Late Neurological Deterioration Research Articles

Neurological Deterioration in Wilson's Disease-Types, Etiology, Course, and Management.

Wilson's disease (WD) is an inherited disorder of copper metabolism in which pathological copper accumulation, mainly in the liver and the brain, leads to hepatic and/or neuropsychiatric signs and symptoms. Chelators and zinc salts can successfully induce negative copper balance in many patients; however, neurological deterioration may still be observed. This phenomenon can be divided into: (1) early 'paradoxical' neurological deterioration, which usually develops in the first 6 months of anti-copper treatment and may be commonly related to drug type, or (2) late neurological deterioration, which mostly occurs after 6 months of treatment and is often related either to non-compliance with treatment, overtreatment resulting in copper deficiency, or adverse drug reactions. Another explanation, especially for early neurological deterioration, is natural WD progression, which can be difficult to differentiate from drug-related deterioration, but usually leads to a worse outcome. There is still no consensus on how to define neurological deterioration in WD using scales or biomarkers, how to distinguish it from the natural disease progression, its risk factors, and optimal management. This narrative review, based on the current literature, aims to provide definitions, prevalence, pathological mechanisms and factors related to neurological deterioration, and also proposes schemes for diagnosis and treatment.

Brain tissue oxygenation monitoring in subarachnoid hemorrhage for the detection of delayed ischemia: a systematic review and meta-analysis.

Subarachnoid hemorrhage (SAH) is a severe subtype of stroke which can be caused by the rupture of an intracranial aneurysm. Following SAH, about 30% of patients develop a late neurologic deterioration due to a delayed cerebral ischemia (DCI). This is a metanalysis and systematic review on the association between values of brain tissue oxygenation (PbtO<inf>2</inf>) and DCI in patients with SAH. The protocol was written according to the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and approved by the International Prospective Register of Systematic Reviews (PROSPERO registration number CRD42021229338). Relevant literature published up to August 1, 2022 was systematically searched throughout the databases MEDLINE, WEB OF SCIENCE, SCOPUS. A systematic review and metanalysis was carried out. The studies considered eligible were those published in English; that enrolled adult patients (≥18years) admitted to neurointensive care units with aneurysmal SAH (aSAH); that reported presence of multimodality monitoring including PbtO<inf>2</inf> and detection of DCI during the period of monitoring. We founded 286 studies, of which six considered eligible. The cumulative mean of PbtO<inf>2</inf>was 19.5 mmHg in the ischemic group and 24.1mmHg in the non ischemic group. The overall mean difference of the values of PbtO<inf>2</inf> between the patients with or without DCI resulted significantly different (-4.32 mmHg [IC 95%: -5.70, -2.94], without heterogeneity, I2 = 0%, and a test for overall effect with P<0.00001). PbtO<inf>2</inf> values were significantly lower in patients with DCI. Waiting for definitive results, monitoring of PbtO<inf>2</inf> should be considered as a complementary parameter for multimodal monitoring of the risk of DCI in patients with SAH.

Long-Term Clinical Course of Patients After Decompression and Posterior Instrumented Fusion Surgery for Thoracic Ossification of the Posterior Longitudinal Ligament: An Average Follow-Up of 18 years.

Retrospective observational study. To evaluate the long-term recurrence rates and functional status of patients with thoracic ossification of the posterior longitudinal ligament (OPLL) after decompression and posterior fusion surgery. Thirty-seven consecutive patients who underwent posterior thoracic spine surgery at a single institution were retrospectively reviewed. The long-term neurological and functional outcomes of 25 patients who were followed up for ≥10years after surgery were assessed. Factors associated with the recurrence of myelopathy were also analyzed. The mean preoperative Japanese Orthopaedic Association score was 3.7, which improved to 6.5 at postoperative year 2 and declined to 6.0 at a mean follow-up of 18years. No patient experienced a relapse of myelopathy due to OPLL within the instrumented spinal segments. However, 15 (60%) patients experienced late neurological deterioration, 10 of whom had a relapse of myelopathy due to OPLL or ossification of the ligamentum flavum (OLF) in the region outside the primary operative lesion, while 4 developed myelopathy due to traumatic vertebral fracture of the ankylosed spine. Young age, a high body mass index, and lumbar OPLL are likely associated with late neurological deterioration. Decompression and posterior instrumented fusion surgery is a reliable surgical procedure with stable long-term clinical outcomes for thoracic OPLL. However, as OPLL may progress through the spine, attention should be paid to the recurrence of paralysis due to OPLL or OLF in regions other than the primary operative lesion and vertebral fractures of the ankylosed spine after surgery for thoracic OPLL.

