Preoperative Neurological Examination Research Articles

Effect of decompressive hemicraniectomy performed within the first 48 hours on mortality in the treatment of malignant infarction of the middle cerebral artery

To evaluate the clinical outcomes of patients with malignant middle cerebral artery (MCA) infarction who underwent wide decompressive hemicraniectomy. Fifty-two patients with large MCA infarcts were retrospectively evaluated, and 12 patients who underwent extensive decompressive hemicraniectomy and duraplasty with a bone flap extending beyond the infarct borders were included in the study. The degree of stroke (stroke volume), preoperative and postoperative midline shift of the craniectomy area and improvement in midline shift were calculated on computed tomography. Preoperative and postoperative neurologic examination scores were determined using the modified Rankin Scale. The mean age was 63 (min: 41, max: 79) years. There was left MCA infarction in one patient and right MCA infarction in 11 patients. The postoperative follow-up period of the operated patients ranged from 14 to 90 days. The neurological examination of seven patients (58.3%) showed significant improvement. Eight (66.6%) patients survived. Postoperatively, the mean midline deviation value of 12 patients decreased from 11.04 to 4.8. It is considered that wide decompressive craniectomy performed in young patients in the early period with strict radiological and clinical follow-up can increase survival and functional recovery.

Early effectiveness of unilateral biportal endoscopic discectomy combined with annulus fibrosus suture in the treatment of lumbar disc herniation

To analyze the early effectiveness of unilateral biportal endoscopic discectomy (UBED) combined with annulus fibrosus suture in the treatment of lumbar disc herniation (LDH). The clinical data of 19 patients with LDH treated with UBED and annulus fibrosus suture between October 2020 and October 2021 were retrospectively analyzed. There were 12 males and 7 females with an average age of 39.1 years (range, 26-59 years). The operative segment was L 4, 5 in 13 cases, and L 5, S 1 in 6 cases. The mean disease duration was 6.7 months (range, 3-15 months). Preoperative neurological examination showed that muscle strength, sensation, and tendon reflex weakened or disappeared in varying degrees. Single annulus fibrosus suture (14 cases) or anchor assisted annulus fibrosus suture (5 cases) was selected according to the location of annulus fibrosus tears. Visual analogue scale (VAS) score was used to assess the low back and leg pain before operation and at 3 days, 3 months, and 6 months after operation. Oswestry disability index (ODI) was used to evaluate the function recovery of lumbar spine before operation and at 3 days, 3 months, and 6 months after operation. At 3 days and 3 months after operation, MRI was used to examine the removal of nucleus pulposus and decompression of nerve root. MacNab criteria was used to evaluate the effectiveness at 6 months after operation and the recovery of nerve root function was recorded. All operations were successfully completed with a mean operation time of 52.7 minutes (range, 40-75 minutes). There was no complication such as nerve injury, spinal cord hypertension syndrome, or dural sac tear during operation, and no complication such as infection, aggravation of nerve damage, or cerebrospinal fluid leakage after operation. All the patients were followed up 6-10 months (mean, 8.2 months). Postoperative MRI showed that the herniated disc was completely removed and nerve roots were fully decompressed. During the follow-up, there was no recurrence of disc herniation. The VAS scores of low back pain and leg pain and ODI at each time point after operation significantly improved when compared with those before operation, and those at 6 months after operation further improved than those at 3 days and 3 months after operation, all showing significant differences ( P<0.05). At 6 months after operation, MacNab standard was used to evaluate the effectiveness, and the results were excellent in 14 cases, good in 4 cases, and fair in 1 case, with an excellent and good rate of 94.7%. Neurological examination showed that the sensation and muscle strength of the affected nerve root innervated area recovered significantly when compared with those before operation ( P<0.05); the recovery of tendon reflex was not obvious, showing no significant difference when compared with that before operation ( P>0.05). UBED combined with annulus fibrosus suture is a safe and effective technique for LDH and early effectiveness is satisfactory.

