Postoperative Neurological Symptoms Research Articles

Comparison of Early Postoperative Diffusion Weighted Magnetic Resonance Imaging Findings After Resection of Gliomas and Meningiomas

Glioma and meningioma require vastly different surgical approaches, even if only involving a simple craniotomy procedure. Diffusion weighted imaging (DWI) is useful for the postoperative evaluation of ischemic damage. The present study evaluated the expected but unproven differences in DWI findings. A total of 41 patients with meningiomas and 63 with gliomas met the inclusion criteria for adult cases with superficial lesions treated through simple supratentorial craniotomy. Postoperative DWI findings of DWI-positive rate, DWI-positive area type, and relationship with neurological deficits were evaluated. The DWI-positive rate (P=0.01) and the proportion of rim-type lesions (P<0.01) were significantly more common in gliomas. Patients with meningiomas and DWI-positive areas presented with higher rates of new neurological deficits (P<0.01), and patients with meningiomas on the left side were more likely to develop new neurological deficits (P=0.02). Patients with gliomas tended to develop new deficits with larger DWI-positive area volumes (P=0.04). Postoperative early DWI-positive rate and rim-type lesions are more common after glioma resection than meningioma resection. Larger volumes of DWI-positive areas may be associated with postoperative neurological symptoms in gliomas. DWI-positive finding is less common after meningioma than glioma resection but more likely to be associated with new neurological symptoms. These differences are important for adequate postoperative DWI evaluation of common supratentorial brain tumors.

Clinical presentation and extent of resection impacts progression-free survival in spinal ependymomas

PurposePrimary treatment of spinal ependymomas involves surgical resection, however recurrence ranges between 50 and 70%. While the association of survival outcomes with lesion extent of resection (EOR) has been studied, existing analyses are limited by small samples and archaic data resulting in an inhomogeneous population. We investigated the relationship between EOR and survival outcomes, chiefly overall survival (OS) and progression-free survival (PFS), in a large contemporary cohort of spinal ependymoma patients.MethodsAdult patients diagnosed with a spinal ependymoma from 2006 to 2021 were identified from an institutional registry. Patients undergoing primary surgical resection at our institution, ≥ 1 routine follow-up MRI, and pathologic diagnosis of ependymoma were included. Records were reviewed for demographic information, EOR, lesion characteristics, and pre-/post-operative neurologic symptoms. EOR was divided into 2 classifications: gross total resection (GTR) and subtotal resection (STR). Log-rank test was used to compare OS and PFS between patient groups.ResultsSixty-nine patients satisfied inclusion criteria, with 79.7% benefitting from GTR. The population was 56.2% male with average age of 45.7 years, and median follow-up duration of 58 months. Cox multivariate model demonstrated significant improvement in PFS when a GTR was attained (p <.001). Independently ambulatory patients prior to surgery had superior PFS (p <.001) and OS (p =.05). In univariate analyses, patients with a syrinx had improved PFS (p =.03) and were more likely to benefit from GTR (p =.01). Alternatively, OS was not affected by EOR (p =.78).ConclusionsIn this large, contemporary series of adult spinal ependymoma patients, we demonstrated improvements in PFS when GTR was achieved.

Differentiation between Anterior and Posterior Roots Using Compound Muscle Action Potential in Intradural Extramedullary Spinal Tumor Surgery.

This study aims to determine the cutoff values for the compound muscle action potential (CMAP) stimulus in anatomically identified anterior (motor nerve) and posterior roots (sensory nerve) during cervical intradural extramedullary tumor surgery. The connection between CMAP data from nerve roots and postoperative neurological symptoms in thoracolumbar tumors was compared with data from cervical lesions. The participants of the study included 22 patients with intradural extramedullary spinal tumors (116 nerve roots). The lowest stimulation intensity to the nerve root at which muscle contraction occurs was defined as the minimal activation intensity (MAI) in the CMAP. In cervical tumors, the MAI was measured after differentiating between the anterior and posterior roots based on the anatomical placement of the dentate ligament and nerve roots. The MAIs for 20 anterior roots in eight cervical tumors were between 0.1 and 0.3 mA, whereas those for 19 posterior roots were between 0.4 and 2.0 mA. The cutoff was <0.4 mA for both the anterior and posterior roots, and sensitivity and specificity were both 100%. In thoracolumbar tumors, the nerve root was severed in 12 of 14 cases. All MAIs were determined to be at the dorsal roots as their scores were higher than the cutoff and did not indicate motor deficits. The MAIs of the anatomically identified anterior and posterior root CMAPs were found to have a cutoff value of <0.4 mA in the cervical lesions. Similar MAI cutoffs were also applicable to thoracolumbar lesions. Thus, CMAP may be useful in detecting anterior and posterior roots in spinal tumor surgery.

