Significant Improvement In Neurological Status Research Articles

Long-Term Functional Outcomes Following Surgical Treatment of Spinal Schwannomas: A Population-Based Cohort Study

Spinal schwannomas are the second most common form of primary intradural spinal tumor. Despite being benign, they may cause spinal cord compression and subsequently acute or chronic neurological dysfunction. The primary treatment is surgical resection. The aim of this study was to identify pre- and postoperative predictors of favorable outcomes after surgical treatment for spinal schwannoma. All adult patients surgically treated for spinal schwannoma between 2006 and 2020 were eligible for inclusion. Medical records and imaging data were retrospectively reviewed. The primary outcome measures were neurological improvement according to the modified McCormick Scale (mMC) and changes in motor deficit, sensory deficit, gait disturbance, bladder dysfunction, and pain at long-term follow-up. In total, 180 patients with a median follow-up time of 4.4 years were included. Pain was the most common presenting symptom (87%). The median time between symptom presentation and surgery was 12 months, while the median time between diagnosis (first MRI) and surgery was 3 months. Gross total resection (GTR) was achieved in 150 (83%) patients and the nerve root could be preserved in 133 (74%) patients. A postoperative complication occurred in 10 patients (5.6%). There were significant postoperative improvements in terms of motor, sensory, gait, and bladder functions, as well as pain (p < 0.001). Of these symptoms, bladder dysfunction was the one most often improved, with complete symptom resolution in all cases. However, no other predictors of improvement could be identified. There were three cases of recurrence after GTR and nine cases of regrowth after STR. Reoperation was performed in six (3.3%) cases. GTR was associated with a significant improvement in neurological status at long-term follow-up and increased the chance of progression-free survival.

Evaluation on the Efficacy and Safety of Panax Notoginseng Saponins in the Treatment of Stroke among Elderly People: A Systematic Review and Meta-Analysis of 206 Randomized Controlled Trials.

Evidence regarding the effect of Panax notoginseng saponins (PNS) on treating elderly stroke patients is scare and inconsistent. This study investigated the efficacy and safety of PNS by means of meta-analysis so as to provide an evidence-based reference for the treatment of elderly patients with stroke. We searched the PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP, Wanfang, and China Biomedical Database to identify the eligible randomized controlled trials (RCTs) concerning using PNS to treat elderly people with stroke from their inception to first, May 2022. Meta-analysis was used for pool analysis of the included studies, whose quality was assessed via Cochrane Collaboration's RCT risk of bias tool. Altogether 206 studies published between 1999 and 2022 with a low risk of bias were included, covering 21,759 participants. The results showed that the improved neurological status shown in the intervention group with PNS alone was statistically significant (SMD = -0.826, 95% CI: -0.946 to -0.707) in contrast to the control group. The total clinical efficacy (Relative risk (RR) = 1.197, 95% Confidence interval (CI): 1.165 to 1.229) and daily living activities (SMD = 1.675, 95% C: 1.218 to 2.133) of elderly stroke patients were significantly improved as well. In addition, the invention group using PNS combined with WM/TAU displayed significant improvement in neurological status (SMD = -1.142, 95% CI: -1.295 to -0.990) and the total clinical efficacy (RR = 1.191, 95% CI: 1.165 to 1.217) compared with the control group. Single PNS intervention or PNS combined with WM/TAU significantly improves the neurological status, the overall clinical efficacy and daily living activities of elderly stroke patients. However, more multicenter RCT research with high quality is required in the future to verify the results in this study. The trial registration number: Inplasy protocol 202330042. doi:10.37766/inplasy2023.3.0042.