Использование большой грудной мышцы для восстановления активного сгибания предплечья у детей с амиоплазией

Introduction Amyoplasia is the most common type of arthrogryposis multiplex congenita. Some patients may lack active elbow flexion due to aplasia of the forearm flexor muscles. The objective was to identify the optimal age for pectoralis major muscle transfer to improve elbow flexion in children with amyoplasia and estimate outcomes of the procedure depending on the level of spinal cord injury. Material and methods Restoration of active elbow flexion was performed for 34 children with amyoplasia (39 upper limbs) between 2011 and 2020 using partial monopolar pectoralis major muscle transfer. The age of patients ranged between 1.5 and 15.5 years (6.24 ± 4.24 years). The patients were divided into 3 groups depending on the level of spinal cord injury: C6–C7 (n = 4; 11.8 %), C5–C7 (n = 24; 70.6 %), C5–Th1 (n = 6; 17.6 %). The outcomes were estimated at 6 to 99 months (44.53 ± 31.72 months). The patients underwent preoperative and postoperative clinical and neurological examination. The results were statistically analyzed. Results Active elbow flexion improved by 56.8 degrees (p &lt; 0.0001), forearm flexor muscles strengthened by 2.0 points (p &lt; 0.0001) and extension deficit improved by 14.5 degrees (p &lt; 0.0001) were postoperatively statistically significant. Results were rated as good in 15 (38.5 %); as fair, in 8 (20.5 %) and poor in 16 (41 %) cases. Greater differences were found between the group of patients with the level of C6-C7 spinal cord injury in relation to the group of patients with the level of C5-Th1 (p &lt; 0.05). There were no statistically significant differences between patients with C6–C7 and C5–C7 lesion levels (p &gt; 0.05). Children of different age groups showed no differences in the results of treatment (p &gt; 0.05). Conclusion Pectoralis major muscle could be used for active elbow flexion restoration in patients with amyoplasia. The best results were observed in patients with C6–C7, C5–C7 segmental lesions of the spinal cord. There was no correlation between age of patient at the time of surgery and the effectiveness of operation.

Effect of Preoperative Serum Transthyretin Levels on Postoperative Clinical Results and Morbidity in Patients Undergoing Spinal Surgery.

Introduction This study aims to investigate the effects of preoperative serum transthyretin (TTR) levels on surgical success, pain scores, and postoperative morbidity. Methods Note that, in our clinic, 188 patients who were operated for spinal pathologies between June 2010 and January 2011 were included in this study. Blood samples were drawn from all patients on the morning of surgery and then serum TTR measurements were made. Demographic data of all patients were collected, and then their preoperative and postoperative neurological examinations, Karnofsky scores, visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, postoperative infection and wound healing status, hospital stay, and morbidity levels were recorded and TTR levels were compared. Results When preoperative TTR level of patients were low, their Karnofsky scores decreased, ODI scores increased, the early postoperative VAS and late postoperative VAS values increased, and the length of hospital stay was increased. Moreover, in patients with low TTR levels, postoperative Karnofsky scores were lower, postoperative ODI levels were higher, postoperative early and late VAS scores were higher, hospital stays were longer, peroperative complication rates were higher, wound infection rates were higher, the delay in wound site healing was higher, and the morbidity rate was higher. Conclusion Consequently, preoperative low TTR levels have been reported to be an effective parameter that can be used to predict surgical results, wound infection and wound site healing status, perioperative complications, and morbidity in spinal surgery.

Does magnetic resonance imaging impact pre-operative plans in adolescent idiopathic scoliosis patients? A retrospective study

Objectives: Adolescent idiopathic scoliosis (AIS) has been rigorously discussed in academia for the better part of a century, primarily due to its nuanced and complex management. To date, there are no universal criteria for its management. The use of pre-operative magnetic resonance imaging (MRI) in all patients with AIS is still debatable. We aimed to determine the necessity of using pre-operative routine MRI assessment in all patients treated for AIS. Methods: A retrospective and descriptive medical chart review study was done. We examined AIS patients diagnosed between 10 and 18 years of age who underwent surgical treatment between 2016 and 2020. A full medical history and a complete spine clinical examination were performed on all patients. Results: Of 267 consecutive patients with verified AIS who underwent surgical correction, 176 were included in the analysis. All patients had normal pre-operative physical and neurological examinations. There were 138 (78%) female and 38 (22%) male patients. MRI findings of neural axis abnormalities were observed in eight of 176 patients (4.54%). Conclusion: In our study, the incidence of abnormalities in the neural axis was low and no additional neurosurgical procedures were performed. This could be due to our strict inclusion criteria. However, we cannot establish a recommendation regarding the routine use of pre-operative MRI. A meta-analysis of the currently available data may provide a better assessment in terms of cost-effectiveness and pave the way for the implementation of guidelines for screening protocols.

