Terms Of Neurological Recovery Research Articles

Value of Direct Decompression of Lumbosacral Roots in Sacral Fractures with Neurologic Deficit: Is It Mandatory?

The value of direct decompression of neural structures to treat lumbosacral plexus injury associated with sacral fractures is still debatable. Direct decompression allows decompression of nerve roots by sacral laminectomy and removal of bone fragments in the spinal canal. In contrast, indirect decompression may offer similar neurological outcomes if good fracture reduction and correction of sacral kyphosis are achieved. In this comparative retrospective study, we analyzed differences between direct and indirect neurological decompression in terms of neurological recovery, complications, and functional outcome. This study included 33 cases with spinopelvic dissociation with variable degrees of lumbosacral plexus injury. All cases were managed by spinopelvic fixation. Eighteen patients (group 1) had direct decompression of lumbosacral nerve roots while 15 patients (group 2) had indirect decompression. Initial sacral kyphosis, quality of fracture reduction, and postoperative residual kyphosis were the main factors that significantly affected functional and neurological outcome in both groups. The final neurological improvement was similar in both groups. No significant difference was observed between both groups in the residual Gibbons' score recorded in the last visit (p = 0.206). The final Majeed score also showed no significant difference between the two groups (p = 0.869). Indirect decompression of sacral fractures showed similar final functional outcome and neurological recovery compared to direct decompression. Restoration of lumbosacropelvic stability and anatomic reduction seem to be the cornerstone for better functional outcome and neurological recovery rather than direct decompression of neural elements.

A Systematic Review on Neurological Outcomes for Cervical Degenerative Myelopathy After Anterior Decompression Surgery: Motion Preservation vs Fusion.

Although it is well established that surgically treated patients with cervical degenerative myelopathy (CDM) improve irrespective of the anterior decompression technique used, no consensus exists on what technique is superior in terms of neurological recovery. A general concern exists that anterior cervical discectomy with arthroplasty (ACDA) leads to less favorable outcomes in CDM due to microtrauma caused by preserved mobility. It is remarkable that current literature mainly uses pain scores to assess clinical outcomes after anterior decompression surgery, especially considering that pain may not be the most relevant outcome for CDM. This systematic review evaluated the literature concerning neurological outcomes in patients with CDM treated with anterior decompression surgery and assessed by validated myelopathy scores. Systematic searches were carried out in PubMed, EMBASE, Web of Science, CINAHL, and the Cochrane Library. Prospective studies were included when patients with isolated CDM were treated with anterior decompression surgery, and a validated myelopathy outcome score was used. A total of 11 studies were included from the 16,032 identified studies. All studies used the modified Japanese Orthopedic Association (JOA) outcome score and showed improvement for all anterior techniques. The mean improvement in anterior cervical discectomy and fusion (ACDF) was 4.80 and 3.64 for the modified JOA and JOA outcome scores, respectively. The JOA for ACDA showed a mean improvement of 5.51. The overall quality of the included articles was low to moderate according to the Cochrane tool. Neurological recovery of CDM is similar after all anterior decompression techniques, including ACDA when compared with ACDF. The current literature gives no reason to dissuade the use of ACDA in cervical myelopathy.

Surgery of atlantoaxial dislocation by Posterior Decompression Fusion & Fixation at Lateral Mass Screw of C1 & Pedicle Screw & Rod by C2: A Study of 30 Cases

Background: Atlantoaxial dislocation (AAD) is a potentially fatal disturbance to the normal occipital-cervical anatomy that affects some populations disproportionately, which may cause permanent neurologic deficits or sagittal deformity if not treated in a timely and appropriate manner. Methods: This was a cross sectional study, which was carried out at the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University from July 2010 to June 2017. We have studied 30 patients of atlantoaxial subluxation. After collecting patient admission data a brief history and clinical examinations were done. We have conducted a retrospective analysis of the outcomes of 30 consecutive spinal surgeries performed for AAS patients, by posterior decompression, fusion & fixation at lateral mass screw of C1 & pedicle screw & rod by C2 in all cases. We have compared our findings with a previous study. We also examined the factors related to poor outcomes. Result: From a surgical method perspective, the patients underwent post decompression, fusion & fixation at lateral mass screw of C1 & pedicle screw & rod by C2. After surgery, closed follow up was done. The highest age group was 21-40 years 40%. Most of the sufferer were male 80%. The commonest cause was road traffic accident 26.66%. The commonest clinical finding was quadriparesis 14(46.67%). The majority of the patients 24(80%) improved after surgery. In our present study after surgery neurological improvement rate is 83.33%, the rate of SSI was indeed high 10.00%, total death rate was 3.33%, the hardware failure rate was 3.33% and the reoperation rate reached 6.66%. Conclusion: The results of this study showed that the C1/2 fixation technique exhibited effectiveness in terms of neurological recovery. Bang. J Neurosurgery 2021; 10(2): 148-153

Single-Stage Combined Anterior Corpectomy and Posterior Instrumented Fusion in Tuberculous Spondylitis With Varying Degrees of Neurological Deficit.