Anterior Cervical Controllable Antedisplacement and Fusion (ACAF): Improving Outcomes for Severe Cervical Ossification of the Posterior Longitudinal Ligament.

The detailed steps to perform ACAF have been described previously1. Briefly, following induction of general endotracheal anesthesia, a standard right- or left-sided Smith-Robinson incision is made. Discectomies are performed at the involved levels. By measuring the thickness of the OPLL on an axial preoperative computed tomography scan at each compressed level, the amount of each anterior vertebral body to be resected can be calculated preoperatively. This was, in general, equal to the thickness of the ossified mass at the same level. The previously calculated portion of each involved body in the vertebral body-OPLL complex is resected. Following the creation of a contralateral longitudinal osseous trough, the prebent anterior cervical plate is then placed, and the screws are installed after proper drilling and taping on the remaining vertebral bodies. The screws utilized in this procedure should not be too short to achieve adequate purchase in the vertebral body. Subsequently, the intervertebral cages are inserted. Thus, the vertebral body-OPLL complex is temporarily stabilized for the next procedure. Next, an ipsilateral longitudinal osseous trough is created to completely isolate the vertebral body-OPLL complex. Notably, the objective of complete isolation of the vertebral body-OPLL complex is to further anteriorly hoist the complex to decompress the spinal cord. Finally, screws are inserted through the plate and into each vertebral body and are gradually tightened to displace the bodies anteriorly. Allogenic iliac bone graft is placed in the longitudinal bone troughs to promote fusion. Nonoperative treatment is frequently ineffective. Traditional surgical interventions have included anterior cervical corpectomy and fusion (ACCF), posterior laminoplasty, and laminectomy2,3. ACCF focuses on resecting the ventral ossified mass in order to obtain direct decompression; however, this technique is very technically demanding, with a high risk of complications. In addition, the clinical benefits of ACCF will be limited when the OPLL extends over >3 levels. Posterior decompression can achieve indirect decompression by allowing the spinal cord to float away from the ossified mass. This technique depends largely on the preoperative presence of cervical lordosis and is contraindicated in patients with kyphosis or severe OPLL. In addition, posterior decompression surgery has been associated with a high incidence of late neurological deterioration and even revision surgery2. ACAF combines the advantages of direct decompression as occurs with ACCF with the limited manipulation of the canal contents as occurs with the posterior approach4-6. The procedure considers the ossified mass and the vertebral body as a single unit. Decompression is accomplished by moving the vertebral body with the OPLL ventrally away from the spinal cord. The preserved part of the vertebral body-OPLL complex becomes part of the anterior wall of the spinal canal. Without direct instrument manipulation inside the canal, the occurrence of cerebrospinal fluid leakage, hemorrhage, and intraoperative neural injury can be minimized5. Compared with a posterior approach, ACAF can achieve more decompression of the cord, especially in patients with cervical kyphosis and those with >60% of the spinal canal occluded6. This procedure can yield satisfactory clinical outcomes with fewer surgery-related complications1,4-6,9. A single-center, prospective, randomized controlled study showed significantly better Japanese Orthopaedic Association scores and recovery rates at 1 year for ACAF compared with laminoplasty for the treatment of multilevel OPLL in cases in which the occupying ratio of the canal was >60% occluded or the K-line (i.e., a virtual line between the midpoints of the anteroposterior canal diameter at C2 and C7) was negative9. In addition, patients who underwent ACAF had better preservation of cervical lordosis and sagittal balance9. The cervical segments to be treated should include all of the segments with OPLL that are causing spinal cord compression.The uncinate process can be utilized as a safe anatomical landmark for the longitudinal osteotomies in order to avoid vertebral artery injury, even in cases with severely ossified masses.Careful evaluation of the vertebral artery on preoperative magnetic resonance imaging or computed tomography is of great importance.Appropriately increasing the curvature of the cervical plate can further enlarge the space for the following antedisplacement of the vertebral body-OPLL complex.The location of the uncinate processes must be confirmed before the creation of the 2 longitudinal osseous troughs7,8.The preserved superior and inferior vertebral end plates should be made as smooth and mutually parallel as possible.The thickness of the anterior part of the vertebral bodies to be resected should be calculated preoperatively.The posterior longitudinal ligament behind the involved segments should not be resected. ACAF = anterior cervical controllable antedisplacement and fusionACCF = anterior cervical corpectomy and fusionOPLL = ossification of the posterior longitudinal ligamentCT = computed tomographyJOA = Japanese Orthopaedic AssociationMRI = magnetic resonance imagingOR = occupying rate of the spinal canalVOC = vertebral bodies-OPLL complexRR = recovery rateCSF = cerebrospinal fluidUP = uncinate processTF = transverse foramen.