NOTCH3 Mutations and CADASIL Phenotype in Pulmonary Arterial Hypertension Associated with Congenital Heart Disease

Background: The etiology of pulmonary arterial hypertension associated with congenital heart disease (PAHCHD) is complicated and the phenotype is heterogeneous. Genetic defects of NOTCH3 were associated with cerebral disease and pulmonary hypertension. However, the relationship between NOTCH3 mutations and the clinical phenotype has not been reported in CHD-PAH. Methods: We eventually enrolled 142 PAH-CHD patients from Fuwai Hospital. Whole exome sequencing (WES) was performed to screen the rare deleterious variants of NOTCH3 gene. Results: This PAH-CHD cohort included 43 (30.3%) men and 99 (69.7%) women with the mean age 29.8 ± 10.9 years old. The pathogenic or likely pathogenic mutations of NOTCH3 were identified in five cases. Patients 2, 5, 8 and 11 carried the same NOTCH3 mutation c.1630C > T (pArg544Cys), which is the hot-spot mutation for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Patient 3 carried the NOTCH3 mutation p.Arg75Gln that has also been reported to be associated with the CADASIL. Patients 2, 5, 8, 11 took the examination of the cerebral magnetic resonance imaging (MRI) and confirmed the phenotype of CADASIL. Conclusions: We first reported the NOTCH3 rare mutations and CADASIL phenotypes in CHD-PAH patients. The NOTCH3 rare variants were with a relatively high positive rate and CADASIL phenotypes were likely enriched in PAH-CHD patients. The preoperative neurological examination might be recommended for PAH-CHD patients to determine the surgical contraindications and reduce intraoperative neurological complications.

Effect of Preoperative Serum Transthyretin Levels on Postoperative Clinical Results and Morbidity in Patients Undergoing Spinal Surgery.

Introduction:This study aims to investigate the effects of preoperative serum transthyretin (TTR) levels on surgical success, pain scores, and postoperative morbidity.Methods:Note that, in our clinic, 188 patients who were operated for spinal pathologies between June 2010 and January 2011 were included in this study. Blood samples were drawn from all patients on the morning of surgery, and then, serum TTR measurements were made. Demographic data of all patients were collected, and then their preoperative and postoperative neurological examinations, Karnofsky scores, Visual Analog Scale (VAS) scores, Oswestry disability index (ODI) scores, postoperative infection and wound healing status, hospital stay, and morbidity levels were recorded, and TTR levels were compared.Results:When preoperative TTR level of patients was low, their Karnofsky scores decreased, ODI scores increased, the early postoperative VAS and late postoperative VAS values increased, and the length of hospital stay was increased. Moreover, in patients with low TTR levels, postoperative Karnofsky scores were lower, postoperative ODI levels were higher, postoperative early and late VAS scores were higher, hospital stays were longer, peroperative complication rates were higher, wound infection rates were higher, the delay in wound site healing was higher, and the morbidity rate was higher.Conclusion:Consequently, preoperative low TTR levels have been reported to be an effective parameter that can be used to predict surgical results, wound infection and wound site healing status, perioperative complications, and morbidity in spinal surgery.