A combined anterior decompression and stabilization followed by posterior instrumented fusion promotes fusion of the affected segment of spine and prevents further progression of deformity. The objective of this study is to report on outcome of patients with tuberculous spondylitis, progressive neurologic deficit, and kyphotic deformity who underwent single-stage anterior corpectomy and fusion and posterior decompression with instrumented fusion. A total of 49 patients (29 males, 20 females) with varying grades of neurological deficit due to tuberculosis of the spine (thoracic, thoracolumbar, and lumbar) were included in this prospective study. The diagnosis of tubercular infection was established after clinical, hematological, radiological, and histological specimens taken at surgery. All were treated with combined anterior and posterior decompression, debridement, and stabilization with direct autologous bone grafting or wrapped bone graft in mesh or expandable cages. Neurological status and visual analog scale (VAS) pain score were recorded at each visit. X-rays, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and liver function were evaluated at 3, 6, and 12 months after surgery and then once a year thereafter. Results were analyzed in terms of neurological recovery (Frankel grade), bony union time, and correction of kyphotic deformity. The mean age was 37.8 years (range, 2-65 years). Mean preoperative VAS scores improved from 5.6 to 1.5. The average ESR and CRP returned to normal within 6 months in all patients. The mean time to fusion was 8.4 months for the whole group. The neurological deficit in 42 of 49 patients had excellent or good clinical outcome (P < .0001). A total of 10 of 17 patients improved from Frankel A and B to Frankel E (normal activity). Three patients each in the thoracic and thoracolumbar groups improved to Frankel D. Radiological measurements showed the mean kyphotic correction was 61%, 66%, and 67% in the thoracic, thoracolumbar, and lumbar/lumbosacral spine, respectively. Combined single-stage anterior decompression and stabilization followed by posterior instrumented fusion is safe and effective in the treatment of tuberculous spondylitis with neurological deficit in the thoracic and lumbar spine. This procedure helps to correct and maintain the deformity, abscess clearance, spinal-cord decompression, and pain relief as well as return to normal motor function. Bony fusion prevents further progression of deformity. 2.

FREQUENCY OF PERIPHERAL NERVE INJURIES IN ATHLETES OF CERTAIN SPORTS CLUBS IN THE CITY OF ZADAR

Peripheral nerves in athletes are susceptible to injury due to an increase in physiological requirements in the training process to neurological structures and to the soft tissues that protect them. The training process is conditioned by the rank and level of competition and its implementation largely depends on the education of professional staff. Common mechanisms of injury are pressure, sprain, strain, ischemia, and sports injury. Seddon's original system of dividing nerve injuries based on neurophysiological changes is most widely used in medicine. The initial stage of nerve injury is neuropraxia, the second stage is axonal degeneration, and the third stage is nerve cutting. Peripheral nerve injuries are more common in the upper extremities than in the lower extremities. They have specifics related to a particular sport, in this case, football and basketball, and often have a biomechanical component in the making. Early detection allows an appropriate rehabilitation program to be initiated and biomechanics changed before the nerve injury becomes permanent. Recognizing nerve injury requires an understanding of peripheral neuroanatomy, knowledge of common nerve injury sites, and awareness of the types of peripheral nerve injuries that are common and specific to a particular sport. Rehabilitation programs in the field of kinesiology can be read through FMS protocols. Electrodiagnostic tests (electromyography), somatosensory evoked potentials, magnetic resonance imaging, and ultrasound are used to diagnose peripheral nerve injuries. Proximal peripheral nerve injuries have a slightly poorer prognosis in terms of neurological recovery in athletes. The survey determined the frequency of injuries in the subjects and that there is a misunderstanding among the athletes themselves, which is a peripheral nerve injury. The survey also found that peripheral nerve injuries occur due to acute injuries, while chronic injuries are excessive, resulting in damage to muscles and joints, and rarely as a result of inappropriate sports equipment. Athletes' knowledge of what constitutes a peripheral nerve injury itself and how this type of injury should be given more importance in further general prevention has also been established.

