Rate Of Neurological Improvement Research Articles

Enlarging study of posterior cervical decompression responsibility segment

Objective To compare the medium-term efficacy of responsibility posterior segmental spinal decompression vs. expansion with traditional C3-C7 posterior decompression for treatment of multilevel cervical spinal stenosis. Methods A retrospective analysis from January 2013 to January 2015 in our hospital was performed on 137 patients undergoing posterior surgery, and responsibility segmental posterior spinal canal decompression group (A, n=64), and traditional C3-C7 posterior decompression group (B, n=73 cases) were set up. According to the results of follow-up, operative time, blood loss, preoperative and postoperative follow-up Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) score, and neurological improvement rate were analyzed. Results In responsibility segment posterior spinal canal decompression surgery group, pre-operative JOA score was (7.3±1.8), (9.3±1.8) at third month, and (13.1±1.1) at the end of follow-up; the pre-operative VAS score was (8.1±1.1), (6.1±0.9) at third month, and (3.3±0.9) at the end of follow-up. In traditional C3-C7 posterior decompression surgery group, pre-operative JOA score was (7.1±1.7), (9.2±1.7) at third month, and (13.0±1.4) at the end of follow-up; the preoperative VAS was (8.2±1.0), (6.4±0.8) at third month, and (2.9±0.9) at the end of follow-up. Pre-operative and post-operative JOA score between the two groups showed no significant difference (P>0.05), and at the end of follow-up VAS score was statistically significant (P 0.05), and blood loss was reduced and operative time was shortened in responsibility posterior segmental spinal canal decompression group as compared with those in the traditional C3-C7 posterior decompression group (P<0.05). Conclusion Responsibility segment posterior spinal canal decompression can also achieve good clinical efficacy. Responsibility segmental decompression operation time is shorter and blood loss is less, and can better improve the medium-term patients’ subjective symptoms. Key words: Cervical spondylosis; Posterior cervical; Responsibility segmental decompression

Bridging Therapy with i. v. rtPA in MCA Occlusion Prior to Endovascular Thrombectomy: aDouble-Edged Sword?

Recent studies suggested that preinterventional intravenous (i. v.) recombinant tissue plasminogen activator (rtPA) as bridging therapy facilitates successful and fast vessel recanalization in endovascular stroke treatment (EST); however, data on this effect and the associated clinical value are discrepant. This study examined if this discrepancy could be related to an effect-modifying variable, specifically to the exact occlusion site. Retrospective analysis of 239 patients with acute occlusion of the middle cerebral artery (MCA) treated with up to date endovascular techniques. Effects of i. v.-rtPA bridging on clinical outcomes and safety/efficacy of EST, defined as the respective rates of successful, first pass and thrombolysis in cerebral infarction (TICI) scale 3 recanalization, were evaluated and stratified according to distal versus proximal occlusion sites. Overall, i. v.-rtPA bridging was associated with asignificantly higher rate of successful recanalization (86.9 % vs. 75.7 %, p= 0.028). i. v.-rtPA bridging-related effects, however, were observable only in distal, but not in proximal MCA-occlusions. In distal occlusions, i. v.-rtPA clearly favored successful recanalization (adj. OR 4.6, 95 %-CI 1.5-13.6, p= 0.006) and first-pass successes (adj. OR 2.8, 95 %-CI 1.0-7.6, p= 0.042), but tended to be associated with lower rates of complete (TICI-3) reperfusion (adj. OR 0.4, 95 %-CI 0.2-1.1, p= 0.068). The net effect was asmall clinical benefit, reflected in higher rates of strong neurological improvement (adj. OR: 2.8, 95 %-CI: 1.1-6.9, p= 0.03). i. v.-rtPA-bridging-related effects are occlusion site-dependent, paralleling similar effects of systemic i. v.-rtPA when applied without subsequent endovascular therapy. In distal occlusions, i. v.-rtPA facilitates thrombectomy, but may also promote distal embolization, with asmall clinical benefit as overall net effect. Randomized trials assessing i.v-rtPA bridging need to be stratified according to occlusions sites.

Good collateral circulation predicts favorable outcomes in intravenous thrombolysis: a systematic review and meta‐analysis

