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Stefanie M, Antonia G, Leah Shyela V, Sabine H, Peter D, Jens F, Daniel B, Christian B, Veit R, Mathias B, Jan L, Ilko L M. T1 mapping in patients with cervical spinal canal stenosis with and without decompressive surgery: A longitudinal study. J Neuroimaging 2024; 34:329-338. [PMID: 38403747 DOI: 10.1111/jon.13195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND AND PURPOSE Cervical spinal canal stenosis (cSCS) is a common cause of spinal impairment in the elderly. With conventional magnetic resonance imaging (MRI) suffering from various limitations, high-resolution single-shot T1 mapping has been proposed as a novel MRI technique in cSCS diagnosis. In this study, we investigated the effect of conservative and surgical treatment on spinal cord T1 relaxation times in cSCS. METHODS T1-mapping was performed in 54 patients with cSCS at 3 Tesla MRI at the maximum-, above and below the stenosis. Subsequently, intraindividual T1-differences (ΔT1) intrastenosis were calculated. Twenty-four patients received follow-up scans after 6 months. RESULTS Surgically treated patients showed higher ΔT1 at baseline (154.9 ± 81.6 vs. 95.3 ± 60.7), while absolute T1-values within the stenosis were comparable between groups (863.7 ± 89.3 milliseconds vs. 855.1 ± 62.2 milliseconds). In surgically treated patients, ΔT1 decreased inverse to stenosis severity. After 6 months, ΔT1 significantly decreased in the surgical group (154.9 ± 81.6 milliseconds to 85.7 ± 108.9 milliseconds, p = .021) and remained unchanged in conservatively treated patients. Both groups showed clinical improvement at the 6-month follow-up. CONCLUSIONS Baseline difference of T1 relaxation time (ΔT1) might serve as a supporting marker for treatment decision and change of T1 relaxation time might reflect relief of spinal cord narrowing indicating regenerative processes. Quantitative T1-mapping represents a promising additional imaging method to indicate a surgical treatment plan and to validate treatment success.
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Affiliation(s)
- Meyer Stefanie
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Geiger Antonia
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Volnhals Leah Shyela
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Hofer Sabine
- Biomedical NMR, Max-Planck-Institute for Multidisciplinary Sciences, Göttingen, Germany
| | - Dechent Peter
- Department of Cognitive Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Frahm Jens
- Biomedical NMR, Max-Planck-Institute for Multidisciplinary Sciences, Göttingen, Germany
| | - Behme Daniel
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Neuroradiology, University Medical Center Magdeburg, Göttingen, Germany
| | - Brelie Christian
- Department of Neurosurgery, Johanniter-Clinics Bonn, Göttingen, Germany
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Rohde Veit
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Bähr Mathias
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Liman Jan
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
- Department of Neurology, Paracelsus Medical School, Nürnberg, Germany
| | - Maier Ilko L
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
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Johansen TO, Holmberg ST, Danielsen E, Rao V, Salvesen ØO, Andresen H, Carmen VLLA, Solberg TK, Gulati S, Nygaard ØP. Long-Term Results After Surgery for Degenerative Cervical Myelopathy. Neurosurgery 2024; 94:454-460. [PMID: 37823669 PMCID: PMC10846761 DOI: 10.1227/neu.0000000000002712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Degenerative cervical myelopathy (DCM) is a frequent cause of spinal cord dysfunction, and surgical treatment is considered safe and effective. Long-term results after surgery are limited. This study investigated long-term clinical outcomes through data from the Norwegian registry for spine surgery. METHODS Patients operated at the university hospitals serving Central and Northern Norway were approached for long-term follow-up after 3 to 8 years. The primary outcome was change in the Neck Disability Index, and the secondary outcomes were changes in the European Myelopathy Scale score, quality of life (EuroQoL EQ-5D); numeric rating scales (NRS) for headache, neck pain, and arm pain; and perceived benefit of surgery assessed by the Global Perceived Effect scale from 1 year to long-term follow-up. RESULTS We included 144 patients operated between January 2013 and June 2018. In total, 123 participants (85.4%) provided patient-reported outcome measures (PROMs) at long-term follow-up. There was no significant change in PROMs from 1 year to long-term follow-up, including Neck Disability Index (mean 1.0, 95% CI -2.1-4.1, P = .53), European Myelopathy Scale score (mean -0.3, 95% CI -0.7-0.1, P = .09), EQ-5D index score (mean -0.02, 95% CI -0.09-0.05, P = .51), NRS neck pain (mean 0.3 95% CI -0.2-0.9, P = .22), NRS arm pain (mean -0.1, 95% CI -0.8-0.5, P = .70), and NRS headache (mean 0.4, 95% CI -0.1-0.9, P = .11). According to Global Perceived Effect assessments, 106/121 patients (87.6%) reported to be stable or improved ("complete recovery," "much better," "slightly better," or "unchanged") at long-term follow-up compared with 88.1% at 1 year. Dichotomizing the outcome data based on severity of DCM did not demonstrate significant changes either. CONCLUSION Long-term follow-up of patients undergoing surgery for DCM demonstrates persistence of statistically significant and clinically meaningful improvement across a wide range of PROMs.
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Affiliation(s)
- Tonje O. Johansen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Siril T. Holmberg
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Elisabet Danielsen
- Department of Clinical Medicine, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Vidar Rao
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Øyvind O. Salvesen
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hege Andresen
- National Advisory Unit on Spinal Surgery, St. Olavs Hospital, Trondheim, Norway
| | | | - Tore K. Solberg
- Institute for Clinical Medicine, UNN The Arctic University of Norway, Tromsø, Norway
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Sasha Gulati
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Øystein P. Nygaard
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
- National Advisory Unit on Spinal Surgery, St. Olavs Hospital, Trondheim, Norway
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Masalma R, Zidan T, Abualhumos KM, Hamayel D, Abukhalil Z, Ghanem AT, Mousa A, Helou M, Tamimi W, Al-Sayed Ahmad M. Unraveling a Rare Case of Epidural Extramedullary Hematopoiesis in a Patient With Transfusion-Dependent Beta Thalassemia Presenting With Spinal Cord Compression. Cureus 2024; 16:e56352. [PMID: 38633951 PMCID: PMC11021873 DOI: 10.7759/cureus.56352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2024] [Indexed: 04/19/2024] Open
Abstract
Thalassemia is known to induce extramedullary hematopoiesis (EMH), which is a compensatory mechanism in which the body forms blood cells outside the bone marrow. While EMH typically affects organs such as the spleen and liver, there are rare instances where it leads to spinal cord compression (SCC) in the epidural space. A 31-year-old male patient with transfusion-dependent beta thalassemia presented with numbness and bilateral limb weakness due to EMH. Neurological examination revealed increased tone in both legs, reduced power, loss of crude touch and pain sensation, and increased deep tendon reflexes. Magnetic resonance imaging (MRI) indicated a lobulated soft tissue structure in the posterior dural intrathecal space causing SCC. Laminectomy of the T2-T8 vertebrae was done, after which the lesion was identified and completely removed. Post-surgery, significant neurological improvements were observed in both motor and sensory functions. Thalassemia patients presenting with symptoms of SCC should be investigated for the presence of epidural EMH. Treatment options include decompressive surgery, blood transfusions, hydroxyurea, and radiotherapy.
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Affiliation(s)
- Raed Masalma
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Thabet Zidan
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Khalil M Abualhumos
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Dalia Hamayel
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Ziad Abukhalil
- Department of Neurosurgery, Palestine Medical Complex, Ramallah, PSE
| | - Ahmed T Ghanem
- Department of Neurosurgery, Palestine Medical Complex, Ramallah, PSE
| | - Adnan Mousa
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Maroun Helou
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Wesam Tamimi
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Mahdi Al-Sayed Ahmad
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
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Yu WJ, Xiao J, Wang GX, Jiang C, Zha W, Liao RF. Predictive visual field outcomes after optic chiasm decompressive surgery by retinal vessels parameters using optical coherence tomography angiography. Int J Ophthalmol 2024; 17:365-373. [PMID: 38371253 PMCID: PMC10827611 DOI: 10.18240/ijo.2024.02.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/19/2023] [Indexed: 02/20/2024] Open
Abstract
AIM To evaluate the predictive value of superficial retinal capillary plexus (SRCP) and radial peripapillary capillary (RPC) for visual field recovery after optic cross decompression and compare them with peripapillary nerve fiber layer (pRNFL) and ganglion cell complex (GCC). METHODS This prospective longitudinal observational study included patients with chiasmal compression due to sellar region mass scheduled for decompressive surgery. Generalized estimating equations were used to compare retinal vessel density and retinal layer thickness pre- and post-operatively and with healthy controls. Logistic regression models were used to assess the relationship between preoperative GCC, pRNFL, SRCP, and RPC parameters and visual field recovery after surgery. RESULTS The study included 43 eyes of 24 patients and 48 eyes of 24 healthy controls. Preoperative RPC and SRCP vessel density and pRNFL and GCC thickness were lower than healthy controls and higher than postoperative values. The best predictive GCC and pRNFL models were based on the superior GCC [area under the curve (AUC)=0.866] and the tempo-inferior pRNFL (AUC=0.824), and the best predictive SRCP and RPC models were based on the nasal SRCP (AUC=0.718) and tempo-inferior RPC (AUC=0.825). There was no statistical difference in the predictive value of the superior GCC, tempo-inferior pRNFL, and tempo-inferior RPC (all P>0.05). CONCLUSION Compression of the optic chiasm by tumors in the saddle area can reduce retinal thickness and blood perfusion. This reduction persists despite the recovery of the visual field after decompression surgery. GCC, pRNFL, and RPC can be used as sensitive predictors of visual field recovery after decompression surgery.