Skip corpectomy in surgical treatment of cervical spondylotic myelopathy

To evaluate the effectiveness and safety of skip corpectomy in surgical treatment of cervical spondylotic myelopathy. The study included 7 patients with cervical myelopathy following extended cervical spine stenosis. All patients underwent skip corpectomy. Clinical examination included degree of neurological disorders according to the modified scale of the Japanese Orthopedic Association (JOA) with assessment of recovery rate and Nurick score, as well as VAS score of pain syndrome. Verification of diagnosis was based on the data of spondylography, magnetic resonance and computed tomography. The indications for surgical treatment were conduction disorders and their spondylotic genesis confirmed by neuroimaging methods. Score of pain syndrome decreased by 2-4 points (mean 3.1) in long-term postoperative period. The JOA, Nurick scores and recovery rate (mean 42.5%) demonstrated significant improvement of neurological status in all patients. In all cases, the follow-up examination confirmed adequate decompression and spinal fusion. Skip corpectomy provides adequate spinal cord decompression in case of extended cervical spine stenosis and minimizes the risk of complications typical for multilevel corpectomy. Recovery rate indicates the effectiveness of this method in surgical treatment of cervical myelopathy caused by multilevel stenosis. However, further studies on sufficient clinical material are needed.

The validity of minimally invasive surgery in treatment of lumbar spine degenerative disease

Objectives: To compare patients with lumbar spine degenerative disease treated by minimally invasive surgery using tubular retractor system and conventional surgical method.Study Design: Cross-sectional study with historical data.Patients and Methods: The single-institution series included 48 adult patients treated with one of the two surgical methods during a one-year period. The patients were divided between a case group consisting of minimally invasively treated patients and a control group of those operated on by conventional surgery. The research data were the following: age, gender, duration of symptoms, type of spinal pathology, type of surgical method, number of surgical levels treated, neurological status, pain intensity assessed by Visual Analogue Scale, duration of surgery and length of hospital stay. Modified Odom’s criteria were used as a primary outcome measure. All data were documented from electronic medical records, statistically analyzed, and correlated between The validity of minimally invasive surgery in treatment of lumbar spine degenerative disease the groups. The level of statistical significance was set at p<0.001.Results: A significant improvement of neurological status after surgery was recorded in all patients (case group, Fisher’s exact test, p=0.002, control group, Fisher’s exact test p=0.012). The pain intensity was significantly reduced after surgery in both groups (case group, Wilcoxon test, p<0.001, control group, Wilcoxon test, p<0.001). A statistically significant difference was observed between the case and the control group in the length of hospital stay (Mann-Whitney U test, p<0.001) and in time elapsed from surgery to patient mobilization (Mann-Whitney U test, p<0.001). In all other data examined, no statistically significant difference was noted between the case and control groups.Conclusion: Surgical treatment of lumbar spine degenerative disease results in significant improvement of neurological status and in reduced pain intensity. Minimally invasive surgery using tubular retractors results in shorter length of stay and earlier patient mobilization.

A Prospective Observational Study on Outcomes of Single Stage Posterior Decompression and Fixation for Dorsolumbar Spine Tuberculosis.

Objective To study the results of only posterior decompression and instrumentation in dorsal and dorsolumbar spine tuberculosis. Methods The patients ( n = 30) who were included in this study had dorsal or dorsolumbar spine tuberculosis, with or without neurological deficit, and with or without deformity. All 30 patients were managed by only posterior approach decompression and instrumentation. We studied cases for correction and maintenance of deformity at dorsal and dorsolumbar spine, functional outcome by the Oswestry disability index (ODI) and visual analogue scale (VAS) scores, as well as neurological outcome by the Frankel grade. Results In the current series, 30 patients were operated with single stage posterior decompression and instrumentation, and showed significant improvement in neurological status and functional outcomes, which were accessed by the ODI score, VAS score, and Frankel grade. Conclusion The posterior (extracavitary) approach provides optimum access to the lateral and anterior aspects of the spinal cord for good decompression. It facilitates early mobilization and avoids problems of prolonged recumbency, provides better functional outcome, and significantly better sagittal plane kyphosis correction.

Risks and neurological benefits of meningioma surgery in elderly patients compared to young patients

