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Introduction Objective Methods Results Conclusion It is not uncommon for patients to experience postoperative neurologic deficit, thoracic radiculopathy, abdominal pain, or lower extremity paresthesia after the implantation of thoracic spinal cord stimulator (SCS) paddle leads. Smaller thoracic canal diameters have previously been associated with postoperative neurologic deficits.This imaging study examined whether postoperative SCS neurologic complaints other than neurologic deficit may be correlated with thoracic spinal canal diameter.Patients who underwent thoracic laminotomy for SCS paddle lead placement between January 2018 and March 2023 were identified. Preoperative thoracic canal diameter was measured on MRI or CT imaging in the sagittal plane from T5/6 to T11/12. The canal diameters of patients with and without new postoperative neurologic complaints were compared.Two hundred forty‐six patients underwent thoracic laminotomy for SCS paddle lead placement. Thoracic radiculopathy, abdominal pain, and lower extremity paresthesia occurred in 3.7% (9/246), 2.8% (7/246), and 2.0% (5/246) patients, respectively. The mean canal diameter for patients without neurologic complaint, thoracic radiculopathy, abdominal pain, and lower extremity paresthesia was 13.1 mm, 12.0 mm (p < 0.0001), 12.1 mm (p < 0.01), and 12.8 mm (p = 0.365), respectively.A smaller thoracic canal diameter is associated with postoperative thoracic radiculopathy and abdominal pain. We believe that surgical planning to create adequate space for SCS leads is critical in preventing postoperative neurologic complaints of deficit, thoracic radiculopathy, and abdominal pain. [ABSTRACT FROM AUTHOR]

The estimation of survival is extremely important for metastatic disease in the spine. The aim of this study was to determine the factors affecting the outcome of patients with spinal metastasis, primarily the character of neurologic deficit and the histopathology of the tumor. A retrospective examination was made of 158 patients with spinal metastasis who were followed up in our clinic between 2010 and 2020 and underwent surgical intervention. The patients were examined in respect of demographic characteristics, the primary tumor, comorbidities, preoperative-postoperative visual aAnalog scale scores, preoperative-postoperative neurologic examinations and neurologic deficit if present and ambulation status, postoperative survival duration, tumor localization, characteristics of the surgeries, complications, the Karnofsky Performance Scale, revised Tokuhashi, and Tomita scores. Spinal metastasis was seen more frequently in males (72.8% male, 27.8% female). Male gender, multiple level involvement, intradural localization, and Karnofsky Performance Scale <70 were seen to cause a shorter survival time. Patients with a primary focus of hematologic malignancy, breast cancer, and lymphoma had a longer survival. The revised Tokuhashi and Tomita scores were observed to be successful in the prediction of survival. A decrease in postoperative visual analog scale score had a positive effect on functional survival. The absence of preoperative neurological deficit and the patient's ability for preoperative and postoperative ambulation affected survival positively. The overall survival period decreased in patients who were mobilized in the early postoperative period but became nonmobile in the late period, and in those who were nonmobile in both the early and late postoperative periods. The neurologic and ambulatory status, the Tomita and Tokuhashi scores, intradural localization, and gender are the factors with a significant effect on prognosis. [ABSTRACT FROM AUTHOR]

Cerebrovascular disease includes some of the most common and devastating disorders: ischemic and hemorrhagic stroke. Stroke is the second leading cause of death worldwide, with 6.2 million dying from stroke in 2015, an increase of 830,000 since 2000. Stroke remains the most common disabling disease worldwide and in many forms is preventable. A stroke, or cerebrovascular accident, is defined as an abrupt onset of a neurologic deficit that is attributable to the focal vascular cause. Thus, the definition of stroke is clinical, and laboratory studies including brain imaging are used to support the diagnosis.

Background: Surgical resection of insular gliomas is a challenge. TO resection is considered more versatile and has lower risk of vascular damage. In this study, we aimed to understand the factors that affect resection rates, ischemic changes and neurological outcomes and studied the utility of IONM in patients who underwent TO resection for IGs. Methods: Retrospective analysis of 66 patients with IG who underwent TO resection was performed. Results: Radical resection was possible in 39% patients. Involvement of zone II and the absence of contrast enhancement predicted lower resection rate. Persistent deficit rate was 10.9%. Although dominant lobe tumors increased immediate deficit and fronto-orbital operculum involvement reduced prolonged deficit rate, no tumor related factor showed significant association with persistent deficits. 45% of patients developed a postoperative infarct, 53% of whom developed deficits. Most affected vascular territory was lenticulostriate (39%). MEP changes were observed in 9/57 patients. 67% of stable TcMEPs and 74.5% of stable strip MEPs did not develop any postoperative motor deficits. Long-term deficits were seen in 3 and 6% patients with stable TcMEP and strip MEPs respectively. In contrast, 25% and 50% of patients with reversible strip MEP and Tc MEP changes respectively had persistent motor deficits. DWI changes were clinically more relevant when accompanied by MEP changes intraoperatively, with persistent deficit rates three times greater when MEP changes occurred than when MEPs were stable. Conclusion: Radical resection can be achieved in large, multizone IGs, with reasonable outcomes using TO approach and multimodal intraoperative strategy with IONM. [ABSTRACT FROM AUTHOR]

Prosthetic endocarditis is a serious complication in a long term. Vegetation as a thromboembolic complication leads to neurologic deficit varying in severity. Case description. A 35-year-old female patient F. underwent surgical treatment at the Department of Surgical Treatment of Acquired Heart Diseases of the National Amosov Institute of Cardiovascular Surgery on September 07, 2016: aortic valve replacement with wrapping tape operation II. The patient was discharged from the hospital on the 9th day after surgery in a satisfactory condition. On November 20, 2019, the patient was admitted to the Institute with the diagnosis of late infective prosthetic aortic valve endocarditis, status post aortic valve replacement and wrapping tape operation in 2016, first-degree atrioventricular block, cerebral infarctions in multiple locations with hemorrhagic transformation, with aphasia elements, ataxia, right-sided pyramidal insufficiency and suspected meningitis. After 21 days of drug therapy, the patient responded to treatment successfully and was discharged from the hospital in a satisfactory condition without surgical treatment. Conclusions. Taking into consideration the serious condition of the patient, timely and carefully selected drug therapy can be the correct solution for the treatment of patients with late infective endocarditis. Thus, surgery is not always the treatment of choice.

Aims: To compare the efficacy and deficiency of conservative management (CM), microsurgery (MS) only, and microsurgery with preoperative embolization (E + MS) for unruptured arteriovenous malformations (AVMs). Methods: We prospectively included unruptured AVMs undergoing CM, MS, and E + MS from our institution between August 2011 and August 2021. The primary outcomes were long‐term neurofunctional outcomes and hemorrhagic stroke and death. In addition to the comparisons among CM, MS, and E + MS, E + MS was divided into single‐staged hybrid and multi‐staged E + MS for further analysis. Stabilized inverse probability of treatment weighting using propensity scores was applied to control for confounders by treatment indication across the three groups. Results: Of 3758 consecutive AVMs admitted, 718 patients were included finally (266 CM, 364 MS, and 88 E + MS). The median follow‐up duration was 5.4 years. Compared with CM, interventions (MS and E + MS) were associated with neurological deterioration. MS could lower the risk of hemorrhagic stroke and death. Multi‐staged E + MS was associated with neurological deterioration and higher hemorrhagic risks compared with MS, but the hybrid E + MS operation significantly reduced the hemorrhage risk. Conclusion: In this study, unruptured AVMs receiving CM would expect better neurofunctional outcomes but bear higher risks of hemorrhage than MS or E + MS. The single‐staged hybrid E + MS might be promising in reducing inter‐procedural and subsequent hemorrhage. [ABSTRACT FROM AUTHOR]

Background: Schwannomas and meningiomas are intradural extramedullary spinal tumors which are regularly encountered in the neurosurgical clinic. These tumors cause neurological deficit by compression on the spinal cord and commonly pain when affecting the cauda equina. The traditional treatment with standard laminectomy (SL) can cause instability to the dorsal segments of the spinal column, and the less invasive option of hemilaminectomy (HL) has therefore been developed. We aim in this study to investigate transition from SL to HL in a population-based cohort. Methods: Adult patients (18 years and older) undergoing primary surgery due to spinal meningioma or schwannoma between 2007 and 2022 at the neurosurgical clinic were included. Data related to clinical, surgical and outcome variables were retrospectively collected. Results: A total of 187 patients were identified: 155 in the SL group, 26 in the HL group and in 6 patients a combination of SL and HL. The mean age of the SL group was 62.7 years (SD14.2) compared to 58.0 (SD15.7) in the HL group (p = 0.16). Preoperative motor deficit was more common in SL group compared to HL group (76.8 % and 61.5 %, respectively, p = 0.14). Thoracal location was most common for both groups (SL 65.8 % and HL 61.5 %). Postoperative change in McCormick grades and early complications were similar between groups. Conclusion: Outcome after hemilaminectomy due to intradural extramedullary schwannoma or meningioma is comparable to standard laminectomy with regards to postoperative complications and neurological improvement. Our findings support the transition to hemilaminectomy in selected cases.