Short- versus long-segment posterior spinal fusion with vertebroplasty for osteoporotic vertebral collapse with neurological impairment in thoracolumbar spine: a multicenter study

BackgroundVertebroplasty with posterior spinal fusion (VP + PSF) is one of the most widely accepted surgical techniques for treating osteoporotic vertebral collapse (OVC). Nevertheless, the effect of the extent of fusion on surgical outcomes remains to be established. This study aimed to evaluate the surgical outcomes of short- versus long-segment VP + PSF for OVC with neurological impairment in thoracolumbar spine.MethodsWe retrospectively collected data from 133 patients (median age, 77 years; 42 men and 91 women) from 27 university hospitals and their affiliated hospitals. We divided patients into two groups: a short-segment fusion group (S group) with 2- or 3-segment fusion (87 patients) and a long-segment fusion group (L group) with 4- through 6-segment fusion (46 patients). Surgical invasion, clinical outcomes, local kyphosis angle (LKA), and complications were evaluated.ResultsNo significant differences between the two groups were observed in terms of neurological recovery, pain scale scores, and complications. Surgical time was shorter and blood loss was less in the S group, whereas LKA at the final follow-up and correction loss were superior in the L group.ConclusionAlthough less invasiveness and validity of pain and neurological relief are secured by short-segment VP + PSF, surgeons should be cautious regarding correction loss.

A systematic review and meta-analysis comparing anterior decompression with fusion and posterior laminoplasty for cervical spondylotic myelopathy

BackgroundThe optimal surgical procedure for the treatment of cervical spondylotic myelopathy (CSM) remains controversial because there are few comprehensive studies that have investigated the surgical methods. Therefore, we conducted a systematic review and meta-analysis to evaluate evidence in the literature and to compare the surgical outcomes between anterior decompression with fusion (ADF) and laminoplasty, which are representative procedures for CSM. MethodsAn extensive literature search was performed using PubMed, Embase, and the Cochrane Library to identify comparative studies of ADF and laminoplasty for CSM. The language was restricted to English, and the publication period was from January 2001 to July 2019. We only included studies of CSM and excluded studies that involved patients with ossification of the posterior longitudinal ligament and treatments with posterior instrumented fusion. We extracted outcomes from the studies, such as preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, cervical alignment, surgical complications and reoperation rates. Then, a meta-analysis was performed on these surgical outcomes. ResultsNine studies were obtained, and the quality of the studies was acceptable. In the meta-analysis, the preoperative JOA score was similar between the ADF and laminoplasty groups. The postoperative JOA scores and neurological recovery rates were not different between the ADF and laminoplasty groups. ADF exhibited more favorable results than laminoplasty in terms of postoperative cervical alignment. In contrast, overall complications were more frequently observed in the ADF group than in the laminoplasty group, leading to higher rates of reoperation. However, postoperative neck pain was more frequently observed in the laminoplasty group than in the ADF group. ConclusionsThis systematic review and meta-analysis showed both the merits and shortcomings of ADF and laminoplasty. ADF and laminoplasty showed similar results in terms of neurological recovery. Postoperative cervical lordosis was better preserved with ADF than with laminoplasty. However, ADF was associated with a higher incidence of surgical complications than laminoplasty.

Comparison of anterior decompression with fusion and posterior decompression with fusion for cervical spondylotic myelopathy—A systematic review and meta-analysis

BackgroundThe optimal surgical procedure for the treatment of cervical spondylotic myelopathy (CSM) remains controversial. Recently, laminectomy/laminoplasty with instrumented fusion (LAMF) has been increasingly applied to treat CSM. However, few comprehensive studies have compared anterior decompression with fusion (ADF) and LAMF. Therefore, we conducted a meta-analysis to evaluate the evidence in the literature and to compare the surgical outcomes between the 2 procedures. Since the surgical outcomes and risks differ between patients with CSM and ossification of the posterior longitudinal ligament (OPLL) and between only posterior decompression and decompression with fusion treatments, we excluded patients with OPLL and patients with only posterior decompression in this review. MethodsAn extensive literature search was performed using PubMed, Embase, and the Cochrane Library to identify comparative studies of ADF and LAMF for the treatment of CSM. The language was restricted to English, and the publication period was from January 2001 to July 2019. We only included studies about CSM and excluded studies that involved patients with ossification of the posterior longitudinal ligament and with the treatment of posterior decompression without fusion. We extracted outcomes from the studies, such as preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, neck disability index (NDI) scores, cervical alignment data, and surgical complications. Then, a meta-analysis was performed on these surgical outcomes. ResultsEleven studies were obtained, and the quality of the studies was acceptable. In the meta-analysis, the pre- and postoperative JOA scores were similar between the ADF and LAMF groups. The ADF group exhibited more favorable results than the LAMF group in terms of postoperative cervical alignment and the NDI. Overall complications were similar between the ADF and LAMF groups; however, C5 palsy was more frequently observed in the LAMF group than in the ADF group. ConclusionsWhile the ADF and LAMF groups demonstrated similar results in terms of neurological recovery, postoperative cervical lordosis and NDI scores were more favorable with ADF than with LAMF. The overall complication rate was similar between the ADF and LAMF groups. Surgeons should understand the merits and shortcomings of both procedures when deciding on a surgical procedure.

