diagnosis and a year after treatment. The improvement of kyphotic (thoracic segments) was defined as narrowing of post-treatment Cobb’s angle. Conversely, lordotic improvement (cervical or lumbar segments) was defined as widening Cobb’s angle. Improvement of neurological status (Frankel classification) was analyzed using chi-square test. The deformity correction and pain relieved were analyzed using independent-samples t-test. All statistical analyses were conducted by SPSS-23. Result: VAS improvement was not significant. Frankle classification in the surgical group was significantly better. The kyphotic deformity correction was 0% (n=8) in the non-surgical group and, 57.1% (n=4) in the surgical group. There lordotic deformity correction was 74.1% (n=4) in non-surgical group and 83.3% (n=5) in surgical group. There is a significant difference of the kyphotic deformity correction between both groups. but no significant difference in lordotic correction. Conclusion: Surgical management showed better outcomes in the degree of correction (stopped and corrected the kyphosis progression), and also in the neurological improvement.

Analysis of Surgical Outcome in Patients with Firearm Injury to Spine

Abstract Aim of Study To see whether surgical intervention in gunshot injuries to the spine leads to recovery in neurologic status. Methods It is a retrospective study conducted at the Jai Prakash Narayan Apex Trauma Centre (JPNATC), All India Institutes of Medical Sciences (AIIMS), New Delhi, where case records of 20 patients with gunshot injury to the spine, admitted between January 2013 to March 2018, were analyzed. Result Out of 20 patients, 17 underwent surgical intervention. Entry wound was most common on the back, with the thoracic vertebrae being the most common segment involved. Nine patients had complete spinal cord injury (SCI) at the time of presentation and seven of them underwent surgery. However, only one of these patients showed neurologic improvement at follow-up. Seven patients with canal compromise underwent surgery, and only two of them showed improvement in neurologic status at follow-up. Early surgery was done in 8 out of 16 patients. All 16 patients underwent decompressive procedure, and 3 underwent additional stabilization procedure. Bullet was removed in nine cases. Intraoperative blood loss was minimal in 9 cases, and dural breach was noticed in 14 cases. At follow-up, 56.25% patients showed improvement in neurologic status. Conclusion Surgical intervention, timing of surgery, amount of intraoperative blood loss, and dural breach had no significant impact on the overall surgical outcome. Neurologic status at the time of presentation is the single most important factor that determines the ultimate outcome. Indication and type of surgical intervention is still an ambiguous topic. Owing to lack of conclusive evidence, we believe that there is role for surgery when it is done with an intention to restore the neurologic function.

Thursday, September 27, 2018 3:35 PM–5:05 PM Section on Motion Technology Abstract Presentations: 133. Cervical disc arthroplasty: 10-year results

BACKGROUND CONTEXT Level I evidence from FDA IDE studies of multiple devices supports cervical disc arthroplasty (CDA) as a safe and effective alternative to anterior cervical discectomy and fusion for appropriately selected patients. Long-term outcomes following CDA continue to be assessed. PURPOSE This reports the 10-year postoperative outcomes of CDA. STUDY DESIGN/SETTING Single-arm follow-up of the investigational group from a prospective, multicenter FDA IDE trial (postapproval study of clinicaltrials.gov: NCT00667459). PATIENT SAMPLE A total of 280 patients with single-level cervical disc disease with radiculopathy and/or myelopathy treated with CDA. OUTCOME MEASURES The primary endpoint was overall success, a composite variable that included five criteria: 1) Neck Disability Index (NDI) score improvement of ≥15 points; 2) maintenance or improvement in neurological status; 3) anterior nor posterior disc height declined by no more than 2 mm compared to 6-week postoperative; 4) no serious adverse event caused by the implant or by both the implant and surgical procedure; and 5) no additional surgery classified as failure. Additional safety and effectiveness endpoints included NDI, neck pain and arm pain numerical rating scales, SF-36, patient satisfaction, range of motion (ROM) and adverse events (AE). METHODS Clinical and radiographic assessments were performed preoperatively, intraoperatively, and postoperatively out to 10 years. RESULTS Follow up was 90.6% at 10 years; overall success rates (without disc height) remained stable at 74.3%. Preoperative, 7-year, and 10-year postoperative scores were as follows: NDI: 55.5±14.7, 15.1±19.8, 15.0±17.8; neck pain: 67.0±20.8, 12.0±22.1, 11.2±19.6; arm pain: 59.6±26.3, 8.8±18.0, 8.5±17.2; SF-36 PCS: 32.2±7.4, 45.6±11.7, 44.5±12.3, SF-36 MCS: 44.5±11.5, 52.9±9.7, 52.4±9.7. All improvements from preoperative to 7 and 10 years postoperative were statistically significant (p CONCLUSIONS CDA remained safe and effective out to 10 years postoperatively. Significant long-term patient-reported and neurological outcomes improvements from baseline were consistent with previous reports, with few additional serious AEs or secondary surgeries. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