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Affiliation(s)
- Wen-Juan Yu
- Department of Ophthalmology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Jin Xiao
- Department of Neurosurgery, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Guang-Xin Wang
- Department of Ophthalmology, the First People's Hospital of Hefei, Hefei 230061, Anhui Province, China
| | - Chang Jiang
- Department of Ophthalmology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Wei Zha
- Department of Ophthalmology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Rong-Feng Liao
- Department of Ophthalmology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
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Griepp DW, Miller A, Sorek S, Naeem K, Moawad S, Klein D, DeMattia JA, Rahme R. Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery. J Neurosurg 2024; 140:544-551. [PMID: 37548576 DOI: 10.3171/2023.5.jns23163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/22/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression. METHODS A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS). RESULTS Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months. CONCLUSIONS With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.
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Affiliation(s)
- Daniel W Griepp
- 1Division of Neurosurgery, SBH Health System, Bronx, New York
- 2Department of Neurosurgery, Ascension Providence Hospital, College of Human Medicine, Michigan State University, Southfield, Michigan
| | - Aaron Miller
- 1Division of Neurosurgery, SBH Health System, Bronx, New York
- 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Sahar Sorek
- 1Division of Neurosurgery, SBH Health System, Bronx, New York
| | - Komal Naeem
- 4Division of Neurosurgery, Lincoln Medical Center, Bronx, New York; and
| | | | - David Klein
- 4Division of Neurosurgery, Lincoln Medical Center, Bronx, New York; and
| | - Joseph A DeMattia
- 1Division of Neurosurgery, SBH Health System, Bronx, New York
- 4Division of Neurosurgery, Lincoln Medical Center, Bronx, New York; and
| | - Ralph Rahme
- 1Division of Neurosurgery, SBH Health System, Bronx, New York
- 4Division of Neurosurgery, Lincoln Medical Center, Bronx, New York; and
- 5CUNY School of Medicine, New York, New York
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Xin JH, Che JJ, Wang Z, Chen YM, Leng B, Wang DL. Effectiveness and safety of interspinous spacer versus decompressive surgery for lumbar spinal stenosis: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2023; 102:e36048. [PMID: 37986330 PMCID: PMC10659713 DOI: 10.1097/md.0000000000036048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/19/2023] [Accepted: 10/19/2023] [Indexed: 11/22/2023] Open
Abstract
STUDY DESIGN A meta-analysis of randomized controlled trials. OBJECTIVE Our meta-analysis was conducted to investigate whether interspinous spacer (IS) results in better performance for patients with lumbar spinal stenosis (LSS) when compared with decompressive surgery (DS). BACKGROUND DATA DS and IS are common surgeries for the treatment of LSS. However, controversy remains as to whether the IS is superior to DS. METHODS We comprehensively searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for prospective randomized controlled trials that compared IS versus DS for LSS. The retrieved results were last updated on July 30, 2023. RESULTS Eight studies involving 852 individuals were included in the meta-analysis. The pooled data indicated that IS was superior to DS considering shorter operation time (P = .003), lower dural violation rate (P = .002), better Zurich Claudication Questionnaire Physical function score (P = .03), and smaller foraminal height decrease (P = .004), but inferior to DS considering the higher rate of reoperation (P < .0001). There was no significant difference between the 2 groups regarding hospital stay (P = .26), blood loss (P = .23), spinous process fracture (P = .09), disc height decrease (P = .87), VAS leg pain score (P = .43), VAS back pain score (P = .26), Oswestry Disability Index score (P = .08), and Zurich Claudication Questionnaire symptom severity (P = .50). CONCLUSIONS In summary, we considered that IS had similar effects with DS in hospital stay, blood loss, spinous process fracture, disc height decrease, VAS score, Oswestry Disability Index score, and Zurich Claudication Questionnaire Symptom severity, and was better in some indices such as operation time, dural violation, Zurich Claudication Questionnaire Physical function, and foraminal height decrease than DS. However, due to the higher rate of reoperation in the IS group, we considered that both IS and DS were acceptable strategies for treating LSS. As a novel technique, further well-designed studies with longer-term follow-up are needed to evaluate the effectiveness and safety of IS.
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Affiliation(s)
- Jian-Hai Xin
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Jia-Ju Che
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Zhe Wang
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Yu-Ming Chen
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Bing Leng
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
| | - Da-Lin Wang
- Department One of Orthopedics, Affiliated Hospital of Beihua University, Jilin, China
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7
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Misra S, Sudhir P, Nath M, Sharma VK, Vibha D. Decompressive surgery in cerebral venous thrombosis: A systematic review and meta-analysis. Eur J Clin Invest 2023; 53:e13944. [PMID: 36576370 DOI: 10.1111/eci.13944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The efficacy of decompressive surgery (DS) in cerebral venous thrombosis (CVT) patients has been reported in several case reports and case series. We aimed at determining the association of DS compared with medical management and timing of surgery with functional outcome and mortality. We also aimed at determining the prevalence of DS in CVT patients. METHODS The literature search was conducted till 7 November 2022 in PubMed, Google Scholar, EMBASE and Cochrane Library databases. Risk of bias was examined using Joanna Briggs Institute scale for case series and case reports. Association of DS compared with medical management and timing of surgery with functional outcome and mortality was determined using odds ratio (OR) and 95% confidence interval (CI). Pooled prevalence of DS in CVT patients with 95%CI was calculated. Heterogeneity was explored using outlier, meta-regression, sensitivity and subgroup analyses. RESULTS Fifty-one studies consisting of 483 CVT cases with DS were included. The OR of poor outcome with surgery was 0.03; (95%CI: 0.00-0.22) and of mortality with surgery was 0.25; (95%CI: 0.02-2.60) versus that with medical management. Surgery done ≤48 h of admission was significantly associated with less mortality (OR: 0.26; 95%CI: 0.10-0.69). Pooled prevalence of DS in CVT was 12% (95%CI: 8%-17%; I2 = 91%). Revised pooled prevalence after removing outliers was 10% (95%CI: 7%-13%; I2 = 73%). CONCLUSIONS Surgery ≤48 h of admission might decrease mortality in CVT patients and may result in improved functional outcome. Further prospective studies with appropriate control arms are required to confirm its efficacy over medical management.
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Affiliation(s)
- Shubham Misra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.,Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Pachipala Sudhir
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Manabesh Nath
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay K Sharma
- Division of Neurology, YLL School of Medicine, National University Hospital, National University of Singapore, Singapore City, Singapore
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Kinoshita H, Kamoda H, Hagiwara Y, Kinoshita S, Ohtori S, Yonemoto T. Predictors of Postoperative Gain in Ambulatory Function After Decompressive Surgery for Metastatic Spinal Cord Compression. Anticancer Res 2023; 43:1767-1773. [PMID: 36974815 DOI: 10.21873/anticanres.16330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/01/2023] [Accepted: 01/16/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND/AIM Reports on the effects of timing of the surgery on the patient survival rate or the results of palliative laminectomy are limited. The aim of the study was to investigate the postoperative ambulatory status of neurologically impaired metastatic spinal cord compression (MSCC) patients who underwent laminectomy and evaluate predictors of postoperative ambulation recovery after laminectomy for MSCC. PATIENTS AND METHODS We included 175 patients who underwent decompressive surgery for MSCC. Changes in the Frankel grade (FG) were evaluated perioperatively. Among all patients, 113 were unable to walk preoperatively and were divided into two groups: 70 and 43 patients in the ambulation-regained and ambulation-not regained postoperatively groups, respectively. The percentage of patients eligible for postoperative chemotherapy and overall survival rate in each group were investigated. Furthermore, predictors of postoperative ambulation recovery after laminectomy for MSCC were examined. RESULTS The most common primary tumor sites were the lung, prostate, and breast. FG improved with surgery in 80 cases, remained unchanged in 94 cases, and worsened in one case. In the ambulation-regained group, 70% were eligible for postoperative chemotherapy, while only 26% of the not-regained group were eligible for postoperative chemotherapy. The postoperative survival rate of the ambulation-regained group was significantly better than that of the not-regained group. Univariate predictors for not regaining the ability to walk were Karnofsky Performance Status ≤40 prior to surgery, FG B prior to surgery, and time to surgery since the inability to walk >48 h. CONCLUSION Decompressive surgery benefits motor function postoperatively. Both good neurological status prior to surgery and prompt surgery for non-ambulatory MSCC are important predictors of improved functional outcome.