Role of minimally invasive percutaneous fixation in thoracolumbar fractures: a prospective study

BackgroundEach year, there are approximately 5 million new vertebral fractures worldwide. Being a mobile flexible segment that is prone to severe stresses and loads, thoracolumbar fractures are considered one of the most controversial and challenging fracture types to manage.ObjectiveThe aim of this study is to explore the technique and to evaluate feasibility, safety, and outcome of percutaneous transpedicular fixation in the management of thoracolumbar fractures.MethodsThis study was carried out in the period between May 2016 and June 2017, where 20 consecutive patients with thoracolumbar fractures, based on TLICS scoring and neurological status, underwent a posterior percutaneous transpedicular fixation. The mean age was 33.85 years, range 20–49 years. Patients were followed up for 12 months. Patients had their clinical outcomes reviewed and evaluated in terms of cosmesis by visual analog scale (VAS) and in terms of Cobb angle correction.ResultsThe length of the procedure varied from 120 to 180 min with mean time of 154.50 min. There was no significant blood loss in all cases. The volume of blood loss ranged from 150 to 200 cc with mean loss of 174.25 cc.No major intraoperative complications happened in our study cases. Six cases had only one laterally malpositioned screw each. All cases returned to their previous activity without limitations (E5). Those who were completely pain free (F5) were 15 patients. Only five patients were suffering from moderate pain (F4). The Prolo scale was either 9 or 10 with mean of 9.60.ConclusionBy comparing our results with other studies, we found more or less equivalence in terms of neurological recovery, functional outcome, fusion rate, and maintenance of correction gain. However, the cosmesis scores for patients in the study were great.

Comparative Effectiveness and Functional Outcome of Open-Door versus French-Door Laminoplasty for Multilevel Cervical Myelopathy: A Meta-Analysis.

BACKGROUND:At present, few reports are comparing these 2 major cervical posterior laminoplasty methods with Open-door and French-door Laminoplasty in terms of neurological recovery, cervical alignment, and surgical complications. Moreover, most of the research has not been well designed.AIM:This study aims to determine comparative effectiveness and functional outcome of open-door versus french-door laminoplasty for multilevel cervical myelopathy.METHODS:The Meta-analysis is used in this study. The study sample is a published research articles on comparative effectiveness and functional outcome of open-door versus french-door laminoplasty for multilevel cervical myelopathy on the internet through databases on PubMed and ProQuest and published between 1997 until December 2018. Weighted mean difference and pooled weighted mean difference are calculated by using the fixed-effect model or random-effect model. Data is processed by using Review Manager 5.3 (RevMan 5.3).RESULTS:This study reviews 58 articles. There are 6 studies conducted a systematic review and continued with Meta-analysis of relevant data. The results showed significant higher postoperative Japanese Orthopaedic Association (JOA) score in open-door laminoplasty (ODL) than French-door laminoplasty (FDL) (weighted mean difference [WMD] = 0.71; 95% confidence interval [CI]: 0.35 to 1.07; p < 0.05). The outcome of procedures treatment of multilevel cervical myelopathy revealed the operative time, cervical range of motion, axial canal diameter postoperative, axial pain reduction and complications events in ODL and FDL there was no significant difference. But for a cervical lordotic angle in ODL and FDL, there was a significant difference; the ODL group were significantly lesser than the FDL group. The recovery rate in ODL and FDL, there was a significant difference; the ODL was shown to be significantly higher than FDL (p < 0.05).CONCLUSION:This analysis suggests that neither cervical laminoplasty approach is superior, based on the postoperative radiological data and complication rate. But the open-door laminoplasty resulted in a higher functional outcome and recovery rate as compared to the French-door laminoplasty.

Role of Autologous Fibula Strut Graft in Surgical Management of Tubercular Spondylitis by Anterior Approach: A Prospective Study.