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.

Comparative Study of Outcome of Brain Abscess Treated by Aspiration Versus Excision With Capsule

Background: There are two common surgical options i.e. Burr hole aspiration and Excision with capsule with craniotomy in the treatment of brain abscess. The purpose of the study is to compare the two surgical methods (Burr hole and craniotomy) used as treatment for cerebral abscess and its outcome in terms of radiological clearance on brain CT, improvement of neurological status, the need for repeated surgery, and mortality and morbidity at six months after surgery. Materials and methods: The study was conducted in the Neurosurgery ward of Chittagong Medical College Hospital in a period (July 2012 to June 2014) of 24 months period. A total of 34 patients were taken as study subjects where two groups were made. Group A (n=20) patients were treated by bur rhole aspiration under general anesthesia and Group B (n=14) patients were treated by craniotomy and excision with capsule under general anesthesia. Peroperative and postoperative outcome was evaluated and compared. The clinical success of the both procedures, length of hospital stay, surgery related complications and neurological outcome were analyzed. Results: Among the 34 patients in both groups postoperative clinical data showed in group B there are more incidence of headache, vomiting, neurological deficit and seizure in three postoperative days than Group A patients. Few cases of fever was found in both groups. Two cases of wound infection was found in Group B at 7 postoperative days. Post operative GCS where Glasgow Coma Scale (GCS) was found to be gradually improving in Group A patients whereas in Group B 2 cases had GCS within 8-12 after 7 postoperative days. Regarding outcome during discharge improved GCS(>12) were found all in group A patients but it was less in Group B patients. Vomiting also found nil in Group A patients whereas in group B it was present in 2 cases during discharge. Seizure and neurological deficit was found nil in Group A patients but 4 cases in Group B had seizure and neurological deficit. There was one case in Group B who had wound infection. Evaluation of post operative hospital stay among the 34 patients in both groups were statistically significant less time was needed in Group A patients than Group B (p<0.05). Conclusion: In our study we found regarding surgical management of brain abscess, burr hole aspiration was found better than craniotomy with excision with capsule.
 JCMCTA 2017 ; 28 (2) : 99-104

Extended Endoscopic Endonasal Approach for Suprasellar Craniopharyngioma.