Management of NF-1 dystrophic scoliosis associated with rib heads dislocation into the spinal canal in neurological intact patients: a systematic literature review.

The management of scoliosis and kyphoscoliosis in patients with Type 1 Neurofibromatosis (NF-1) among spinal surgeons is still challenging due to the severity of the deformity especially in dystrophic deformity types. This rapid and progressive condition is likely to be associated with dislocated rib heads into the spinal canal, hence representing a real dilemma on the decision making between its resection versus not resection during the corrective surgery, especially in patients with normal neurological status. The objective of this publication is to discuss the management options in this patient population through a literature review. A comprehensive systematic literature search was performed for relevant studies using PubMed, Web of Science, and Scopus databases. Previous publications depicting neurologically intact patients with NF-1 and rib dislocation into the canal were reviewed. Articles reporting individual cases or case series/cohorts with patient-discriminated findings were included. The data collection retrieved a total of 55 neurologically intact patients with NF-1 dystrophic scoliosis and rib penetration into the canal who underwent spinal surgery. Among them, 37 patients underwent surgery without head rib resection and 18 patients with rib excision. No patient presented postoperative neurological deficit except for one case of late postoperative neurological deterioration reported in a patient within situ fusion in which the surgeons ignored the presence of previous spinal cord compression. Corrective surgery for patients with NF-1 and rib penetration into the canal in neurologically intact patients can be safely performed without the resection of the dislocated rib heads without a higher risk of neurological compromise.

Dome Laminotomies at Adjacent Segments in Cervical Laminoplasty.

Cervical laminoplasty is an established and effective surgical treatment for neurologic dysfunction associated with cervical myelopathy. "Dome laminotomies" involve undercutting the laminae adjacent to the laminoplasty levels to decompress and prevent spinal cord kinking on the lamina edges. The technique allows for a decrease in the number of instrumented laminae, smaller surgical exposure, and preservation of muscular attachments at the top of C2 and C7. We investigated whether dome laminotomies are associated with satisfactory neurologic and pain outcome. This study involved a retrospective review of consecutive patients treated at a single institution between November 2015 and September 2018. The patients underwent a C3-C6 laminoplasty with dome laminotomies of the caudal edge of C2 and the cranial edge of C7 lamina. Postoperative evaluations of pain, myelopathy symptoms, and complications occurred at early (mean, ∼2 months) and late (mean, ∼15 months) time points. Twenty-one patients were enrolled (mean age, 62 years). Mean axial pain score improved significantly at both the early (P = .02) and late (P = .045) postoperative evaluations compared with the mean baseline pain score. A total of 92% of patients experienced resolution of baseline hand dysfunction at the early postoperative follow-up, and 84% maintained it at the late follow-up. Two-thirds of patients experienced (late) significant improvement (P < 0.05) in baseline balance impairment. Postoperative response rates for urinary dysfunction were 58% (early) and 42% (late). There were no wound complications, late neurologic deterioration, kyphosis, or C5 palsy. C3-C6 laminoplasty with C2 and C7 dome laminotomies was safe, well tolerated, and associated with satisfactory early and late improved neurologic function and decreased pain.

Reoperation for Late Neurological Deterioration After Laminoplasty in Individuals With Degenerative Cervical Myelopathy: Comparison of Cases of Cervical Spondylosis and Ossification of the Posterior Longitudinal Ligament: Erratum.

Reoperation for Late Neurological Deterioration After Laminoplasty in Individuals With Degenerative Cervical Myelopathy: Comparison of Cases of Cervical Spondylosis and Ossification of the Posterior Longitudinal Ligament: Erratum.