Baseline collateral status has been correlated with outcomes of acute ischaemic stroke patients receiving intravenous thrombolysis (IVT) in previous studies. We carried out the current systematic review and meta-analysis to synthesize currently available evidence regarding such correlations. Full-text articles published since 2000 were retrieved and screened. The overall effect sizes of good versus poor collateral status over a series of outcomes and certain baseline features were estimated by random-effects models and presented in risk ratios (RRs) or mean differences. Overall, 28 (3057 patients) and 14 (1584 patients) studies were included in qualitative and quantitative synthesis, respectively. Compared with poor pre-treatment collateral status, good collaterals showed a beneficial effect over the primary outcome of a favorable functional outcome at 3 or 6months [RR, 2.45; 95% confidence interval, 1.94-3.09; P<0.001] in acute ischaemic stroke patients receiving IVT treatment. However, such an effect tended to be different between studies with prescribed time windows of 3, 4.5 and >4.5h (up to 7h), with the RRs being 2.21, 2.48 and 5.00, respectively (I2 =53%). Good pre-treatment collaterals were also associated with a smaller infarct size at baseline, and a lower rate of symptomatic intracranial hemorrhage and a higher rate of neurological improvement early after IVT treatment. The present study has demonstrated the prognostic value of baseline collateral circulation for outcomes of acute ischaemic stroke patients receiving intravenous reperfusion therapies, studied with different time windows of up to 7h after ictus for IVT therapy.

A novel technique for unstable Hangman’s fracture: lag screw-rod (LSR) technique

The goal of the study was to describe the lag screw-rod (LSR) technique for the treatment of unstable Hangman's fracture as an attempt to pull C2 vertebral body back to posterior elements easily and immobilize C2 relative to C3 simultaneously. Twenty-one patients with unstable Hangman's fracture were treated with the LSR technique from January 2008 to October 2014. The clinical and radiological records were reviewed retrospectively. The angulation and displacement of C2 on C3 were evaluated. Complications, neck pain, neurological improvement, and fusion rate were assessed. The LSR technique was used for C2-C3 pedicle fixation and fusion in all the patients. The C2 vertebral body was pulled back to posterior elements successfully. The angulation and displacement of C2 on C3 were rectified obviously. No intra-operative or post-operative spinal cord or vertebral injury was observed. Visual analogue scale (VAS) scores for neck pain decreased gradually after operation. The patients with spinal cord injury were recovered at final following up. All patients achieved bony fusion without internal fixation failures. The LSR technique is an effective and reliable treatment for unstable Hangman's fractures. The technique has the advantages of pulling back the C2 vertebral body back to posterior elements easily and immobilizing C2 relative to C3 simultaneously.

Impact of thrombolysis in acute ischaemic stroke without occlusion: an observational comparative study

The impact of intravenous recombinant tissue plasminogen activator (IV-rtPA) in patients with acute ischaemic stroke (AIS) but no arterial occlusion is currently a matter of debate. This study aimed to assess functional outcome of such patients with respect to IV-rtPA use. A retrospective case-control analysis was performed comparing the outcome of AIS patients without arterial occlusion with or without IV-rtPA use. Patients were selected from prospective consecutive observational registries of five European university hospitals. The primary study outcome was excellent outcome at 3 months after stroke, as defined by a modified Rankin Scale (mRS) 0-1. A total of 488 patients without arterial occlusion documented by angiography were included in the present study; 300 received IV-rtPA and 188 did not. No between-group difference was found for excellent outcome before and after adjustment for baseline characteristics (adjusted odds ratio for no IV-rtPA use 0.79, 95% confidence interval 0.51-1.24, P = 0.31). Similar results were found for favourable outcome (defined as a 90-day mRS of 0-2) whereas a higher rate of early neurological improvement was found in IV-rtPA-treated patients (adjusted odds ratio 1.99; 95% confidence interval 1.29-3.07, P = 0.002). Sensitivity analyses yielded similar results. Our study suggests that AIS patients without visible arterial occlusion treated with IV-rtPA may have no better outcome at 3 months than those untreated. However, only a randomized controlled trial would provide a definitive answer about the impact of rtPA in acute stroke patients without occlusion. Until then, these patients should be treated by rtPA as recommended.

Generalization of the Right Acute Stroke Prevention Strategies in Reducing in-Hospital Delays.

The aim of this study was to reduce the door-to-needle (DTN) time of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) through a comprehensive, hospital-based implementation strategy. The intervention involved a systemic literature review, identifying barriers to rapid IVT treatment at our hospital, setting target DTN time intervals, and building an evolving model for IVT candidate selection. The rate of non-in-hospital delay (DTN time ≤ 60 min) was set as the primary endpoint. A total of 348 IVT cases were enrolled in the study (202 and 146 in the pre- and post-intervention group, respectively). The median age was 61 years in both groups; 25.2% and 26.7% of patients in the pre- and post-intervention groups, respectively, were female. The post-intervention group had higher rates of dyslipidemia and minor stroke [defined as National Institutes of Health Stroke Scale (NIHSS) ≤ 3]; less frequent atrial fibrillation; higher numbers of current smokers, heavy drinkers, referrals, and multi-model head imaging cases; and lower NIHSS scores and blood sugar level (all P < 0.05). All parameters including DTN, door-to-examination, door-to-imaging, door-to-laboratory, and final-test-to-needle times were improved post-intervention (all P < 0.05), with net reductions of 63, 2, 4, 28, and 23 min, respectively. The rates of DTN time ≤ 60 min and onset-to-needle time ≤ 180 min were significantly improved by the intervention (pre: 9.9% vs. post: 60.3%; P < 0.001 and pre: 23.3% vs. post: 53.4%; P < 0.001, respectively), which was accompanied by an increase in the rate of neurological improvement (pre: 45.5% vs. post: 59.6%; P = 0.010), while there was no change in incidence of mortality or systemic intracranial hemorrhage at discharge (both P > 0.05). These findings indicate that it is possible to achieve a DTN time ≤ 60 min for up to 60% of hospitals in the current Chinese system, and that this logistical change can yield a notable improvement in the outcome of IVT patients.