IntroductionWhile surgery is the primary treatment choice for intracranial meningiomas in young patients, surgery in elderly patients, especially those with pre-existing comorbidities, has been the subject of repeated discussion. This study investigated the postoperative risks and neurological benefits of meningioma surgery in elderly patients compared to young patients.MethodsIn total, 768 patients were included and divided into two main groups: group I (age: ≤ 64 years; 484 young patients) and group II (age: ≥ 65 years; 284 elderly patients). Group II was subdivided into: IIa (age: 65–69 years), IIb (age: 70–79 years); and IIc (age: ≥ 80 years).ResultsThe total tumor resection rate was higher in the elderly cohort than in the young cohort (84.5 and 76.2%, respectively). 154 young patients (31.8%) and 132 elderly patients (46.5%) developed postoperative morbidities, with the three most common being bleeding (12.9%), cranial nerve disorder (10%) and CSF fistula (8.1%). Postoperative bleeding, palsy, speech disorder, pneumonia and renal insufficiency were dependent on age (r = 0.123, p = 0.001; r = 0.089, p = 0.014; r = 0.100, p = 0.006; r = 0.098, p = 0.007 and r = 0.084, p = 0.020) and presented more often in elderly patients. 6 young and 15 elderly patients died during the 17.4-year observation period. Most patients showed a significant improvement in postoperative KPS (p < 0.001), except those over 80 years old (p = 0.753). The KPS at the last follow-up was significantly improved in all patients (p < 0.001).ConclusionMeningioma surgery is associated with a higher rate of postoperative complications in elderly patients than in young patients. Most elderly patients, similar to young patients, show a significant improvement in neurological status postoperatively.

Efficacy and safety of carotid endarterectomy in the acute phase of ischemic stroke

Introduction.Nowadays it’s recommended to perform carotid endarterectomy (CEA) in up to 14 days after nondisabling stroke; the procedure is aimed at the prevention of recurrent stroke.The objectiveof this research was the comparison of short-term and long-term (12 months) outcomes with early (in up to 30 days) and delayed (30-180 days) CEA in patients who suffered strokes of various severities.Materials and methods. The research involved 88 patients who underwent CEA in the early stage (Group 1) and 88 patients who underwent CEA in their late period (Group 2). We assessed primary endpoints: ipsilateral stroke, myocardial infarction, 30-day Lethality, 30-day lethality after the surgery, any stroke or infarction (MACE). Secondary endpoints: the same parameters within 12 months after the surgery, post-surgery local or systemic complications, restenosis, changes in neurologic or cognitive status.Results.In 30 days we observed ipsilateral strokes in 3 patients in Group 1 (3.4 percent), it was lethal in 1 patient (1.1 percent). 170 of 176 (96 percent) patients were followed up for 12 months. One lethal stroke was registered in the group of late interventions (1.1 percent). No statistically significant differences were observed between the outcomes in early and late treatment groups. The severity of disability (mRS) in patients of the early intervention group was significantly smaller at discharge and in 12 months after surgery.Conclusion.The advisability of early CEA performance was proven by the absence of differences in post-surgery 30-day and longterm lethality as well as the progress of stroke or infarction with early or late CEA. In 12 months after the surgeries, significant improvement in neurologic status by mRS was only observed in the group of early interventions.

Functional outcome of traumatic paraplegia and paraparesis patients treated with pedicle screw stabilization with decompression

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; In this study, unstable thoracolumbar spine fractures with neurological deficit fixed with Moss Miami pedicle screw and decompression were followed up for neurological improvement (sensory and motor functions). Patients were admitted in the department of Orthopaedics, Government medical college, Kottayam from November 2016 to October 2017.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this observational study, 96 patients (aged 17 to 60 years) are followed up. The preoperative neurological status and post-operative recovery are follow-up at 1, 3 and 6 months and graded by Frankel’s grading. Change from Frankel’s grade A OR B to Frankel grade C, D OR E was said to be improved neurologically.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 87.3% males and 12.7% females with 58.3% patients having fall from height sustained wedge compression fractures (49.1%), burst fractures (46.8%) and fracture dislocations (4.1%). vertebra fractured were L1-31.4%, T12-22.9% and L2-19.7%. Complete paralysis was 44.8% and 55.2% incomplete. At 6 months 75% patients showed improvement and 25% patients showed nil. 95.5% patients (18-30 years) showed improvement and only 50% (51-60 years). Incomplete neurological deficit showed significant improvement (100%) compared to patients with complete paralysis (44.2%). Preoperative Frankel score has significant relationship with final neurological (44% of patients with Frankel A and 100% with Frankel D.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Moss Miami pedicle screw stabilization with decompression is an effective surgical technique in maintaining stability of spine in traumatic paraplegia and paraparesis patients and there is significant improvement in neurological status.&lt;/p&gt;

