Neurologically Normal Research Articles

Total Esophagogastric and Cologastric Dissociation in Neurologically Normal Children: Systematic Review.

Total esophagogastric dissociation (TEGD) was first described by Bianchi as a definitive procedure for gastroesophageal reflux disease (GERD) in neurologically impaired children. In the last 20 years, different centers extended the indication to neurologically normal (NN) patients with GERD associated with congenital or acquired esophageal anomalies. The aim of this paper is to analyze the role of TEGD in this cluster of patients. A PubMed and Google Scholar search was conducted. All cases of NN children who underwent TEGD for GERD were collected. Patient characteristics and outcomes were analyzed. Complications were classified according to Clavien–Dindo classification. Forty-eight children were identified. In 56.25%, TEGD was the first anti-reflux procedure, while in 43.75% it was performed after failed fundoplications. Mean follow-up was 5.5 years. Mortality related to surgery was 2.08%. All of the survivors improved their condition, with resolution of GERD and weight gain. In addition, 50% of children weaned off enteral nutrition, with 14.6% having their gastrostomy removed, while 41.67% maintained partial enteral supplementation. Respiratory symptoms almost disappeared in 54.17% of patients. This review suggests that TEGD can also be considered for NN children where conventional methods seem insufficient to control reflux and preserve pulmonary function. Nevertheless, long-term follow-up is still required.

Evaluation of cervical spine injury and predicting neurological deficit by magnetic resonance imaging

Background: The consequences of cervical spine injuries range from simple neck pain, to quadriplegia, or even death. MR imaging has become part of the diagnostic and prognostic tools for spinal cord injury. Aim: To prospectively evaluate cervical spine injuries by MR imaging and to find out association of MR imaging findings with degree of neurological deficit. Material and Methods: Descriptive longitudinal hospital based study was conducted on 30 patients with known or suspected cervical spine trauma who presented to the emergency department. Results: Mean age of the cases was about 42 years, with female to male ratio of 1:6.5. C6-C7 spinal level was most commonly involved. Proportions complete spinal cord injury (CSCI), incomplete spinal cord injury (ISCI) and neurologically normal (NN) were 23.33%, 60% and 16.67% respectively. Out of 12 MRI findings, cord haemorrhage, contusion, posterior element fracture, disc injury, prevertebral hematoma, subluxation and soft tissue injury was statistically associated with degree of neurological deficit. Cord contusion, cord haemorrhage and posterior element fracture were potential predictors of neurological status at admission. Cord contusion, cord haemorrhage and subluxation were potential predictors at 3 months. Conclusion: MRI proved a pivotal role in the diagnosis of SCIs, deciding prompt management and predicting neurological deficit and prognosis of neurological recovery. So, MRI is an excellent diagnostic modality for the evaluation of spinal trauma and predicting the degree of neurological deficit and recovery.

Efficacy of antireflux surgery in children with or without neurological impairment: a systematic review.

Antireflux surgery is commonly performed in children, yet evidence for its efficacy is limited. The aim of this review was to determine the effect of antireflux surgery with regard to objective measures of quality of life (QoL) and value of upper gastrointestinal investigations in neurologically normal (NN) and neurologically impaired (NI) children. A systematic review was conducted of articles reporting children undergoing antireflux surgery in whom preoperative and postoperative objective testing was performed. Primarily, Embase, CINAHL, MEDLINE and PubMed were searched from inception to April 2019. Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess article quality. Of 789 articles, 14 met the eligibility criteria, 12 prospective observational and 2 retrospective studies. The median MINORS score was 59·4 (i.q.r. 39 to 62·5) per cent. Seven studies reported assessment of validated QoL measures before and after antireflux surgery in 148 children. Follow-up ranged from 1 to 180 months. All studies confirmed significant improvements in QoL measures among NN and NI children at all follow-up points. Eleven studies reported on preoperative and postoperative investigations in between 416 and 440 children children. Follow-up ranged from 0·5 to 180 months. Nine studies confirmed improvements in gastro-oesophageal reflux using 24-h oesophageal pH monitoring with or without manometry, but conflicting results were identified for four studies reporting gastric emptying. No studies reported fluoroscopy or endoscopy adequately. Based on the results of studies of low-to-moderate quality, antireflux surgery improved QoL and reduced oesophageal acid exposure in NN and NI children in the short and medium term. Although antireflux surgery is a common elective operation, the lack of rigorous preoperative and postoperative evaluation(s) in the majority of patient-reported studies is striking.