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Background: Neurologic deficit is known as a rare complication of thoracic spinal cord stimulator (SCS) paddle lead implantation, but many believe its incidence after SCS paddle lead placement is under‐reported. It is possible that imaging characteristics may be used to help predict safe paddle lead placement. Objective: This imaging study was undertaken to determine the minimum canal diameter required for safe paddle lead placement. Methods: Patients who underwent thoracic laminotomy for new SCS paddle lead placement from January 2018 to March 2023 were identified retrospectively. Preoperative thoracic canal diameter was measured in the sagittal plane perpendicular to the disc space from T5/6 to T11/12. These thoracic levels were chosen because they span the most common levels targeted for SCS placement. Patients with and without new neurologic deficits were compared using a Mann–Whitney U‐test. Results: Of 185 patients initially identified, 180 had thoracic imaging available for review. One (0.5%) and 2 (1.1%) of 185 patients complained of permanent and transient neurologic deficit after thoracic SCS placement, respectively. Patients with neurologic deficits had average canal diameters of <11 mm. The average canal diameter of patients with and without neurologic deficits was 10.2 mm (range 6.1–12.9 mm) and 13.0 mm (range 5.9–20.2), respectively (p < 0.0001). Conclusion: Postoperative neurologic deficit is an uncommon complication after thoracic laminotomy for SCS paddle lead placement. The authors recommend ensuring a starting thoracic canal diameter of at least 12 mm to accommodate a SCS paddle lead measuring 2 mm thick to ensure a final diameter of >10 mm. If canal diameter is <12 mm, aggressive undercutting of the lamina, a second laminotomy, or placement of smaller SCS wire leads should be considered. [ABSTRACT FROM AUTHOR]

ObjectiveThe extent of surgery and the role of the frozen elephant trunk (FET) for surgical repair of acute aortic dissection type I are still subjects of debate. The aim of the study is to evaluate the short- and long-term results of acute surgical repair of aortic dissection type I using the FET compared to standard proximal aortic repair.MethodsBetween October 2009 and December 2016, 172 patients underwent emergent surgery for acute type I aortic dissection at our center. Of these, n = 72 received a FET procedure, while the other 100 patients received a conventional proximal aortic repair. Results were compared between the two surgery groups. The primary endpoints included 30-day rates of mortality and neurologic deficit and follow-up rates of mortality and aortic-related reintervention.ResultsDemographic data were comparable between the groups, except for a higher proportion of men in the FET group (76.4% vs. 60.0%, p = 0.03). The median age was 62 years [IQR (20), p = 0.17], and the median log EuroSCORE was 38.6% [IQR (31.4), p = 0.21]. The mean follow-up time was 68.3 ± 33.8 months. Neither early (FET group 15.3% vs. proximal group 23.0%, p = 0.25) nor late (FET group 26.2% vs. proximal group 23.0%, p = 0.69) mortality showed significant differences between the groups. There were fewer strokes in the FET patients (FET group 2.8% vs. proximal group 11.0%, p = 0.04), and the rates of spinal cord injury were similar between the groups (FET group 4.2% vs. proximal group 2.0%, p = 0.41). Aortic-related reintervention rates did not differ between the groups (FET group 12.1% vs. proximal group 9.8%, p = 0.77).ConclusionEmergent FET repair for acute aortic dissection type I is safe and feasible when performed by experienced surgeons. The benefits of the FET procedure in the long term remain unclear. Prolonged follow-up data are needed.

Introduction: Stroke is one of the leading causes of mortality and morbidity worldwide, with ischaemic stroke being the most common . Inflammation plays a key role in the pathogenesis of ischaemic stroke and the tissue injury that occurs poststroke, leading to stroke severity. Aim: To assess whether the Neutrophil to Lymphocyte Ratio (NLR), Lymphocyte to Monocyte Ratio (LMR), and Platelet to Lymphocyte Ratio (PLR) ratios correlate with the severity of ischaemic stroke in acute ischaemic stroke cases. Materials and Methods: This was a prospective cohort study conducted at KR Hospital, Mysore, Karnataka, India from July 2021 to June 2022, wherein 106 ischaemic stroke cases presenting within 24 hours of symptom onset were assessed, and the outcomes at discharge or at the end of one week were noted. Routine investigations and Non Contrast Computed Tomography (NCCT) brain scans were performed at the time of admission. National Institute of Health Stroke Scale (NIHSS) scoring was conducted at admission, and patients were grouped into mild to moderate stroke (

Study Design: Multi-center, prospective, observational cohort. Objective: To compare myelopathic vs. non-myelopathic ambulatory patients in short- and long-term neurologic function, operative treatment, and patient-reported outcomes. Methods: Pediatric deformity patients from 16 centers were enrolled with the following inclusion criteria: aged 10-21 years-old, a Cobb angle ≥100° in either the coronal or sagittal plane or any sized deformity with a planned 3-column osteotomy, and community ambulators. Patients were dichotomized into 2 groups: myelopathic (abnormal preoperative neurologic exam with signs/symptoms of myelopathy) and non-myelopathic (no clinical signs/symptoms of myelopathy). Results: Of 311 patients with an average age of 14.7 ± 2.8 years, 29 (9.3%) were myelopathic and 282 (90.7%) were non-myelopathic. There was no difference in age (P = 0.18), gender (P = 0.09), and Risser Stage (P = 0.06), while more patients in the non-myelopathic group had previous surgery (16.1% vs. 3.9%; P = 0.03). Mean lower extremity motor score (LEMS) in myelopathic patients increased significantly compared to baseline at every postoperative visit: Baseline: 40.7 ± 9.9; Immediate postop: 46.0 ± 7.1, P = 0.02; 1-year: 48.2 ± 3.7, P < 0.001; 2-year: 48.2 ± 7.7, P < 0.001). The non-myelopathic group had significantly higher LEMS immediately postoperative (P = 0.0007), but by 1-year postoperative, there was no difference in LEMS between groups (non-myelopathic: 49.3 ± 3.6, myelopathic: 48.2 ± 3.7, P = 0.10) and was maintained at 2-years postoperative (non-myelopathic: 49.2 ± 3.3, myelopathic: 48.2 ± 5.7, P = 0.09). Both groups improved significantly in all SRS domains compared to preoperative, with no difference in scores in the domains for pain (P = 0.12), self-image (P = 0.08), and satisfaction (P = 0.83) at latest follow-up. Conclusion: In severe spinal deformity pediatric patients presenting with preoperative myelopathy undergoing spinal reconstructive surgery, myelopathic patients can expect significant improvement in neurologic function postoperatively. At 1-year and 2-year postoperative, neurologic function was no different between groups. While non-myelopathic patients had significantly higher postoperative outcomes in SRS mental-health, function, and total-score, both groups had significantly improved outcomes in every SRS domain compared to preoperative. [ABSTRACT FROM AUTHOR]