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Affiliation(s)
| | - Hiroto Kamoda
- Department of Orthopedic Surgery, Chiba Cancer Center, Chiba, Japan
| | - Yoko Hagiwara
- Department of Orthopedic Surgery, Chiba Cancer Center, Chiba, Japan
| | - Seiko Kinoshita
- Laboratory of Oncogenomics, Chiba Cancer Center Research Institute, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tsukasa Yonemoto
- Department of Orthopedic Surgery, Chiba Cancer Center, Chiba, Japan
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Batchelor P, Bernard S, Gantner D, Udy A, Board J, Fitzgerald M, Skeers P, Battistuzzo C, Stephenson M, Smith K, Nunn A. Immediate Cooling and Early Decompression for the Treatment of Cervical Spinal Cord Injury: A Safety and Feasibility Study. Ther Hypothermia Temp Manag 2023. [PMID: 36779969 DOI: 10.1089/ther.2022.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
Cervical spinal cord injury (SCI) usually results in severe, long-term disability. Early therapeutic hypothermia (33-34°C) has been used to improve outcomes in preclinical studies, but previous clinical studies have commenced cooling after arrival at hospital. The objective of the study is to determine the feasibility and safety of early therapeutic hypothermia initiated by paramedics and maintained for up to 24 hours in hospital in patients with SCI. This is a pilot clinical study. The study was undertaken at Ambulance Victoria and The Alfred Hospital, Victoria, Australia. A total of 17 consecutive patients with suspected acute traumatic cervical SCI were enrolled. Patients with suspected cervical SCI were administered a bolus (up to 20 mL/kg) intravenous (IV) cold (4°C) normal saline in the prehospital phase of care. After hospital admission and spinal imaging, further cooling used IV catheter temperature control or surface cooling. Major complications and long-term outcomes were compared with historical controls admitted to the same center before the study. A decrease in core temperature of 1.1°C was achieved during prehospital care and the target temperature was achieved in 6 hours with mechanical temperature management devices in the hospital. There were no major safety concerns. Patients with motor complete SCI who underwent early decompressive surgery had a favorable rate of partial spinal cord recovery compared with historical controls. Therapeutic hypothermia induced using bolus, large-volume, ice-cold saline prehospital and maintained for 24 hours using mechanical devices appears to be feasible and safe in patients with SCI. Larger trials need to be undertaken to determine whether prehospital cooling combined with early decompressive surgery improves outcomes in patients with complete cervical SCI. Australian and New Zealand Clinical Trials Registry (ACTRN12616001086459).
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Affiliation(s)
- Peter Batchelor
- Department of Neurology, University Hospital Geelong, Geelong, Australia
| | - Stephen Bernard
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Ambulance Victoria, Doncaster, Australia.,Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dashiell Gantner
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care-Research Center, Melbourne, Australia
| | - Andrew Udy
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care-Research Center, Melbourne, Australia
| | - Jasmin Board
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care-Research Center, Melbourne, Australia
| | - Mark Fitzgerald
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Peta Skeers
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | - Camila Battistuzzo
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mick Stephenson
- Ambulance Victoria, Doncaster, Australia.,Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,School of Primary and Allied Health Care, Monash University Peninsula Campus, Frankston, Australia
| | - Karen Smith
- Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Nunn
- Victorian Spinal Cord Service, Austin Hospital, Heidelberg, Australia
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10
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von Spreckelsen N, Ossmann J, Lenz M, Nadjiri L, Lenschow M, Telentschak S, Meyer J, Keßling J, Knöll P, Eysel P, Goldbrunner R, Perrech M, Scheyerer M, Celik E, Zarghooni K, Neuschmelting V. Role of Decompressive Surgery in Neurologically Intact Patients with Low to Intermediate Intraspinal Metastatic Tumor Burden. Cancers (Basel) 2023; 15:cancers15020385. [PMID: 36672334 PMCID: PMC9857075 DOI: 10.3390/cancers15020385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Surgical decompression (SD) followed by radiotherapy (RT) is superior to RT alone in patients with metastatic spinal disease with epidural spinal cord compression (ESCC) and neurological deficit. For patients without neurological deficit and low- to intermediate-grade intraspinal tumor burden, data on whether SD is beneficial are scarce. This study aims to investigate the neurological outcome of patients without neurological deficit, with a low- to intermediate-ESCC, who were treated with or without SD. METHODS This single-center, multidepartment retrospective analysis includes patients treated for spinal epidural metastases from 2011 to 2021. Neurological status was assessed by Frankel grade, and intraspinal tumor burden was categorized according to the ESCC scale. Spinal instrumentation surgery was only considered as SD if targeted decompression was performed. RESULTS ESCC scale was determined in 519 patients. Of these, 190 (36.6%) presented with no neurological deficit and a low- to intermediate-grade ESCC (1b, 1c, or 2). Of these, 147 (77.4% were treated with decompression and 43 (22.65%) without. At last follow-up, there was no difference in neurological outcome between the two groups. CONCLUSIONS Indication for decompressive surgery in neurologically intact patients with low-grade ESCC needs to be set cautiously. So far, it is unclear which patients benefit from additional decompressive surgery, warranting further prospective, randomized trials for this significant cohort of patients.
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Affiliation(s)
- Niklas von Spreckelsen
- Department of General Neurosurgery, Center for Neurosurgery, Cologne University Hospital, Faculty of Medicine and University Hospital, University of Cologne, 50937 Cologne, Germany
- Correspondence: (N.v.S.); (V.N.)
| | - Julian Ossmann
- Department of General Neurosurgery, Center for Neurosurgery, Cologne University Hospital, Faculty of Medicine and University Hospital, University of Cologne, 50937 Cologne, Germany
| | - Maximilian Lenz
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50937 Cologne, Germany
| | - Lukas Nadjiri
- Department of Radiooncology and Cyberknife Center, University of Cologne, 50937 Cologne, Germany
| | - Moritz Lenschow
- Department of General Neurosurgery, Center for Neurosurgery, Cologne University Hospital, Faculty of Medicine and University Hospital, University of Cologne, 50937 Cologne, Germany
| | - Sergej Telentschak
- Department of General Neurosurgery, Center for Neurosurgery, Cologne University Hospital, Faculty of Medicine and University Hospital, University of Cologne, 50937 Cologne, Germany
| | - Johanna Meyer
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50937 Cologne, Germany
| | - Julia Keßling
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50937 Cologne, Germany
| | - Peter Knöll
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50937 Cologne, Germany
| | - Peer Eysel
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50937 Cologne, Germany
| | - Roland Goldbrunner
- Department of General Neurosurgery, Center for Neurosurgery, Cologne University Hospital, Faculty of Medicine and University Hospital, University of Cologne, 50937 Cologne, Germany
| | - Moritz Perrech
- Department of General Neurosurgery, Center for Neurosurgery, Cologne University Hospital, Faculty of Medicine and University Hospital, University of Cologne, 50937 Cologne, Germany
| | - Max Scheyerer
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50937 Cologne, Germany
| | - Eren Celik
- Department of Radiooncology and Cyberknife Center, University of Cologne, 50937 Cologne, Germany
| | - Kourosh Zarghooni
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50937 Cologne, Germany
| | - Volker Neuschmelting
- Department of General Neurosurgery, Center for Neurosurgery, Cologne University Hospital, Faculty of Medicine and University Hospital, University of Cologne, 50937 Cologne, Germany
- Correspondence: (N.v.S.); (V.N.)