Anterior transpetrosal approach and the tumor removal rate, postoperative neurological changes, and complications: experience in 274 cases over 33 years.

The authors report on the anterior transpetrosal approach (ATPA) and the results of surgeries performed over a 33-year period for petroclival tumors, including meningioma, trigeminal schwannoma, chordoma, and epidermoid tumor. They analyze early postoperative neurological changes, surgical complications, and trends over the decades. A retrospective analysis of 274 surgical cases that had undergone the ATPA from January 1984 to March 2017 was conducted. Data were collected from charts, clinical summaries, operative records, and operative videos. The analyzed parameters included patient diagnosis, tumor size, disease location, operation date, tumor removal rate, pre- and postoperative neurological symptoms (consciousness level, motor and sensory deficits of the limbs, sensory aphasia, and cranial nerve III-VIII injuries), surgical deaths, and radiologically recognized brain injuries after the operation (contusion, infarction, hemorrhage). Gross-total resection (GTR) was achieved in 53.5% of the 243 tumors with available data. The GTR rate for meningiomas (148 cases) was 54.1%. Trigeminal schwannomas had a high GTR rate of 87.1%, whereas chordomas had a low GTR rate of 14.3%. The rate of early neurological deterioration immediately after the ATPA, referred to as "early neurological change," was as follows: consciousness disturbance in 1.9% of cases (5 cases), improvement of hemiparesis in 45.0% of cases but deterioration in 8.1% of cases, sensory aphasia in 2.3% of cases due to temporal lobe injury, improvement of cerebellar symptoms in 39.3% of cases with rare deterioration (1.9% of cases), worsening of preoperative diplopia in 49.4% of patients and rarely improving, improvement of trigeminal symptoms in 19.1% of cases (mostly trigeminal neuralgia) among the 43.7% of patients who had them preoperatively, and deterioration of facial hypesthesia and/or paresthesia in 27.4% of cases. Early neurological deterioration was monitored in 183 patients for 6 months to determine the surgical complications of ATPA. Consciousness disturbance recovered in half of the cases but persisted in 3 (1.5%). Hemiparesis fully recovered in 63.2% of cases, resulting in a complication rate of 3.0%. The most frequent complication was diplopia (36.4%), with a complete remission rate of 26.4%. The second most frequent complication was facial hypesthesia (24.0%), with a recovery rate of 16.1%. Facial nerve palsy improved in 63.0% of cases and had a complication rate of 4.9%. Cerebellar symptoms showed complete recovery in all cases. The ATPA allows the removal of petroclival tumors extending into Meckel's cave and the middle fossa, making it preferred for dumbbell trigeminal schwannomas and meningiomas. However, the ATPA's aggressive tumor removal can risk a lower recovery of cranial nerve IV-VI deficits. For benign meningiomas, initial observation with regular follow-up is recommended. Surgery is appropriate for high-growth cases aiming for total removal, accompanied by a thorough explanation of the risks. If the risks are not accepted, subtotal removal can be considered, and radiosurgery is suggested for residual tumor.

Inhalational Anesthesia Reduced Transient Neurological Events After Revascularization Surgery for Moyamoya Disease