Butterfly glioblastoma (bGBM) is a grade 4 glioma with a poor prognosis. Surgical treatment of these cancers has been reviewed in the literature with some recent studies supporting resection as a safe and effective treatment instead of biopsy and adjuvant therapy. This meta-analysis was designed to determine whether there are significant differences in overall survival (OS) and postoperative neurologic deficits (motor, speech, and cranial nerve) following intervention in patients who underwent tumor resection as part of their treatment, compared to patients who underwent biopsy without surgical resection. A literature search was conducted using PubMed (National Library of Medicine) and Embase (Elsevier) to identify articles from each database's earliest records to May 25, 2021, that directly compared the outcomes of biopsy and resection in bGBM patients and met predetermined inclusion criteria. A meta-analysis was conducted to compare the effects of the two management strategies on OS and postoperative neurologic deficits. Six articles met our study inclusion criteria. OS was found to be significantly longer for the resection group at 6 months (odds ratio [OR] 2.94, 95% confidence interval [CI] 1.23–7.05) and 12 months (OR 3.75, 95% CI 1.10–12.76) than for the biopsy group. No statistically significant differences were found in OS at 18 and 24 months. Resection was associated with an increased rate of postoperative neurologic deficit (OR 2.05, 95% CI 1.02–4.09). Resection offers greater OS up to 1 year postintervention than biopsy alone; however, this comes at the cost of higher rates of postoperative neurologic deficits. [ABSTRACT FROM AUTHOR]

Objectives To explore the difference between tracheostomy and non‐tracheostomy and identify the risk factors associated with the need for tracheostomy after traumatic cervical spinal cord injury (TCSCI). Methods The demographic and injury characteristics of 456 TCSCI patients, treated in the Xinqiao Hospital from 2010 to 2019, were retrospective analyzed. Patients were divided into the tracheostomy group (n = 63) and the non‐tracheostomy group (n = 393). Variables included were age, gender,smoking history, mechanism of injury, concomitant injury, American Spinal Injury Association (ASIA) Impairment Scale, the neurological level of injury, Cervical Spine Injury Severity Score (CSISS), surgery, and length of stay in ICU and hospital. SPSS 25.0 (SPSS, Chicago, IL) was used for statistical analysis and ROC curve drawing. Chi‐square analysis was applied to find out the difference of variables between the tracheostomy and non‐tracheostomy groups. Univariate logistic regression analysis (ULRA) and multiple logistic regression analysis (MLRA) were used to identify risk factors for tracheostomy. The area under the ROC curve (AUC) was used to evaluate the performance of these risk factors. Results Of 456 patients who met the inclusion criteria, 63 (13.8%) underwent tracheostomy. There were differences in age (χ2 = 6.615, P = 0.032), mechanism of injury (χ2 = 9.87, P = 0.036), concomitant injury (χ2 = 6.131, P = 0.013),ASIA Impairment Scale (χ2 = 123.08, P

One of the worst complications of surgery for spinal deformity is postoperative neurological deficit. Multimodal intraoperative neuromonitoring (IONM) can be used to detect impending neurological injuries. This study aimed to analyze IONM in non-idiopathic scoliosis using a minimally invasive fusionless surgical technique. This retrospective, single-center study was performed from 2014 to 2018. Patients with non-idiopathic scoliosis who underwent a minimally invasive fusionless procedure and had at least 2 years of follow-up were included. IONM was performed using a neurophysiological monitoring work station with somatosensory evoked potentials (SSEP) and neurogenic mixed evoked potentials (NMEP). A total of 290 patients were enrolled. The mean age at surgery was 12.9±3 years. The main etiology was central nervous system (CNS) disorders (n =139, 48%). Overall, 35 alerts (11%) in the SSEP and 10 (7%) in the NMEP occurred. There were two neurological deficits with total recovery after 6 months. There were no false negatives in either SSEP or NMEP, although there was one false positive in SSEP and two false positives for NMEP in the group without signal recovery. There was no significant relationship between the incidence of SSEP or NMEP loss and age, body mass index (BMI), number of rods used, upper instrumented vertebrae (p =0.36), lower instrumented vertebrae, or type of surgery. A preoperative greater Cobb angle was associated with a significantly higher risk of NMEP loss (p =0.02). In CNS patients, a higher BMI was associated with a statistically significant risk of NMEP loss (p =0.004). The use of a traction table was associated with a higher risk of signal loss (p =0.0005). A preoperative higher Cobb angle and degree of correction were associated with a significant risk of NMEP loss. In CNS scoliosis, a higher BMI was associated with a significant risk of NMEP loss. The use of a traction table was associated with a higher risk of signal loss. [ABSTRACT FROM AUTHOR]

The ketogenic diet (KD) has been shown to be effective in treating various brain pathologies. In this study, we conducted detailed transcriptomic and metabolomic profiling of rat brains after KD and ischemic stroke in order to investigate the effects of KD and its underlying mechanisms. We evaluated the effect of a two-month KD on gene expression in intact brain tissue and after middle cerebral artery occlusion (MCAO). We analyzed the effects of KD on gut microbiome composition and blood metabolic profile as well as investigated the correlation between severity of neurological deficits and KD-induced changes. We found transcriptional reprogramming in the brain after stroke and KD treatment. The KD altered the expression of genes involved in the regulation of glucose and fatty acid metabolism, mitochondrial function, the immune response, Wnt-associated signaling, stem cell development, and neurotransmission, both in intact rats and after MCAO. The KD led to a significant change in the composition of gut microbiome and the levels of amino acids, acylcarnitines, polyunsaturated fatty acids, and oxylipins in the blood. However, the KD slightly worsened the neurological functions after MCAO, so that the therapeutic effect of the diet remained unproven., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Cervical epidural abscess (CEA) is an unusual but severe condition. In most cases, it can be related to infections such as the methicillin-sensitive Staphylococcus aureus at the sites of intravenous cannulae. The current case report describes a patient who developed a right epidural abscess at C₅-C₇, diagnosed following persistent chest pain and fever. He eventually recovered after surgical decompression with intravenous antibiotics. The diagnosis of spinal epidural abscess (SEA) is very challenging because of the nonspecific character of symptoms. Early diagnosis using leukocytosis, elevated erythrocyte sedimentation rate (ESR), and MRI is crucial for preventing irreversible neurological deficits, as this case illustrates the importance of prompt intervention and meticulous follow-up to avoid complications like irreversible neurological deficits and enable spinal stabilization., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ulavala et al.)

We describe the case of a 74-year-old male with ankylosing spondylitis (AS) who presented to the Emergency Department for evaluation of acutely worsened left-sided weakness following a fall from standing. Computed tomography (CT) and magnetic resonance imaging (MRI) of his cervical spine revealed a chalk-stick fracture of C5-C7, which required surgical intervention. Chalk-stick fractures are rare, typically occurring in patients with AS, and often occurring from low-energy mechanisms. In the acute setting, providers should maintain a low threshold for obtaining CT or MRI imaging to evaluate spinal injury in patients with AS., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Baldwin et al.)

Oblique lumbar interbody fusion (OLIF) is known as a minimally invasive technique for disc space augmentation. Motor weakness after OLIF has been known to occur in some cases. This study aimed to report the incidence and potential risk factors for motor weakness following OLIF. We enrolled 36 patients and 57 segments who underwent OLIF. Computed tomography was performed before and after OLIF. Clinical data, including age, sex, presenting symptoms, bone mineral density, visual analog scale score, operating segments, and postoperative complications, were collected. We divided the patients into groups with and without neurologic deficit. The disc height was measured and compared between the 2 groups. We also divided the segments into groups with and without neurologic deficit. Foramen height and osteophyte length were measured and compared between the 2 groups. The neurologic deficit group included 3 patients (8%), whereas non-neurologic deficit group included 33 patients (92%). The neurologic deficit group included 5 segments (4%), whereas the non-neurologic deficit group included 109 segments (96%). The disc and foramen heights did not differ significantly between the groups with and without neurologic deficit; however, the osteophyte lengths were longer in the neurologic deficit group. In our study, vertebral osteophyte length was found to be a potential risk factor for motor weakness after OLIF. For patients with long osteophytes, additional laminectomy following OLIF or another surgical approach for direct decompression should be considered. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to give a systematic overview over the rate and location of concomitant injuries, the probability of suffering from neurological deficits, and to give evidence of the timing of surgery in severely injured patients with unstable thoracic vertebral body fractures. Methods: This review is based on articles retrieved by a systematic search in the PubMed and Web of Science database for publications up to November 2020 dealing with unstable fractures of the mid-thoracic spine. Results: Altogether, 1109 articles were retrieved from the literature search. A total of 1095 articles were excluded. Thus, 16 remaining original articles were included in this systematic review depicting the topics timing of surgery in polytraumatized patients, outcome neurologic deficits, and impact of concomitant injuries. The overall level of evidence of the vast majority of studies is low. Conclusion: The evidence of the available literature is low. The cited studies reveal that thoracic spinal fractures are associated with a high number of neurological deficits and concomitant injuries, particularly of the thoracic cage and the lung. Thereby, diagnostic algorithm should include computer tomography of the whole thoracic cage if there is any clinical sign of concomitant injuries. Patients with incomplete neurologic deficits benefit from early surgery consisting of decompression and long-segmental stabilization. [ABSTRACT FROM AUTHOR]