Decompression of cord in tubercular paraplegia is a mainstay treatment with favorable neurological improvement. Anterior decompression and stabilization with autologous bone grafts promotes fusion of affected segment of spine and prevents further progression of deformity. The objective of this study is to assess the role of autologous fibula strut graft in correction of tubercular kyphosis without instrumentation. Twenty patients of tubercular spine (Gulhane Askeri Tip Akademisi type II or III) with paraplegia were treated with anterior decompression, debridement, and stabilization with various autologous bone graft in combination without instrumentation. Patients were further grouped as follows (10 in each group): group A includes patients where autologous fibula strut, rib, and iliac crest grafts were used in combination; group B includes patients where only autologous rib and iliac crest grafts were used. Results were analyzed in terms of neurological recovery (Frankel grade), graft union time (graft uptake), correction and progression of kyphotic deformity, and graft subsidence. Patients in both groups A and B show similar neurological recovery from Frankel grade A/B to E. Group A (fibula strut group) patients show mean correction of 6.7° (3°-22°) in kyphosis with no loss of correction after a 2-year follow-up, whereas patients in group B (nonfibular strut group) show increase in kyphosis in immediate postoperative period without further progression on follow up. Graft uptake was good in all 19 cases, and graft subsidence was seen in 1 patient of group A. Bone grafting is indispensable in surgical management of tubercular spine. It allows fusion of affected segment and prevents further progression of deformity. However, the neurological recovery of patient depends upon the adequate decompression of cord, debridement, and adequate stabilization of anterior and middle column vertebral body height loss. The use of autologous fibular strut graft along with cancellous graft is superior to only cancellous grafts in terms of kyphosis correction.

Surgical Outcome between Early and Delayed Surgery of Extradural Haematoma (EDH) in Closed Head Injury

Background: Surgical management of Extradural Haematoma (EDH) in Closed Head Injury is an essential issue.&#x0D; Objective: The purpose of the present study was to compare the surgical outcome between early and delayed surgery of extradural haematoma (EDH) in closed head injury.&#x0D; Methodology: This comparative cross-sectional study was carried out from January 2010 to June 2011 for a period of one year and six months in the Department of Neurosurgery, Dhaka medical College Hospital, Dhaka, Bangladesh. All patients presented with traumatic head injury having extradural haematoma in any age with both sexes who were underwent surgical management were selected as study population. The patients were categorized into groups designated as group A or early surgery group where operation was done within 24 hours of head injury and group B or delayed surgery group where operation was done after 24 hours to 3 days of head injury. Inclusion of patients in group B was not intentional but due to delayed referral from primary and secondary hospitals of` different parts of' the country. Glasgow coma scale (GCS) was used for initial assessment and Glasgow outcome scale (GOS) was applied to assess outcome in terms of neurological recovery in all patients. General and neurological examinations and findings were recorded. Surgical outcome was noted and recorded in the data collection sheet.&#x0D; Result: Eighty (80) patients of traumatic head injury with EDH operation (EDH operated within 24 hours and after 24 hours of head injury) were enrolled in this study. Mean (±SD) age of the patients of group A and group B was 32.66±16.65 and 33.23±13.38 respectively. In this study the patient's age ranged from 3 years to 64 years. In group A, 6 patients were admitted with GCS (14-15) and 01 patient in group B. With GCS (9~13), 19 patients in group A and 22 patients in group B. With GCS (3-8), 15 patients were admitted in group A and 17 patients in group B. Out of all patients’ good recovery occurred in 80.0% in group A and 45.0% in group B. Moderate disability and severe disability in both group A and group B was 12.5% vs 30% and 7.5% vs 12.5% respectively. Furthermore 5.0% persistent vegetative state and 7.5% death occurred only among the patients of group B (p&lt;0.05). Out of all patients good recovery occurred in 82.6% in group A and 54.0% in group B. Moderate disability and severe disability in both group A and group B was 10.0% vs 27.5% and 7.5% vs 13.51% respectively. 5.41% persistent vegetative state occurred only in patients of group B (p&lt;0.05).&#x0D; Conclusion: In conclusion morbidity and mortality rate can be reduced in patients with EDH by early surgical intervention in better GCS score.&#x0D; Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 24-28

MicroRNA Biomarkers in Cerebrospinal Fluid and Serum Reflect Injury Severity in Human Acute Traumatic Spinal Cord Injury.