Surgical Decompression for Cervical Spondylotic Myelopathy in Patients with Associated Hypertension: A Single-Center Retrospective Cohort and Systematic Review of the Literature

To explore the relationship between spinal cord compression and hypertension through analysis of blood pressure (BP) variations in a cervical spondylotic myelopathy (CSM) cohort after surgical decompression, along with a review of the literature. A single-institution retrospective review of patients with CSM who underwent cervical decompression between 2016 and 2017 was conducted. Baseline clinical and imaging characteristics, preoperative and postoperative BP readings, heart rate, functional status, and pain scores were collected. In addition, a PRISMA guidelines-based systematic review was performed. We identified 264 patients with CSM treated surgically; 149 (56.4%) of these had hypertension. The degree of spinal canal compromise and spinal cord compression, preoperative neurologic examination, and the presence of T2-signal hyperintensity on magnetic resonance imaging were associated with hypertension. Overall mean arterial pressure (MAP) decreased significantly at 1 and 12 months after surgery. Patients without T2-signal hyperintensity on imaging showed a MAP reduction at 12 months postoperatively, whereas those with T2-signal hyperintensity showed a transient MAP reduction at 1 month postoperatively before returning to preoperative values. At 12 months after surgery, 24 of 97 patients (24.7%) with initially uncontrolled hypertension had controlled BP values with significant reduction of MAP, systolic BP, and diastolic BP. Including the present study, 5 articles were eligible for systematic review, with all reporting a BP decrease in patients with CSM after decompression. Analysis of our retrospective cohort and a systematic review suggest that cervical surgical decompression reduces BP in some patients with CSM. However, this improvement is less apparent in patients with preoperative spinal cord T2-signal hyperintensity.

Endovascular treatment of vertebral artery dissecting aneurysms : a 20-year institutional experience

BackgroundThe ideal treatment for unruptured vertebral artery dissecting aneurysms (VADAs) and ruptured dominant VADAs remains controversial. We report our experience in the management and endovascular treatment of patients with VADAs.MethodsPatients...

Expanded Endoscopic Endonasal Approach (EEEA) for Clival Chordomas

Objective: To evaluate the role of expanded endoscopic endonasal approach in removal of clival chordomas. Patients & Methods: Nine patients with clival chordomas were operated upon in Cairo University hospital from September 2015 to September 2018 using the EEEA a recurrent case and seven new cases were involved in these study and ten operations were done. All patients had preoperative neurological and radiological examination. The study was focusing on the approach, efficacy of tumor removal, reconstruction of the base and complications related to this approach. Results: Nine patients were operated in this study in which ten operations were done. It included six males (66.6%) and three females (33.3%) with age ranging from 4 years to 63 years with average age 40.7 years. Headache and diplopia were the most common symptoms found in six patients (66.6%). Brainstem affection was found in two patients (22.2%). Lower cranial nerves affection was found in two patients (22.2%). One case developed CSF leakage postoperatively (11.1%). Two patients underwent tracheostomy. We achieve total removal in four patients (44.4%), near total removal in one patient (11.1%) and subtotal tumor resection in four patients (44.4%). Conclusion: EEEA for clival chordomas is safe and effective approach regarding the results of the incidence of complications, and the percentage of tumor resection.

In Hospital Outcome of CEA And CAS in the German National Carotid Registry 2014-2015