Abstract Background In 2011, the World Health Organization recommended injectable artesunate as the first-line therapy for severe malaria (SM) due to its superiority in reducing mortality compared to quinine. There are limited data on long-term clinical and neurobehavioral outcomes after artemisinin use for treatment of SM. Methods From 2008 to 2013, 502 Ugandan children with two common forms of SM, cerebral malaria and severe malarial anemia, were enrolled in a prospective observational study assessing long-term neurobehavioral and cognitive outcomes following SM. Children were evaluated a week after hospital discharge, and 6, 12, and 24 months of follow-up, and returned to hospital for any illness. In this study, we evaluated the impact of artemisinin derivatives on survival, post-discharge hospital readmission or death, and neurocognitive and behavioral outcomes over 2 years of follow-up. Results 346 children received quinine and 156 received parenteral artemisinin therapy (artemether or artesunate). After adjustment for disease severity, artemisinin derivatives were associated with a 78% reduction in in-hospital mortality (adjusted odds ratio, 0.22; 95% CI, 0.07–0.67). Among cerebral malaria survivors, children treated with artemisinin derivatives also had reduced neurologic deficits at discharge (quinine, 41.7%; artemisinin derivatives, 23.7%, p=0.007). Over a 2-year follow-up, artemisinin derivatives as compared to quinine were associated with better adjusted scores (negative scores better) in internalizing behavior and executive function in children irrespective of the age at severe malaria episode. After adjusting for multiple comparisons, artemisinin derivatives were associated with better adjusted scores in behavior and executive function in children

Abstract Background To evaluate the incidence and risk factors associated with unintended return to the operating room in adult spinal deformity after spinal deformity corrective surgery. Methods Retrospect of 141 adult spinal deformity patients in a single institution between January 2017 and December 2019. Inclusion criteria enrolled 18 to 80 years old patients who diagnosed with congenital/idiopathic/syndromic/acquired spinal deformity underwent posterior corrective spinal surgery. The surgical details and complications were recorded. The rate of unintended return to the operating room (UIROR) during hospitalization was examined, and the risk factors of unintended return to the operating room were investigated via multivariate analysis. Results This is a retrospective study. One hundred and forty-one patients who underwent spinal deformity surgery with a mean age of 31.8 years (range 18-69 years) were studied. The rate of unintended return to the operating room was 10.64% (15/141). Two of 15 patients had twice unintended surgery during hospitalization (13.33%). The most principal complication was neurologic deficit (73.3%); six of 15 postoperative present implants deviation causes severe lower limbs radiating pain (40%). The multivariate analysis shows higher apical vertebral rotation (AVR>grade II, odds ratio [OR] = 9.362; 95% CI= 1.930-45.420; P= .006), obesity (OR = 11.448; 95% CI= 1.320-99.263; P= .027), and previous neurological symptom (OR = 7.358; 95% CI= 1.798-30.108; P= .006) were independent predictors of unintended return to the operating room. Conclusion Postoperative neurologic deficit and short-term implant malposition are essential causes of unintended return to the operating room in adult spinal deformity patients. Preoperative factors such as higher AVR (> grade II), obesity, and previous neurological symptom may significantly increase the risk of morbidity in UIROR. Spine surgeons should be alert to these risk factors and require adequate preoperative evaluations to reduce the incidence of unintended return to the operating room.

Nationwide study results have suggested varying trends in the incidence of aneurysmal subarachnoid hemorrhage (aSAH) over time. Herein, trends over time for aSAH treated at a quaternary care center are compared with low-volume hospitals. Cases were retrospectively reviewed for patients with aSAH treated at our institution. Trend analyses were performed on the number of aSAH hospitalizations, treatment type, Charlson Comorbidity Index (CCI), Hunt and Hess grade, aneurysm location, aneurysm type, and in-hospital mortality. The National Inpatient Sample (NIS) was queried to compare the CCI scores of our patients with those of patients in low-volume hospitals (<20 aSAH/year) in our census division. Some 1248 patients (321 during 2004−2006; 927 during 2008−2018) hospitalized with aSAH were treated with endovascular therapy (489, 39%) or microsurgery (759, 61%). A significant downtrend in the annual aSAH caseload occurred (123 patients in 2004, 75 in 2018, P < 0.001). A linear uptrend was observed for the mean CCI score of patients (R 2 = 0.539, P < 0.001), with no change to in-hospital mortality (R 2 = 0.220, P = 0.24). Mean (standard deviation) CCI for small-volume hospitals treating aSAH within our division was significantly lower than that of our patient population (1.8 [1.6] vs 2.1 [2.0]) for 2012−2015. A decreasing number of patients were hospitalized with aSAH throughout the study. Compared with patients with aSAH admitted in 2004, those admitted more recently were sicker in terms of preexisting comorbidity and neurologic complexity. These trends could be attributable to the increasing availability of neurointerventional services at smaller-volume hospitals capable of treating healthier patients. [ABSTRACT FROM AUTHOR]

Background: Symptomatic spinal epidural veins (SEV) are a rare cause of neurologic dysfunction. Treatment is centered upon addressing the underlying venous pathology to relieve mechanical compression of the neurologic structures. However, open surgical ligation is often associated with considerable blood loss.Objective: We discuss a unique case of a large symptomatic epidural venous varix and potential treatment strategy.Methods and Materials: A 15-year-old female presented with a 1-year history of left L5 radicular pain and weakness. Lumbar MRI demonstrated a central L5/S1 herniated disc and a large extradural anomalous SEV compressing the exiting left L5 nerve root at the L5/S1 neuroformina. The SEV was treated using a transvenous liquid embolic agent providing symptomatic relief. At 16-months follow-up, she reported recurrent symptoms. She ultimately underwent a left L5/S1 MIS decompression without complication.Conclusion: Transvenous liquid embolization of large symptomatic SEV may provide temporary neurologic relief and decrease morbidity associated with open surgical treatment options. [ABSTRACT FROM AUTHOR]