BACKGROUND AND OBJECTIVES: The choice between inhalational and total intravenous anesthesia (TIVA) in revascularization surgery for Moyamoya disease (MMD) remains a topic of debate. Anesthesia methods have changed with the advent of new anesthetics. This study investigated whether modern anesthesia methods affected the development of neurological symptoms after revascularization surgery for MMD. METHODS: This single-center retrospective study included 63 adult patients (82 hemispheres) with MMD treated with direct and indirect bypass surgeries at our hospital between 2013 and 2022. Patients were divided into inhalational anesthesia (IA) and TIVA groups based on the anesthesia maintenance method. Baseline patient characteristics; postoperative neurological symptoms, including hyperperfusion syndrome, cerebral infarction, and transient neurological events (TNEs); and cortical hyperintensity belt (CHB) sign scores (5-point scale from 0 to 4) on postoperative magnetic resonance imaging were compared between the two groups. The operation methods, anesthetics, and intraoperative hemodynamic and ventilatory parameters were compared between patients with and without TNEs. RESULTS: The IA and TIVA groups comprised 39 and 43 hemispheres, respectively. The frequency of postoperative hyperperfusion syndrome and cerebral infarction did not differ between the groups, but the number of TNEs in the IA group (5/39; 13%) was significantly lower than that in the TIVA group (16/43; 37%). Multivariate logistic regression analysis revealed that TNEs were associated with TIVA (odds ratio, 3.91; 95% CI, 1.24-12.35; P = .02). The median [IQR] postoperative CHB sign score in the IA group (2 [1-3]) was significantly lower than that in the TIVA group (4 [3-4]). CONCLUSION: The IA group had fewer postoperative TNEs and lower CHB sign scores than the TIVA group. Although further studies are needed, this study provides insights into the prevention of TNEs with IA and reconsideration of the optimal anesthesia for MMD.

Intraoperative contrast-enhanced ultrasound evaluates the hemodynamic change of cerebral revascularization in adult moyamoya disease: Preliminary results

PurposeThis study aimed to determine the feasibility of using intraoperative contrast-enhanced ultrasound (CEUS) to assess subcortical hemodynamic changes in moyamoya disease patients who had undergone combined revascularization. It also aimed to investigate the correlation between quantitative CEUS parameters and post-operative neural functional recovery. MethodsThis study included seventeen patients diagnosed with moyamoya disease, confirmed through cerebral angiography, who underwent combined revascularization. Intraoperative subcortical hemodynamics were assessed using CEUS before and immediately after cerebrovascular bypass. Hemodynamic parameters were calculated by analyzing the time-intensity curve generated from a defined region of interest in each CEUS video. Post-operative neurological symptoms, computed tomography records, and short-term modified Rankin Scale (mRS) scores were also recorded. ResultsDuring the post-operative follow-up, 29.4 % of the patients experienced new neurological symptoms, including epilepsy, dyskinesia, and language impairment. Overall, CEUS quantitative parameters suggested that blood supply improved after surgery. And certain hemodynamic parameters exhibited a stronger correlation with the mRS scores, with correlation coefficients ranging up to 0.73 (p < 0.01). However, no statistically significant differences were observed among the different functional groups. The advanced parameter of wash-out intensity (δ WOI), which signifies the rate of change at the point when blood flow is completely washed out, demonstrated a significant difference between two functional groups (p = 0.02) and exhibited a correlation with mRS scores (correlation coefficients: 0.55, p = 0.02). ConclusionsThis preliminary study suggests that quantitative intraoperative CEUS can measure subcortical hemodynamic changes. It provides a novel non-invasive method that may predict the short-term post-operative neural functional recovery of combined revascularization in moyamoya disease patients.

Factors influencing the surveillance of re-emerging intracranial infections in elective neurosurgical patients: A single-center retrospective study.

At present, many studies have reported the risk factors for postoperative intracranial reinfection, including age, sex, time to surgery, duration of postoperative catheterization, emergency procedures, type of disease and cerebrospinal fluid leakage, but the academic community has not reached a unified conclusion. To find factors influencing the surveillance of re-emerging intracranial infections in elective neurosurgical patients. Ninety-four patients who underwent elective craniotomy from January 1, 2015 to December 31, 2022 in the Department of Neurosurgery, First Hospital of Jilin University, were included in this study. Of those, 45 patients were enrolled in the infection group, and 49 were enrolled in the control group. The clinical data of the patients were collected and divided into three categories, including preoperative baseline conditions, intraoperative characteristics and postoperative infection prevention. The data were analyzed using SPSS 26.0 software. There were 23 males and 22 females in the infection group with a mean age of 52.8 ± 15.1 years and 17 males and 32 females in the control group with a mean age of 48.9 ± 15.2 years. The univariate analysis showed that the infection group had higher systolic blood pressures and postoperative temperatures, fewer patients who underwent a supratentorial craniotomy, more patients with a history of hypertension and higher initial postoperative white blood cell counts than the control group, with statistically significant differences (P < 0.05). The multifactorial logistic regression analysis showed that a history of hypertension and a high postoperative body temperature were independent risk factors for postoperative infection in neurosurgical patients. The results obtained in this study indicated that a history of hypertension and a high postoperative body temperature were independent risk factors for postoperative neurological symptoms.