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11
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Zhang B, Yu H, Zhao X, Cao X, Cao Y, Shi X, Wang Z, Liu Y. Preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression: A retrospective analysis. Front Oncol 2022; 12:1098182. [PMID: 36591512 PMCID: PMC9798328 DOI: 10.3389/fonc.2022.1098182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/29/2022] [Indexed: 12/16/2022] Open
Abstract
Purpose The purpose of the study was to assess the effectiveness and safety of preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression (MESCC). Methods A retrospective analysis of 138 MESCC patients who underwent decompressive surgery and spine stabilization was performed in a large teaching hospital. Among all enrolled patients, 46 patients were treated with preoperative embolization (the embolization group), whereas 92 patients did not (the control group). Patient's baseline clinical characteristics, surgery-related characteristics, and postoperative neurological status, complications, and survival prognoses were collected and analyzed. Subgroup analysis was performed according to the degree of tumor vascularity between patients with and without preoperative embolization. Results Patients with severe hypervascularity experienced more mean blood loss in the control group than in the embolization group, and this difference was statistically significant (P=0.02). The number of transfused packed red cells (PRC) showed a similar trend (P=0.01). However, for patients with mild and moderate hypervascularity, both blood loss and the number of PRC transfusion were comparable across the two groups. Regarding decompressive techniques, the embolization group (64.29%, 9/14) had a higher proportion of circumferential decompression in comparison to the control group (30.00%, 9/30) among patients with severe hypervascularity (P=0.03), whereas the rates were similar among patients with mild (P=0.45) and moderate (P=0.54) hypervascularity. In addition, no subgroup analysis revealed any statistically significant differences in operation time, postoperative functional recovery, postoperative complications, or survival outcome. Multivariate analysis showed that higher tumor vascularity (OR[odds ratio]=3.69, 95% CI [confident interval]: 1.30-10.43, P=0.01) and smaller extent of embolization (OR=4.16, 95% CI: 1.10-15.74, P=0.04) were significantly associated with more blood loss. Conclusions Preoperative embolization is an effective and safe method in treating MESCC patients with severe hypervascular tumors in terms of intra-operative blood loss and surgical removal of metastatic tumors. Preoperative tumor vascularity and extent of embolization are independent risk factors for blood loss during surgery. This study implies that MESCC patients with severe hypervascular tumors should be advised to undergo preoperative embolization.
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Affiliation(s)
- Bin Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Chinese PLA General Hospital, Beijing, China
| | - Haikuan Yu
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Chinese PLA Medical School, Beijing, China
| | - Xiongwei Zhao
- Department of Orthopedic Surgery, The Fifth Clinical Medical College of Anhui Medical University, Beijing, China,Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xuyong Cao
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, The Fifth Clinical Medical College of Anhui Medical University, Beijing, China
| | - Yuncen Cao
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, The Fifth Clinical Medical College of Anhui Medical University, Beijing, China
| | - Xiaolin Shi
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China,*Correspondence: Yaosheng Liu, ; ; Zheng Wang, ; Xiaolin Shi,
| | - Zheng Wang
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,*Correspondence: Yaosheng Liu, ; ; Zheng Wang, ; Xiaolin Shi,
| | - Yaosheng Liu
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Chinese PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China,*Correspondence: Yaosheng Liu, ; ; Zheng Wang, ; Xiaolin Shi,
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12
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Rades D, Küchler J, Graumüller L, Abusamha A, Schild SE, Gliemroth J. Radiotherapy with or without Decompressive Surgery for Metastatic Spinal Cord Compression: A Retrospective Matched-Pair Study Including Data from Prospectively Evaluated Patients. Cancers (Basel) 2022; 14:1260. [PMID: 35267568 DOI: 10.3390/cancers14051260] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 11/30/2022] Open
Abstract
Simple Summary In a retrospective matched-pair study including data of prospectively evaluated patients who were treated for metastatic spinal cord compression, 79 patients assigned to surgery plus radiotherapy were compared to 79 patients receiving radiotherapy alone. Improvement of motor function occurred more significantly often after surgery plus radiotherapy, whereas no significant differences were found for post-treatment ambulatory rates, local progression-free survival, overall survival, and freedom from in-field recurrence. Ten patients died within 30 days after radiotherapy alone and 12 patients within 30 days after surgery. More than one third of surgically treated patients did not complete their radiotherapy due to early death or decreased performance score following surgery. Thus, when selecting a patient for upfront surgery, the individual patient’s prognosis must be considered and weighed against the risk of perioperative complications and 30-day mortality. Abstract In 2005, a randomized trial showed that addition of surgery to radiotherapy improved outcomes in patients with metastatic spinal cord compression (MSCC). Since then, only a few studies compared radiotherapy plus surgery to radiotherapy alone. We performed a retrospective matched-pair study including data from prospective cohorts treated after 2005. Seventy-nine patients receiving radiotherapy alone were matched to 79 patients assigned to surgery plus radiotherapy (propensity score method) for age, gender, performance score, tumor type, affected vertebrae, other bone or visceral metastases, interval tumor diagnosis to MSCC, time developing motor deficits, and ambulatory status. Improvement of motor function by ≥1 Frankel grade occurred more often after surgery plus radiotherapy (39.2% vs. 21.5%, p = 0.015). No significant differences were found for post-treatment ambulatory rates (59.5% vs. 67.1%, p = 0.32), local progression-free survival (p = 0.47), overall survival (p = 0.51), and freedom from in-field recurrence of MSCC (90.1% vs. 76.2% at 12 months, p = 0.58). Ten patients (12.7%) died within 30 days following radiotherapy alone and 12 patients (15.2%) died within 30 days following surgery (p = 0.65); 36.7% of surgically treated patients did not complete radiotherapy as planned. Surgery led to significant early improvement of motor function and non-significantly better long-term control. Patients scheduled for surgery must be carefully selected considering potential benefits and risk of perioperative complications.
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13
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Bock T, Heller RA, Haubruck P, Raven TF, Pilz M, Moghaddam A, Biglari B. Pursuing More Aggressive Timelines in the Surgical Treatment of Traumatic Spinal Cord Injury (TSCI): A Retrospective Cohort Study with Subgroup Analysis. J Clin Med 2021; 10:5977. [PMID: 34945273 DOI: 10.3390/jcm10245977] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/07/2021] [Accepted: 12/17/2021] [Indexed: 12/17/2022] Open
Abstract
Background: The optimal timing of surgical therapy for traumatic spinal cord injury (TSCI) remains unclear. The purpose of this study is to evaluate the impact of “ultra-early” (<4 h) versus “early” (4–24 h) time from injury to surgery in terms of the likelihood of neurologic recovery. Methods: The effect of surgery on neurological recovery was investigated by comparing the assessed initial and final values of the American Spinal Injury Association (ASIA) Impairment Scale (AIS). A post hoc analysis was performed to gain insight into different subgroup regeneration behaviors concerning neurological injury levels. Results: Datasets from 69 cases with traumatic spinal cord injury were analyzed. Overall, 19/46 (41.3%) patients of the “ultra-early” cohort saw neurological recovery compared to 5/23 (21.7%) patients from the “early” cohort (p = 0.112). The subgroup analysis revealed differences based on the neurological level of injury (NLI) of a patient. An optimal cutpoint for patients with a cervical lesion was estimated at 234 min. Regarding the prediction of neurological improvement, sensitivity was 90.9% with a specificity of 68.4%, resulting in an AUC (area under the curve) of 84.2%. In thoracically and lumbar injured cases, the estimate was lower, ranging from 284 (thoracic) to 245 min (lumbar) with an AUC of 51.6% and 54.3%. Conclusions: Treatment within 24 h after TSCI is associated with neurological recovery. Our hypothesis that intervention within 4 h is related to an improvement in the neurological outcome was not confirmed in our collective. In a clinical context, this suggests that after TSCI there is a time frame to get the right patient to the right hospital according to advanced trauma life support (ATLS) guidelines.