Background: Outpatient surgical deformity correction for Charcot-Marie-Tooth (CMT) disease is limited by effective postoperative pain control. Our previous institutional protocol for foot and ankle surgery in this population included preoperative single-injection nerve blocks, but patients often experienced uncontrolled pain when the block wore off postoperative day 0 or 1, resulting in high opioid requirements and unplanned emergency department visits. The use of ultrasonography-guided continuous nerve catheters in CMT patients has not previously been studied. We aimed to prospectively investigate the safety and efficacy of ultrasonography-guided indwelling popliteal catheters in CMT patients undergoing outpatient foot deformity correction surgery. Methods: Twenty CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasonography-guided popliteal catheters. This series included 24 total outpatient procedures; 4 were staged bilateral. Indwelling popliteal catheters were maintained on discharge, providing continuous infusion until postoperative day (POD) 3, and then self-discontinued. Patients were prescribed oxycodone 5 mg (60-80 pills) as needed for breakthrough pain. Outcomes collected included daily pain scores (0-10), an opioid pill count on POD 14, and patient satisfaction ratings. Neurologic evaluation by 5-point 10g Semmes-Weinstein monofilament testing was performed preoperatively and on POD 14. Results: There were no observed catheter-site infections or hematomas. Nine of the patients had pre-existing sensory deficits involving at least 2 areas on the 5-point monofilament test. Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative pain scores were typically low, with median values (interquartile ranges [IQRs]) of 3.5 (2.0-5.0) on POD 1, 2.5 (2.0-5.0) on POD 2, and 2.5 (1.0-3.75) on POD 3. At POD 14, pain was 1.0 (0-1.0). Patients consumed a median of 25 oxycodone pills (IQR 8-43) over 2 weeks, less than half the prescribed number. Patient satisfaction was high. All patients reported they would choose to have a nerve catheter again for a similar surgery. Conclusion: This cases series demonstrated that regional anesthesia using ultrasonography-guided indwelling popliteal catheters was safe and effective for pain control in CMT patients undergoing outpatient foot and ankle surgery. Opioid consumption was comparable to published rates following major bony procedures, and no patients required emergent treatment or hospital admission for uncontrolled pain. No new sensory deficits were detected and patients with underlying sensory deficits remained unchanged. Patients were highly satisfied. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Stroke is a leading cause of adult disability. In our previous study, transplantation of human umbilical mesenchymal stem cells (HUMSCs) in Wharton's jelly in the acute phase of ischemic stroke promotes recovery in rats. Unfortunately, there is no cure for chronic stroke. Patients with chronic stroke can only be treated with rehabilitation or supportive interventions. This study aimed to investigate the potential of xenograft of HUMSCs for treating chronic stroke in rats. Rats were subjected to 90 min middle cerebral artery occlusion and then reperfusion to mimic ischemic cerebral stroke. On day 14 following stroke, HUMSCs were transplanted into the damaged cerebral cortex. The motor function in rats of the Stroke + HUMSCs group exhibited significant improvement compared to that of the Stroke + Saline group, and the trend persisted until day 56 post stroke. The cerebral cortex changes were tracked using magnetic resonance imaging, showing that cerebral atrophy was found starting on day 7 and was reduced significantly in rats receiving HUMSCs compared to that in the Stroke + Saline group from day 21 to day 56. HUMSCs were found to be existed in the rats' cerebral cortex on day 56, with signs of migration. The grafted HUMSCs did not differentiate into neurons or astrocytes and may release cytokines to improve neuroprotection, decrease inflammation and increase angiogenesis. Our results demonstrate that xeno-transplantation of HUMSCs has therapeutic benefits for chronic ischemic stroke. Most importantly, patients do not need to use their own HUMSCs, which is a gospel thing for clinical patients. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective review of prospectively collected multicenter registry data.Objective: To identify rates and timing of postoperative complications in adult spinal deformity (ASD) patients, the impact of complication type and timing on health related quality of life (HRQoL) outcomes, and the impact of complication timing on readmission and reoperation rates. Better understanding of complication timing and impact on HRQoL may improve patient selection, preoperative counseling, and postoperative complication surveillance.Summary Of Background Data: ASD is common and associated with significant disability. Surgical correction is often pursued, but is associated with high complication rates. The International Spine Study Group, AO Spinal Deformity Forum, and European Spine Study Group have developed a new complication classification system for ASD (ISSG-AO spine complications classification system).Methods: The ISSG-AO spine complications classification system was utilized to assess complications occurring over the 2-year postoperative time period amongst a multicenter, prospectively enrolled cohort of patients who underwent surgery for ASD. Kaplan-Meier survival curves were established for each complication type. Propensity score matching was performed to adjust for baseline disability and comorbidities. Associations between each complication type and HRQoL, and reoperation/readmission and complication timing, were assessed.Results: Of 584 patients meeting inclusion criteria, cardiopulmonary, gastrointestinal, infection, early adverse events, and operative complications contributed to a rapid initial decrease in complication-free survival. Implant-related, radiographic, and neurologic complications substantially decreased long-term complication-free survival. Only radiographic and implant-related complications were significantly associated with worse 2-year HRQoL outcomes. Need for readmission and/or reoperation was most frequent among those experiencing complications after postoperative day 90.Conclusion: Surgeons should recognize that long-term complications have a substantial negative impact on HRQoL, and should carefully monitor for implant-related and radiographic complications over long-term follow-up.Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

The purpose of this case report was to present successfully treated case of symptomatic cement leakage after percutaneous vertebroplasty procedure (PVP) with technical tips to avoid such injury and to present literature review. PVP is a simple solution to treat osteoporotic vertebral compression fracture (OVCF) if it is performed with right indications. Cement leak into spinal canal during PVP can lead to catastrophic accident and cause severe neurological deficit that requires an urgent exploration and removal of cement. To avoid medial pedicle breach, there should be a definitive guideline during PVP. An 81-year-old lady had PVP after injury for OVCF at D12. She developed severe neurological deficit immediately after the procedure; however, she was managed conservatively. On presentation to us, urgent investigations with CT scan revealed cement leak into spinal canal from medial pedicle breach extending from D10-12 level with severe cord compression. Her surgery was performed with wide laminectomy at D10-D12 levels with transpedicular stabilization D9-L2 along with neuromonitoring. Cement mass was isolated from the dura and removed achieving decompression of the cord. Postoperatively, patient showed significant neurological improvement and walked independently with the help of stick in three months. In conclusion, although PVP is a convenient solution for painful OVCF, care must be taken while considering this option such as timing, insertion of needle, viscosity of cement, and C-arm monitoring. If neurological deficit occurs, urgent CT scan for the diagnosis and exploration with removal of cement with or without stabilization is mandatory.

This article describes a teenager who developed anisocoria with no obvious neurologic deficits or decline after a motor vehicle accident. The condition resolved over several hours before reappearing in the opposite eye 2 days later. Again no clinical neurologic deficits were noted and the condition resolved after several hours. The patient's asymptomatic anisocoria was finally determined to be secondary to aerosolized ipratropium treatments and an ill-fitting mask. [ABSTRACT FROM AUTHOR]

Objectives: To explore the difference between tracheostomy and non‐tracheostomy and identify the risk factors associated with the need for tracheostomy after traumatic cervical spinal cord injury (TCSCI). Methods: The demographic and injury characteristics of 456 TCSCI patients, treated in the Xinqiao Hospital from 2010 to 2019, were retrospective analyzed. Patients were divided into the tracheostomy group (n = 63) and the non‐tracheostomy group (n = 393). Variables included were age, gender,smoking history, mechanism of injury, concomitant injury, American Spinal Injury Association (ASIA) Impairment Scale, the neurological level of injury, Cervical Spine Injury Severity Score (CSISS), surgery, and length of stay in ICU and hospital. SPSS 25.0 (SPSS, Chicago, IL) was used for statistical analysis and ROC curve drawing. Chi‐square analysis was applied to find out the difference of variables between the tracheostomy and non‐tracheostomy groups. Univariate logistic regression analysis (ULRA) and multiple logistic regression analysis (MLRA) were used to identify risk factors for tracheostomy. The area under the ROC curve (AUC) was used to evaluate the performance of these risk factors. Results: Of 456 patients who met the inclusion criteria, 63 (13.8%) underwent tracheostomy. There were differences in age (χ2 = 6.615, P = 0.032), mechanism of injury (χ2 = 9.87, P = 0.036), concomitant injury (χ2 = 6.131, P = 0.013),ASIA Impairment Scale (χ2 = 123.08, P < 0.01), the neurological level of injury (χ2 = 34.74, P < 0.01), and CSISS (χ2 = 19.612, P < 0.01) between the tracheostomy and non‐tracheostomy groups. Smoking history, CSISS ≥ 7, AIS A and, NLI ≥ C5 were identified as potential risk factors for tracheostomy by ULRA. Smoking history (OR = 2.960, 95% CI: 1.524–5.750, P = 0.001), CSISS ≥ 7 (OR = 4.599, 95% CI: 2.328–9.085, P = 0.000), AIS A (OR = 14.213, 95% CI: 6.720–30.060, P = 0.000) and NLI ≥ C5 (OR = 8.312, 95% CI: 1.935–35.711, P = 0.004) as risk factors for tracheostomy were determined by MLRA. The AUC for the risk factors of tracheostomy after TCSCI was 0.858 (95% CI: 0.810–0.907). Conclusions: Smoking history, CSISS ≥ 7, AIS A and, NLI ≥ C5 were identified as risk factors needing of tracheostomy in patients with TCSCI. These risk factors may be important to assist the clinical decision of tracheostomy. [ABSTRACT FROM AUTHOR]

Correction of severe spinal deformity is a significant challenge for spinal surgeons. Although halo-gravity traction (HGT) has been shown to be well-tolerated and safe, we report here a case of neurologic decline during treatment. A 24-year-old male presents with severe thoracic kyphoscoliosis with > 180° of 3-dimensional deformity. Magnetic resonance imaging showed his thoracic spinal cord draped across his T7–9 apex. His neurologic exam showed lower extremity myelopathy. During week 7 at a goal traction weight of 18.1 kg, his distal lower extremity exam declined from 4+/5 to 2/5. His traction weight was lowered to 11.3 kg. He subsequently sustained a ground-level fall and became paraparetic with a motor exam of 1–2/5. He subsequently underwent a T1–L4 posterior spinal instrumentation and fusion with a T7–9 vertebral column resection. Postoperatively, he was noted to have a complete return to his baseline neurologic exam. At his 4-month postoperative visit, he was now full strength in his lower extremities with complete resolution of his myelopathy. We present here a case of neurologic decline in a patient with severe kyphoscoliosis who underwent HGT and discuss the management decisions associated with this challenging scenario.