Neurogenic Orofacial Weakness and Speech in Adults With Dysarthria

This study compared orofacial strength between adults with dysarthria and neurologically normal (NN) matched controls. In addition, orofacial muscle weakness was examined for potential relationships to speech impairments in adults with dysarthria. Matched groups of 55 adults with dysarthria and 55 NN adults generated maximum pressure (Pmax) against an air-filled bulb during lingual elevation, protrusion and lateralization, and buccodental and labial compressions. These orofacial strength measures were compared with speech intelligibility, perceptual ratings of speech, articulation rate, and fast syllable-repetition rate. The dysarthria group demonstrated significantly lower orofacial strength than the NN group on all tasks. Lingual strength correlated moderately and buccal strength correlated weakly with most ratings of speech deficits. Speech intelligibility was not sensitive to dysarthria severity. Individuals with severely reduced anterior lingual elevation Pmax (< 18 kPa) had normal to profoundly impaired sentence intelligibility (99%-6%) and moderately to severely impaired speech (26%-94% articulatory imprecision; 33%-94% overall severity). Results support the presence of orofacial muscle weakness in adults with dysarthrias of varying etiologies but reinforce tenuous links between orofacial strength and speech production disorders. By examining individual data, preliminary evidence emerges to suggest that speech, but not necessarily intelligibility, is likely to be impaired when lingual weakness is severe.

Routine gastrostomy tube placement in children: Does preoperative screening upper gastrointestinal contrast study alter the operative plan?

BackgroundUpper GI (UGI) studies are routinely ordered to screen for malrotation before routine placement of gastrostomy (G) tubes. However, the usefulness of this study is unknown. MethodsA retrospective review of children with surgically placed G-tubes over a 2year period (2011–2013) was performed. Patients with concomitant fundoplications were excluded. ResultsThree hundred ninety-three patients underwent G-tube placement. Of these, 299 patients (76%) had preoperative UGI, and 11 patients (3.7%) were identified with malrotation on UGI. Five (1.7%) patients underwent a Ladd’s procedure. The remaining 6 either had malrotation associated with gastroschisis (n=5) or were lost to follow-up (n=1). Children <1year did not have different rates of malrotation compared to older children (4.3% vs. 3.2%, p=0.617). Likewise, children with neurologic impairment (NI) had similar rates of malrotation compared to neurologically normal (NN) children (2.6% vs. 3.8%, p=0.692). The only significant difference in malrotation rate was between those with congenital gastrointestinal anomalies (24%) and those without (1.5%) (p<0.001). ConclusionPreoperative screening UGI before routine G-tube placement led to an unexpected diagnosis of malrotation in only 1.7%. Given the added radiation risk associated with an UGI, our data suggest that an UGI is unnecessary prior to routine G-tube placement. A larger prospective study is warranted to validate these results.

Perinatal management of preterm premature ruptured membranes affects neonatal prognosis

To determine the factors affecting neonatal prognosis in preterm premature rupture of membranes (PPROM). We conducted a case-control study involving 92 women between the years 2000 and 2010 diagnosed with PPROM between 25 and 31 weeks' gestation, who received antenatal steroids, and delivered between 26 and 31 weeks' gestation; a retrospective cohort study was conducted based on the results. We used data from four tertiary centers and compared the frequencies of neonatal neurologic deficits and neonatal deaths. There was a difference between the two groups; specifically, the ND group (n=18) consisted of patients whose infants had neurologic deficits and/or neonatal deaths and the neurologically normal (NN) group (n=74) included NN neonates amongst the patients who had expectant management (94% vs. 73%, respectively). Multivariable analysis revealed that expectant management was independently associated with an increased risk for neonatal neurologic deficits and neonatal deaths (odds ratio, 16.14). All neonates with poor prognosis in the expectant-management group delivered within 14 days after PPROM. Expectant management within 14 days after PPROM is associated with poor neonatal outcomes. Decisions regarding an expectant strategy should be made carefully. An immediate, planned delivery after steroid administration should be considered to improve neonatal prognosis in patients who have PPROM after 26 weeks' gestation.