Surgical treatment of patients with primary and metastatic spinal tumor with use of the O-Arm intraoperative portable computed tomography scanner

The study objective is to demonstrate our experience of employment of O-Arm intraoperative portable сomputed tomography scanner combined with navigation system Stealth Station Treon Plus (Medtronic Navigation) during decompressive-stabilizing surgeries for patients with primary and metastatic spinal tumors.Materials and methods. We have reviewed results of surgical treatment of 44 patients (24 males and 20 females, average age is 54.3 ± 1.8), who were hospitalized and operated in the department of spinal neurosurgery in Federal Centre of Neurosurgery (Tyumen). All surgeries were performed by one surgical team in the period of April 2011 to June 2017. All patients underwent full clinical examination according to diagnostic algorithm, including assessment of general condition, degree of bone and visceral dissemination, neurological status, quality of life, pain syndrome intensity. The most common cause of vertebral lesions was plasma cell myeloma (15 patients, 34.1 %), metastatic spinal lesions (12 patients, 27.3 %). Patients were subjected to posterior decompression and stabilization with total and subtotal excision of mass lesions. Assessment of degree of decompression and transpedicular fixation were carried out visually using O-Arm combined with navigation station.Results. In 6 to 12 months after surgery 79.5 % of patients demonstrated significant improvement of neurological status, specifically a decrease of conduction and sensory disorders. Degree of pain syndrome was reduced by 3.6 times. Using O-Arm combined with navigation station we placed screws adequately in 99.6 % of the cases. The main technical problem that occurred during the surgery was the failure of navigation system caused by: defect of reflective spheres, distant installation and shift of referential frame, aging of Jamshidi needle, malfunction of navigation camera, failure of data transfer from navigation station.Conclusion. The use of O-Arm combined with navigation station for decompressive and stabilizing surgeries in patients with spine and spinal cord tumors let us perform surgeries with 3D control and navigation, conduct surgeries in areas where it is hard to determine surgical landmarks, ensure precision of transpedicular screw implantation, accomplish total resection of mass lesions with minimal blood loss and less aggressive surgical intervention and properly decompress the spinal canal which, eventually, result in positive anatomical and functional characteristics, and contribute to good general outcome of surgical intervention.Conflict of interest. The authors declare no conflict of interest.Informed consent. All patients gave written informed consent to participate in the study and to the publication of their data.

Hypothermic treatment after computer-controlled compression in minipig: A preliminary report on the effect of epidural vs. direct spinal cord cooling.

The aim of the present study was to investigate the therapeutic efficacy of local hypothermia (beginning 30 min post-injury persisting for 5 h) on tissue preservation along the rostro-caudal axis of the spinal cord (3 cm cranially and caudally from the lesion site), and the prevention of injury-induced functional loss in a newly developed computer-controlled compression model in minipig (force of impact 18N at L3 level), which mimics severe spinal cord injury (SCI). Minipigs underwent SCI with two post-injury modifications (durotomy vs. intact dura mater) followed by hypothermia through a perfusion chamber with cold (epidural t≈15°C) saline, DMEM/F12 or enriched DMEM/F12 (SCI/durotomy group) and with room temperature (t≈24°C) saline (SCI-only group). Minipigs treated with post-SCI durotomy demonstrated slower development of spontaneous neurological improvement at the early postinjury time points, although the outcome at 9 weeks of survival did not differ significantly between the two SCI groups. Hypothermia with saline (t≈15°C) applied after SCI-durotomy improved white matter integrity in the dorsal and lateral columns in almost all rostro-caudal segments, whereas treatment with medium/enriched medium affected white matter integrity only in the rostral segments. Furthermore, regeneration of neurofilaments in the spinal cord after SCI-durotomy and hypothermic treatments indicated an important role of local saline hypothermia in the functional outcome. Although saline hypothermia (24°C) in the SCI-only group exhibited a profound histological outcome (regarding the gray and white matter integrity and the number of motoneurons) and neurofilament protection in general, none of the tested treatments resulted in significant improvement of neurological status. The findings suggest that clinically-proven medical treatments for SCI combined with early 5 h-long saline hypothermia treatment without opening the dural sac could be more beneficial for tissue preservation and neurological outcome compared with hypothermia applied after durotomy.