Introduction - The German National Quality Assurance Registry includes the datasets of all procedures (CEA and CAS) performed in German hospitals. The in-hospital outcome is reported by a questionnaire and finally evaluated and monitored by a federal institution (IQTIG) with the assistance of a clinical advisory board. It is the aim of this presentation to report the outcome of CEA vs. CAS as well as of simultaneous procedures combined with cardiac surgery or intracranial endovascular procedures. Methods - Data were collected at discharge on a electronic basis and primarily transferred to local state agencies (n=11) for plausibility check and monitoring. The data sets from 11 agencies were then anonymously compiled and evaluated by a federal institute (IQTIG). The quality of the registry is checked on a yearly basis by random sample analysis of individual charts. Data collection is linked to reimbursement of the procedure. The reports from 2014 and 2015 include the data sets from n= 64.868patients. 12.156 CAS (18,7%) and n=52.712 CEA (81,3%) were performed. 2,3% of CEA and 8,4% of the CAS procedures were special indications, including interventions prior to intracranial interventional procedures or other indications. Emergency procedures were included in the registry (7,44% CEA, 16,98% CAS). Results - 654[KM1] hospitals performed CEA and/or CAS in 2014 and with 648 in 2015). 282 (2015) / 297 (2014)hospitals reported <20 cases CEAs[KM2] per year (51,9% (2015) / 53,1% (2014)). 293 (2015) /280 (2014) hospitals reported < 20 CAS procedures 87,2% (2015) / 85,9% (2014)) The rates of preoperative neurological examination was 68,6% ( CEA) and 79,3% ( CAS, the postoperative rates were 58,2% (CEA) and 71,7% ( CAS). The results for stroke and death were below the AHA limit of 3% for asymptomatic carotid stenosis in both groups, with stroke/death rates of 1.76[KM3] % (2014) and 1.58% (2015) for CAS and 1.12% resp. 1.45% for CEA. In the case of contralateral stenosis the results were: 1.40% resp. 2.77% for CAS and 2.64% resp. 1.61% for CEA. In symptomatic stenosis, stroke/death rates for CAS were 3,5% (2014) and 3.91% (2015). CEA resulted in stroke/death rates of 2.35% resp.2.55%. The ratio observed/expected for severe stroke and death rose from 1.00 to 1.41 in the case of CAS, with values for 1.0 and 1.03 for CEA (2014 vs. 2015). Conclusion - The percentage of CAS (18% ) in the population did not change in the last two years. Both methods resulted in acceptable results for treatment of asymptomatic stenosis on a national scale. Risk adjustement was done to make individual hospitals comparable. There were differences in indications: CAS was more often used in acute stroke and in combination with intracranial procedures. CEA was also performed in combination with ACBG; the results of simultaneous ACBG and CEA were poor and reached unacceptable high stroke/death rates. The interpretation of these registry data is somewhat limited due to missing follow-up data as well as due to the fact the the data sets were pooled, and therefore a detailed statistical comparison was not possible.

Neurophysiological examination combined with functional intraoperative navigation using TMS in patients with brain tumor near the central region-a pilot study.

Feasibility and value of non-invasive transcranial magnetic brain stimulation (TMS MAGVENTURE® MagPro R30 Denmark) for preoperative diagnosis and surgical planning of brain tumor operations in everyday clinical practice. A prospective monocentric study was conducted, which included preoperative neurological and electrophysiological examination, TMS, and display of functional data in the navigation system (LOCALITE® TMS Navigator Germany). During surgery, the TMS data were correlated with the intraoperative monitoring (IOM). Twenty-four hours to 96h and after at least 3months, follow-ups with neurological, electrophysiological examinations and TMS stimulation were performed. Twenty-five patients with tumors in or near by the primary motor cortex region were included in the study. Twenty-one patients completed preoperative and first postoperative TMS and the neurological examination. Eight of 21 patients showed slight worsening of primary motor cortex function, 8 patients had an unchanged state, and 4 patients showed an improvement early after surgery. The changes of the electrophysiological examination like significant delay of the latency and/or reduced amplitudes matched well with the postoperative neurological outcome: if patients showed a worsening of the SEP's and MEP's, the postoperative results revealed deterioration. A preoperatively performed TMS using the MAGVENTURE® MagPro R30 and the LOCALITE® TMS Navigator could be established in our clinical daily practice and allowed a safe and reliable mapping of the primary motor cortex in order to minimize the risk of postoperative neurological deficits and improve the neurological outcome of the patients.

Do Curve Characteristics Influence Stenosis Location and Occurrence of Radicular Pain in Adult Degenerative Scoliosis?