Spinal cord injury (SCI) is a devastating condition with variability in injury mechanisms and neurologic recovery. Spinal cord impairment after SCI is measured and classified by a widely accepted standard neurological examination. In the very acute stages post-injury, however, this examination is extremely challenging (and often impossible) to conduct and has modest prognostic value in terms of neurological recovery. The lack of objective tools to classify injury severity and predict outcome is a barrier for clinical trials and thwarts development of therapies for those with SCI. Biological markers (biomarkers) represent a promising, complementary approach to these challenges because they represent an unbiased approach to classify injury severity and predict neurological outcome. Identification of a suitable panel of molecular biomarkers would comprise a fundamental shift in how patients with acute SCI are evaluated, stratified, and treated in clinical trials. MicroRNA are attractive biomarker candidates in neurological disorders for several reasons, including their stability in biological fluids, their conservation between humans and model mammals, and their tissue specificity. In this study, we used next-generation sequencing to identify microRNA associated with injury severity within the cerebrospinal fluid (CSF) and serum of human patients with acute SCI. The CSF and serum samples were obtained 1-5 days post-injury from 39 patients with acute SCI (24 American Spinal Injury Association Impairment Scale [AIS] A, 8 AIS B, 7 AIS C) and from five non-SCI controls. We identified a severity-dependent pattern of change in microRNA expression in CSF and identified a set of microRNA that are diagnostic of baseline AIS classification and prognostic of neurological outcome six months post-injury. The data presented here provide a comprehensive description of the CSF and serum microRNA expression changes that occur after acute human SCI. This data set reveals microRNA candidates that warrant further evaluation as biomarkers of injury severity after SCI and as key regulators in other neurological disorders.

Retrospective analysis of surgical outcomes for atlantoaxial subluxation

BackgroundAtlantoaxial subluxation (AAS) is characterized by excessive movement at the junction between the atlas (C1) and axis (C2) as a result of either a bony or ligamentous abnormality. Surgical intervention is a therapeutic choice for AAS. In addition to C1 laminectomy (LAM), surgical fixation for subluxation or instability is performed by various techniques. While surgical treatment options for AAS have increased, the outcomes of different surgical techniques remain unclear.MethodsThe authors conducted a retrospective analysis of the outcomes of 30 consecutive spinal surgeries performed for AAS patients, C1 LAM in 11 cases and C1/2 fixation in 19 cases. We investigated the correlation between the clinical outcomes and the surgical methods. We also examined the factors related to poor outcomes (the recovery rate of the Japanese Orthopedic Association score for cervical myelopathy < 40%) following AAS surgeries.ResultsFrom a surgical method perspective, the patients in the C1 LAM group were older than those in the C1/2 fixation group (74.6 years vs 68.0 years), and the average recovery rate from the preoperative status was as follows: the C1 LAM group, 39.4%; the C1/2 fixation group, 49.8%. The C-JOA score was significantly improved after surgery in the C1/2 fixation group (from 9.8 to 13.1 points). The fixation technique seemed to successfully reduce C1/2 displacement. Each group exhibited a slight increase in the C1/2 angle and a decrease in the C2–7 angles after the operation. A higher preoperative atlantodental interval (ADI) was associated with good outcomes after the C1/2 fixation. The postoperative ADI was significantly reduced from 8.6 mm to 3.8 mm in the good outcome group after fixation. Patients with higher C1/2 angle showed good outcomes after C1 LAM. Despite the good neurological improvement, the C1/2 fixation method showed higher complication rates compared with C1 LAM method.ConclusionsThe results of this study showed that the C1/2 fixation technique exhibited effectiveness in terms of neurological recovery. However, there was a high complication rate in surgeries for AAS, especially in the C1/2 fixation. C1 LAM would be considered for high-risk AAS cases such as elderly patients with multiple comorbidities.

Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion.

OBJECTIVE Peripheral nerve transfers to regain elbow flexion via the ulnar nerve (Oberlin nerve transfer) and median nerves are surgical options that benefit patients. Prior studies have assessed the comparative effectiveness of ulnar and median nerve transfers for upper trunk brachial plexus injury, yet no study has examined the cost-effectiveness of this surgery to improve quality-adjusted life years (QALYs). The authors present a cost-effectiveness model of the Oberlin nerve transfer and median nerve transfer to restore elbow flexion in the adult population with upper brachial plexus injury. METHODS Using a Markov model, the authors simulated ulnar and median nerve transfers and conservative measures in terms of neurological recovery and improvements in quality of life (QOL) for patients with upper brachial plexus injury. Transition probabilities were collected from previous studies that assessed the surgical efficacy of ulnar and median nerve transfers, complication rates associated with comparable surgical interventions, and the natural history of conservative measures. Incremental cost-effectiveness ratios (ICERs), defined as cost in dollars per QALY, were calculated. Incremental cost-effectiveness ratios less than $50,000/QALY were considered cost-effective. One-way and 2-way sensitivity analyses were used to assess parameter uncertainty. Probabilistic sampling was used to assess ranges of outcomes across 100,000 trials. RESULTS The authors' base-case model demonstrated that ulnar and median nerve transfers, with an estimated cost of $5066.19, improved effectiveness by 0.79 QALY over a lifetime compared with conservative management. Without modeling the indirect cost due to loss of income over lifetime associated with elbow function loss, surgical treatment had an ICER of $6453.41/QALY gained. Factoring in the loss of income as indirect cost, surgical treatment had an ICER of -$96,755.42/QALY gained, demonstrating an overall lifetime cost savings due to increased probability of returning to work. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about cost of surgery, probability of good surgical outcome, and spontaneous recovery of neurological function with conservative treatment. Two-way sensitivity analysis demonstrated that surgical intervention was cost-effective with an ICER of $18,828.06/QALY even with the authors' most conservative parameters with surgical costs at $50,000 and probability of success of 50% when considering the potential income recovered through returning to work. Probabilistic sampling demonstrated that surgical intervention was cost-effective in 76% of cases at a willingness-to-pay threshold of $50,000/QALY gained. CONCLUSIONS The authors' model demonstrates that ulnar and median nerve transfers for upper brachial plexus injury improves QALY in a cost-effective manner.