Incidence and management of idiopathic peri-lead edema (IPLE) following deep brain stimulation (DBS) surgery: Case series and review of the literature

ObjectiveIdiopathic peri-lead edema (IPLE) is being increasingly described as a potential complication occurring after DBS surgery. Its incidence and relationship to post-operative symptoms, though, are still poorly defined and its understanding and management yet limited. MethodsWe reviewed delayed (≥ 72 h) post-operative CT imaging of patients who underwent DBS surgery at our Institution. A comparison of clinical and laboratory findings was carried out between patients with IPLE and controls. Results61 patients, accounting for 115 electrodes, were included. Incidence of IPLE was 37.7 % per patient and 29.5 % per electrode. Patients with IPLE were significantly older than controls (52.82 ± 15.65 years vs 44.73 ± 18.82 years, p = 0.04). There was no difference in incidence of new-onset neurological symptoms between patients with IPLE and controls. Longer operative time (180.65 ± 34.30 min vs 158.34 ± 49.28 min, p = 0.06) and a greater number of MERs per electrode were associated with IPLE (3.37 ± 1.21 vs 3.00 ± 1.63, p = 0.089), though these comparisons did not meet the statistical significance. None of the patients with IPLE underwent hardware removal, with IPLE vanishing spontaneously over months. ConclusionsIPLE is an underestimated, benign event that may occur after DBS surgery. Age, longer operative time and MER use may represent risk factors for IPLE formation, but further studies are needed. The presence of post-operative neurological symptoms and fever was not associated with IPLE presence, highlighting its benign nature and suggesting that empiric treatment may not be always justified.

Postoperative neurological symptoms following arthroscopic shoulder surgery with interscalene block: an exploratory secondary analysis of pooled randomized controlled trial data

ObjectivePostoperative neurological symptoms (PONS) are recognized complications of regional anesthesia and orthopedic surgery. We aimed to better characterize prevalence and potential risk factors in a homogeneous population of randomized, controlled...

Motor Evoked Potential

Motor evoked potential(MEP)is the most widely used intraoperative neurophysiological monitoring measure. It includes cortical direct stimulation MEP(dMEP), which directly stimulates the primary motor cortex of the frontal lobe identified by short-latency somatosensory evoked potentials, and transcranial MEP(tcMEP), which involves high-current or high-voltage transcranial stimulation using cork-screw electrodes installed in the scalp. dMEP is performed in brain tumor surgery close to the motor area. tcMEP is simple, safe, and widely used in spinal and cerebral aneurysm surgeries. The increase in sensitivity and specificity with compound muscle action potential(CMAP)after peripheral nerve stimulation normalization performed in MEP to remove the effect of muscle relaxants is unclear. However, tcMEP for decompression in compressive spinal and spinal nerve diseases may predict the recovery of postoperative neurological symptoms with CMAP normalization. The anesthetic fade phenomenon can be avoided with CMAP normalization. The cutoff rate of loss of amplitude that causes postoperative motor paralysis in intraoperative MEP monitoring is 70%-80%, and setting an alarm at each facility based on this is necessary.

A Case of Glossopharyngeal Schwannoma Protruding to the Larynx: A Case Report

Schwannoma is benign tumor that can occur in any part of the nerve that contains a Schwann cell. It is rare in the head and neck region and is characterized by common postoperative neurologic symptoms. We experienced a cervical schwannoma in a 22-year-old young man. Except for a foreign body sensation in the neck and a mass in the anterior region, there were no other complaints. A retropharyngeal schwannoma was most suspected considering neck computed tomography, magnetic resonance imaging, laryngoscopy and fine needle aspiration. Surgical treatment was performed, and the origin of the schwannoma was diagnosed as the tonsillar branch of the glossopharyngeal nerve. Histopathological examination confirmed the presence of a schwannoma with typical characteristics. After surgery, the patient recovered without any side effects. We report this case with a review of the literature.