A Systematic Review of Clinical Outcomes and Prognostic Factors for Patients Undergoing Surgery for Spinal Metastases Secondary to Breast Cancer.

Study Design Review of the literature.Objective Surgery and cement augmentation procedures are effective palliative treatment of symptomatic spinal metastases. Our objective is to systematically review the literature to describe the survival, prognostic factors, and clinical outcomes of surgery and cement augmentation procedures for breast cancer metastases to the spine.Methods We performed a literature review using PubMed to identify articles that reported outcomes and/or prognostic factors of the breast cancer patient population with spinal metastases treated with any surgical technique since 1990.Results The median postoperative survival for metastatic breast cancer was 21.7 months (8.2 to 36 months), the mean rate of any pain improvement was 92.9% (76 to 100%), the mean rate of neurologic improvement was 63.8% (53 to 100%), the mean rate of neurologic decline was 4.1% (0 to 8%), and the local tumor control rate was 92.6% (89 to 100%). Kyphoplasty studies reported a high rate of pain control in selected patients. Negative prognostic variables included hormonal (estrogen and progesterone) and human epidermal growth factor receptor 2 (HER2) receptor refractory tumor status, high degree of axillary lymph node involvement, and short disease-free interval (DFI). All other clinical or prognostic parameters were of low or insufficient strength.Conclusion With respect to clinical outcomes, surgery consistently yielded neurologic improvements in patients presenting with a deficit with a minimal risk of worsening; however, negative prognostic factors associated with shorter survival following surgery include estrogen receptor/progesterone receptor negativity, HER2 negativity, and a short DFI.

Purely endoscopic endonasal surgery of the craniovertebral junction: A systematic review.

Endoscopic endonasal surgery (EES) is a relatively novel approach to the craniovertebral junction (CVJ). The purpose of this analysis is to determine the surgical outcomes of patients who undergo purely EES of the CVJ. A search for articles related to EES of the CVJ was performed using the MEDLINE/PubMed database. A bibliographic search was done for additional articles. Demographics, presenting symptoms, imaging findings, complications, follow-up, and patient outcomes were analyzed. Eighty-five patients from 30 articles were included. The mean patient age was 47.9 ± 24.8 years (range, 3 to 96 years), with 44.7% being male. The most common presenting symptom was myelopathy (n = 64, 75.3%). The most common indications for surgery were brainstem compression secondary to basilar invagination (n = 41, 48.2%) and odontoid pannus (n = 20, 23.5%). Odontoidectomy was performed in 97.6% of cases. Intraoperative complications occurred in 16 patients (18.8%) and postoperative complications occurred in 18 patients (21.2%). Six patients developed postoperative respiratory failure necessitating a tracheostomy. Neurologic improvement was seen in 89.4% of patients at a mean follow-up of 22.2 months. Our analysis found that EES of the CVJ results in a high rate of neurologic improvement with acceptable complication rates. Given its minimally invasive nature and high success rate, this approach appears to be a reasonable alternative to the traditional transoral approach in select cases. This study represents the largest pooled sample size of EES of the CVJ to date. Increasing use of the endoscopic endonasal approach will allow for further studies with greater statistical power.

A Systematic Review of Clinical Outcomes and Prognostic Factors for Patients Undergoing Surgery for Spinal Metastases Secondary to Breast Cancer