Study DesignRetrospective cohort. ObjectiveThe aim of this study was to describe the various locations of spinal stenosis (LSS) in lumbar scoliosis and its related clinical symptoms. IntroductionAdults with lumbar scoliosis often present with pain and disability. Association of scoliosis and stenosis is not rare, but remains sparsely explored. Consequences of scoliosis on stenosis location and treatment remain debatable. MethodsPatients operated for symptomatic LSS with lumbar scoliosis (Cobb angle >20°) from 2015 to 2016 were included. All patients completed preoperative clinical and neurologic examination. Coronal and sagittal radiographic parameters, rotatory subluxation (RS), and spondylolisthesis were analyzed on full spine radiographs. Computed tomographic scan multiplanar reconstructions were performed to measure central, foraminal, and lateral recess stenosis, from T10 to the sacrum. ResultsA total of 76 patients were included (69 ± 9 years old, 77% female). Sixty percent had neurogenic claudication, and L5 was the most common radicular pain (41%). The mean Cobb angle was 33° ± 16°. Overall, 35 (46%) patients had coronal malalignment; in 69%, side of the coronal tilt corresponded to side of the concavity of the lumbosacral curve. Sixty patients had RS (most frequent level L3–L4). In 50% of the cohort, RS was located at the junction between the lumbar and lumbosacral curves. In 70% (n = 53) of the patients, central stenosis occurred at the junction between the lumbar and lumbosacral curves. Foraminal and lateral stenosis were most frequently observed in the concavity of the distal lumbosacral curve. L5 radicular pain was significantly more frequent in case of lumbosacral contra-curve and right coronal malalignment. ConclusionLSS is frequent in lumbar scoliosis. Relationships exist between curve characteristics and symptomatic LSS in lumbar scoliosis; especially, concavity of the lumbosacral contra-curve and the junctional level between the lumbar curve and the lumbosacral contra-curve. Therefore, accurate analysis of stenosis in ASD seems mandatory, to at least perform decompression because perfect planned treatment for stenosis and scoliosis correction might not always be possible because of the patient's general health status. Level of EvidenceLevel 4.

Incidence of and risk factors for major complications or death in dogs undergoing cytoreductive surgery for treatment of suspected primary intracranial masses.

OBJECTIVE To determine incidence of and risk factors for major complications occurring in dogs within 30 days after cytoreductive surgery performed by a single pair of surgeons for treatment of suspected primary intracranial masses. DESIGN Retrospective cohort study. ANIMALS 160 client-owned dogs that underwent cytoreductive surgery for treatment of suspected primary intracranial masses between January 2009 and December 2015 at a veterinary teaching hospital. PROCEDURES Medical records were retrospectively reviewed for complications occurring within 30 days after surgery. Data (eg, signalment, clinical signs, previous treatments, preoperative neurologic examination findings, neuroanatomical location, time from onset of clinical signs to surgery, surgical approach, and histopathologic diagnosis) were analyzed for associations with death and with development of major complications other than death. RESULTS 21 (13.1%) dogs died (11 during hospitalization and 10 after discharge) and 30 (18.8%) developed major complications other than death during the first 30 days after surgery. Dogs with abnormal preoperative neurologic examination findings were more likely to develop complications or die. Dogs undergoing a suboccipital approach were more likely to die. The most common postoperative complications other than death were seizures (n = 18 [11.3%]), worsening of neurologic status (6 [3.8%]), and aspiration pneumonia (6 [3.8%]). CONCLUSIONS AND CLINICAL RELEVANCE Results of the present study provided valuable information on predisposing factors, odds of major complications or death, and incidences of major complications or death in dogs during the first 30 days after undergoing cytoreductive surgery for treatment of suspected primary intracranial masses. Careful case selection may help improve outcomes and minimize complications.

Сравнительный анализ динамики температурно-болевой чувствительности после коррекции тяжелых и нетяжелых деформаций позвоночника у больных с идиопатическим сколиозом