Three-dimensional pseudo-continuous arterial spin labeling for evaluation of cerebral hemodynamic changes after revascularization in adult patients with moyamoya disease

To evaluate cerebral hemodynamic changes using three-dimensional pseudo-continuous arterial spin labeling (3D-pCASL) and its association with the changes of neurological symptoms in adult patients with moyamoya disease after revascularization. We prospectively collected the clinical and radiographic data of 40 adult patients with moyamoya disease diagnosed by digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) undergoing unilateral superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. All the patients underwent 3D-pCASL examination before and after the surgery, and were followed up for 3 to 11 months after the operation. The region of interest (ROI) was located in the middle cerebral artery cortical territory covering the surgical side and ipsilateral cerebellar hemisphere. Cerebral blood flow (CBF) and relative CBF (rCBF) values were compared before and after the surgery, and the changes in cerebral hemodynamics were evaluated. The correlations were analyzed between preoperative rCBF and Suzuki stage and between the changes in postoperative neurological symptoms and rCBF. The mean CBF of the patients increased significantly from 53.96±10.04 mL·100 g-1·min-1 to 58.90±13.57 mL·100 g-1·min-1 after the operation (t=-3.068, P=0.004); the mean rCBF also increased significantly after the operation (0.96 ± 0.14 vs 1.15 ± 0.18; t=-7.155, P < 0.001). The changes in postoperative neurological symptoms were significantly correlated with the changes in rCBF (P=0.017) and the type of disease onset (P < 0.001). 3D-pCASL is an valuable means for noninvasive monitoring of hemodynamic changes after revascularization in adult patients with moyamoya disease without the use of contrast agent.

Assessment of intraoperative neurophysiological monitoring techniques in intramedullary spinal cord tumor removal surgery

ObjectiveIntraoperative neurophysiological monitoring in intramedullary spinal cord tumor removal surgery helps surgeons detect early warning signs of postoperative nerve damage, in order to reduce or prevent permanent neuron injury. We performed a study to evaluate the value of intraoperative neurophysiological monitoring techniques in intramedullary spinal cord tumor resection surgery. MethodsWe performed a retrospective study of 29 patients undergoing surgery for intramedullary spinal cord tumors and intraoperative neurophysiological monitoring from 2017 to 2021 at the University Medical Center, Ho Chi Minh City. Clinical assessment before and after surgery, intraoperative neurophysiological monitoring to find out the sensitivity, specificity, positive predictive value, and negative predictive value of intraoperative neurophysiological monitoring techniques were performed. ResultsOf the 29 patients, 4 patients had worse postoperative neurological symptoms (13.8%) at 1 day after surgery. The rate of postoperative worsening neurological symptoms decreased to 10.3% at the 1-month follow-up. SSEP (somatosensory evoked potential) had 75% sensitivity and 72% specificity in detecting postoperative nerve damage, while the sensitivity and specificity of MEP (motor evoked potential) were 100% and 80%, respectively. ConclusionBoth SSEP and MEP have a high sensitivity in detecting postoperative nerve damage, meanwhile, MEP is more sensitive than SSEP. These techniques help predict and possibly prevent timely neurological damage during intramedullary spinal cord resection surgery.

Modified lumbar foraminoplasty using a power-aided reciprocating burr for percutaneous transforaminal endoscopic lumbar discectomy: A technical note and clinical report.

One of the main difficulties in a transforaminal endoscopic lumbar discectomy (TELD), and simultaneously the most critical step, is performing an effective and safe foraminoplasty, which is especially difficult for beginners. To make it safer and faster for beginners to perform, we have used a specially designed power-aided reciprocating burr for TELD and reported the technical details. From Jan. 2019 to Nov. 2022, 432 patients with single-level, symptomatic L4/5 or L5/S1 disc herniation were treated with TELD using a novel power-aided reciprocating burr. The surgical procedure is described in detail. Magnetic resonance imaging (MRI) was performed the following day and 3 months after the operation. The learning curves of surgeons with different seniority levels are displayed. The Visual Analogue Scale (VAS) score and the Oswestry Disability Index (ODI) were used to measure low back pain, leg pain, and lumbar function. All patients were followed up for at least 1 year. All patients underwent endoscopic surgery successfully. Among the 432 patients, radicular outer membrane damage was observed in 6 cases, and 1 case had hernia of the nerve tract. Except for this patient with aggravation of postoperative numbness, the postoperative neurological symptoms of all patients were significantly improved. The mean VAS scores for low back pain and leg pain and ODI scores were significantly decreased 6 w post-operatively and were maintained until 12 months post-operatively compared to preoperative scores (P < 0.05). All three doctors involved in the study had substantial experience in traditional open spinal surgery. The more operations all three surgeons completed, the more time spent on intervertebral foraminoplasty decreased (P < 0.05). Among them, doctors without experience in TELD surgery became proficient in this technique after accumulating experience in 13 cases. There was no significant difference in foraminoplasty time among these three surgeons during the same growing period (P > 0.05). Current clinical data demonstrated the safety and efficacy of modified TELD using a power-aided reciprocating burr for treating lumbar disc herniation (LDH) and showed that this technique significantly reduces the learning curve for beginners when performing foraminoplasty.