Predictors and Outcomes of Neurological Deterioration in Intracerebral Hemorrhage: Results from the TICH-2 Randomized Controlled Trial

Neurological deterioration is common after intracerebral hemorrhage (ICH). We aimed to identify the predictors and effects of neurological deterioration and whether tranexamic acid reduced the risk of neurological deterioration. Data from the Tranexamic acid in IntraCerebral Hemorrhage-2 (TICH-2) randomized controlled trial were analyzed. Neurological deterioration was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) of ≥ 4 or a decline in Glasgow Coma Scale of ≥ 2. Neurological deterioration was considered to be early if it started ≤ 48 h and late if commenced between 48 h and 7 days after onset. Logistic regression was used to identify predictors and effects of neurological deterioration and the effect of tranexamic acid on neurological deterioration. Of 2325 patients, 735 (31.7%) had neurological deterioration: 590 (80.3%) occurred early and 145 (19.7%) late. Predictors of early neurological deterioration included recruitment from the UK, previous ICH, higher admission systolic blood pressure, higher NIHSS, shorter onset-to-CT time, larger baseline hematoma, intraventricular hemorrhage, subarachnoid extension and antiplatelet therapy. Older age, male sex, higher NIHSS, previous ICH and larger baseline hematoma predicted late neurological deterioration. Neurological deterioration was independently associated with a modified Rankin Scale of > 3 (aOR 4.98, 3.70–6.70; p < 0.001). Tranexamic acid reduced the risk of early (aOR 0.79, 0.63–0.99; p = 0.041) but not late neurological deterioration (aOR 0.76, 0.52–1.11; p = 0.15). Larger hematoma size, intraventricular and subarachnoid extension increased the risk of neurological deterioration. Neurological deterioration increased the risk of death and dependency at day 90. Tranexamic acid reduced the risk of early neurological deterioration and warrants further investigation in ICH. URL:https://www.isrctn.com Unique identifier: ISRCTN93732214

Late Neurological Deterioration after Acute Intracerebral Hemorrhage: A post hoc Analysis of the ATACH-2 Trial

Background: Neurological deterioration (ND) has a major influence on the prognosis of intracerebral hemorrhage (ICH); however, factors associated with ND occurring after 24 h of ICH onset are unknown. Methods: We performed exploratory analyses of data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial, which compared intensive and standard blood pressure lowering treatment in ICH. NDs were captured on the adverse event case report form. Logistic regression analysis was performed to examine the independent predictors of late ND. Results: Among 1,000 participants with acute ICH, 82 patients (8.2%) developed early ND (≤24 h), and 64 (6.4%) had late ND. Baseline hematoma volume (adjusted OR [aOR] per 1-cm³ increase 1.04, 95% CI 1.02–1.06, p < 0.0001), hematoma volume increase in 24 h (aOR 2.24, 95% CI 1.23–4.07, p = 0.008), and the presence of intraventricular hemorrhage (IVH; aOR 2.38, 95% CI 1.32–4.29, p = 0.004) were independent predictors of late ND (vs. no late ND). Late ND was a significant risk factor for poor 90-day outcome (OR 3.46, 95% CI 1.82–6.56). No statistically significant difference in the incidence of late ND was noted between the 2 treatment groups. Conclusions: Initial hematoma volume, early hematoma volume expansion, and IVH are independent predictors of late ND after ICH. Intensive reduction in the systolic blood pressure level does not prevent the development of late ND.

Association between neurological deterioration and outcomes in patients with stroke.

Neurological deterioration (ND) shortly after stroke is common in Chinese patients. We aimed to determine the effects of ND during hospitalization on stroke prognosis. We retrospectively reviewed files from the stroke registry of the Department of Neurology of Tianjin Huanhu Hospital between October 1, 2008, and December 31, 2015. The inclusion criteria were: age ≥18 years, diagnosis of acute ischemic stroke, and first-ever ischemic stroke occurring within 7 days prior to admission. ND was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points during hospitalization. Early neurological deterioration (END) was defined as an increase in the NIHSS score by ≥4 points between the baseline and 48-hour evaluations. Late neurological deterioration (LND) was defined as an increase in the NIHSS score by ≥4 points between the 48-hour and discharge evaluations. Multivariate regression was used to evaluate the relationship between early and late ND and short- and long-term outcomes. Primary and secondary outcomes based on the modified Rankin scale (mRS) were evaluated at 3 months and 1 year. Favorable and poor outcomes were defined as mRS scores of 0-2 and ≥3, respectively. A total of 9,650 patients were included. ND occurred in 293 patients (3.0%) during hospitalization. Among them, 192 (65.5%) were in the END group, and 101 (34.5%) were in the LND group. After adjusting for age, gender, and NIHSS scores, END was a significant independent predictor of poor outcome at both 3 months (primary outcome OR 8.069, secondary outcome OR 8.194) and 1 year (primary outcome OR 7.895, secondary outcome OR 5.679). The same pattern was seen in the LND group (3 months primary outcome OR 7.608, secondary outcome OR 6.349, 1-year primary outcome OR 10.793, secondary outcome OR 5.245). ND during hospitalization, regardless of whether it occurs in the early or late period after stroke, is an independent predictor of poor prognosis.