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14
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Basha AK, Mahmoud MA, Al Ashwal MI, Aglan O, ElShawady SB, Abdel-Latif AM, Elsayed AM, AbdelGhany W. Management of Severe Traumatic Brain Injury: A Single Institution Experience in a Middle-Income Country. Front Surg 2021; 8:690723. [PMID: 34746219 PMCID: PMC8570277 DOI: 10.3389/fsurg.2021.690723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Severe traumatic brain injury (TBI) is a major public health problem usually resulting in mortality or severe disabling morbidities of the victims. Intracranial pressure (ICP) monitoring is recently recognized as an imperative modality in the management of severe TBI, whereas growing evidence, based on randomized controlled trials (RCTs), suggests that ICP monitoring does not affect the outcome when compared with clinical and radiological data-based management. Also, ICP monitoring carries a considerable risk of intracranial infection that cannot be overlooked. The aim of this study is to assess the different aspects of our current local institutional management of severe TBI using non-invasive ICP monitoring for a potential need to change our management strategy. Methods: We retrospectively reviewed our data of TBI from June 2019 through January 2020. Patients with severe TBI were identified. Their demographics, Glasgow coma score (GCS) at presentation, treatments received, and imaging data were extracted from the charts. Glasgow outcome scale extended (GOS-E) at 6 months was also assessed for the patients. Results: Twenty patients with severe TBI were identified on chart review. Ten patients received only medical treatment measures to lower the ICP, whereas the other 10 patients had additional surgical interventions. In one patient, a ventriculostomy tube was inserted to monitor ICP and to drain cerebrospinal fluid (CSF). This was complicated by ventriculostomy-associated infection (VAI) and the tube was removed. In our cohort, the total mortality rate was 40%. The average GOS-E for the survivor patients managed without ICP monitoring based on the clinical and radiological data was 6.2 at 6 months follow-up. The 6-month overall good outcome, based on GOS-E, was 33.3%. Conclusion: Although recent guidelines advocate for the use of ICP monitoring in the management of severe TBI, they remain underutilized in our practice due to many factors. External ventricular drains were mainly used to drain CSF; however, the higher rates of VAIs in our institution compared with the literature-reported rates are not in favor of the use of ICP monitoring. We recommend doing a comparative study between our current practice using clinical-and radiological-based management and subdural or intraparenchymal bolts. More structured RCTs are needed to validate these findings in our setting.
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Affiliation(s)
| | | | | | - Osama Aglan
- Neurosurgery Department, Ain Shams University, Cairo, Egypt
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15
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Shah S, Kutka M, Lees K, Abson C, Hadaki M, Cooke D, Neill C, Sheriff M, Karathanasi A, Boussios S. Management of Metastatic Spinal Cord Compression in Secondary Care: A Practice Reflection from Medway Maritime Hospital, Kent, UK. J Pers Med 2021; 11:jpm11020110. [PMID: 33572084 PMCID: PMC7914482 DOI: 10.3390/jpm11020110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 01/27/2021] [Accepted: 02/05/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction: Malignant spinal cord compression (MSCC) is one of the most devastating complications of cancer. This event requires rapid decision-making on the part of several specialists, given the risk of permanent spinal cord injury or death. The goals of treatment in spinal metastases are pain control and improvement of neurological function. There can be challenges in delivering prompt diagnosis and treatment in a secondary care setting. We have reflected on the experience of managing MSCC in a district general setting. Aim: Our retrospective audit identified 53 patients with suspected MSCC who entered the relevant pathway from April 2017 to March 2018 at Medway, United Kingdom (UK). Our audit standards were set out by Medway Maritime Hospital and Maidstone and Tunbridge Wells NHS Trust MSCC working group members, using a combination of published evidence and best practice. Results: The patients with suspected MSCC were 53 and 29 of them (54.7%) had confirmed MSCC. The most common malignancies within the confirmed MSCC were lung (11 patients, 37.9%), breast (5 patients 17.2%), and renal (3 patients, 10.3%), followed by prostate, myeloma and carcinoma of unknown primary (2 patients (6.9%) each), as well as pancreatic, colorectal, lymphoma and, bladder (1 patient (3.4%) each). A magnetic resonance imaging (MRI) scan was performed in 48 patients (90.5%); the majority (31 patients, 64.6%) underwent the MRI within the first 24 h, whereas 3 patients had the investigation between 24 and 72 h from the admission. Among the 29 patients with confirmed MSCC, 6 (20.6%) were treated with surgical decompression, while 20 (69%) received radiotherapy (RT) and 3 (10.3%) best supportive care, respectively. Median time to surgery was 5 days (ranged between 2 and 8 days), whereas for RT 44.4 h (ranged between 24 and 72 h). Finally, all 3 patients that decided on symptom control were referred to a palliative care team within the first 24 h following the MRI scan. Conclusions: MSCC is frequently presented outside tertiary care. This may cause subsequent delays in investigation, diagnosis, and treatment, which can be improved by following a fast track referral pathway.
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Affiliation(s)
- Sidrah Shah
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, Kent, UK; (S.S.); (M.K.); (D.C.); (C.N.); (A.K.)
| | - Mikolaj Kutka
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, Kent, UK; (S.S.); (M.K.); (D.C.); (C.N.); (A.K.)
| | - Kathryn Lees
- Kent Oncology Centre, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone ME16 9QQ, Kent, UK; (K.L.); (C.A.); (M.H.)
| | - Charlotte Abson
- Kent Oncology Centre, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone ME16 9QQ, Kent, UK; (K.L.); (C.A.); (M.H.)
| | - Maher Hadaki
- Kent Oncology Centre, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone ME16 9QQ, Kent, UK; (K.L.); (C.A.); (M.H.)
| | - Deirdre Cooke
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, Kent, UK; (S.S.); (M.K.); (D.C.); (C.N.); (A.K.)
| | - Cherie Neill
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, Kent, UK; (S.S.); (M.K.); (D.C.); (C.N.); (A.K.)
| | - Matin Sheriff
- Department of Urology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, Kent, UK;
| | - Afroditi Karathanasi
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, Kent, UK; (S.S.); (M.K.); (D.C.); (C.N.); (A.K.)
| | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, Kent, UK; (S.S.); (M.K.); (D.C.); (C.N.); (A.K.)
- King’s College London, Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, London SE1 9RT, UK
- AELIA Organization, 9th Km Thessaloniki-Thermi, 57001 Thessaloniki, Greece
- Correspondence: or or
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16
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Zheng W, Lei M, Liu Y, Lu X, Yu D, Zhang X. An Algorithm to Stratify the Risk of Postoperative Emotional Distress in Cancer Patients with Advanced Metastatic Spinal Disease. Psychol Res Behav Manag 2020; 13:721-731. [PMID: 32982501 PMCID: PMC7490437 DOI: 10.2147/prbm.s261613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/22/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose We wish (1) to assess what variables are significantly associated with postoperative emotional distress in patients with the metastatic spinal disease after surgery and (2) to develop and validate an algorithm to stratify patients at risk of postoperative emotional distress. Patients and Methods We retrospectively enrolled 171 patients with the metastatic spinal disease treated with surgery. Twelve potential variables were used to analyze postoperative emotional distress. Postoperative emotional well-being was measured using the Hospital Anxiety and Depression Scales (HADS). Significant variables were included in the algorithm and assigned scores based on odds ratios (ORs) from the multiple logistic regression analysis. The predictive performance of the risk algorithm was validated on the basis of discrimination and calibration. Results Twenty-six (15.20%) patients had a HADS of 19 points or more. Of all the 12 variables, age (P=0.06), marital status (P=0.02), primary cancer types (P=0.004), and physical well-being (P=0.006) were included in the algorithm. This algorithm ranged from 0 to 24. Higher scores represented higher rates of postoperative emotional distress. Patients were stratified into three risk groups: patients in the group A had scores of 0 to 9 and the rate of postoperative emotional distress was only 1.14%, patient in the group B had scores of 10 to 15 and the rate of postoperative emotional distress was 21.31%, and patient in the group C had scores of 16 to 24 and the rate of postoperative emotional distress was up to 54.55%. The area under the receiver operating characteristic curve (AUROC) for the algorithm was 0.84, and the correct classification rate was 81.3%. Conclusion Postoperative emotional distress is common in patients with the metastatic spinal disease after surgery. We propose and validate an algorithm that can be used as a potential screening tool to identify patients at high risk of postoperative emotional distress.