Objectives We illustrate a suprasellar craniopharyngiomas treated with an extended endoscopic endonasal approach (EEEA). Design Case report of a 43-year-old male affected by cerebral lesion located in suprasellar region involving the third ventricle and compressing the neurovascular structures, causing an anterosuperior dislocation of the chiasma. There is a complete disruption of the pituitary stalk that can explain the clinical finding of partial anterior hypopituitarism and hyperprolactinemia. The lesion is characterized by a solid and cystic component. Considering the absence of lateral extension and the suprasellar location of the lesion, an EEEA is preferred. Setting University Hospital “Ospedale di Circolo,” Department of Neurosurgery, Varese, Italy. Participants Neurosurgical and ENT Skull Base Team. Main Outcome Measures A bilateral parasagittal approach is performed using a four-hand technique. The first step of the surgery is the preparation of the Hadad's flap. The approach is extended to the planum sphenoidalis to expose the suprasellar region. The lesion is completely removed employing also an ultrasound aspirator. Skull base reconstruction is performed with three-layer technique: graft of fat tissue, fascia lata, and nasoseptal flap. Results No postoperative complications occurred. In the post-op, the patient presents a panhypopituitarism and an improvement in neurological status. The visual deficit remains stable. Post-op magnetic resonance imaging at 1 year documents the complete absence of pathological contrast enhancement. Conclusions EEEA is a feasible approach in treating craniopharyngioma with suprasellar extension. The advantages include optimal visualization, good resection rate, and absence of brain retraction. The link to the video can be found at: https://youtu.be/IYm-8P1jbBo .

43. Intraoperative neurophysiological monitoring in spine surgery: A significant tool for neuronal protection and functional restoration

Although there is recent evidence for the role of intraoperative neurophysiological monitoring (IONM) in spine surgery, there are no uniform opinions on the optimal combination of the different tools. We analyzed the impact of the multimodal IONM (mIONM) on the preservation of neuronal structures and on functional restoration in a prospective series of our patients who underwent spine surgery. The mIONM approach in spine surgery involves the evaluation of somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) with electrical transcranial stimulation, including the use of a multipulse technique with multiple myomeric registration of responses from limbs, and a single-pulse technique with D-wave registration through epi- and intradural recording, and free running and evoked electromyography. We observed an improvement of neurological status in 50% of the patients. The D-wave registration was the most useful intraoperative tool, especially when MEP and SEP responses were absent or poorly recordable. Our preliminary data confirm that mIONM plays a fundamental role in the identification and functional preservation of the spinal cord and nerve roots. It is highly sensitive and specific for detecting and avoiding neurological injury during spine surgery and represents a helpful tool for achieving optimal postoperative functional outcome.

Surgical Treatment of Metastatic Lesions at the Cervicothoracic Spinal Junction

Background Data: Metastatic spine disease continues to be an increasing burden. The cervicothoracic junction represents a transition from the semi rigid thoracic spine to the mobile sub axial cervical spine. Pathologic lesions are prone to result in kyphotic deformity as well as to the possibility of neurological deficits.Purpose: The aim of this study is to review our experience with surgical stabilization of metastatic lesions affecting the cervicothoracic junction (C7-T2).Study Design: A descriptive analytic cross section retrospective study involving 12 patients.Patients and Methods: The authors retrospectively reviewed their archive between February 2011 and July 2016, and twelve patients who were operated upon due to cervicothoracic junction metastasis were included. All patients underwent surgical treatment by either anterior corpectomy and fixation or posterior decompression and stabilization utilizing tapered rods. The patients were periodically followed up.Results: A total of twelve patients were included in this study including six males and six females. They had their primary in the breast in five patients, in the lung in three patients, in the prostate in two patients, and fro adenocarcinoma in two patients. The anterior approach was used in nine patients while the posterior approach was used in three patients. There was clinical improvement in neurological status according to Frankel grades of paraplegia in eleven of the twelve patients. There was no loss of correction in any patient of the study group.Conclusion: Patients with cervicothoracic metastatic lesions can be treated with either anterior or posterior approaches after considering each individual’s potential instability and disease burden. (2017ESJ135)

Timing of Decompression in Patients With Acute Spinal Cord Injury: A Systematic Review.