Compromiso cerebrovascular agudo en síndrome hemolítico urémico: descripción de dos casos pediátricos

To report two pediatric cases of D+HUS with severe neurological involvement due to cerebrovascular disease, and review available literature. Two previously healthy 15- and 21-month-old children debuted with seizures and impairment of consciousness within the first week of a D+HUS. Both presented hypertension, severe acute renal failure, and focal motor deficit. One child showed significant improvement in neurologic status after five sessions of plasmapheresis. Brain magnetic resonance showed in the first child multiple bilateral infarcts of small vessels and lesions of white matter. In the second patient, large bilateral infarcts on both middle cerebral arteries territories were identified. One year after the acute event, both children showed functional impairment; The first patient evolved with language delay and spastic hemiparesis; the second patient with spastic quadriparesis, epilepsy with poor seizure control and marked functional impairment. Although most of the children with D+HUS and brain involvement do not have long-term sequelae, cerebrovascular disease in the acute period causes permanent damage, and in addition to the management of electrolyte disturbances, hypertension, and renal failure, therapies directed at specific pathophysiological mechanisms that trigger vascular compromise may improve prognosis.

Myasthenia Gravis after Botulinum Toxin Type A Injection

Botulinum toxin type A (BoNT type A) is a neurotoxin produced by Clostridium botulinum, which causes paralysis by presynaptically binding to the cholinergic nerve terminals at the neuromuscular junction and decreasing the release of acetylcholine (1). BoNT type A, first used to treat strabismus, is now widely used to treat dystonia, spasticity, and other movement disorders, and also autonomic nervous system disorders including hyperhidrosis and sialorrhea (2). As with the effects of the toxin, the adverse effects are also reversible. The most common and severe adverse effects of the toxin are unwanted and excessive weakness of muscle after injection, paralysis of adjacent muscles caused by diffusion of the toxin and iatrogenic botulism characterized by widespread paralysis including the bulbar muscles. Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction, which is caused by antibodies produced against acetylcholine receptors. Fluctuating weakness is the main characteristic of the disease. A woman aged 80 years who presented with forceful contractions of the jaw and tongue, which caused difficulty in opening the mouth, was diagnosed as having oromandibular dystonia. Ten MU (mouse units) of BoNT type A was administered to each hypoglossal muscle once every 3 months. The patient was admitted to the emergency service with bilateral dropping of the eyelids, diplopia, dysphagia, general weakness, and shortness of breath, ten days after the 9th injection. Neurologic examination showed right dominant bilateral ptosis, mild restriction of lateral gaze of the right eye, isochoric pupils, and weakness of eye tightening. Her speech had a nasal quality. The masseter muscles, tongue, and the flexors of neck were weak. Motor examination of other muscles was normal. Generalized botulism, a rare adverse effect of BoNT type A injection, was considered in the patient. Supportive treatment and pyridostigmine 60 mg 5 times per day were given. Worsening of the symptoms, fluctuating weakness, and inadequate response to pyridostigmine suggested the diagnosis of MG. Repetitive nerve stimulation performed 6 weeks after BoNT type A injection revealed dysfunction of neuromuscular junction and autoantibodies against acetylcholine receptors were found positive in serum. Thorax computerized tomography performed for diagnosis of thymoma was normal. Treatment of 0.5 mg/kg/d prednisolone following 0.4 g/kg/d intravenous immunoglobulin was given because dysphagia and shortness of breath worsened. In time, necessity for pyridostigmine decreased and a significant improvement in neurologic status was achieved. Neurologic examination after 6 months was normal except bilateral mild ptosis. Unfortunately, the patient died of acute myocardial infarction 3 weeks after her last follow-up examination. After BoTN type A injection, symptoms including unilateral ptosis, diplopia, and dysphagia can occur and mimic MG (3). Patients with MG are rarely reported to show movement disorders including blepharospasm and cervical dystonia in the literature (4). The occurrence of symptoms of MG after BoTN type A injection

Tuberculosis of spine: An experience of 30 cases over two years.