Neuropathies Following an Ultrasound-Guided Axillary Brachial Plexus Block.

Ultrasound-guided brachial plexus block (UGBPB) has interscalene, supraclavicular, infraclavicular, and axillary approaches. The axillary block is considered to be the safest and with fewer adverse events compared to the interscalene (eg, phrenic nerve block, spinal cord or vertebral artery puncture) and supraclavicular (eg, pneumothorax). However, with regard to postoperative neurological symptoms (PONS), it is controversial whether its incidence after an axillary block was higher than that after non-axillary approaches". In this study, we investigated whether the incidence of a neuropathy after an axillary block was higher than that after non-axillary approaches. This was a single-center, retrospective cohort study. All UGBPBs were performed under general anesthesia between January 2014 and March 2020. The outcomes included the overall incidence of PONS and neuropathies for axillary and non-axillary approaches. The etiology, symptoms, and outcomes of patients were investigated. Of the 992 patients, 143 (14%) and 849 (86%) were subjected to axillary and non-axillary approaches, respectively. Among 19 cases (19.2:1000; 95% confidence interval [CI], 18.2-20.1) of PONS, four (4.0:1000; 95% CI, 3.8-4.2) were neuropathies attributed to the UGBPB, three (21.0:1000; 95% CI, 18.1-23.8) to the axillary and one (2.8:1000; 95% CI, 2.6-3.1) to non-axillary approaches. The incidence of neuropathies after an axillary block was significantly higher than that after non-axillary approaches (P = 0.005). The incidence of neuropathies after US-guided axillary block under general anesthesia was significantly higher than that after non-axillary approaches.

Surgery for Spinal Lipoma of the Conus Medullaris

Lipoma of the conus medullaris(LCM)can cause neurological symptoms known as tethered cord syndrome(TCS). The symptoms can be seen at diagnosis and during long-term follow-up. Even after surgical treatment, some patients can present with neurological deterioration indicating a TCS, defined as retethered cord syndrome(ReTCS). In this report the surgical technique for conus lipoma comprising wide osteoplastic laminotomy with confirmed whole spinal lipoma and adjacent normal spinal tissue is described, with dissection performed from the proximal side to the distal side with confirmed normal spinal cord and roots under operative microscope, expansive dural plasty aiming to get low cord/sac ratio was reported. Considering that some patients with LCM show postoperative neurological symptoms due to TCS in a long-term follow-up period, careful postoperative follow-up is necessary.

Cage Obliquity and Radiological Outcomes in Oblique Lateral Interbody Fusion.

Retrospective radiological study. This study aimed to examine whether cage obliquity affects radiological outcomes in oblique lateral interbody fusion (OLIF). The OLIF cage enters the disk space in the oblique direction and is then turned to the true orthogonal orientation. However, orthogonal cage placement is often hindered by cage rotation limitations. Few studies have examined the degree of cage obliquity and its effects in OLIF. This study involved 171 levels in 118 consecutive patients who underwent OLIF between L2-L3 and L4-L5 with a minimum two-year follow-up. Cage obliquity was divided into three groups on postoperative axial computed tomography images; cage obliquity <10° (group 1), cage obliquity ≥10° and <20° (group 2), and cage obliquity ≥20° (group 3). The radiological outcomes included anterior/posterior disk height, intervertebral disk angle, foraminal height, fusion, and cage subsidence. Postoperative complications related to cage obliquity were examined. The mean cage obliquity of the 171 cages was 11.3±6.9°. Cage obliquity was greater at the L4-L5 level (13.4±6.4°) than at other levels (L2-L3 and L3-L4: 6.5±7.0° and 10.1±6.2°, respectively) ( P <0.05). There were no significant differences in radiological outcomes among the groups. There were two cases of postoperative contralateral neurological symptoms in group 3. Our study showed that the orthogonal cage rotation in OLIF achieved adequate lateral cage placement. Although accurate cage rotation can be limited at the lower lumbar segments, radiological outcomes were not affected by cage obliquity.

CORR Insights®: What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials.

CORR Insights®: What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials.

What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials.