Study Design:Systematic review.Objective:To conduct a systematic review and synthesis of the literature to assess the comparative effectiveness, safety, and cost-effectiveness of early (≤24 hours) versus late decompression (>24 hours) in adults with acute spinal cord injury (SCI).Methods:A systematic search was conducted of Medline, EMBASE, the Cochrane Collaboration Library, and Google Scholar to identify studies published through November 6, 2014. Studies published in any language, in humans, and with an abstract were considered for inclusion. Included studies were critically appraised and the overall strength of evidence was determined using methods proposed by the Grading of Recommendation Assessment, Development and Evaluation working group.Results:The search yielded 449 potentially relevant citations. Sixteen additional primary studies were identified through other sources. Six studies met inclusion criteria. All but 2 studies were considered to have moderately high risk of bias. Across studies and injury levels, the impact of early surgical decompression (≤24 hours) on clinically important improvement in neurological status was variable. Isolated studies reported statistically significant and clinically important improvements at 6 months (cervical injury, low strength of evidence) and following discharge from inpatient rehabilitation (all levels, very low strength of evidence) but not at other time points; another study observed a statistically significant 6 point improvement in ASIA Impairment Scale (AIS) among patients with AIS B, C, or D, but not for those with AIS A (very low strength of evidence). In one study of acute central cord syndrome without instability, a clinically and statistically meaningful improvement in total motor scores was reported at 6 and 12 months in patients treated early (versus late). There were, however, no significant differences in AIS improvement between early and late surgical groups at 6- or 12-months (very low strength of evidence). One of 3 studies found a shorter length of hospital stay associated with early surgical decompression. Of 3 studies reporting on safety, no significant differences in rates of complications (including mortality, neurologic deterioration, pneumonia or pressure ulcers) were noted between early and late decompression groups.Conclusions:Results surrounding the efficacy of early versus late decompressive surgery, as well as the quality of evidence available, were variable depending on the level of SCI, timing of follow-up, and specific outcome considered. Existing evidence supports improved neurological recovery among cervical SCI patients undergoing early surgery; however, evidence regarding remaining SCI populations and clinical outcomes was inconsistent.

Factors affecting outcome of acute cervical spine injury: A prospective study

Background:Injury to the spine and spinal cord is one of the common cause of disability and death. Several factors affect the outcome; but which are these factors (alone and in combination), are determining the outcomes are still unknown. The aim of the study was to evaluate the factors influencing the outcome following acute cervical spine injury.Materials and Methods:A prospective observational study at single-center with all patients with cervical spinal cord injury (SCI), attending our hospital within a week of injury during a period of October 2011 to July 2013 was included for analysis. Demographic factors such as age, gender, etiology of injury, preoperative American Spinal Injury Association (ASIA) grade, upper (C2-C4) versus lower (C5-C7) cervical level of injury, imageological factors on magnetic resonance imaging (MRI), and timing of intervention were studied. Change in neurological status by one or more ASIA grade from the date of admission to 6 months follow-up was taken as an improvement. Functional grading was assessed using the functional independence measure (FIM) scale at 6 months follow-up.Results:A total of 39 patients with an acute cervical spine injury, managed surgically were included in this study. Follow-up was available for 38 patients at 6 months. No improvement was noted in patients with ASIA Grade A. Maximum improvement was noted in ASIA Grade D group (83.3%). The improvement was more significant in lower cervical region injuries. Patient with cord contusion showed no improvement as opposed to those with just edema wherein; the improvement was seen in 62.5% patients. Percentage of improvement in cord edema ≤3 segments (75%) was significantly higher than edema with >3 segments (42.9%). Maximum improvement in FIM score was noted in ASIA Grade C and patients who had edema (especially ≤3 segments) in MRI cervical spine.Conclusions:Complete cervical SCI, upper-level cervical cord injury, patients showing MRI contusion, edema >3 segments group have worst improvement in neurological status at 6 months follow-up.