Background: Schwannomas and meningiomas are intradural extramedullary spinal tumors which are regularly encountered in the neurosurgical clinic. These tumors cause neurological deficit by compression on the spinal cord and commonly pain when affecting the cauda equina. The traditional treatment with standard laminectomy (SL) can cause instability to the dorsal segments of the spinal column, and the less invasive option of hemilaminectomy (HL) has therefore been developed. We aim in this study to investigate transition from SL to HL in a population-based cohort., Methods: Adult patients (18 years and older) undergoing primary surgery due to spinal meningioma or schwannoma between 2007 and 2022 at the neurosurgical clinic were included. Data related to clinical, surgical and outcome variables were retrospectively collected., Results: A total of 187 patients were identified: 155 in the SL group, 26 in the HL group and in 6 patients a combination of SL and HL. The mean age of the SL group was 62.7 years (SD14.2) compared to 58.0 (SD15.7) in the HL group (p = 0.16). Preoperative motor deficit was more common in SL group compared to HL group (76.8 % and 61.5 %, respectively, p = 0.14). Thoracal location was most common for both groups (SL 65.8 % and HL 61.5 %). Postoperative change in McCormick grades and early complications were similar between groups., Conclusion: Outcome after hemilaminectomy due to intradural extramedullary schwannoma or meningioma is comparable to standard laminectomy with regards to postoperative complications and neurological improvement. Our findings support the transition to hemilaminectomy in selected cases., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Ltd.)

Introduction: This study evaluated the presence of neurologic sequelae among trauma patients after flexion-extension (F/E) radiographs., Methods: Authors of the study conducted a retrospective review of patients (age ≥ 14 years) with a Glasgow Coma Score of 15 who sustained a blunt traumatic injury and received F/E radiographs. Radiographic scans were defined as positive, negative, inconclusive, or incomplete. The neurologic status of each patient was assessed before and after the F/E radiographs, and at discharge and follow-up., Results: Of the 501 patients included in the analysis, 84.6% (n = 424) had negative F/E radiographs, and 3.2% (n = 16) had positive F/E radiographs. Ten percent (n = 51) of patients had incomplete F/E radiographs, and 2.0% (n = 10) were inconclusive due to the inability to rule out a ligamentous injury. Three patients (0.6%) had MRI-confirmed ligamentous injuries, all of which had initial incomplete F/E radiographs due to pain. No patient had a documented neurological deficit before or after the F/E exam. Three patients with an initial negative F/E radiograph returned to the clinic with symptoms of neurologic sequelae. Two of these patients had symptom resolution with no further issues at future follow-up appointments. The third patient was found to have chronic neurologic symptoms after further evaluation., Conclusions: The inclusion of F/E exams in cervical spine clearance protocols did not demonstrate any new long-term iatrogenic neurologic injuries. Consideration should be given to performing MRIs on patients with incomplete F/E radiographs that cannot rule out a ligamentous injury., (Copyright © 2024 Durler, et al.)

Introduction: Neurologic complications after complex adult spinal deformity (ASD) surgery are important, yet outcomes are heterogeneously reported, and long-term follow-up of actual lower extremity motor function is unknown. Objective: To prospectively evaluate lower extremity motor function scores (LEMS) before and at 5 years after surgical correction of complex ASD. Design: Retrospective analysis of a prospective, multicenter, international observational study. Methods: The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers around the world. Inclusion criteria were Cobb angle of > 80°, corrective osteotomy for congenital or revision deformity and/or 3-column osteotomy. Among patients with 5-year follow-up, comparisons of LEMS to baseline and within each follow-up period were made via documented neurologic exams on each patient. Results: Seventy-seven (28.3%) patients had 5-year follow-up. Among these 77 patients with 5-year follow-up, rates of postoperative LEMS deterioration were: 14.3% hospital discharge, 10.7% at 6 weeks, 6.5% at 6 months, 9.5% at 2 years and 9.3% at 5 years postoperative. During the 2–5 year window, while mean LEMS did not change significantly (−0.5, p = 0.442), eight (11.1%) patients deteriorated (of which 3 were ≥ 4 motor points), and six (8.3%) patients improved (of which 2 were ≥ 4 points). Of the 14 neurologic complications, four (28.6%) were surgery-related, three of which required reoperation. While mean LEMS were not impacted in patients with a major surgery-related complication, mean LEMS were significantly lower in patients with neurologic surgery-related complications at discharge (p = 0.041) and 6 months (p = 0.008) between the two groups as well as the change from baseline to 5 years (p = 0.041). Conclusions: In 77 patients undergoing complex ASD surgery with 5-year follow-up, while mean LEMS did not change from 2 to 5 years, subtle neurologic changes occurred in approximately 1 in 5 patients (11.1% deteriorated; 8.3% improved). Major surgery-related complication did not result in decreased LEMS; however, those with neurologic surgery-related complications continued to have decreased lower extremity motor function at 5 years postoperative. These results underscore the importance of long-term follow-up to 5 years, using individual motor scores rather than group averages, and comparing outcomes to both baseline and last follow-up. [ABSTRACT FROM AUTHOR]

Background: Glioma is the most common intra-axial tumor, and its location relative to critical areas of the brain is important for treatment decision-making. Studies often report tumor location based on anatomical taxonomy alone since the estimation of eloquent regions requires considerable knowledge of functional neuroanatomy and is, to some degree, a subjective measure. An unbiased and reproducible method to determine tumor location and eloquence is desirable, both for clinical use and for research purposes. Objective: To report on a voxel-based method for assessing anatomical distribution and proximity to eloquent regions in diffuse lower-grade gliomas (World Health Organization grades 2 and 3). Methods: A multi-institutional population-based dataset of adult patients (≥18 years) histologically diagnosed with lower-grade glioma was analyzed. Tumor segmentations were registered to a standardized space where two anatomical atlases were used to perform a voxel-based comparison of the proximity of segmentations to brain regions of traditional clinical interest. Results: Exploring the differences between patients with oligodendrogliomas, isocitrate dehydrogenase (IDH) mutated astrocytomas, and patients with IDH wild-type astrocytomas, we found that the latter were older, more often had lower Karnofsky performance status, and that these tumors were more often found in the proximity of eloquent regions. Eloquent regions are found slightly more frequently in the proximity of IDH -mutated astrocytomas compared to oligodendrogliomas. The regions included in our voxel-based definition of eloquence showed a high degree of association with performing biopsy compared to resection. Conclusion: We present a simple, robust, unbiased, and clinically relevant method for assessing tumor location and eloquence in lower-grade gliomas. [ABSTRACT FROM AUTHOR]

Introduction: The incidence of spontaneous spinal epidural hematoma is relatively rare and it may cause a spinal cord injury possibly associated with related severe disabling conditions: sensory-motor impairments, back pain, neurogenic bladder and bowel. The MRI is the golden standard diagnostic examination in patients suspected of spinal epidural hematoma. Still, such a spontaneous condition can be, not-seldom, asymptomatic. Materials and methods: This paper presents the case of a 79-year-old male patient with permanent atrial fibrillation, treated with acenocoumarol, who was admitted, first in the General Surgery Clinic Division with rectal tenesmus and acute urinary retention and, subsequently developed a sudden onset of motor deficit, as presented in the body text. The patient was diagnosed with epidural hematoma (C7-T10) resulting in AIS/Frankel C paraplegia, with T10 neurological level. The positive and differential diagnoses concluded that the acenocoumarol overdose was the main etiopathogenic factor. Results: The patient--being promptly transferred to the Spinal Neurosurgical Clinic Division--received conservative treatment, followed by a neuro-muscular rehabilitation program achieved in our Neuro-Rehabilitation Clinic Division, with mainly favorable outcomes: at discharge he was able to walk independently on short distances. Conclusions: The clinical outcomes and quality of life of patients suffering from spinal epidural hematoma depend on the fast diagnosis and efficient acute neurosurgical/conservative treatment, followed by an appropriate rehabilitation program, including with medium and long term medical follow-up. This clinical case has received the Teaching Emergency Hospital "Bagdasar-Arseni" Bioethics Committee approval No. 27/1935-25.02.2021. [ABSTRACT FROM AUTHOR]