Serotonin Reuptake Inhibitor Drugs Are Associated with Contrast Extravasation and Clinical Outcome in Patients with Intracerebral Haemorrhage

Background: Antidepressants that inhibit the reuptake of serotonin (SRIs) have been related to the appearance of intracerebral haemorrhage (ICH). Some studies have described bigger haematoma volumes in these patients. So far, no studies have demonstrated an association between SRIs and contrast extravasation (CE). We propose to investigate the relationship of SRIs with CE and clinical outcome. Patients and Methods: We aimed a prospective registry of 294 patients with ICH. All previous treatments were registered, including SRIs intake. The presence of CE and the number of spot sign in CT angiography were collected. Early neurological deterioration (END) and late neurological deterioration (LND) were registered. Follow-up was completed at day 90. Results: Two hundred and ninety-four patients were included, mean age 66.5 years, 27.6% female. A total of 28 (9.5%) were taking SRIs at the time of the ICH. This group of patients presented statistically significantly more CE (46.4 vs. 19.9%, p = 0.012), ≥2 spot sign (25 vs. 6.8%, p = 0.017), END (46.4 vs. 25.2%, p = 0.018) and LND (14.3 vs. 4.9%, p = 0.032). In addition, this group of patients showed a tendency to have higher mortality (32.1 vs. 22.2%, p = 0.553) and a lower functional independence (modified Rankin Scale 0–2) at day 90 (25 vs. 36.5%, p = 0.230). In the multivariate analysis, SRIs intake was identified as an independent predictor of CE (adjusted OR 3.37; 95% CI 1.033–10.989; p = 0.044) together with hematoma volume at baseline and alcohol use. Conclusions: In our studied population, previous SRIs intake in patients with ICH was independently associated to CE. Further studies are needed to confirm this association.

Surgical results and complications of anterior controllable antedisplacement fusion as a revision surgery after initial posterior surgery for cervical myelopathy due to ossification of the posterior longitudinal ligament

Posterior surgery has been widely used as an initial surgery for cervical ossification of the posterior longitudinal ligament (OPLL). However, some patients require revision surgery because of failure of symptom relief or late neurological deterioration after posterior surgery. The aim of this study is to retrospectively investigated the surgical results and complications of anterior controllable antedisplacement fusion (ACAF) as a revision surgical technique after initial posterior surgery for OPLL. The present study concluded 13 patients. The operation duration, blood loss and hospital stay was estimated. Radiologic assessment included type and extent of OPLL, decompression width and antero-posterior (AP) diameter of the spinal cord. The JOA scoring system was used to evaluate the neurological status. Surgery- and implant-related complications such as cerebrospinal fluid (CSF) leakage, spinal cord or nerve injury, subsidence and pseudoarthrosis were all recorded. The results showed that nine patients undergoing revision ACAF because of residual stenosis after initial posterior surgery, two because of OPLL progression, one because of lamina closure, one because of a blind man requiring better neurological function of both hands. The mean decompression width and AP diameter of the spinal cord was 20.3 ± 2.1 mm and 5.8 ± 1.1 mm respectively. The mean postoperative JOA score at last follow-up was significantly better than preoperation (14.8 ± 2.5 vs. 8.5 ± 2.7 points, P < 0.01), with a mean improvement rate of 75.3% ± 12.2%. No complication such as CSF leakage, spinal cord or nerve injury, subsidence and pseudoarthrosis occurred. In conclusion, ACAF is a well choice for revision surgery after initial posterior surgery for OPLL.