180 Long-Term Outcomes of Arthroplasty for Cervical Myelopathy Versus Radiculopathy, and Arthroplasty Versus Arthrodesis for Cervical Myelopathy

Abstract INTRODUCTION Cervical disc arthroplasty (CDA) is an effective treatment for symptomatic cervical disc disease (SCDD). Concerns remain about the appropriateness of CDA to treat patients with myelopathy. This study compares long-term safety and effectiveness of CDA in patients with myelopathy versus radiculopathy. METHODS Retrospective analysis of prospective 84-month data from IDE clinical trial of CDA vs ACDF for SCDD at 2 adjacent levels: NDI, neck/arm pain, SF-36 PCS, neurological status, adverse events (AEs), secondary surgeries at index and adjacent levels. A total of 397 patients were enrolled: 287 radiculopathy alone and 110 myelopathy +/− radiculopathy. Two comparisons were performed: 1)CDA for myelopathy vs radiculopathy. 2)CDA vs ACDF for myelopathy. RESULTS >All groups significantly improved for NDI, neck/arm pain, and PCS at 84 months. Comparison#1: Myelopathy and radiculopathy groups showed similar improvement for NDI (37.8 vs 35.8, P = 0.352), neck pain (12.0 vs 12.1, P = 0.477), arm pain (11.6 vs 9.6, P = 0.480), and PCS (14.1 vs 13.7, P = 0.863). Both groups had similar maintenance or improvement in neurological status (87.2% vs 93.5%, P = 0.218), serious AEs (54.5% vs 57.5%, P = 0.291) secondary surgeries at index (3.7% vs 4.4%, P = 0.839) and adjacent levels (3.7% vs 7.6%, P = 0.367). Comparison#2: The CDA and ACDF groups showed similar improvement for NDI (37.8 vs 31.1, P = 0.147), neck pain (12.0 vs 10.4, P = 0.337), arm pain (11.6 vs 11.4, P = 0.791) and PCS (14.1 vs 11.2, P = 0.363). Both groups had similar maintenance or improvement in neurological status (87.2% vs 96.2%, P = 0.409) and similar rates of secondary surgeries at the index (3.7% vs 9.4%, P = 0.374) and lower rates of surgeries at adjacent levels (3.7% vs 15.4%, P = 0.088). Compared to ACDF, CDA group demonstrated lower rates of serious AEs (54.5% vs 65.9%, P = 0.019). CONCLUSION Long-term, CDA is safe and effective for the treatment of myelopathy. Myelopathy patients gain similar improvement from CDA to patients with radiculopathy only. Furthermore, myelopathy patients report similar levels of improvement from CDA compared with ACDF, but suffer fewer serious AEs

Circumferential Reconstruction of Subaxial Cervical and Cervicothoracic Spine by Simultaneously Combined Anterior-posterior Approaches in the Sitting Position.

To introduce and analyze the feasibility of a new surgical strategy for circumferential reconstruction of subaxial cervical and cervicothoracic spine by simultaneously combined anterior-posterior approach in the sitting position. A retrospective review was performed for seven patients who underwent the above surgical procedure between July 2011 and January 2015. Among the seven patients, there were six men and one woman, with an average age of 52 years (range, 36-79 years). Six patients were confirmed to have a lower subaxial cervical fracture and dislocation with a locked facet joint, and the other patient had an invasive tumor involving both anterior and posterior parts of vertebrae and lamina, detected by radiological examination. The levels involved for all patients were from C4 to T2 . According to American Spinal Injury Association (ASIA) classification, one case was class A, four were class B, and two were class D. The patients were restricted in the sitting position with traction and a halo in extension to immobilize the head during the operation. The simultaneously combined anterior-posterior operation for reduction, decompression or tumor resection and circumferential reconstruction was carried out. Both anterior and posterior procedures were successfully completed simultaneously in the sitting position in all cases. There were no perioperative complications. The average operative time was 175 ± 32 min (range, 120-240 min), and the mean blood loss was 430 ± 85 mL (range, 200-1100 mL). The patients were followed up for 35.8 months (range, 18-60 months). The symptom of neck pain improved distinctly and no evidence of implant failure was noted in any patients. Neurological status improvement was confirmed in six patients, who had suffered incomplete paralysis. The ASIA grade improved in five patients, and two cases had no change in grade. The "sitting position" simultaneously combined anterior-posterior approach is safe and is superior to the traditional prone position and supine position, and the surgical results are satisfactory.