Introduction Despite a great number of researches on idiopathic scoliosis reported there is still no instrumentation assessment of sensitivity before and after surgical correction of the curve found in literature. The purpose of the work was to explore dynamics in thermal pain sensitivity following correction of severe and mild spinal curves in patients with idiopathic scoliosis. Material and methods The work included results of examination of 25 patients with idiopathic scoliosis. Sampling population was divided into two groups depending on the extent of preoperative curve in major arch: Group I included patients with the curve of ≤ 60o (15 cases); Group II consisted of patients with the curve of > 60o (10 patients). Preoperative neurological examination showed no motor, reflex and sensory impairments. Acute deformity correction and spine stabilization with transpedicular systems were produced in all the cases. Thermal pain sensitivity was explored preoperatively and postoperatively at Th1-S2 dermatomes using electric esthesiometer. Results Disturbed thermal pain sensitivity of various extent was observed preoperatively in the study dermatomes of all patients with idiopathic scoliosis and was not shown to be dependent on the amount of the curve. Positive dynamics in thermal pain sensitivity revealed itself in reduced pain and heat thresholds and restored heat sensitivity and was observed in 41.5 to 54.1 % of the cases Group I following spine deformity correction. Deterioration was seen in 29.2 to 34.7 % of the cases. Group II showed negative dynamics in thermal pain sensitivity in 35.4 to 50 % of the cases with either increased or decreased pain threshold, enhanced heat threshold and loss of heat sensitivity. Sensitivity improved in 29.4 to 31.8 % of the patients. No changes in neurological status were noted in both groups after surgical correction with subclinical changes in thermal pain sensitivity to be considered. Conclusion Positive dynamics in thermal pain sensitivity prevailed in patients with idiopathic scoliosis following baseline curve correction of ≤ 60o. Negative dynamics in thermal pain sensitivity was seen in patients with baseline curve correction of > 60o with a greater risk of neurological complications.

Retrospective Assessment of Early Changes in the Sacroiliac Joint After Posterior Lumbar Fusion Surgery via Magnetic Resonance Imaging and Computed Tomography

The need for lumbar-lumbosacral fusion surgery has increased in the recent decade. Although this type of surgical approach has been reported to provide better improvement in low back pain compared with conventional conservative treatments, the ratio of failure varies between 5% and 30% in different studies. This retrospective study was conducted through screening patient files between January 2013 and January 2016. Preoperative and postoperative neurologic examination, Visual Analogue Scale, Oswestry Disability Index, and medical and surgical treatments of 66 patients were evaluated. The data from these 66 patients was included in this study. Of the patients, 28 were male and 38 were female. Mean age was 58.3 years for male and 60.1 years for female subjects. Mean duration of follow-up was 15 months. Our study has revealed that lumbosacral fusion surgery increases sacroiliac joint degeneration. We consider that magnetic resonance imaging is superior to computed tomography for detection of early stage sacroiliac joint degeneration.

Limits of endoscopic endonasal approach for cranio-vertebral junction tumors.

The endoscopic endonasal approach has been recently proposed for cranio-vertebral junction lesions. The more common indication for this sagittal extension of the endonasal route is represented by odontoidectomy for irreducible ventral brainstem compression due to congenital or degenerative conditions. However, in an increasing number of studies its adoption for tumors involving the cranio-cervical junction has been reported. The aim of this study is to consider retrospectively our surgical series, focusing on the advantages and limits of this approach. Each consecutive case of tumor involving the cranio-vertebral junction since 2007 to 2017 treated through an endoscopic endonasal approach has been included. All patients undergone preoperative neurological examination and neuroimaging (magnetic resonance imaging [MRI] and computed tomography angiography). These examinations were repeated after 3 months and then annually. Complementary treatments, recurrence rate and clinical status at mean follow-up of 18±7.3 months were considered. Seven patients have been included in this study, mean age was of 47±17 years; male-to-female ratio was of 3:4. Series is composed by 6 chordomas and one foramen magnum meningioma. One patient had been already posteriorly stabilized for cranio-vertebral instability. Gross tumor removal was achieved in two cases, in the others a subtotal removal was demonstrated at postoperative MRI. One patient presented a transitory worsening of CN XII palsy, resolved within 3 months. For preoperative dysphagia and inhalation pneumonia, one case undergone tracheostomy and was fed with oro-gastric tube for 10 days. Three patients died for chordoma progression and at follow-up one presented a local recurrence. Despite our experience is preliminary, the endoscopic endonasal approach has resulted safe for cranio-cervical junction tumor with a reduced number of complications. It can give a straight and direct trajectory to this deep region. We suggest that lateral extension of the tumor beyond the plane of cranial nerves is a limit for this approach, as well as an inferior expansion caudal to C1. Larger series and longer follow-up are required to assess the proper indications of this approach.