Introduction Surgical treatment and cement augmentation procedures are effective palliative techniques for the treatment of symptomatic spinal metastases. However, clinical results specific to a breast cancer cohort are generally lacking. We aim to systematically review the literature for clinical outcomes following operative interventions and prognostic factors for the treatment of breast metastases to the spine. Specifically, we describe the survival and clinical outcomes of surgery and cement augmentation procedures for breast metastases to the spine and to determine prognostic variables that may help recognize which patients will perform better or worse following surgery. Methods We performed a literature review using PubMed to identify articles that reported outcomes and/or prognostic factors of the breast cancer patient population with spinal metastases treated with any surgical technique since 1990. Results A total of 19 surgical studies, 4 cement augmentation studies, and 6 nonsurgical prognostic variable studies met the preset inclusion criteria. All but three studies (two surgical and one cement augmentation) were retrospective in nature, and all studies were of level of evidence IV. Median postoperative survival for metastatic breast cancer was 21.7 months (8.2–36 months), mean rate of pain improvement was 92.9% (76–100%), mean rate of neurological improvement was 63.8% (53–100%), mean rate neurological decline was 4.1% (0–8%), and mean rate LTC was 92.6% (89–100%). Kyphoplasty studies reported a high rate of pain control in selected patients. Negative prognostic variables included: hormonal (estrogen and progesterone) and HER2 receptor refractory tumor status, high degree of axillary lymph node involvement, and short disease-free interval (DFI). All other clinical or prognostic parameters were of low or insufficient strength. Conclusion With respect to clinical outcomes, studies consistently found that surgery resulted in neurological improvement for a majority of patients, with a minimal risk of worsening, and kyphoplasty studies reported a high rate of pain control. Increased postoperative survival 2002 onwards was likely due to FDA approval of new chemotherapies. However, specific factors associated with shorter survival following surgery involve hormone and HER2 receptor status and disease-free interval.

Tuberculosis of the spine – Prospective neurological and patient reported outcome study

ObjectiveTo prospectively investigate the rate of neurological recovery and patient reported outcome of tuberculosis (TB) spine patients following surgery at a tertiary referral hospital.TB spine remains a major cause of neurological impairment in the developing world fuelled by poor socio-economic conditions and HIV co-infection. Although numerous retrospective studies are available, there is a paucity of prospective data regarding rate of neurological improvement and patient reported outcome. MethodsTwenty adult patients were prospectively recruited. The average age was 44.5 years. Half had co-existent HIV infection.All patients underwent decompressive surgery utilising a variety of anterior and posterior procedures. All received a minimum of 9 months TB medication.They were followed up at 4, 8, 12, 26 and 52 weeks post operatively. Neurological status was monitored by Nurick, mJOA and ASIA systems. Patient reported outcome was monitored by SF36 questionnaires at all-time points. ResultsAll patients improved neurologically including 4 ASIA A's. By last follow up, 17 could walk as opposed to 5 pre-op. The Nurick average score improved from 5.5 to 1.9 and the mJOA lower limb score 1.8–5.5.The SF36 improved from 31 to 62 over the year with the biggest gains occurring after 3 months. This was confirmed in all domains except pain and social, which improved earlier. ConclusionsThere is a positive prognosis for neurological outcome in TB spine following a variety of surgical decompressive procedures and medical therapy. The majority of the recovery occurs after the 3 months post-operative mark.

Abstract T P66: Safety and Effectiveness of Intravenous Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke Patients on Aspirin and Clopidogrel

Background: The number of acute ischemic stroke patients who are on both aspirin and clopidogrel treatment at time of acute ischemic event is increasing. There is limited data regarding the safety and efficacy of intravenous recombinant tissue plasminogen activator (rt-PA) treatment in such patients. Methods: We reviewed the medical records and imaging data of consecutive patients with acute ischemic stroke who received IV rt-PA within 4.5 hours of symptom onset. We stratified the patients based on active regular use of antiplatelet medications: monotherapy (aspirin or clopidogrel), combination therapy (aspirin and clopidogrel), and no therapy and compared the rates of symptomatic intracerebral hemorrhage (ICH), neurological improvement (≥4 points in National Institutes of Health Stroke Scale [NIHSS], and favorable outcome (modified Rankin scale [mRS] 0-1) at discharge between the three groups. Results: A total of 88 acute ischemic stroke patients (mean age±SD; 69.88 ±15) were treated with IV rt-PA within the study duration. Of the 88 patients 45 (50.6%), 37 (41.6%), and 52 (58.4) were on monotherapy, combination therapy, or no therapy at time of presentation. The proportion of patients who developed symptomatic ICHs were similar (p=0.8) in monotherapy, combination therapy, and no therapy groups (3.3%, 0.0%, and 4.1%, respectively). The rates of neurological improvement were greater in patients on monotherapy (20%) (p=0.03) followed by combination therapy (11.1%), and no therapy groups (2.0%). There was no significant reduction in the rate of favorable outcome at discharge among patients on combination treatment compared with no treatment (odds ratio 0.8 , 95% confidence interval 0.4-1.8 ) after adjusting for age and initial NIHSS score strata (&lt;10, 10-19, and ≥20). Conclusions: Compared with patients on no antiplatelet treatment, acute ischemic stroke patients who are actively using aspirin and clopidogrel appear to have similar risks and benefits with IV rt-PA treatment.