Emergency department DNR order in patients with spontaneous intracerebral hemorrhage

ObjectivesTo explore the determinant factors and prognostic significance of emergency department do-not-resuscitate (ED-DNR) orders for patients with spontaneous intracerebral hemorrhage (SICH). MethodsConsecutive adult SICH patients treated in our ED from January 1, 2012 to December 31, 2016 were selected as the eligible cases from our hospital's stroke database. Patients' information was comprehensively reviewed from the database and medical and nursing charts. ED-DNR orders were defined as DNR orders written during ED stay. Multiple logistic regression analysis was used to identify significant determinants of ED-DNR orders. Thirty- and 90-day neurological outcomes were analyzed to test the prognosis impact of ED-DNR orders. ResultsAmong 835 enrolled patients, 112 (12.1%) had ED-DNR orders. Significant determinant factors of ED-DNR orders were age, ambulatory status before the event, brain computed tomography findings of midline shift, intraventricular extension, larger hematoma size, and ED arrival GCS ≤8. Patients with and without ED-DNR orders had a similar 30-day death rate if they had the same initial ICH score point. During 30 to 90days, patients with ED-DNR orders had a significantly increased mortality rate. However, the rate of improvement in neurological status between the two groups was not significantly different. ConclusionsOlder and sicker SICH patients had higher rate of ED-DNR orders. The mortality rates between patients with and without ED-DNR orders for each ICH score point were not significantly different. During the 30-to-90-day follow-up, the rates of neurological improvement in both groups were similar.

Pattern of Neurological Improvements in Patient with Lumbar Disc Herniation after Microdiscectomy: Experience at the Fourth Oldest Western Medical Facility in South Asia

The pattern of improvement in Neurological status after disc surgery is different. The chronology of improvement in Medical Research Council (MRC) scores, sensory status and improvement in Straight Leg Raise (SLR) test degrees is beneficial in management part to surgeons, relatives and the patients.To assess pattern of neurological outcomes in patients with lumbar disc herniation after microdiscectomy in terms of muscle power, sensory status and SLR.A Quasi experimental study comprising 70 consecutive cases though non-probability purposive sampling technique of both the sexes admitted in Neurosurgery department, Mayo Hospital operated for the 1st time for any disc pathology with no other spinal lesions giving consent themselves or though legal guardians was conducted. Pain for leg and back was measured pre and post-operatively was done by VAS which had 42 days of follow up. Standard Neurological examinations were conducted pertaining to muscle power (by MRC), sensory status and SLR test pre and post-operatively. Variables according to their nature were expressed in the form of Mean±SD, Median (Range) and Frequency (percentage). Mc Neumer’s chi square test and paired t test were used to see association between preoperative and post-operative Neurological status depending on their nature viz: qualitative or quantitative respectively in SPSS version 15.Out of 70 patients 74% were male and 26% were females. Mean±SD of patients was 37.6±13.0 years. Majority were Laborers after housewives. Illiterates, Poor lifting techniques were the most common characteristics in the respective headings of education and employment. Most common level of disc herniation was L4-L5, L5- S1 level (96%) where Prolapse and extrusion were most common MRI findings. As compared to pre-operative (3.4) muscle power 1st and 42nd day power were respectively 4.0 and 4.7 (p=0.001). Pre-operatively only 32 (45.7%) had normal sensation which improved to 38 (54.3%) and 51 (72.9%) respectively in 1st and 42nd day of surgery (p=0.001). Pre-operative mean SLR improved to 98.6 degrees in 1st POD and continued to be the same till 42nd day (p=0.001). All the MRC findings, sensory status and SLR values in each post-operative days were statistically significant with the baseline by paired t test (p=0.001). MRC and Sensory status had same pattern of improvement (r=0.0. p=0.04) unlike SLR which total improvements were see in 1st POD itself.In conclusion, muscle power and sensory improvement follows same improvement pattern whereas maximum SLR improves in the 1st POD itself.Nepal Journal of Neuroscience, Vol. 14, No. 2, 2017 Page: 8-15