BackgroundGlioma is the most common intra-axial tumor, and its location relative to critical areas of the brain is important for treatment decision-making. Studies often report tumor location based on anatomical taxonomy alone since the estimation of eloquent regions requires considerable knowledge of functional neuroanatomy and is, to some degree, a subjective measure. An unbiased and reproducible method to determine tumor location and eloquence is desirable, both for clinical use and for research purposes.ObjectiveTo report on a voxel-based method for assessing anatomical distribution and proximity to eloquent regions in diffuse lower-grade gliomas (World Health Organization grades 2 and 3).MethodsA multi-institutional population-based dataset of adult patients (≥18 years) histologically diagnosed with lower-grade glioma was analyzed. Tumor segmentations were registered to a standardized space where two anatomical atlases were used to perform a voxel-based comparison of the proximity of segmentations to brain regions of traditional clinical interest.ResultsExploring the differences between patients with oligodendrogliomas, isocitrate dehydrogenase (IDH) mutated astrocytomas, and patients with IDH wild-type astrocytomas, we found that the latter were older, more often had lower Karnofsky performance status, and that these tumors were more often found in the proximity of eloquent regions. Eloquent regions are found slightly more frequently in the proximity of IDH-mutated astrocytomas compared to oligodendrogliomas. The regions included in our voxel-based definition of eloquence showed a high degree of association with performing biopsy compared to resection.ConclusionWe present a simple, robust, unbiased, and clinically relevant method for assessing tumor location and eloquence in lower-grade gliomas.

Background: In 2011, the World Health Organization recommended injectable artesunate as the first-line therapy for severe malaria (SM) due to its superiority in reducing mortality compared to quinine. There are limited data on long-term clinical and neurobehavioral outcomes after artemisinin use for treatment of SM.Methods: From 2008 to 2013, 502 Ugandan children with two common forms of SM, cerebral malaria and severe malarial anemia, were enrolled in a prospective observational study assessing long-term neurobehavioral and cognitive outcomes following SM. Children were evaluated a week after hospital discharge, and 6, 12, and 24 months of follow-up, and returned to hospital for any illness. In this study, we evaluated the impact of artemisinin derivatives on survival, post-discharge hospital readmission or death, and neurocognitive and behavioral outcomes over 2 years of follow-up.Results: 346 children received quinine and 156 received parenteral artemisinin therapy (artemether or artesunate). After adjustment for disease severity, artemisinin derivatives were associated with a 78% reduction in in-hospital mortality (adjusted odds ratio, 0.22; 95% CI, 0.07-0.67). Among cerebral malaria survivors, children treated with artemisinin derivatives also had reduced neurologic deficits at discharge (quinine, 41.7%; artemisinin derivatives, 23.7%, p=0.007). Over a 2-year follow-up, artemisinin derivatives as compared to quinine were associated with better adjusted scores (negative scores better) in internalizing behavior and executive function in children irrespective of the age at severe malaria episode. After adjusting for multiple comparisons, artemisinin derivatives were associated with better adjusted scores in behavior and executive function in children <6 years of age at severe malaria exposure following adjustment for child age, sex, socioeconomic status, enrichment in the home environment, and the incidence of hospitalizations over follow-up. Children receiving artesunate had the greatest reduction in mortality and benefit in behavioral outcomes and had reduced inflammation at 1-month follow-up compared to children treated with quinine.Conclusions: Treatment of severe malaria with artemisinin derivatives, particularly artesunate, results in reduced in-hospital mortality and neurologic deficits in children of all ages, reduced inflammation following recovery, and better long-term behavioral outcomes. These findings suggest artesunate has long-term beneficial effects in children surviving severe malaria. [ABSTRACT FROM AUTHOR]

Lymphangiomas are benign lesions consisting of abnormal proliferations of lymphatic vessels. Lymphangiomas associated with bone involvement, particularly in vertebral bodies, accompanied by cord compression, are extremely rare, and our literature review yielded only a few relevant reports. We describe a 61-year-old man presenting with progressive paraparesis and sphincter disturbance of 5 months’ duration. Magnetic resonance imaging (MRI) revealed an enhancing T8 vertebral body involvement as well as a homogeneously enhancing posterior epidural mass at the T7–T8 level, with severe cord compression and cerebrospinal fluid (CSF) blockade. The patient underwent surgery via T7–T8 laminectomy, and after the removal of the epidural mass, the surgical procedure was stopped due to severe bleeding. Histopathologic examination reported a lymphangioma. After 10 days, the patient was able to walk. In the sixth postoperative month, MRI showed complete relief of the mass effect. The wide spectrum of the preoperative differential diagnosis of lymphangiomas renders a definite preoperative diagnosis impossible; therefore, histopathologic examination is the sole definite route for their diagnosis. In case of the solitary lymphangiomas of the spine with epidural compression, preoperative angiography and embolization should be considered to reduce intraoperative bleeding and enhance the chance of total resection and total surgical resection should be performed to decrease the likelihood of recurrence.

Study Design Prospective cohort study. Purpose The study was aimed at evaluating clinicoradiological factors affecting recovery of neurological deficits in cases of lumbar disc herniation (LDH) treated by lumbar microdiscectomy. Overview of Literature The majority of the available literature on neurological recovery following neurodeficit is limited to retrospective series. The literature is currently limited regarding variables that can help predict the recovery of neurodeficits following LDH. Methods A prospective analysis was performed on 70 consecutive patients who underwent lumbar microdiscectomy (L1–2 to L5–S1) owing to neurological deficits due to LDH. Patients with motor power ≤3/5 in L2–S1 myotomes were considered for analysis. Follow-up was performed at 2, 6, and 12 months to note recovery of motor deficits. Clinicoradiological parameters were compared between the recovered and nonrecovered groups. Results A total of 65 patients were available at the final follow-up: 41 (63%) had completely recovered by 2 months; four showed delayed recovery at the 6-month follow-up; and 20 (30.7%) showed no recovery at 1 year. Clinicoradiological factors, including diabetes, complete initial deficit, areflexia, multilevel disc prolapse, longer duration since initial symptoms, and ≥2 previous symptomatic episodes were associated with a significant risk of poorer recovery (p0.05 for all). Diabetes mellitus (p=0.033) and complete initial motor deficit (p=0.028) were significantly associated with delayed recovery in the multivariate analysis. Conclusions The overall neurological recovery rate in our study was 69%. Diabetes mellitus (p=0.033) and complete initial motor deficit were associated with delayed motor recovery.

Amaç: Perfüzyon ağırlıklı manyetik rezonans görüntüleme, santral sinir sisteminin mikrovasküler dolaşımını değerlendirmek için kullanılan yeni bir tekniktir. Bu çalışmamızda nörolojik defisite sahip multipl skleroz hastalarını perfüzyon görüntüleme ile değerlendirmeyi ve elde edilen değerleri kontrol grubu ile karşılaştırmayı amaçladık.Gereç ve Yöntem: Ataklarla seyreden 25 multipl skleroz hastası ve 25 yaş/cinsiyet eşleştirmeli kontrol grubu çalışmaya dâhil edildi. Tüm hastalara klinik testler uygulandı ve takip eden 48 saat içerisinde perfüzyon ağırlıklı manyetik rezonans görüntüleme yapıldı.Bulgular: Periventriküler normal beyaz cevherden elde edilen hasta ve kontrol grubuna ait perfüzyon verilerinin karşılaştırılmasında, serebral kan hacmi haritasından elde edilen perfüzyon değerlerinde her iki grup arasında anlamlı fark izlenirken p