Surgical outcome and prognostic factors of anterior decompression and fusion for cervical compressive myelopathy due to ossification of the posterior longitudinal ligament

Background contextAnterior decompression and fusion (ADF) for ossification of the posterior longitudinal ligament (OPLL) is technically demanding and associated with complications. Although various factors affecting clinical outcome have been investigated in posterior decompression, prognostic factors of ADF remain unclear. PurposeThe purpose of the study was to identify surgical outcome and prognostic factors of ADF for cervical myelopathy due to OPLL. Study designThis was a retrospective case study. Patient sampleBetween 2005 and 2012, 913 patients underwent decompression surgery for cervical OPLL at our institution. Among them, 131 who underwent ADF and 221 who underwent laminoplasty were enrolled. Inclusion criteria were (1) diagnosis of OPLL; (2) cervical compressive myelopathy; and (3) no trauma, infection, tumor, or previous surgery. We excluded 60 patients with ADF and 157 patients with laminoplasty owing to inadequate follow-up or absence of preoperative myelopathy. Finally, 71 patients with ADF and 64 patients with laminoplasty were enrolled in this study (mean follow-up, 48 vs 41 months). Outcome measuresNeurologic assessment was conducted using the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy. Rate of neurologic improvement was calculated by comparing preoperative and postoperative JOA scores. MethodsWe investigated the effects of such variables as age, gender, body mass index (BMI), presence of diabetes mellitus (DM), smoking history, type of OPLL, shape of the ossified lesion, occupying ratio of OPLL, presence of intramedullary increased signal intensity (ISI) on magnetic resonance imaging (MRI), and sagittal alignment of the cervical spine on surgical outcome. Severity of ISI was classified into three groups based on T2-weighted sagittal MRI as follows: Grade 0, none; Grade 1, ISI limited to one disc level; or Grade 2, ISI beyond one disc level. This work was supported by the 2013 Korea Health Technology R&D Project of the Ministry of Health and Welfare of the Republic of Korea (A120254). ResultsIn patients with an occupying ratio ≥60% or with presence of ISI on MRI, ADF yielded better surgical outcome than laminoplasty. A higher ISI grade (B=−28.5, p=.000) and a higher occupying ratio (B=0.88, p=.04) were significantly associated with a lower recovery rate (R=0.56, p=.006). Older age also was associated with a lower recovery rate. Gender, BMI, presence of DM, smoking history, type of OPLL, shape of the ossified lesion, and cervical alignment were not associated with recovery rate. ConclusionAnterior decompression and fusion has favorable outcome in patients with an occupying ratio ≥60% or with presence of ISI on MRI. Presence of higher ISI grade, higher occupying ratio, and older age were associated with a poor long-term surgical prognosis. Therefore, evaluating ISI and occupying ratio on preoperative MRI is important for selecting the appropriate surgical approach and for predicting clinical outcome after surgery for cervical compressive myelopathy due to OPLL.

Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data

Information pertaining to the natural history of intramedullary spinal cord cavernous malformations (ISCCMs) and patient outcomes after surgery is scarce. To evaluate factors associated with favorable outcomes for patients with surgically and conservatively managed ISCCMs, the authors performed a systematic review and metaanalysis of the literature. In addition, they included their single-center series of ISCCMs. The authors searched MEDLINE, EMBASE, CINAHL, Google Scholar, and The Cochrane Library for studies published through June 2013 that reported cases of ISCCMs. Data from all eligible studies were used to examine the epidemiology, clinical features, and neurological outcomes of patients with surgically managed and conservatively treated ISCCMs. To evaluate several variables as predictors of favorable neurological outcomes, the authors conducted a meta-analysis of individual patient data and performed univariate and multivariate logistic regression analyses. Variables included patient age, patient sex, lesion spinal level, lesion size, cerebral cavernomas, family history of cavernous malformations, clinical course, presenting symptoms, treatment strategy (operative or conservative), symptom duration, surgical approach, spinal location, and extent of resection. In addition, they performed a meta-analysis to determine a pooled estimate of the annual hemorrhage rate of ISCCMs. Eligibility criteria were met by 40 studies, totaling 632 patients, including the authors' institutional series of 24 patients. Mean patient age was 39.1 years (range 2-80 years), and the male-to-female ratio was 1.1:1. Spinal levels of cavernomas were cervical (38%), cervicothoracic (2.4%), thoracic (55.2%), thoracolumbar (0.6%), lumbar (2.1%), and conus medullaris (1.7%). Average cavernoma size was 9.2 mm. Associated cerebral cavernomas occurred in 16.5% of patients, and a family history of cavernous malformation was found for 11.9% of evaluated patients. Clinical course was acute with stepwise progression for 45.4% of patients and slowly progressive for 54.6%. Symptoms were motor (60.5%), sensory (57.8%), pain (33.8%), bladder and/or bowel (23.6%), respiratory distress (0.5%), or absent (asymptomatic; 0.9%). The calculated pooled annual rate of hemorrhage was 2.1% (95% CI 1.3%-3.3%). Most (89.9%) patients underwent resection, and 10.1% underwent conservative management (observation). Outcomes were better for those who underwent resection than for those who underwent conservative management (OR 2.79, 95% CI 1.46-5.33, p = 0.002). A positive correlation with improved neurological outcomes was found for resection within 3 months of symptom onset (OR 2.11, 95% CI 1.31-3.41, p = 0.002), hemilaminectomy approach (OR 3.20, 95% CI 1.16-8.86, p = 0.03), and gross-total resection (OR 3.61, 95% CI 1.24-10.52, p = 0.02). Better outcomes were predicted by an acute clinical course (OR 1.72, 95% CI 1.10-2.68, p = 0.02) and motor symptoms (OR 1.76, 95% CI 1.08-2.86, p = 0.02); poor neurological recovery was predicted by sensory symptoms (OR 0.58, 95% CI 0.35-0.98, p = 0.04). Rates of neurological improvement after resection were no higher for patients with superficial ISCCMs than for those with deep-seated ISCCMs (OR 1.36, 95% CI 0.71-2.60, p = 0.36). Intramedullary spinal cord cavernous malformations tend to be clinically progressive. The authors' findings support an operative management plan for patients with a symptomatic ISCCM. Surgical goals include gross-total resection through a more minimally invasive hemilaminectomy approach within 3 months of presentation.