Long-Term Catch-Up Weight Gain Following Fundoplication in Children

Laparoscopic fundoplication for severe gastroesophageal reflux (GOR) is well established in children. However, there are only a few reports on the long-term nutritional outcome following fundoplication. The aim of this study was to assess weight gain following fundoplication in children. In this study, 127 children who underwent laparoscopic fundoplication ± gastrostomy between July 1998 and April 2007 were followed up for a median of 29.6 months postsurgery. Data (demography, weight) at fundoplication were collected prospectively, with ethical approval. Weights were converted to Z-scores for age (Z-score of 0 is equivalent to 50th percentile, -1 to 16th centile, and -2.0 is equivalent to 2nd centile). Severe failure to thrive (FTT) was defined as a Z-score of less than or equal to -2. Data were compared using the two-tailed Student t test, and multilevel regression modeling was applied. At the time of operation, patients had a low weight-for-age Z-score (-1.87 ± 0.19) and 61 children (48%) had FTT. Children who received a simultaneous gastrostomy had a significantly lower Z-score at operation (-2.80 ± 0.22) than those who did not (-0.68 ± 0.25, p < 0.001). Overall, patients exhibited significant catch-up weight gain following surgery (+0.88 ± 0.14, p < 0.001). The greatest increase in weight was mostly marked in patients who had a gastrostomy inserted (+1.22 ± 0.20, p < 0.001), but it was also significant in patients who did not receive a gastrostomy (+0.44 ± 0.17, p = 0.013). Catch-up weight gain occurred in neurologically impaired (NI) patients with (+1.31 ± 0.22, p < 0.001) or without (+0.81 ± 0.29, p = 0.012) gastrostomy. Weight of neurologically normal (NN) patients was within normal range but slightly lower than average before surgery (-0.45 ± 0.24) and this did not significantly change following surgery. There was no significant catch-up weight gain in patients (n = 9) with "esophageal pathologies" (Z-score of -1.35 ± 0.61 at operation compared with -0.35 ± 0.34 at follow-up; p = 0.14). Laparoscopic fundoplication (with or without gastrostomy placement) resulted in significant weight gain in children with GOR. Insertion of a gastrostomy at the same time resulted in greater weight gain. Pronounced weight gain occurred in NI children, whereas NN children and those with esophageal pathologies did not demonstrate any significant benefit in terms of weight gain following fundoplication.

Laparoscopic Nissen fundoplication in infants and children: analysis of 106 consecutive patients with special emphasis in neurologically impaired vs. neurologically normal patients

The laparoscopic Nissen fundoplication has become a frequently performed procedure in infants and children who suffer from gastroesophageal reflux disease (GERD). In this study we describe our 8-year experience with 106 consecutive laparoscopic Nissen fundoplications. From January 1994 to May 2002, we included 106 consecutive patients (57 neurologically normal (NN) and 49 neurologically impaired (NI)). The indications were symptomatic GERD, pulmonary symptoms or a combination of both. Patient's outcome was assessed by symptom evaluation, technical examinations and a questionnaire. Mortality was 0% and conversion rate was 2.8%. Major postoperative complications occurred in 12 patients, mostly neurologically impairment. Dysphagia occurred in 23 patients of which 4 required dilatations and 2 a redo Nissen. Gas bloating occurred in 15 children, with spontaneous regression in all. Recurrent pneumopathies were seen in four children. Documented recurrence of reflux occurred in three symptomatic patients. Redo laparoscopic surgery was performed in six patients. A questionnaire was sent to each patient's parents. This showed that most patients had a normal or clearly improved quality of life (93.1% NN, 90.5% NI). Most patients were satisfied with the result and up to 39.5% gave a maximum satisfaction score. The laparoscopic Nissen fundoplication can safely be performed with a low conversion rate and no surgical mortality in neurologically normal and neurologically impaired children. Neurologically impaired children are more susceptible to per- and postoperative complications. A good quality of life and a high index of satisfaction could be achieved in most patients.