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Affiliation(s)
- Wenjing Zheng
- Department of Orthopedic Surgery, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Mingxing Lei
- Department of Orthopedic Surgery, The Hainan Hospital of Chinese PLA General Hospital, Sanya, People's Republic of China
| | - Yaosheng Liu
- Department of Orthopedic Surgery, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xin Lu
- Department of General Surgery, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Dan Yu
- Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xin Zhang
- Nursing Department, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, People's Republic of China
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17
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Puetz V, Gerber JC, Krüger P, Kuhn M, Reichmann H, Schneider H. Cerebral Venous Drainage in Patients With Space-Occupying Middle Cerebral Artery Infarction: Effects on Functional Outcome After Hemicraniectomy. Front Neurol 2018; 9:876. [PMID: 30459703 PMCID: PMC6232900 DOI: 10.3389/fneur.2018.00876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/27/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Cerebral venous drainage might influence brain edema characteristics and functional outcome of patients with severe ischemic stroke. The purpose of the study was to evaluate whether hypoplasia of transverse sinuses or the internal jugular veins is associated with poor functional outcome in patients with space-occupying middle cerebral artery (MCA) infarction who underwent decompressive surgery. Methods: We performed a retrospective analysis of patients with space-occupying MCA infarction treated with decompressive surgery at our university hospital. The transverse sinuses and the internal jugular veins were evaluated on baseline images and categorized as normal, hypoplastic or occluded. We defined composite variables for ipsilateral, contralateral or any abnormal cerebral venous drainage. We assessed the functional outcome at 12 months with the modified Rankin scale (mRS) score and defined poor functional outcome as mRS scores 5 and 6. Results: We analyzed 88 patients with available baseline imaging data [mean [SD] patient age 53 (±9) years; median[IQR] time to decompressive surgery 31(22-51) h]. At 12 months 44 patients (50%) had a poor outcome. In univariate analysis neither ipsilateral (OR 1.98;95%CI: 0.75-5.40), nor contralateral (OR 1.56;95%CI: 0.59-4.24) or any (OR 1.6; 95%CI: 0.68-3.79) hypoplasia or occlusion of venous drainage were significantly associated with poor functional outcome. In multivariate analyses, higher patient age (OR 1.07;95%CI 1.01-1.14) and baseline stroke severity (OR 3.42;95%CI 1.31-9.40) were independent predictors of poor functional outcome, but not ipsilateral hypoplasia or occlusion of venous drainage (OR 1.31;95%CI 0.47-3.67). Conclusions: The cerebral venous drainage pattern was not significantly associated with poor functional outcome in our cohort of patients with space-occupying MCA infarction who underwent decompressive surgery.
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Affiliation(s)
- Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Johannes C Gerber
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Philipp Krüger
- Department of Anesthesiology, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Matthias Kuhn
- Carl Gustav Carus Faculty of Medicine, Institute for Medical Informatics and Biometry, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Neurology, Klinikum Augsburg, Augsburg, Germany
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Boussios S, Hayward C, Cooke D, Zakynthinakis-Kyriakou N, Tsiouris AK, Chatziantoniou AA, Kanellos FS, Karathanasi A. Spinal Ewing Sarcoma Debuting with Cord Compression: Have We Discovered the Thread of Ariadne? Anticancer Res 2018; 38:5589-5597. [PMID: 30275176 DOI: 10.21873/anticanres.12893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/14/2018] [Accepted: 09/17/2018] [Indexed: 11/10/2022]
Abstract
Ewing's sarcoma (ES) of the spine with cord or radicular compression as an initial sign is infrequent. It is unclear, in alleviating a neurological deficit, whether decompressive laminectomy is preferred over chemotherapy. Herein, a literature review of the treatment approaches to the primary or metastatic ES of the spine has been performed. Collected data included clinical features of the patients, treatment, and outcome. There are reported 69 cases with initial presentation of cord or radicular compression of spinal cord, arising from primary or metastatic ES, treated either with initial chemotherapy and/or radiotherapy (RT) (33.33%, n=23), or decompressive surgery (66.66%, n=46). The median age at diagnosis was 17.95 years old (range=0.06-60), and 38 patients (55.07%) were male. Eighteen (78.26%) were initially treated with chemotherapy combined with RT, whereas 3 (13.04%) were managed with RT alone. One patient (4.35%) received only corticosteroids, while there are not available data for the treatment of another one (4.35%). The remaining 46 patients (66.66%) were initially treated with decompressive surgery. Among them, 40 (57.97%) received postoperative chemotherapy, RT or combined modality therapy, whereas 6 patients (8.69%) were not treated adjuvantly. Sixteen out of 23 patients (69.6%) treated with systemic therapy, and 37 from 46 (80.43%) of those managed with decompressive laminectomy were still alive at a mean follow-up period of 2.11 years (range=0.16-6) and 3.45 years (range=0.16-26.08), respectively. To summarize, spinal resection and reconstruction followed by adjuvant treatment reduce the risk of local recurrence, and improve long-term survival. However, ES of the spine is not a distinct clinical entity and can be either managed with chemotherapy and/or RT, similarly to other localization.
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Affiliation(s)
- Stergios Boussios
- Acute Oncology Assessment Unit, Medway NHS Foundation Trust, Kent, U.K.
| | - Catherine Hayward
- Acute Oncology Assessment Unit, Medway NHS Foundation Trust, Kent, U.K
| | - Deirdre Cooke
- Acute Oncology Assessment Unit, Medway NHS Foundation Trust, Kent, U.K
| | | | - Alexandros K Tsiouris
- Department of Biological Applications and Technology, University of Ioannina, Ioannina, Greece
| | | | - Foivos S Kanellos
- Department of Biological Applications and Technology, University of Ioannina, Ioannina, Greece
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Wang S, Wang Y, Yu Z, Gao K, Shao J, Li A, Gao Y. Surgical results and clinical risks of postoperative complications in patients with painful malignant spinal cord compression after decompressive surgery. J Pain Res 2018; 11:1679-1687. [PMID: 30214278 PMCID: PMC6120563 DOI: 10.2147/jpr.s162435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction This study aims to analyze clinical outcome in patients with painful malignant spinal cord compression due to advanced cancers after the decompressive surgery and identify risk factors for postoperative complications in these patients. Furthermore, we created a scoring model to predict the risk of postoperative complications based on identified significant risk factors. Methods We retrospectively analyzed survival outcomes, pain outcomes, and postoperative complications of patients with painful malignant spinal cord compression who were surgically treated in our department. Identification of risk factors for postoperative complications was also performed, and significant factors according to the multiple logistic regression models were included in the scoring model. Results As a result, 105 patients were enrolled. The overall median survival time was 9.1 months (95% CI, 7.1–11.4 months). The mean worst pain score was 8.0 in a 24-hour period before surgery, while it decreased to 6.0, 5.0, 3.5, 3.3, and 3.6 (all P<0.01, when compared with baseline date) at 1 week, 1 month, 3, 6, and 12 months after surgery, respectively. Similar decreases were also observed in the average pain and the pain interference. Thirty-one complications occurred within 4 weeks after operation in 26 patients (24.8%, 26/105). Based on multiple logistic regression models, age (P=0.03), Karnofsky performance status (P<0.01), and Charlson Comorbidity Index (P=0.04) were significantly associated with postoperative complications and were included in the scoring model. Three risk groups were created based on the complication rates of each scoring points. The corresponding postoperative complication rates of the three groups were 7.7% in group A (0–3 points), 26.7% in group B (4–6 points), and 60.9% in group C (7–10 points), respectively (OR, 4.32, 95% CI: 2.24–8.31, P<0.01). Conclusion Decompressive surgery for painful malignant spinal cord compression was found to be useful for pain control with a tolerable rate of complications. We created a scoring model to predict the risk of postoperative complications in patients with painful malignant spinal cord compression after surgery. This scoring model may guide doctors to choose the appropriate care strategies to realize better pain management.
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Affiliation(s)
- Shengjie Wang
- Department of Orthopedics, Henan Provincial People's Hospital, Zhengzhou, 450003, China,
| | - Yunhao Wang
- Department of Orthopedics, Shanghai General Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Zhenghong Yu
- Department of Orthopedics, Henan Provincial People's Hospital, Zhengzhou, 450003, China,
| | - Kun Gao
- Department of Orthopedics, Henan Provincial People's Hospital, Zhengzhou, 450003, China,
| | - Jia Shao
- Department of Orthopedics, Henan Provincial People's Hospital, Zhengzhou, 450003, China,
| | - Ang Li
- Department of Orthopedics, Henan Provincial People's Hospital, Zhengzhou, 450003, China,
| | - Yanzheng Gao
- Department of Orthopedics, Henan Provincial People's Hospital, Zhengzhou, 450003, China,
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Roethlisberger M, Gut L, Zumofen DW, Fisch U, Boss O, Maldaner N, Croci DM, Taub E, Corti N, Burkhardt JK, Guzman R, Bozinov O, Mariani L. Cerebral venous thrombosis requiring invasive treatment for elevated intracranial pressure in women with combined hormonal contraceptive intake: risk factors, anatomical distribution, and clinical presentation. Neurosurg Focus 2018; 45:E12. [PMID: 29961388 DOI: 10.3171/2018.4.focus1891] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Women taking combined hormonal contraceptives (CHCs) are generally considered to be at low risk for cerebral venous thrombosis (CVT). When it does occur, however, intensive care and neurosurgical management may, in rare cases, be needed for the control of elevated intracranial pressure (ICP). The use of nonsurgical strategies such as barbiturate coma and induced hypothermia has never been reported in this context. The objective of this study is to determine predictive factors for invasive or surgical ICP treatment and the potential complications of nonsurgical strategies in this population. METHODS The authors conducted a 2-center, retrospective chart review of 168 cases of CVT in women between 2000 and 2012. Eligible patients were classified as having had a mild or a severe clinical course, the latter category including all patients who underwent invasive or surgical ICP treatment and all who had an unfavorable outcome (modified Rankin Scale score ≥ 3 or Glasgow Outcome Scale score ≤ 3). The Mann-Whitney U-test was used for continuous parameters and Fisher's exact test for categorical parameters, and odds ratios were calculated with statistical significance set at p ≤ 0.05. RESULTS Of the 168 patients, 57 (age range 16-49 years) were determined to be eligible for the study. Six patients (10.5%) required invasive or surgical ICP treatment. Three patients (5.3%) developed refractory ICP > 30 mm Hg despite early surgical decompression; 2 of them (3.5%) were treated with barbiturate coma and induced hypothermia, with documented infectious, thromboembolic, and hemorrhagic complications. Coma on admission, thrombosis of the deep venous system with consecutive hydrocephalus, intraventricular hemorrhage, and hemorrhagic venous infarction were associated with a higher frequency of surgical intervention. Coma, quadriparesis on admission, and hydrocephalus were more commonly seen among women with unfavorable outcomes. Thrombosis of the transverse sinus was less common in patients with an unfavorable outcome, with similar distribution in patients needing invasive or surgical ICP treatment. CONCLUSIONS The need for invasive or surgical ICP treatment in women taking CHCs who have CVT is partly predictable on the basis of the clinical and radiological findings on admission. The use of nonsurgical treatments for refractory ICP, such as barbiturate coma and induced hypothermia, is associated with systemic infectious and hematological complications and may worsen morbidity in this patient population. The significance of these factors should be studied in larger multicenter cohorts.