A novel revision surgery for treatment of cervical ossification of the posterior longitudinal ligament after initial posterior surgery: preliminary clinical investigation of anterior controllable antidisplacement and fusion

BackgroundCervical ossification of the posterior longitudinal ligament (OPLL) is a progressive disease. Posterior decompression surgery is reported to be an effective and comparatively safe procedure with few complications for treatment of patients with myelopathy caused by OPLL. However, some patients require revision surgery because of late neurological deterioration due to OPLL progression or kyphotic changes in cervical alignment. This study reports preliminary clinical results of anterior controllable antidisplacement and fusion (ACAF), a novel revision surgery after initial posterior surgery for OPLL.MethodsFrom January 2017 to June 2018, ten patients with cervical OPLL who underwent ACAF revision surgery after initial posterior surgery were included in this study. The mean age was 62.1 ± 8.0 years (52–78), and the mean interval between initial posterior surgery and revision was 78.0 ± 48.2 months (5–180). The Japanese Orthopaedic Association (JOA) scales, Neck Disability Index (NDI), visual analog scale (VAS), and surgical complications were recorded.ResultsThe mean surgery time was 179.3 ± 41.8 min (120–240), and the mean blood loss was 432.5 ± 198.3 ml (225–850). The patients were followed up for at least 12 months. The JOA scores improved from 8.7 ± 2.8 to 13.4 ± 2.4; the mean improvement rate was 59.9% ± 16.1%. Postoperative NDI and VAS scores were 13.3 ± 3.7 and 2.0 ± 1.6, respectively, and were significantly improved compared to those before the procedure (P < 0.05). Cervical lordosis improved from 3.8 ± 4.3° to 17 ± 4.6° after revision surgery. There was only one instance of cerebrospinal fluid (CSF) leakage; no instances of postoperative hematoma, C5 root palsy, or hoarseness occurred.ConclusionsThe present study demonstrates that excellent postoperative outcomes can be achieved with the ACAF technique for revision treatment of OPLL. Though further study is required to confirm the conclusion, this novel technique has the potential to serve as an alternative surgical technique for revision treatment of OPLL.

Isolated Intraventricular Hemorrhage Associated with Cerebral Vasospasm and Delayed Cerebral Ischemia following Arteriovenous Malformation Rupture

Background: Although it is well characterized in aneurysmal subarachnoid hemorrhage, vasospasm is exceedingly rare following cerebral arteriovenous malformation (AVM) rupture. Subsequently, this complication is poorly characterized with regard to delayed cerebral ischemia (DCI). We review cases of ruptured AVM to assess the frequency and severity of vasospasm on cerebral angiography, and DCI. Summary: We reviewed our institutional database of acute intracranial hemorrhages between 2005 and 2014. We identified patients with cerebral AVM rupture and evidence of vasospasm, which was confirmed with digital subtraction angiography (DSA). Cerebral angiograms were evaluated by 2 blinded neurointerventionalists for vasospasm. Statistical analyses were conducted on the angiographic results and variables of interest to determine predictors and associations of vasospasm and DCI. Thirty-six patients with acute intracranial hemorrhage due to ruptured cerebral AVM subsequently underwent cerebral angiography. The interrater reliability for vasospasm was 0.81. The incidence of vasospasm was 13.9% and the incidence of subsequent DCI was 11.1%. A significant relationship existed between isolated intraventricular hemorrhage and vasospasm (p = 0.001) and subsequent DCI (p = 0.006). Radiographic vasospasm was associated with DCI in 80% of the patients (p < 0.0001). No statistical significance existed between subarachnoid hemorrhage and the development of vasospasm or DCI (p = 1.000 and p = 0.626, respectively). All differences were significant at a 99% level of significance. Key Message: In cases of ruptured AVM, isolated intraventricular hemorrhage appears to be an independent risk factor for vasospasm and DCI. Vasospasm must be considered during late neurological deterioration following AVM hemorrhage, especially in the setting of isolated intraventricular hemorrhage.

Tuberculosis of the spine with severe angular kyphosis: mean 34-year post-operative follow-up shows that prevention is better than salvage.