Is it feasible to treat unstable hangman's fracture via the primary standard anterior retropharyngeal approach?

The goal of this study was to evaluate the results and feasibility of primary anterior cervical discectomy and fusion (ACDF) with plating for unstable traumatic spondylolisthesis of the axis, the so-called hangman's fracture, via the standard anterior retropharyngeal approach. The clinical and radiological records of 17 patients (14 males and 3 females, mean age: 51 years, range 17-73 years) with unstable hangman's fracture who were treated between January 1996 and June 2012 were reviewed retrospectively. ACDF with plating at C2-3 level was performed in all patients (type II fracture: 12 patients, type IIA fracture: 3 patients and type III fracture: 2 patients, based on the Levine and Edwards classification). Combined morbidity, complications, neurological improvement and fusion rate were assessed. Seventeen patients underwent fusion surgery via the standard anterior retropharyngeal approach. Four patients required an additional posterior arthrodesis to augment the anterior procedure. Patients wore a Philadelphia collar for 4-6 weeks and fusion at C2-3 was achieved in all patients. Two cases of complications were observed during treatment, comprising of one case of non-union and one case of transient dysphagia that resolved after 3 months. However, none of the patients experienced worsening of the neurological function post-operatively. There were no cases of permanent nerve injury or infection. Treatment of the hangman's fracture is dependent on the stability of the injury. Although the treatment for unstable hangman's fracture is still controversial, we carefully suggest that primary ACDF with plating via the standard anterior retropharyngeal approach may be a feasible treatment option. It provides immediate stability and allows for early ambulation while promoting a stable bone union with minimal morbidity.

Early neurological improvement after intravenous tissue plasminogen activator infusion in patients with ischemic stroke aged 80 years or older

BackgroundEarly neurological improvement has been observed in patients with stroke receiving treatment with standard intravenous recombinant tissue plasminogen activator. However, the effectiveness of thrombolytic treatment and the risk of hemorrhagic transformation are not well understood in patients aged ≥80 years. In this study, we investigated the influence of age on early neurological improvement and hemorrhagic transformation rates in patients with stroke aged ≥80 years and receiving recombinant tissue plasminogen activator. MethodsThe study included 157 patients who received recombinant tissue plasminogen activator infusion at a teaching hospital. The National Institutes of Health Stroke Scale was used to evaluate stroke severity. Early neurological improvement was defined as an improvement of 8 or more points on this scale (compared with baseline) 24 hours after thrombolytic treatment. Neurological improvement was defined as an improvement of 8 or more points (compared with baseline) at discharge. Neurological deterioration was defined as an increase of 4 or more points (compared with baseline). Multivariate analysis was used to evaluate the associations among age, neurological improvement, and hemorrhagic transformation. ResultsThe rate of early neurological improvement was 36.9% (58/157 patients) and the rate of hemorrhagic transformation was 22.3% (35/157 patients). At discharge, the rate of neurological improvement was 50.9% (80/157 patients) and the rate of neurological deterioration was 13.4% (21/157 patients). There was no statistically significant difference between patients aged ≥80 years and those <80 years of age with respect to rates of early neurological improvement, neurological deterioration, or hemorrhagic transformation. Among patients ≥80 years, the rate of neurological improvement in those receiving thrombolytic treatment was higher than the rate in those patients not receiving thrombolytic treatment (58.8% vs. 14.1%, p < 0.01). We concluded that thrombolysis increases the rate of neurological improvement in patients aged ≥80 years. ConclusionIn older patients, thrombolytic treatment increased the rate of neurological improvement compared with patients not receiving the treatment. The study showed that thrombolytic treatment may be beneficial for patients ≥80 years, but should be performed with extreme care.