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Affiliation(s)
| | | | - Daniel Walter Zumofen
- Departments of1Neurosurgery and
- 2Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Basel and University of Basel, Basel
| | | | | | | | | | | | | | - Jan-Karl Burkhardt
- 5Department of Neurological Surgery, NYU School of Medicine, NYU Langone Medical Center, New York, New York
- 6Neurosurgery, University Hospital Zürich and University of Zürich, Zürich, Switzerland; and
| | | | - Oliver Bozinov
- 6Neurosurgery, University Hospital Zürich and University of Zürich, Zürich, Switzerland; and
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21
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Ferro JM, Bousser MG, Canhão P, Coutinho JM, Crassard I, Dentali F, di Minno M, Maino A, Martinelli I, Masuhr F, Aguiar de Sousa D, Stam J. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology. Eur J Neurol 2017; 24:1203-1213. [PMID: 28833980 DOI: 10.1111/ene.13381] [Citation(s) in RCA: 315] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/27/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Current guidelines on cerebral venous thrombosis (CVT) diagnosis and management were issued by the European Federation of Neurological Societies in 2010. We aimed to update the previous European Federation of Neurological Societies guidelines using a clearer and evidence-based methodology. METHOD We followed the Grading of Recommendations, Assessment, Development and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews and writing recommendations based on the quality of available scientific evidence. RESULTS We suggest using magnetic resonance or computed tomographic angiography for confirming the diagnosis of CVT and not routinely screening patients with CVT for thrombophilia or cancer. We recommend parenteral anticoagulation in acute CVT and decompressive surgery to prevent death due to brain herniation. We suggest preferentially using low-molecular-weight heparin in the acute phase and not direct oral anticoagulants. We suggest not using steroids and acetazolamide to reduce death or dependency. We suggest using antiepileptics in patients with an early seizure and supratentorial lesions to prevent further early seizures. We could not make recommendations concerning duration of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest that, in women who have suffered a previous CVT, contraceptives containing oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but use of prophylactic low-molecular-weight heparin should be considered throughout pregnancy and puerperium. CONCLUSIONS Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of CVT.
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Affiliation(s)
- J M Ferro
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa.,Universidade de Lisboa, Lisboa, Portugal
| | - M-G Bousser
- Service de Neurologie, Hôpital Lariboisière, Paris, France
| | - P Canhão
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa.,Universidade de Lisboa, Lisboa, Portugal
| | - J M Coutinho
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - I Crassard
- Service de Neurologie, Hôpital Lariboisière, Paris, France
| | - F Dentali
- Department of Clinical Medicine, Insubria University, Varese
| | - M di Minno
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, 'Federico II' University, Naples.,Unit of Cell and Molecular Biology in Cardiovascular Diseases, Centro Cardiologico Monzino, IRCCS, Milan
| | - A Maino
- A. Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - I Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - F Masuhr
- Department of Neurology, Bundeswehrkrankenhaus, Berlin, Germany
| | - D Aguiar de Sousa
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa
| | - J Stam
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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22
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Ferro JM, Bousser MG, Canhão P, Coutinho JM, Crassard I, Dentali F, di Minno M, Maino A, Martinelli I, Masuhr F, de Sousa DA, Stam J. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology. Eur Stroke J 2017; 2:195-221. [PMID: 31008314 DOI: 10.1177/2396987317719364] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/13/2017] [Indexed: 12/21/2022] Open
Abstract
The current proposal for cerebral venous thrombosis guideline followed the Grading of Recommendations, Assessment, Development, and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews of all available evidence and writing recommendations and deciding on their strength on an explicit and transparent manner, based on the quality of available scientific evidence. The guideline addresses both diagnostic and therapeutic topics. We suggest using magnetic resonance or computed tomography angiography for confirming the diagnosis of cerebral venous thrombosis and not screening patients with cerebral venous thrombosis routinely for thrombophilia or cancer. We recommend parenteral anticoagulation in acute cerebral venous thrombosis and decompressive surgery to prevent death due to brain herniation. We suggest to use preferentially low-molecular weight heparin in the acute phase and not using direct oral anticoagulants. We suggest not using steroids and acetazolamide to reduce death or dependency. We suggest using antiepileptics in patients with an early seizure and supratentorial lesions to prevent further early seizures. We could not make recommendations due to very poor quality of evidence concerning duration of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest that in women who suffered a previous cerebral venous thrombosis, contraceptives containing oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but use of prophylactic low-molecular weight heparin should be considered throughout pregnancy and puerperium. Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of cerebral venous thrombosis.
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Affiliation(s)
- José M Ferro
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa, Portugal.,Universidade de Lisboa, Lisboa, Portugal
| | | | - Patrícia Canhão
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa, Portugal.,Universidade de Lisboa, Lisboa, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | | | | | - Matteo di Minno
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, "Federico II" University, Naples, Italy.,Unit of Cell and Molecular Biology in Cardiovascular Diseases, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Alberto Maino
- A. Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ida Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Florian Masuhr
- Department of Neurology, Bundeswehrkrankenhaus, Berlin, Germany
| | - Diana Aguiar de Sousa
- Department of Neurosciences, Serviço de Neurologia, Hospital de Santa Maria, Lisboa, Portugal.,Universidade de Lisboa, Lisboa, Portugal
| | - Jan Stam
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
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23
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Jeon SB, Park JC, Kwon SU, Kim YJ, Lee S, Kang DW, Kim JS. Intracranial Pressure Soon After Hemicraniectomy in Malignant Middle Cerebral Artery Infarction. J Intensive Care Med 2016; 33:310-316. [PMID: 28523953 DOI: 10.1177/0885066616675598] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Decompressive hemicraniectomy reduces secondary brain injury related to brain edema and increased intracranial pressure (ICP) in patients with malignant middle cerebral artery infarction (MMI). However, a substantial proportion of patients still die despite hemicraniectomy due to refractory brain swelling. OBJECTIVE We aim to investigate whether ICP measured immediately after hemicraniectomy may indicate decompression effects and predict survival in patients with MMI. METHODS We included 25 patients with MMI who underwent ICP monitoring and brain computed tomography within the first hour of hemicraniectomy. Midline shifts were measured as radiological surrogates of decompression. The Glasgow Coma Scale and pupillary enlargements during the first day after hemicraniectomy were assessed as clinical surrogates of decompression. Long-term survival status at 6 months was used as the final outcome. We analyzed the relationships between early ICP and findings of midline shift, Glasgow Coma Scale, pupillary enlargement, and survival. RESULTS Initial ICP was correlated with mean ICP ( P < .001) and maximal ICP ( P < .001) during the first postoperative day. Intracranial pressure was associated with midline shifts ( P = .009), lower Glasgow Coma Scale scores ( P = .025), and the pupillary enlargement ( P = .015). Sixteen (64.0%) patients survived at 6 months. In a Cox proportional hazard model, elevated ICP was associated with mortality at 6 months (hazard ratio: 1.13; 95% confidence interval: 1.03-1.24; P = .008). CONCLUSION Increase in ICP soon after hemicraniectomy was associated with midline shift, poor neurological status, and mortality in patients with MMI. Measurements of ICP soon after hemicraniectomy may permit earlier interventions as well as more refined clinical assessments.