To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy. This is a retrospective clinical review of prospectively collected imaging data based at a single institute. A total of 24 patients of Southern Chinese origin who presented with spinal TB with a mean of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria were reviewed. Plain radiographs were used to assess the degree of spinal deformity. Myelography, CT and MRI were used when available to assess the integrity of the spinal cord and canal. Patient demographics, age of onset of spinal TB and interventions, types of surgical procedure, intra- and post-operative complications, and neurological status were assessed. All except one of the 24 patients were treated with anti-TB chemotherapy when they were first diagnosed with spinal TB. They subsequently received surgery either for neurological deterioration, or deformity correction in later life. The mean follow-up was 34 years (11 to 59) since these surgical interventions. Some 16 patients (66.7%) suffered from late neurological deterioration at a mean of 26 years (8 to 49) after the initial drug treatment. The causes of neurological deterioration were healed disease in nine patients (56.2%), re-activation in six patients (37.5%) and adjacent level spinal stenosis in one patient (6.3%). The result of surgery was worse in healed disease. Eight patients without neurological deterioration received surgery to correct the kyphosis. The mean correction ranged from 97°to 72°. Three patients who were clinically quiescent with no neurological deterioration were found to have active TB of the spine. Solid fusion was achieved in all cases and no patient suffered from neurological deterioration after 42 years of follow-up. On final follow-up, six patients were noted to have deceased (age range: 47 years to 75 years). Our study presents one of the longest assessments of spinal TB with severe kyphosis. Severe post-TB kyphosis may lead to significant health problems many years following the initial drug treatment. Early surgical correction of the kyphosis, solid fusion and regular surveillance may avoid late complications. Paraplegia, restrictive lung disease and early onset kyphosis might relate to early death. Clinically quiescent disease does not mean cure. Cite this article: Bone Joint J 2017;99-B:1381-8.

Postlaminectomy membrane with dynamic spinal cord compression disclosed with computed tomographic myelography: a case report and literature review.

It has been hypothesized that postoperative epidural scar, postlaminectomy membrane, may be responsible for late neurological deterioration after cervical laminectomy in some cases, but there is a lack of radiological studies in the literature showing the clinical significance of postlaminectomy membrane. We describe a rare case with radiological evidence of dynamic spinal cord compression caused by the postlaminectomy membrane, which may have been related to neurological deterioration. A 73-year-old male developed recurrent cervical myelopathy 6 months after C4-C6 laminectomy. In addition to atlantoaxial subluxation and kyphotic deformity, dynamic spinal cord compression by the postlaminectomy membrane was identified on computed tomographic myelography. The patient underwent atlantoaxial fixation and C3-C7 posterior decompression and fixation combined with removal of the thick and firm postlaminectomy membrane adhering to the dura mater. Histopathological findings of the postlaminectomy membrane revealed chronic inflammation around exogenous materials, presumably surgical materials remaining after the first operation, in the thick fibrous tissue. The patient's symptoms improved without recurrence of symptoms and postlaminectomy membrane formation for 3 years. Compared with cervical laminoplasty, cervical laminectomy entails several postoperative problems, including postlaminectomy membrane formation. Postlaminectomy membranes may cause dynamic effects related to late neurological deterioration, and the evaluation of dynamic factors is important for neurological recurrence after cervical laminectomy. In the present case, chronic inflammation caused by surgical materials remaining after the first operation might have contributed to the rapid development of the postlaminectomy membrane.

Recurrent Neurological Deterioration after Conservative Treatment for Acute Traumatic Central Cord Syndrome without Bony Injury: Seventeen Operative Case Reports.

The mechanisms of late recurrent neurological deterioration after conservative treatment for acute traumatic central cord syndrome (ATCCS) remain unclear. Seventeen operative cases sustaining late recurrent neurological deterioration after conservative treatment for ATCCS were reviewed to investigate the mechanisms. The assessment of neurological status was based on International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Gender, age, cause of injury, results of image, conservative treatment and operative data, and neurological status at different time points were recorded. The mean age of 17 patients was 43.8 ± 2.3 years old, and the causes of the cervical injury were 14 vehicle accidents and 3 falls. The neurological deficits of 17 patients on admission were not serious, and patients recovered quickly after conservative treatment. No fractures or dislocation were found in any patient's radiographs or CT scan images. All 17 patients performed first MRI test in 4 days and there was a slight or mild compression on the spinal cord in 16 patients. Eight patients had a second MRI scan ∼6 weeks later, which showed that there was aggravated compression on the spinal cord in six patients. All patients underwent an anterior approach to cervical decompression and internal fixation operation. During the operation, there were loose discs found in all 17 patients, obvious ruptures of disks found in 3 patients, obvious ruptures of anterior longitudinal ligaments (ALLs) found in 8 patients, and obvious ruptures of posterior longitudinal ligaments (PLLs) found in 7 patients. There was serious adhesion between PLLs and cervical disks in 12 patients. In five patients, partial ossification of PLLs was detected. All patients had a good neurological outcome at 6 month follow-up. Ruptures of ALLs, PLLs, and discs resulting in cervical instability and secondary compression on the spinal cord were important causes for recurrent neurological deterioration after conservative treatment for ATCCS. With timely spinal decompression after recurrent neurological deterioration, patients could achieve a good neurological outcome.