Stereotactic radiosurgery for cerebellopontine angle meningiomas

To assess the long-term outcomes of stereotactic radiosurgery (SRS) for cerebellopontine angle (CPA) meningiomas, the authors retrospectively reviewed data from a 20-year experience. They evaluated progression-free survival as well as improvement, stabilization, or deterioration in clinical symptoms. Seventy-four patients with CPA meningiomas underwent SRS involving various Gamma Knife technologies between 1990 and 2010. The most common presenting symptoms were dizziness or disequilibrium, hearing loss, facial sensory dysfunction, and headache. The median tumor volume was 3.0 cm(3) (range 0.3-17.1 cm(3)), and the median radiation dose to the tumor margin was 13 Gy (range 11-16 Gy). The median follow-up period was 40 months (range 4-147 months). At last imaging follow-up, the tumor volume had decreased in 46 patients (62%), remained stable in 26 patients (35%), and increased in 2 patients (3%). The progression-free survival after SRS was 98% at 1 year, 98% at 3 years, and 95% at 5 years. At the last clinical follow-up, 23 patients (31%) showed neurological improvement, 43 patients (58%) showed no change in symptoms or signs, and 8 patients (11%) had worsening symptoms or signs. The neurological improvement rate after SRS was 16% at 1 year, 31% at 3 years, and 40% at 5 years. The post-SRS deterioration rate was 5% at 1 year, 10% at 3 years, and 16% at 5 years. A multivariate analysis demonstrated that trigeminal neuralgia was the symptom most likely to worsen after SRS (HR 0.08, 95% CI 0.02-0.31; p = 0.001). Asymptomatic peritumoral edema occurred in 4 patients (5%) after SRS, and symptomatic adverse radiation effects developed in 7 patients (9%). Stereotactic radiosurgery for CPA meningiomas provided a high tumor control rate and relatively low risk of ARE. Tumor compression of the trigeminal nerve by a CPA meningioma resulted in an increased rate of facial pain worsening in this patient experience.

Skull base meningiomas: neurological outcome after microsurgical resection

Microsurgical resection is the primary treatment of skull base meningiomas. Maximal resection provides the best tumor control rates but can be associated with high surgical morbidity. To understand the relation between extent of resection (EOR) and functional outcome we have analyzed the neurological improvement and recurrence rate in a large consecutive series of skull base meningioma patients. In addition, we defined anatomical and biological factors predictive for recurrence and overall outcome. We investigated 226 skull base meningioma patients receiving tumor resection in our institution. The most frequent location was the medial sphenoid ridge (29.6 %). EOR was rated according to the Simpson scale. Overall performance was measured by the Karnofsky performance score (KPS); neurological deficits were quantified using the Medical Research Council Neurological Severity Score (MRC-NPS). Complete resection was achieved in 62.8 % and the EOR was significantly correlated to tumor location. The morbidity and mortality rate was 32.1 and 2.7 % respectively, new permanent neurological deficits occurred in 3.5 % of all patients. From all patients with focal neurological deficits, 60.1 % experienced significant improvement. Both the MRC-NPS and the KPS significantly improved from the preoperative status to discharge, however the improvement rate was dependent on the tumor location. Recurrence rate was 15.5 %; tumor size, bone- and venous sinus infiltration, WHO grade, poor EOR but not MIB-1 labeling index were independent factors predictive for recurrence. Microsurgical resection of skull base meningiomas improves neurological impairment in the majority of patients. Specific risk factors for recurrence require consideration for postoperative management.

The relationship between plasma D-dimer levels and outcome of Chinese acute ischemic stroke patients in different stroke subtypes

High-level plasma D-dimer suggests hypercoagulable states. There is a lack of correlation study of plasma D-dimer level and prognosis according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. The goal of this study is to explore the relationship between the plasma D-dimer level and the outcome of acute ischemic stroke patients among different stroke subtypes. We conducted a study of acute ischemic stroke patients admitted to the Department of Neurology in Second Hospital of Lanzhou University within 7days of symptom onset. They were divided into different groups based on their subtypes according to TOAST criteria. In all the patients the plasma D-dimer levels were detected within 24h of admission. Clinical neurological assessments were performed in line with National Institutes of Health Stroke Scale (NIHSS) once daily on the day of admission and on the 14th day. The outcome was evaluated by neurological improvement rate. Comparisons were made among the different subtypes based on the level of plasma D-dimer and the outcome. A total of 300 patients with acute ischemic stroke were included, 40 with cardioembolism; 47 with large-artery atherosclerosis; 143 with small-artery occlusion, 5 with other etiology stroke; and 65 with undetermined etiology stroke. The level of plasma D-dimer was negatively related to the outcome (r=-0.41; P=0.013). Patients with cardioembolism had the highest level of plasma D-dimer and they suffered the most serious neurological deficit and the worst outcome among the five subtypes, the difference was statistically significant (F=5.34; P=0.012); while the lacunar stroke patients had the best outcome with the lowest level of D-dimer. High-level plasma D-dimer of acute period strongly indicates an unfavorable clinical outcome.