The risk of neurologic symptoms after regional anesthesia in orthopaedic surgery is estimated to approach 3%, with long-term deficits affecting 2 to 4 per 10,000 patients. However, current estimates are derived from large retrospective or observational studies that are subject to important systemic biases. Therefore, to harness the highest quality data and overcome the challenge of small numbers of participants in individual randomized trials, we undertook this systematic review and meta-analysis of contemporary randomized trials. In this systematic review and meta-analysis of randomized trials we asked: (1) What is the aggregate pessimistic and optimistic risk of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery? (2) What block locations have the highest and lowest risk of postoperative neurologic symptoms? (3) What is the timing of occurrence of postoperative neurologic symptoms (in days) after surgery? We searched Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Web of Science, Scopus, and PubMed for randomized controlled trials (RCTs) published between 2008 and 2019 that prospectively evaluated postoperative neurologic symptoms after peripheral nerve blocks in operative procedures. Based on the Grading of Recommendations, Assessment, Development, and Evaluation guidance for using the Risk of Bias in Non-Randomized Studies of Interventions tool, most trials registered a global rating of a low-to-intermediate risk of bias. A total of 12,532 participants in 143 trials were analyzed. Data were pooled and interpreted using two approaches to calculate the aggregate risk of postoperative neurologic symptoms: first according to the occurrence of each neurologic symptom, such that all reported symptoms were considered mutually exclusive (pessimistic estimate), and second according to the occurrence of any neurologic symptom for each participant, such that all reported symptoms were considered mutually inclusive (optimistic estimate). At any time postoperatively, the aggregate pessimistic and optimistic risks of postoperative neurologic symptoms were 7% (915 of 12,532 [95% CI 7% to 8%]) and 6% (775 of 12,532 [95% CI 6% to 7%]), respectively. Interscalene block was associated with the highest risk (13% [661 of 5101] [95% CI 12% to 14%]) and axillary block the lowest (3% [88 of 3026] [95% CI 2% to 4%]). Of all symptom occurrences, 73% (724 of 998) were reported between 0 and 7 days, 24% (243 of 998) between 7 and 90 days, and 3% (30 of 998) between 90 and 180 days. Among the 31 occurrences reported at 90 days or beyond, all involved sensory deficits and four involved motor deficits, three of which ultimately resolved. When assessed prospectively in randomized trials, the aggregate risk of postoperative neurologic symptoms associated with peripheral nerve block in upper extremity surgery was approximately 7%, which is greater than previous estimates described in large retrospective and observational trials. Most occurrences were reported within the first week and were associated with an interscalene block. Few occurrences were reported after 90 days, and they primarily involved sensory deficits. Although these findings cannot inform causation, they can help inform risk discussions and clinical decisions, as well as bolster our understanding of the evolution of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery. Future prospective trials examining the risks of neurologic symptoms should aim to standardize descriptions of symptoms, timing of evaluation, classification of severity, and diagnostic methods. Level I, therapeutic study.

Traumatic Cervical Spinal Cord Injury: Correlation of Imaging Findings with Neurological Outcome

Abstracts Background Traumatic spinal cord injury (TSCI) is extremely costly to the global health system. Due to the significant frequency rate of traumatic cervical spinal cord injuries (TCSCI), the possible association between imaging findings and clinical outcome is not yet clear. In this study, we quantified maximum spinal cord compression and maximum cord swelling following TCSCI and determined the relevance of imaging findings to clinical outcome in patients. Materials and Methods This retrospective cohort comprises 20 patients with TCSCIs (C3-C7), classified as complete, incomplete, and no SCI, who were treated at the Poursina Hospital, Iran, from 2018 to 2020, and underwent spinal surgery. Patients with penetrating injuries and multiple trauma were excluded. Imaging findings revealing spinal cord compression, swelling, and canal stenosis, based on the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades of patients from hospital admission (up to 48 hours after injury) and improvement of postoperative neurological symptoms (6–12 months) were evaluated. Results Cord compression (p = 0.05) and cord swelling (p = 0.02) were significantly related to predictive neurological outcomes in all cases. Evaluation with AIS at hospital admission and at 6 to 12 months postoperatively showed significant correlation with fracture type (p = 0.05) and the longitudinal length of the intramedullary lesion (IML); p = 0.01, respectively. Conclusion According to the results obtained in this study, it may be concluded that there is a significant association between cervical spinal cord compression and swelling, and clinical outcomes in patients with complete, incomplete, and no SCI.