Severe Lateral Thoracic Fracture-Dislocation without Neurological Deficit – Case Report

Introduction A case report of a thoracic fracture-dislocation (T11–T12) without neurological deficit is presented. Objective Report the diagnosis and treatment of a traumatic severe fracture with lateral dislocation at the thoracolumbar junction without neurological deficit. Background Fracture-dislocation of the thoracic spine without neurological deficit is a rare lesion. We retrieved only 15 cases reported in the literature. Surgical treatment with spinal decompression, fusion and realignment is the treatment of choice. Case A 40-year-old man suffered a bicycle accident and was admitted with severe back pain but neurologically intact. He was treated with a wide laminectomy and spinal cord decompression followed by correction of his deformity using pedicle screw instrumentation and rod maneuvers. Results After three days, the patient was able to walk, and after one month he had just mild back pain, but was neurologically intact, and was able to return to his usual daily activities. After six months, he was neurologically intact and performing routine physical activities. Conclusions Fracture-dislocation of the thoracic spine without neurological deficit is a rare injury. A good outcome can be obtained with modern spinal stabilization surgical techniques, avoiding late neurological deterioration.

Mid-term Outcomes of Anterior Cervical Fusion for Cervical Spondylosis With Sympathetic Symptoms

Prospective study. The purpose of this study is to elucidate mid-term outcomes of anterior cervical fusion for cervical spondylosis with sympathetic symptoms (CSSS). The terminology, pathogenesis, diagnosis, and treatment of CSSS remain controversial. Surgical treatment of CSSS has been rarely reported. This is the first prospective study to evaluate the mid-term outcome of surgical treatment of CSSS. Thirty-one patients who were diagnosed with CSSS in 2006 were evaluated prospectively. All patients were assigned to undergo anterior cervical fusion with posterior longitudinal ligament (PLL) resection and followed up for ≥5 years. Sympathetic symptoms such as vertigo, headache, and tinnitus, etc. were evaluated using the sympathetic symptom 20-point score. Neurological status was assessed using the Japanese Orthopedic Association (JOA) score. Clinical and radiologic data were prospectively collected before surgery, and at 1 week, 2 months, 6 months, 2 years, and 5 years after surgery. Surgical complications and morbidities of other diseases during the follow-up were also recorded. The mean 20-point score decreased significantly from 7.3±3.5 before surgery to 2.2±2.7 at the final follow-up (P<0.001), giving a mean recovery rate of 66.1%±50.3%. Good to excellent results were attained in 80.6% of these patients. The sympathetic symptoms were relieved in 23 of the 31 patients in the early postoperative period, and 5 patients in 2 months. No relief of sympathetic symptoms was found in 3 patients. The mean JOA score improved significantly from 12.0±1.9 before surgery to 14.8±1.5 by the end of the follow-up (P<0.001). No late neurological deterioration was found in this group. The mid-term outcomes of anterior cervical fusion with PLL resection for CSSS have been satisfactory. Differential diagnosis before surgery is of great importance. PLL may play a role in presenting sympathetic symptoms.

Delineation of radiation therapy target volumes for patients with postoperative glioblastoma: a review.

Glioblastoma is the most aggressive and lethal primary malignancy of the brain, and radiotherapy (RT) is a fundamental part of its treatment. However, the optimal radiation treatment conditions are still a matter of debate, and there is no clear consensus concerning the inclusion of peritumoral edema in the clinical target volume calculation. Target delineation calculations that use postoperative residual tumor and cavity volumes plus 2 cm margins result in smaller volumes of normal brain receiving high-dose irradiation, compared to calculations that include expanded edema. Smaller RT fields may be more appropriate than larger RT fields, possibly reducing the risk of late neurological deterioration, especially in patients with significant peritumoral edema. This review focuses on the factors influencing target delineation, such as peritumoral edema, failure patterns, and prognostic factors (clinical and pathological characteristics) of patients with glioblastoma. Based on this information, we make three suggestions for radiation oncologists to refer to in daily practice. Further study is necessary to investigate the unresolved problems related to routine clinical application of RT.