Prognostic value of changes in spinal cord signal intensity on magnetic resonance imaging in patients with cervical compressive myelopathy

Background contextSignal intensity on preoperative cervical magnetic resonance imaging (MRI) of the spinal cord has been shown to be a potential predictor of outcome of surgery for cervical compressive myelopathy. However, the prognostic value of such signal remains controversial. One reason for the controversy is the lack of proper quantitative methods to assess MRI signal intensity. PurposeTo quantify signal intensity and to correlate intramedullary signal changes on MRI T1- and T2-weighted images (WIs) with clinical outcome and prognosis. Study designRetrospective case study. Patient samplePatients (n=148; cervical spondylotic myelopathy, n=102 and ossified posterior longitudinal ligament, n=46) who underwent surgery for cervical compressive myelopathy and had high signal intensity change on sagittal T2-WI MRI before surgery between 2006 and 2010. Outcome measureNeurologic assessment was conducted with the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy. The rate of neurologic improvement was calculated with the use of preoperative and postoperative JOA scores. MethodsQuantitative analysis of MRI signal on both T1- and T2-WIs via use of the signal intensity ratio (SIR; signal intensity of lesion relative to that at C7-T1 disc level) was performed. Correlations between SIR on T1- and T2-WIs and preoperative JOA score, JOA improvement rate, disease duration, and MRI morphologic classification (cystic or diffuse type) were analyzed. Multivariate regression analysis for JOA improvement rate was also analyzed. In a substudy, 25 patients underwent follow-up MRI starting from 6 months after surgery to analyze the relationship between changes in SIR on follow-up MRI and clinical outcome. ResultsSIR on T1-WIs, but not SIR on T2-WIs, correlated with postoperative neurologic improvement. The disease duration correlated negatively with SIR on T1-WIs and JOA improvement rate but not with SIR on T2-WIs. SIR on T2-WIs of “cystic type” was significantly greater than of “diffuse type,” but SIR on T1-WI and JOA improvement rate were not different in the two types. Stepwise multivariate regression analysis indicated that SIR on T1-WIs and long disease duration were significant predictors of postoperative neurologic outcome. SIR on follow-up T1-WI and changes in SIR on T1-WI after surgery correlated positively with postoperative improvement rate. SIR on follow-up T2-WI and changes on T2-WI correlated negatively with postoperative neurologic improvement. ConclusionsOur results suggest that low intensity signal on preoperative T1-WIs but not T2-WIs correlated with poor postoperative neurologic outcome. Furthermore, decreased signal intensity on postoperative T1-WIs and increased signal intensity on postoperative T2-WIs are predictors of poor neurologic outcome.

The Effects of the Timing of Spinal Surgery after Traumatic Spinal Cord Injury: A Systematic Review and Meta-Analysis

Abstract The debate over the effects of the timing of surgical spinal decompression after traumatic spinal cord injury (tSCI) has remained unresolved for over a century. The aim of the current study was to perform a systematic review and quality-adjusted meta-analysis of studies evaluating the effects of the timing of spinal surgery after tSCI. Studies were searched for through the MEDLINE(®) database (1966 to August 2012) and a 15-item, tailored scoring system was used for assessing the included studies' susceptibility to bias. Random effects and quality effects meta-analyses were performed. Models were tested for robustness using one way and criterion-based sensitivity analysis and funnel plots. Results are presented as weighted mean differences (WMDs) and odds ratios (ORs) with 95% confidence intervals (CIs). A total of 18 studies were analyzed. Heterogeneity was evident among the studies included. Quality effects models showed that - when compared with "late" surgery - "early" spinal surgery was significantly associated with a higher total motor score improvement (WMD: 5.94 points, 95% CI:0.74,11.15) in seven studies, neurological improvement rate (OR: 2.23, 95% CI:1.35,3.67) in six studies, and shorter length of hospital stay (WMD: -9.98 days, 95% CI:-13.10,-6.85) in six studies. However, one way and criterion-based sensitivity analyses demonstrated a profound lack of robustness among pooled estimates. Funnel plots showed significant proof of publication bias. In conclusion, despite the fact that "early" spinal surgery was significantly associated with improved neurological and length of stay outcomes, the evidence supporting "early" spinal surgery after tSCI lacks robustness as a result of different sources of heterogeneity within and between original studies. Where the conduct of a surgical, randomized controlled trial seems to be an unfeasible undertaking in acute tSCI, methodological safeguards require the utmost attention in future cohort studies. (Prospero registration number: PROSPERO CRD42012003182. See also http://www.crd.york.ac.uk/NIHR_PROSPERO/ ).