A Study of 42 Cases of Pott’s Paraplegia with Anterior Spinal Decompression &amp; Stabilisation with Rib Graft Alone

Background: Spinal tuberculosis is mostly secondary to either Pulmonary or Abdominal lesions, and may result in Paraplegia either due to pressure effects of the cold abscess or due to collapse of the vertebra. Most of the patients with Grade I and II paraparesis respond well to chemotherapy, while Grade III and IV patients and some of the patients in Grade I and II who do not respond to chemotherapy need Spinal decompression to prevent irreparable damage to the Spinal who did not respond to 3-4 weeks of chemotherapy and rest or deteriorated during treatment. They were treated by anterior trans-thorasic and trans-pleural spinal decompression by partial or total carpectomy depending on the extent of involvement of the bodies and anterior spinal fusion using rib graft alone, during the period Feb. 2007 to May 2014, in Government General and Chest hospital, Osmania Medical College, Hyderabad. Results: Out of 42 patients complete neurological recovery was seen in 40 patients, 1 patient had partial recovery while 1 patient died of post-operative complications. Conclusions: Anterior spinal decompression and stabilization using rib graft alone is a good choice of surgical treatment in terms of neurological recovery, healing of the lesion, and is a cost-effective treatment option for the patient. Post-operative rehabilitation is also early.

Comparison of minimally invasive surgery with standard open surgery for vertebral thoracic metastases causing acute myelopathy in patients with short- or mid-term life expectancy: surgical technique and early clinical results

OBJECT Spinal metastasis is common in patients with cancer. About 70% of symptomatic lesions are found in the thoracic region of the spine, and cord compression presents as the initial symptom in 5%-10% of patients. Minimally invasive spine surgery (MISS) has recently been advocated as a useful approach for spinal metastases, with the aim of decreasing the morbidity associated with more traditional open spine surgery; furthermore, the recovery time is reduced after MISS, such that postoperative chemotherapy and radiotherapy can begin sooner. METHODS Two series of oncological patients, who presented with acute myelopathy due to vertebral thoracic metastases, were compared in this study. Patients with complete paraplegia for more than 24 hours and with a modified Bauer score greater than 2 were excluded from the study. The first group (n = 23) comprised patients who were prospectively enrolled from May 2010 to September 2013, and who were treated with minimally invasive laminotomy/laminectomy and percutaneous stabilization. The second group (n = 19) comprised patients from whom data were retrospectively collected before May 2010, and who had been treated with laminectomy and stabilization with traditional open surgery. Patient groups were similar regarding general characteristics and neurological impairment. Results were analyzed in terms of neurological recovery (American Spinal Injury Association grade), complications, pain relief (visual analog scale), and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] QLQ-C30 and EORTC QLQ-BM22 scales) at the 30-day follow-up. Operation time, postoperative duration of bed rest, duration of hospitalization, intraoperative blood loss, and the need and length of postoperative opioid administration were also evaluated. RESULTS There were no significant differences between the 2 groups in terms of neurological recovery and complications. Nevertheless, the MISS group showed a clear and significant improvement in terms of blood loss, operation time, and bed rest length, which is associated with a more rapid functional recovery and discharge from the hospital. Postoperative pain and the need for opioid administration were also significantly less pronounced in the MISS group. Results from the EORTC QLQ-C30 and QLQ-BM22 scales showed a more pronounced improvement in quality of life at follow-up in the MISS group. CONCLUSIONS In the authors' opinion, MISS techniques should be considered the first choice for the treatment for patients with spinal metastasis and myelopathy. MISS is as safe and effective for spinal cord decompression and spine fixation as traditional surgery, and it also reduces the impact of surgery in critical patients. However, further studies are needed to confirm these findings.