Objective:Tuberculosis of spine is still a very common condition in India. Here, the results of 30 cases of tuberculosis of spine treated in SSG Hospital, Vadodara, Gujarat, in the last two years, are reviewed.Materials and Methods:A total of 30 patients with tuberculosis of spine were treated in SSG Hospital in the last two years. They were classified into three groups, based on the GATA, GATA = Gulhane Askeri Tip Akademisi (Gulhane Military Medical Academy) classification for spinal tuberculosis, with few modifications. Their neurologic status was evaluated by the Frankel's grading. All the patients were started on four drug anti-tuberculosis medication given every alternate day as per the DOTS and RNTCP program of the Government of India for 6 months. Patients in group 1 were treated by bed rest, analgesics, and antituberculous drugs after confirmation of the diagnosis by CT-guided biopsy. Patients in group 2 were treated by surgical of USG-guided aspiration of abscesses followed by full course of antituberculous drugs. Twenty-one patients in group 3 underwent surgery. A single-stage anterior decompression and anterior fixation was done in all the cases.Results:All the nine patients in group I and 2 responded well to medical management and were cured of the disease. Out of the 21 operated patients, 19 had significant improvement in neurological status and return to their normal activities. The first operated patient died. The neurological status of one patient did not improve till 1 month after surgery and was lost to follow-up. Thus, 100% of group 1 and 2 patients were cured of the disease and 90% of group 3 patients had good neurological recovery.Conclusions:If treated timely and adequately, the outcome for tuberculosis of spine is relatively good. Anterolateral approach to the spine with decompression and fixation gives good result with respect to neurological function.

Feasibility and results of pull-percutaneous endoscopic gastrostomy for enteral nutrition in adults with severe cerebral palsy

Eating and swallowing impairments often get worse as patients with severe cerebral palsy (CP) get older, creating increased demand for percutaneous endoscopic gastrostomy (PEG) tube placement. Here we investigated the feasibility, safety, adverse events (AEs) and outcomes of PEG in adult CP. We performed a retrospective study of 26 consecutive severe adult (age: 28 [19-48] yrs) CP patients who underwent pull-PEG tube placement under general anesthesia between 2005 and 2012 (median follow-up: 23 [6-64] months) at the same tertiary hospital centre. The procedure was a technical success for 19 patients (BMI: 13.8 [10.7-21.4]) with (n=11) or without (n=8) previous respiratory disorder. Indications were mainly swallowing disorders (n=14) and inadequate oral intake (n=8). Early AEs were 7 transient oxygen needs, 3 local wound infections and 2 transient ileus. Long-term AEs were 9 non-severe gastrostomy incidents. There was no significant improvement in neurological status but respiratory function was improved in 6 patients and enteral nutrition enabled a significant median weight gain of 4.2 [1-8.8]kg (P<0.01). Quality-of-life assessed by relatives and the healthcare team was improved in 13/16 and 13/15 cases respectively. AEs and outcomes did not differ significantly with previous respiratory disorder or nutritional status. PEG tube placement is feasible in adult CP, although the risk of failure is increased by anatomical specificities. Previous respiratory disorders and undernourishment did not increase AE rates or modify outcomes. There were positive changes over time for nutritional status and perceived quality-of-life, but no neurological improvement.

P07.02 * THE ROLE OF INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING IN SURGERY OF INTRADURAL EXTRAMEDULLARY SPINAL CORD TUMORS