Outcome of Nissen fundoplication using intraoperative manometry in children

Background: Intraoperative manometry is useful in performing Nissen fundoplication (NF) in children. Long-term clinical outcome information after use of this method is lacking. Methods: A retrospective review of the outcomes of 62 consecutive NFs using intraoperative manometry was performed. The follow-up period was 3.4 years. Approximately half of the patients were neurologically normal (NN) and half were neurologically impaired (NI). All patients with gastroesophageal reflux disease (GERD) did not respond to an adequate trial of medical treatment. Results: The NF was tailored to result in a twofold increase in the lower esophageal sphincter pressure (LESP) and a 75% increase in the LES length (LESL). An accelerated growth rate in 40% of “failure to thrive” (FTT) patients was demonstrated. Eighty-four percent of caregivers reported improved quality of life after NF. There was a twofold reduction in the number of hospital admissions and a sixfold reduction in total inpatient days for both NI and NN children. The early and late mortality rate was 13%, and the complication rate was similar to other series reported in the literature, with more complications occurring in NI patients. There was a 2% incidence of wrap herniation. An improvement in long-term outcomes after NF was seen in 89% of NN children and over half of NI patients. Conclusions: Intraoperative manometry is useful in standardizing the tightness of the wrap in NF. There was a low incidence of complications, dysphagia, recurrent emesis, and GERD in this series. Long-term outcomes using this technique were deemed very good based on caregivers' responses.

Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients.

To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large children's surgery centers in the United States. During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients. Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used. The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.

Neonatal Rather Than Prenatal Factors Predict Neurologic Impairment (NI) and Cerebral Palsy (CP) in VLBW (&lt;1.5 kg) Infants ♦ 1267

Neurologic impairment (NI), including CP, is considered to be largely determined by antenatal events. To explore the impact of antenatal and neonatal events and therapies we compared 72 singleton inborn infants born'83-'91 with neurologic impairment (NI) at 20 months corrected age (xbar Bwt 1kg; xbar GA 28 wks, 58% black, 53% male), including 50 with CP (25 di-, 12 hemi-, 13 quadri-plegia); 11 hypotonia, 4 hypertonia and 7 hydrocephalus to the next born neurologically normal (NN) VLBW matched by BWt, GA, and race, and sex.

Results and complications of toupet partial posterior wrap: 10 years' experience

A 270° posterior wrap, described by Toupet, was performed in 112 patients with medically refractory gastroesophageal reflux (GER) over a 10-year period. The mean age was 39 months (range, 2 months to 19 years). Thirty percent of the patients were neurologically impaired (NI). The approximation of the crura, the posterior fixation of the wrap, and the posterior partial fundoplication were performed with nonabsorbable sutures, over a bougie. Thirty percent of the NI and 15% of the neurologically normal (NN) children underwent a gastrostomy. Early postoperative complications were found in 24% of NI and 18% of NN children; these were treated medically, except for two bowel obstructions. Eight patients died for reasons unrelated to surgery, and nine were lost to follow-up. The mean follow-up period for the 95 remaining patients was 3.5 years for NI and 4.9 years for NN children. The evaluation showed that 6 patients had temporary dysphagia and two had food impaction. Nine wrap herniations (10%) were found; three of them without symptoms were noted by routine upper gastrointestinal series and received no treatment. Six wrap herniations with recurrent reflux were reoperated on successfully. With 90% of patients free of symptoms, the results of the Toupet procedure compare favorably with those of the Nissen fundoplication because of the retained ability to belch or vomit.