Background: Stroke diagnosis can be challenging in patients with dizziness without neurologic deficits. The aim of this study was to evaluate the predictive value of C-reactive protein (CRP) for identifying acute stroke in such patients.Methods: Data from adult patients (>18 years) admitted to the emergency department from August 2019 to February 2020 were evaluated. The study subjects were 1,188 patients presenting with dizziness without neurological deficits whose serum CRP level was measured within 2 h of arriving at the emergency department and who underwent brain magnetic resonance imaging. The relationship between CRP and acute stroke was analyzed using univariable and multivariable models.Results: Acute stroke was detected in 53 (4.4%) patients (40 with brain infarction, 10 with vertebrobasilar insufficiency, 2 with intracerebral hemorrhage, and 1 with subarachnoid hemorrhage). The CRP levels did not differ significantly between the acute stroke and non-stroke groups [0.10 (0.10–0.31) vs. 0.10 (0.10–0.16), P = 0.074]. The area under receiver operating characteristic curve of CRP for acute stroke was not statistically significant (0.567, P = 0.101). On multivariable analysis, the following variables were associated with acute stroke: age (odds ratio [OR], 1.041; 95% confidence interval [CI], 1.011–1.071), history of cerebrovascular accidents (OR, 1.823; 95% CI, 1.068–3.110), white blood cell count (OR, 1.126; 95% CI, 1.017–1.248), and hemoglobin (OR, 1.316; 95% CI, 1.056–1.640). However, CRP (P = 0.183) was not associated with acute stroke.Conclusion: Serum CRP levels do not have significant discriminative value for identifying acute stroke in patients with dizziness without definite neurologic deficits.

Background: Stroke diagnosis can be challenging in patients with dizziness without neurologic deficits. The aim of this study was to evaluate the predictive value of C-reactive protein (CRP) for identifying acute stroke in such patients. Methods: Data from adult patients (>18 years) admitted to the emergency department from August 2019 to February 2020 were evaluated. The study subjects were 1,188 patients presenting with dizziness without neurological deficits whose serum CRP level was measured within 2 h of arriving at the emergency department and who underwent brain magnetic resonance imaging. The relationship between CRP and acute stroke was analyzed using univariable and multivariable models. Results: Acute stroke was detected in 53 (4.4%) patients (40 with brain infarction, 10 with vertebrobasilar insufficiency, 2 with intracerebral hemorrhage, and 1 with subarachnoid hemorrhage). The CRP levels did not differ significantly between the acute stroke and non-stroke groups [0.10 (0.10–0.31) vs. 0.10 (0.10–0.16), P = 0.074]. The area under receiver operating characteristic curve of CRP for acute stroke was not statistically significant (0.567, P = 0.101). On multivariable analysis, the following variables were associated with acute stroke: age (odds ratio [OR], 1.041; 95% confidence interval [CI], 1.011–1.071), history of cerebrovascular accidents (OR, 1.823; 95% CI, 1.068–3.110), white blood cell count (OR, 1.126; 95% CI, 1.017–1.248), and hemoglobin (OR, 1.316; 95% CI, 1.056–1.640). However, CRP (P = 0.183) was not associated with acute stroke. Conclusion: Serum CRP levels do not have significant discriminative value for identifying acute stroke in patients with dizziness without definite neurologic deficits. [ABSTRACT FROM AUTHOR]

Background: To evaluate the incidence and risk factors associated with unintended return to the operating room in adult spinal deformity after spinal deformity corrective surgery. Methods: Retrospect of 141 adult spinal deformity patients in a single institution between January 2017 and December 2019. Inclusion criteria enrolled 18 to 80 years old patients who diagnosed with congenital/idiopathic/syndromic/acquired spinal deformity underwent posterior corrective spinal surgery. The surgical details and complications were recorded. The rate of unintended return to the operating room (UIROR) during hospitalization was examined, and the risk factors of unintended return to the operating room were investigated via multivariate analysis. Results: This is a retrospective study. One hundred and forty-one patients who underwent spinal deformity surgery with a mean age of 31.8 years (range 18-69 years) were studied. The rate of unintended return to the operating room was 10.64% (15/141). Two of 15 patients had twice unintended surgery during hospitalization (13.33%). The most principal complication was neurologic deficit (73.3%); six of 15 postoperative present implants deviation causes severe lower limbs radiating pain (40%). The multivariate analysis shows higher apical vertebral rotation (AVR>grade II, odds ratio [OR] = 9.362; 95% CI= 1.930-45.420; P=.006), obesity (OR = 11.448; 95% CI= 1.320-99.263; P=.027), and previous neurological symptom (OR = 7.358; 95% CI= 1.798-30.108; P=.006) were independent predictors of unintended return to the operating room. Conclusion: Postoperative neurologic deficit and short-term implant malposition are essential causes of unintended return to the operating room in adult spinal deformity patients. Preoperative factors such as higher AVR (> grade II), obesity, and previous neurological symptom may significantly increase the risk of morbidity in UIROR. Spine surgeons should be alert to these risk factors and require adequate preoperative evaluations to reduce the incidence of unintended return to the operating room. [ABSTRACT FROM AUTHOR]

The outcomes of conservative and operative treatment of os odontoideum in children remain unclear. Our objective was to study the outcomes of conservative and surgical treatment of idiopathic os odontoideum in children and compare these outcomes in age- and treatment-matched nonidiopathic children with os odontoideum. A retrospective multicenter review identified 102 children with os odontoideum, of whom 44 were idiopathic with minimum 2-year follow-up. Ten patients were treated conservatively, and 34 underwent spinal arthrodesis. Both groups were matched with nonidiopathic patients by age and type of treatment. Cervical arthrodesis was recommended for patients with increased atlantoaxial distance or reduced space available for the cord in flexion-extension radiographs. All 20 children undergoing conservative treatment remained asymptomatic during follow-up, but 1 nonidiopathic patient developed cervical instability. The idiopathic group had significantly less severe radiographic cervical instability and less neurologic complications than the nonidiopathic group (P < 0.05 for all comparisons). Thirty-three (97%) patients in the idiopathic group and 32 (94%) patients in the nonidiopathic group (94%) had spinal fusion at final follow-up (P = 0.55). The risk of complications (15% vs. 41%; odds ratio 0.234, 95% confidence interval 0.072–0.757, P = 0.015) and nonunion (6% vs. 24%; odds ratio 0.203, 95% confidence interval 0.040–0.99, P = 0.040) were significantly lower in the idiopathic than in the nonidiopathic group. Idiopathic children undergoing rigid fixation achieved spinal fusion. Idiopathic patients with stable atlantoaxial joint at presentation remained asymptomatic and intact during conservative treatment. Idiopathic children with os odontoideum undergoing spinal arthrodesis had significantly fewer complications and nonunion than nonidiopathic children. III [ABSTRACT FROM AUTHOR]

Study Design: Prospective analysis of example cases.Objective: The aim of this study was to analyze the accuracy and repeatability of a new comprehensive classification system for capturing complications data in adult spinal deformity.Summary Of Background Data: Complications are common in adult spinal deformity surgery. However, no consensus exists on the definition or classification of complications in adult spinal deformity surgery. The lack of consensus significantly limits understanding of complications' effects on outcomes in surgery for adult spinal deformity.Methods: Using a Delphi method, members of the International Spine Study Group, AO Spine, and the European Spine Study Group collaborated to develop an adult spinal deformity classification system. The multidomain classification system accounts for medical complications (cancer, cardiopulmonary, central nervous system, gastrointestinal, infectious, musculoskeletal, renal) and surgical complications (implant complications, radiographic complications, neurologic events, intraoperative events, and wound complications). Seventeen individuals ("event readers"), including spine surgeons, trainees, and research coordinators, used the new classification system two separate times to analyze complications in ten example cases. The accuracy and repeatability of the classification system were subsequently calculated based on the providers' responses for the example cases.Results: The 10 example cases included 22 complications. Nearly 95% of complications were captured by >95% of the event readers. The system demonstrated good repeatability of 86.9% between the first and second set of responses provided by event readers.Conclusion: The ISSG-AO Multi-Domain Spinal Deformity Complication Classification System for Adult Spinal Deformity demonstrated good accuracy and repeatability among both surgeons and research coordinators in capturing complications in adult spinal deformity surgery. The ISSG-AO system may be applied to help better understand the impact of complications on outcomes and costs in adult spinal deformity surgery.Level of Evidence: 5. [ABSTRACT FROM AUTHOR]