INTRODUCTION: Surgery of intradural extramedullary spinal cord tumors (IESCT) carries the risk of new neurological deficits in the post-operative period. Intraoperative neurophysiological monitoring (IONM) represents the most effective technique able to improve clinical and functional outcomes, which are obtained through identification and real-time intraoperative monitoring of spinal cord, giving informations about neurological conduction of both, spinal cord long pathways and cauda equina radices. The most widely used and reliable techniques are somatosensory evoked potentials (SEPs), motor evoked potentials (MEPs) and D-wave registration. Although in the literature there are recent evidences of the IONM usefulness, there are not uniform opinions about the different techniques employed, and, their use in IESCT. In the present study we describe the results in our 2-year experience at the Neurosurgery of the University of Messina Hospital. MATERIALS AND METHODS: Our protocol includes evaluation of SEPs from posterior tibial nerve stimulation, MEPs obtained with elevate voltage electrical transcranial stimulation (through multiple myomeric registration of motor evoked responses from inferior limbs), D-Wave registration (through epi- and intradural registration after single pulse electrical transcranial stimulation) in spinal tumor surgery. RESULTS: We did not recorded any intraoperative complication by the use of our IONM protocol. In all patients IONM was useful for correct neurological and functional identification of spinal cord. We observed an optimal correlation between neurological examination on admission and responses from IONM of inferior limbs SEPs and MEPs. In fifty percent of patients, the D-wave registration was the most useful intraoperative tool, due to the lack of motor and somatosensory evoked responses. We matched all pre and post-operative neurological and neurophysiological data, along with tumors' features (localization, dimensions and histology) in order to quantify the impact of IONM on outcome. In our series, none of the patients presented with neurological worsening in the post-operative period. Conversely, surgical treatment of IESCT lead to a significant improvement of neurological status of our patients. CONCLUSIONS: Our preliminary data, although based on a limited series of patients evaluated at a single institution, confirm the role of IONM as an essential tool in operative work-up of all spine surgeries, including IESCT, to achieve an optimal post-operative functional outcome. This study gives further evidences about relevance, impact and usefulness of IONM in IESCT surgery.

Neurological and functional outcomes of subdural hematoma evacuation in patients over 70 years of age

Background:Subdural hematoma (SDH) is a common disease entity treated by neurosurgical intervention. Although the incidence increases in the elderly population, there is a paucity of studies examining their surgical outcomes.Objectives:To determine the neurological and functional outcomes of patients over 70 years of age undergoing surgical decompression for subdural hematoma.Materials and Methods:We retrospectively reviewed data on 45 patients above 70 years who underwent craniotomy or burr holes for acute, chronic or mixed subdural hematomas. We analyzed both neurological and functional status before and after surgery.Results:Forty-five patients 70 years of age or older were treated in our department during the study period. There was a significant improvement in the neurological status of patients from admission to follow up as assessed using the Markwalder grading scale (1.98 vs. 1.39; P =0.005), yet no improvement in functional outcome was observed as assessed by Glasgow Outcome Score. Forty-one patients were admitted from home, however only 20 patients (44%) were discharged home, 16 (36%) discharged to nursing home or rehab, 6 (13%) to hospice and 3 (7%) died in the postoperative period. Neurological function improved in patients who were older, had a worse pre-operative neurological status, were on anticoagulation and had chronic or mixed acute and chronic hematoma. However, no improvement in functional status was observed.Conclusion:Surgical management of SDH in patients over 70 years of age provides significant improvement in neurological status, but does not change functional status.

Sex Differences in Clinical Presentation and Treatment Outcomes in Moyamoya Disease

Moyamoya (MM) disease is an idiopathic steno-occlusive angiopathy occurring more frequently in females. To evaluate sex differences in preoperative symptoms and treatment outcomes after revascularization surgery. We analyzed 430 MM disease patients undergoing 717 revascularization procedures spanning 19 years (1991-2010) and compared gender differences in preoperative symptoms and long-term outcomes after surgical revascularization. A total of 307 female and 123 male patients (ratio, 2.5:1) with a mean age of 31.0 ± 16.7 years and adults-to-children ratio of 2.5:1 underwent 717 revascularization procedures. Female patients were more likely to experience preoperative transient ischemic attacks (odds ratio: 2.1, P = .001) and less likely to receive a diagnosis of unilateral MM disease (odds ratio: 0.6, P = .04). No association was observed between sex and risk of preoperative ischemic or hemorrhagic stroke. There was no difference in neurological outcome because both male and female patients experienced significant improvement in the modified Rankin Scale score after surgery (P < .0001). On Kaplan-Meier survival analysis, 5-year cumulative risk of adverse postoperative events despite successful revascularization was 11.4% in female vs 5.3% in male patients (P = .05). In multivariate Cox proportional hazards analysis, female sex trended toward an association with adverse postoperative events (hazard ratio: 1.9, P = .14). Female patients are more susceptible to the development of preoperative transient ischemic attack and may be at higher risk of adverse postoperative events despite successful revascularization. There is, however, no sex difference in neurological outcome because patients of both sexes experience significant improvement in neurological status with low risk of the development of future ischemic events after surgical revascularization.