Stroke pattern and outcome of management in type 2 diabetics in a tertiary hospital in North Western Nigeria

Background: Diabetes mellitus is a well-recognized risk factor for stroke. Clinical features, as well as outcome of stroke, difference between diabetic and nondiabetic patients. The objective of this study is to determine the pattern and outcome of management in diabetes-stroke co-morbidity. Materials and Methods: This is a retrospective study where case folders of patient admitted from January 1 to December 31, 2009 with the clinical diagnosis of stroke were traced. A questionnaire was used to extract relevant data from case folders. Results: A total of 115 patients with the clinical diagnosis of stroke were admitted during the study period, but only 88 had complete information out of which 12 (13.6%) had type 2 diabetes. The mean age of the diabetic group (69.67 ± 12.7 years) was found to be significantly higher than that of the nondiabetic group (56.93 ± 16.06 years) (t = 2.615, P = 0.011). Ischemic stroke occurred more frequently in the diabetes stroke the co-morbid group. However, the difference was not statistically significant (χ2 =0.079, P = 0.540). Outcome in terms of neurological recovery tended to be poor in the diabetes-stroke co-morbid group as compared to the nondiabetes stroke group (χ2 =13.93, P = 0.006). Conclusion: Stroke pattern and outcomes are different in the diabetic patient compared to nondiabetic patient. There is more prevalence of ischemic stroke in the diabetic group of patients often with slow recovery.

Surgical results and prognostic factors of anterior cervical corpectomy and fusion for ossification of the posterior longitudinal ligament.

BackgroundMechanism of ossification of the posterior longitudinal ligament (OPLL) has not been elucidated clearly. Surgical decompression is usually necessary for the patients with neurological symptoms. Anterior decompression and resection of OPLL seems to be a radical surgical option, because the spinal cord is compressed from the anterior direction.MethodsAmong 229 patients who underwent ACF for OPLL between January 2001 and December 2007 in our hospital, a total of 133 patients responded to the invitation and made return visits, with a follow-up rate of 58.1%. For these patients, clinical data were collected from medical and operative records. Neurological status were evaluated by using the Japanese Orthopedic Association (JOA) scoring system. Radiological evaluations including C2-7 lordotic angle, sagittal vertical axis (SVA), occupying rate of OPLL, double-layer sign and high-intensity zone were obtained from all the patients. Complications and causes of revision surgery were also investigated. Correlations between the long-term surgical outcome and various prognostic factors were statistically analyzed.FindingsEighty-four males and forty-nine females completed the follow-up, with a mean age at operation of 56.8 years. The overall average JOA score significantly increased, with a mean recovery rate of 64.1%±14.2%. The mean C2-7 lordotic angle and SVA were also significantly improved, and fusion rate was satisfactory. The incidence of complications was consistent to the previous reports and most of them were controllable by suitable treatments. Multiple regression analysis showed that number of corpectmies and preoperative JOA score were important predictors of surgical outcome.ConclusionsACF is a reliable and effective method for treating OPLL patients in terms of neurological recovery, maintenance of radiological parameters, fusion rate and complications. Number of corpectomies and preoperative JOA score are important predictors for the clinical outcome when this procedure is used.

Anterior versus posterior approach for treatment of thoracolumbar burst fractures: a meta-analysis

To critically review and summarize the literature comparing the results of surgery via an anterior approach and that via a posterior approach for the treatment of thoracolumbar burst fractures to identify the better approach. In this meta-analysis, we conducted electronic searches of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and other databases using the search terms "thoracolumbar fractures", "anterior", "posterior", "controlled clinical trials". Relevant journals or conference proceedings were also searched manually. Data extraction and quality assessment were in accordance with Cochrane Collaboration guidelines. The analysis was performed on individual patient data from all the trials that met the selection criteria. Sensitivity analysis was performed when there was significant heterogeneity. Results were expressed as risk difference for dichotomous outcomes and mean difference for continuous outcomes with 95 % confidence interval. Four randomized clinical trials and three controlled clinical trials comparing the results of the anterior versus posterior approach in the treatment of thoracolumbar burst fractures were retrieved; these studies included 179 and 152 patients in the anterior and posterior approach groups, respectively. There were no differences in terms of neurological recovery, return to work, complications and Cobb angle between the two groups. The anterior approach was associated with longer operative time, greater blood loss and higher cost than the posterior approach. The posterior approach may be more effective than the anterior approach. However, more high-quality, randomized controlled trials are required to compare these approaches and guide clinical decision-making. Level of Evidence Level II, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.