Complications of gastroesophageal antireflux surgery in neurologically impaired versus neurologically normal children

Antireflux surgery was performed in 234 children over a 5-year period; 153 were neurologically impaired (NI) and 81 were neurologically normal (NN). Initial presentation, demographic data, and type of antireflux operation were similar in the two groups. Eighty-six percent of the NI group versus 30% of the NN group had gastrostomy tubes placed. The incidence of late postoperative complications was 26% in the NI group and 12% in the NN group ( P < .01). During the late postoperative period, NI children underwent reoperation four times as frequently as NN children (19% v 5%, respectively; P < .01). Wrap herniation accounted for 38% of complications and 59% of reoperations in the late postoperative period. Mortality due to aspiration occurred in 9% of the NI group versus 1% of the NN group. Combined failure rate (reoperation plus aspiration-induced deaths) was 28% in NI and 6% in NN ( P < .01). We conclude that neurological status is the major predictor of operative success and that wrap herniation due to crural disruption is the most common cause of operative failure.

Transient Neurologic Signs in Infancy and Motor Outcomes at 4 1/2 Years in Children Born Biologically At Risk

This study was designed to investigate the effects of transient neurologic signs evident in infancy on motor outcomes in 41/2-year-old children born biologically at risk. Children who appeared neurologically normal at each of the 4-month, 12-month, and 24-month visits in the Neonatal Intensive Care Unit Follow-Up Clinic were assigned to the neurologically normal (NN) group ( n = 42). Children who appeared to have neuromotor abnormalities at either or both the 4-month and 12-month visits, and who were then rated as “normal” at the 24-month visit, were assigned to the transient neurological signs (TNS) group ( n = 19). The groups were compared on motor and cognitive measures at the 41/2-year clinic visit. No significant differences between groups were found except on the measure of pencil prehension, in which the TNS group scored significantly lower ( p &lt; .01) than the NN group. A more thorough assessment of fine motor skills at the preschool level may be indicated when following the neurodevelopmental course of children born biologically at risk.

Language performance on visual processing tasks in right hemisphere lesion cases

Seven language tests were constructed or adapted to assess the performance of three groups of 10 right-handed adult subjects: a right hemisphere lesion (RHL) group, a left hemisphere lesion (LHL) group, and a neurologically normal (NN) control group. Both the LHL and RHL groups produced poorer scores than the NN group on six of the seven tests. On two of the six significant tests, the RHL performed more poorly than the NN group. Analyses of words uttered during an oral story telling test indicated that the RHL group told significantly fewer complete stories using significantly more nouns, adjectives, and conjunctions than the NN group. On a 7-point scale, three judges rated the overall communication abilities of the RHL group as having “mild problems,” a significantly different rating than the ratings of the LHL and NN groups. The findings suggest that underlying visual spatial and perceptual deficits may be accompanied by clearly recognizable language differences in certain subjects.

Suspected neurological impairment (SNI) and cognitive abilities: A longitudinal study of selected skills and predictive accuracy1

Abstract The purpose of the study was to investigate the relationship between suspected neurological impairment (SNI) and cognitive abilities. Performances on cognitive measures administered between 8 months and and 8 years of age were compared employing a SNI group and a neurologically normal (NN) group. In addition, the accuracy of early cognitive skills in predicting later academic achievement was investigated for the SNI group. Neurological classification was determined by physicians based on specific neurological examinations. Differences between mean scores of SNI‐7 vs. NN groups were analyzed for significance using t‐tests. For the SNI‐7 group, performances on measures administered between 8 months and 4 years of age and attribute variables of sex, birth, weight, and maternal education were entered into stepwise regression analyses to determine the extent to which they predicted 8‐year academic achievement. Significant differences between the NN and the SNI‐7 group were demonstrated on all but two measures. Although the multiple regression analyses revealed the 3‐year Speech, Language, and Hearing Battery to be the best single predictor of 8‐year academic achievement, none of the resulting equations accurately predicted achievement. It was demonstrated that the SNI‐7 children had a globally depressed pattern of cognitive development in comparison to the NN children, indicating the need for screening programs for children as early as 4 years of age. Moreover, the need for the identificaton or development of discerning language measures for use with young children was also indicated.