P016 Electrophysiological examination combined with functional intraoperative navigation using TMS of the motor cortex in patients with brain tumors in the vicinity of the central region

Question Surgery in the area of the motor cortex demands a combination of different neurological and image based examinations to improve outcome of the patients. Some examinations like intraoperative monitoring (IOM) with sensory evoked potentials (SEP) are established standard procedures. The question of our study is if the combination with presurgical transcranial magnetic brain stimulation (TMS) and its use combined with intraoperative navigation may improve the safety of the surgical procedure and neurological outcome. Obejctive and methods A prospective study including preoperative neurological and electrophysiological examination with SEP and TMS (MagPro R30, 230 V) was conducted. During surgery the TMS data combined with Neuronavigation LOCALITE were correlated with the intraoperative monitoring (IOM). Between 24 h and 96 h after the operation and after 3 months a neurological, electrophysiological examination and an additional TMS stimulation were performed. Results A total of 17 patients, with tumors nearby or in the motor cortex were included in the study. 9 patients completed either the whole study or were included in the pre- and the first postoperative examination. During the IOM including SEP, 5 out of 9 patients showed stable results, 3 showed persistent alterations, 1 showed a temporary change. 6 patients (66%), with the stable results and the temporary change, did not show a new neurological deficit. A preserved continuity of intraoperative SEP‘s leads to an improvement of the postoperative clinical outcome. The intraoperative SEP, as a valid method, matched 100 % with the postoperative outcome. The TMS data included in the intraoperative navigation correlated exactly with the intraoperative electrophysiological examination. A correspondence between the intraoperative findings, postoperative electrophysiological and neurological examination was found. Conclusion In summary the TMS as a nonvasive method provides data for constant representability of the motor cortex during surgery. In addition, with the intraoperative SEP’s, it contributes to a reduced surgical scope and finally an enhanced clinical outcome.

Awake Craniotomy Procedure: Its Effects on Neurological Morbidity and Recommendations.

To present our experience with the awake craniotomy (AC) method starting from the preoperative period, to report the morbidity and the functional outcomes along with the complications in patients who underwent AC, and to make recommendations for possible problems. This study involved 46 cases- 2 of which were pediatric cases with lesions localized in the functional area - who were operated with the AC method between September 2011 and January 2016 at our clinic. The age range was 12 to 81 years. The average age was 48 years. Both preoperative and postoperative (1, 3, 6 and 12 months) neurological examinations were recorded. Of the 46 patients who had AC surgery in this series, 17 were observed to have neurological deterioration in the intraoperative period. At the month 1 follow-up, 13 of these 17 patients were observed to have full neurological recovery. Moreover, 4 patients that developed hemiplegia were able to mobilize with support at the month 6 follow-up. All patients were observed to have a return of language skills to baseline preoperative function on month 1 follow-up. When the results of the AC method were examined, it was observed that persistent postoperative neurological deficit rates were very low in the follow-up period. Based on our practice presented here, it could be concluded that the precise synchrony between the surgeon, the anesthesia team and the patient is required for successful AC and the preservation of language and motor functions.

The Role of Cine Flow Magnetic Resonance Imaging in Patients with Chiari 0 Malformation.

To define the role of phase-contrast cine magnetic resonance imaging (MRI) in deciding the therapeutic strategy and underlying pathophysiology resulting in syrinx formation in patients with Chiari type 0 malformation. Seven patients who were admitted to our clinic with the diagnosis of Chiari 0 malformation from January 2005 to July 2016 were enrolled in the study. All patients underwent a detailed preoperative neurological examination. Entire neuroaxis MRI and phase-contrast cine MRI were obtained preoperatively and postoperatively. Seven patients (5 female and 2 male) with Chiari type 0 malformation fulfilled the inclusion criteria. All of the patients had absent cine flow at the craniovertebral junction except two patients. These five patients underwent surgical interventions; suboccipital decompression and duraplasty. All of them showed both clinical and radiological improvement in the postoperative period. Cine flow MRI appears to be a useful tool in the management of patients with Chiari 0 malformation. There was a good correlation between the clinical presentation and cine flow preoperatively, and between clinical improvement and cine flow in the postoperative period.