A double blind placebo RCT to investigate the effects of serotonergic modulation on brain excitability and motor recovery in stroke patients

Motor excitability is increased in both hemispheres in stroke patients during motor recovery. Pharmacologically controlled changes of cortical excitability might be beneficial for synaptic plasticity and therefore facilitate functional recovery after a brain lesion. In particular, it has been suggested that antidepressant drugs can modulate motor excitability. Several recent reports suggest the possibility of monitoring pharmacological effects on brain excitability through transcranial magnetic stimulation (TMS). The aim of this study was to investigate motor area excitability in patients with stroke after oral administration of citalopram. We conducted a prospective randomised placebo controlled study. Twenty patients with unilateral stroke were included in the study: ten patients treated by antidepressive drug and ten patients with placebo. A selective serotonergic drug (citalopram) or a placebo was administered using a mean dosage of 10 mg/day in combination with physiotherapy. Motor cortex excitability was studied by single and paired transcranial magnetic stimulation. TMS recording was tested before (T1) and 1 month after (T2) beginning drug treatment. Patients treated by the serotonergic drug, compared to patients that received a placebo, showed a significant improvement in neurological status as measured by NIHSS and a decrease of motor excitability over the unaffected hemisphere, while no differences were observed over the affected hemisphere. Our findings suggest that treatment with serotonergic drugs can bring about a significant decrease of the motor cortex excitability in stroke patients with effects on both the affected and unaffected hemispheres associated with a better motor recovery.

Improvement of Sexual Function in Male Patients Treated Surgically for Cervical Spondylotic Myelopathy

A prospective follow-up study. To analyze the recovery of sexual function loss in surgically treated male patients with cervical spondylotic myelopathy. Cervical spondylotic myelopathy is common in the elder population and can lead to sexual dysfunction. Although numerous studies have shown that surgical treatment of cervical spondylotic myelopathy achieved satisfactory neurologic and functional improvement, only few researchers mentioned sexual dysfunction. A total of 22 patients with combined cervical spondylotic myelopathy and sexual dysfunction on admission were treated with surgery. The patients' preoperative and postoperative neurologic status was recorded according to the Japanese Orthopedic Association (JOA) Scoring System. The sexual function was assessed using the International Index of Erectile Function (IIEF). Special attention was also given to the preoperative and postoperative presence or absence of a reflexogenic and psychogenic erection. In most cases, there was significant improvement in neurologic status after surgery, with a mean improvement of JOA score of 3.6. The difference between the preoperative and postoperative JOA score was significant (P < 0.05). Most of these patients had an abnormal psychogenic erection (18/22, 82%) before surgery, but only few had an abnormal reflexogenic erection (4/22, 18%). After surgery, most patients had improvement in sexual function, and the average IIEF score was 28.5 before and 60.2 after surgery. The difference between preoperative and postoperative IIEF scores was statistically significant (P < 0.05). In addition to neurologic deficits, cervical spondylotic myelopathy also causes sexual dysfunction. Most of these patients had an abnormal psychogenic erection and normal reflexogenic erection. Along with neurologic recovery, most patients had improvement in sexual function after surgery.

Chemotherapy for brain stem gliomas.

Approximately 80% of tumors arising in the brain stem are diffuse intrinsic lesions. Patients typically present with a short duration of symptoms and signs with significant neurological impairment. Imaging findings are typical, and biopsy is not usually necessary to make a diagnosis. Standard treatment consists of radiotherapy alone. Although the majority of patients will show a significant improvement in neurological status following such treatment, the prognosis is very poor. The median time to disease progression is of the order of 5-6 months, the median survival time less than 1 year, and survival at 2 years and beyond, less than 10%. Over the last 10-15 years, numerous studies have been undertaken in an attempt to develop more effective treatment for children with diffuse intrinsic brain stem tumors. Using a hyperfractionated (twice-daily) schedule, doses of radiotherapy as high as 78 Gy have been given without success. Other approaches use chemotherapy combined with radiotherapy in a variety of different ways, including up-front, concurrent, and adjuvant chemotherapy, and high-dose chemotherapy with rescue. The results of these studies using chemotherapy, as well as other approaches using other systemic agents, are reviewed in detail.