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Affiliation(s)
- Sang-Beom Jeon
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Cheol Park
- 2 Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun U Kwon
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon-Jung Kim
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seungjoo Lee
- 2 Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Wha Kang
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong S Kim
- 1 Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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24
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Hecht N, Müller MM, Sandow N, Pinczolits A, Vajkoczy P, Woitzik J. Infarct prediction by intraoperative laser speckle imaging in patients with malignant hemispheric stroke. J Cereb Blood Flow Metab 2016; 36:1022-32. [PMID: 26661215 PMCID: PMC4908625 DOI: 10.1177/0271678x15612487] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 09/23/2015] [Indexed: 12/12/2022]
Abstract
Currently, a reliable method for real-time prediction of ischemia in the human brain is not available. Here, we took a first step towards validating non-invasive intraoperative laser speckle imaging (iLSI) for prediction of infarction in 22 patients undergoing decompressive surgery for treatment of malignant hemispheric stroke. During surgery, cortical perfusion was visualized and recorded in real-time with iLSI. The true morphological infarct extension within the iLSI imaging field was superimposed onto the iLSI blood flow maps according to a postoperative MRI (16 h [95% CI: 13, 19] after surgery) with three-dimensional magnetization-prepared rapid gradient-echo and diffusion-weighted imaging reconstruction. Based on the frequency distribution of iLSI perfusion values within the infarcted and non-infarcted territories, probability curves and perfusion thresholds of normalized cerebral blood flow predictive of eventual infarction or non-infarction were calculated. Intraoperative LSI predicted and excluded cortical ischemia with 95% probability at normalized perfusion levels below 40% and above 110%, respectively, which represented 73% of the entire cortical surface area. Together, our results suggest that iLSI is valid for (pseudo-) quantitative assessment of blood flow in the human brain and may be used to identify tissue at risk for infarction at a given time-point in the course of ischemic stroke.
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Affiliation(s)
- Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marc-Michael Müller
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nora Sandow
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexandra Pinczolits
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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Suppli MH, Af Rosenschold PM, Pappot H, Dahl B, Morgen SS, Vogelius IR, Engelholm SA. Stereotactic radiosurgery versus decompressive surgery followed by postoperative radiotherapy for metastatic spinal cord compression (STEREOCORD): Study protocol of a randomized non-inferiority trial. J Radiosurg SBRT 2016; 4:S1-S9. [PMID: 29296431 PMCID: PMC5658847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 05/15/2015] [Indexed: 06/07/2023]
Abstract
Current treatment standard for patients with metastatic spinal cord compression (MSCC) is decompressive surgery followed by radiotherapy. Stereotactic radiosurgery (SRS) could be considered a treatment option for MSCC for patients with minor neurologic deficits. If SRS is safely and effectively delivered with equivalent functional outcome, the patients would avoid the risks associated with an invasive procedure. This paper presents the design of a non-inferiority clinical trial evaluating the safety, tolerability and feasibility of SRS vs. current standard treatment for patients with MSCC. Patients fulfilling inclusion criteria will be randomized 1:1 to each arm. The primary endpoint is ability to walk six weeks after treatment. Secondary endpoints are levels of pain, bladder control, quality of life, response rate, toxicity and number of treatment days. 65 patients in each arm are required for the power of 89% to detect a clinically relevant inferior outcome.
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Affiliation(s)
- Morten H Suppli
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, Copenhagen, Denmark
| | | | - Helle Pappot
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshopitalet, Copenhagen, Denmark
- University of Copenhagen, Denmark
| | - Søren S Morgen
- Spine Unit, Department of Orthopedic Surgery, Rigshopitalet, Copenhagen, Denmark
| | - Ivan R Vogelius
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, Copenhagen, Denmark
| | - Svend A Engelholm
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, Copenhagen, Denmark
- University of Copenhagen, Denmark
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Parker SL, Anderson LH, Nelson T, Patel VV. Cost-effectiveness of three treatment strategies for lumbar spinal stenosis: Conservative care, laminectomy, and the Superion interspinous spacer. Int J Spine Surg 2015; 9:28. [PMID: 26273546 DOI: 10.14444/2028] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Lumbar spinal stenosis is a painful and debilitating condition resulting in healthcare costs totaling tens of billions of dollars annually. Initial treatment consists of conservative care modalities such as physical therapy, NSAIDs, opioids, and steroid injections. Patients refractory to these therapies can undergo decompressive surgery, which has good long-term efficacy but is more traumatic and can be associated with high post-operative adverse event (AE) rates. Interspinous spacers have been developed to offer a less-invasive alternative. The objective of this study was to compare the costs and quality adjusted life years (QALYs) gained of conservative care (CC) and decompressive surgery (DS) to a new minimally-invasive interspinous spacer. METHODS A Markov model was developed evaluating 3 strategies of care for lumbar spinal stenosis. If initial therapies failed, the model moved patients to more invasive therapies. Data from the Superion FDA clinical trial, a prospective spinal registry, and the literature were used to populate the model. Direct medical care costs were modeled from 2014 Medicare reimbursements for healthcare services. QALYs came from the SF-12 PCS and MCS components. The analysis used a 2-year time horizon with a 3% discount rate. RESULTS CC had the lowest cost at $10,540, while Spacers and DS were nearly identical at about $13,950. CC also had the lowest QALY increase (0.06), while Spacers and DS were again nearly identical (.28). The incremental cost-effectiveness ratios (ICER) for Spacers compared to CC was $16,300 and for DS was $15,200. CONCLUSIONS Both the Spacer and DS strategies are far below the commonly cited $50,000/QALY threshold and produced several times the QALY increase versus CC, suggesting that surgical care provides superior value (cost / effectiveness) versus sustained conservative care in the treatment of lumbar spinal stenosis.
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Affiliation(s)
- Scott L Parker
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville TN
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27
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Neugebauer H, Jüttler E. Hemicraniectomy for malignant middle cerebral artery infarction: current status and future directions. Int J Stroke 2014; 9:460-7. [PMID: 24725828 DOI: 10.1111/ijs.12211] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 09/08/2013] [Indexed: 12/01/2022]
Abstract
Malignant middle cerebral artery infarction is a life-threatening sub-type of ischemic stroke that may only be survived at the expense of permanent disability. Decompressive hemicraniectomy is an effective surgical therapy to reduce mortality and improve functional outcome without promoting most severe disability. Evidence derives from three European randomized controlled trials in patients up to 60 years. The recently finished DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY - II trial gives now high-level evidence for the effectiveness of decompressive hemicraniectomy in patients older than 60 years. Nevertheless, pressing issues persist that need to be answered in future clinical trials, e.g. the acceptable degree of disability in survivors of malignant middle cerebral artery infarction, the importance of aphasia, and the best timing for decompressive hemicraniectomy. This review provides an overview of the current diagnosis and treatment of malignant middle cerebral artery infarction with a focus on decompressive hemicraniectomy and outlines future perspectives.
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Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, RKU - University and Rehabilitation Hospitals, Ulm, Germany
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28
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Abstract
INTRODUCTION Degenerative lumbar spinal disorder is common in Japan, and the L5 nerve root is commonly involved in this disorder. The symptoms of L5 radiculopathy are irradiating lateral leg pain, and numbness and weakness of tibialis anterior and the hip abductor muscle. There has been only one report on the results of surgery for hip abductor muscle weakness caused by degenerative lumbar spinal disorder. PATIENTS AND METHODS In this study, we analyzed the strength of the hip abductor muscle before and after decompressive surgery in 26 cases and the relationship between the lumbar disc herniation (LDH) and lumbar spinal canal stenosis (LSCS) groups. RESULTS Of the total 26 cases, muscle strength improved in 23 cases (88%), with complete recovery in 17 cases (65%). In the LDH group, the improvement rate was 92%. In the LSCS group, the improvement rate was 68%. Although the improvement rate for the LDH group was higher than that for the LSCS group, the difference was not significant (P = 0.054). DISCUSSION Decompressive surgery may be an effective method to improve hip abductor muscle weakness in degenerative lumbar spinal disorder.
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Affiliation(s)
- Tatsuro Sasaji
- Department of Orthopedic Surgery, Fukushima Rosai Hospital, 3-Numajiri, Tsuzura-machi, Uchigo, Iwaki 973-8403, Japan.
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