Category: Trauma

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The Fast and the Fragile: Neurosurgical Trauma in the Age of Micromobility

Neurosurgery 98:974–983, 2026

This study analyzes five years of micromobility-related trauma at a Level-1 urban trauma center, quantifying injury mechanisms, patient demographics, device types, and neurosurgical outcomes. Findings show rising electric device involvement, frequent motor-vehicle collisions, low helmet use, substantial ICU and operative resource needs, and a 1.2% in-hospital mortality.

Key implications highlight pedestrians—especially those struck by electric devices—as highest-risk, evening hours and alcohol as modifiable contributors, and helmet use and infrastructure redesign as actionable prevention targets to reduce neurosurgical burden.

Scope Retrospective cohort review of micromobility-related injuries (electric/mechanical bikes and scooters, plus pedestrians struck) presenting to Bellevue Hospital Center (Level-1 trauma center) from 2018–2023, assessing mechanisms, risk factors, injury patterns, and outcomes.

Growing burden 914 patients accounted for 6.9% of all trauma admissions; annual volume and electric-device involvement increased over time.

Mechanisms The most common injury mechanism was collision with a motor vehicle (49.9%), followed by falls (33.8%).

Clinical severity & utilization Most patients required hospital admission (~68%), 30.2% required ICU care, median LOS was 3 days, about half underwent a procedure/intervention, and in-hospital mortality was 1.2%.

Neurotrauma patterns TBI was frequent (about one-third of patients) and neurosurgical interventions occurred in 3.7% (eg, craniotomy/hemicraniectomy 1.1%, ICP monitor/EVD 0.8%, spine decompression/instrumentation 0.7%).

Helmet use Helmet use was low (31.7% with documented status); not wearing a helmet was associated with higher rates of TBI and craniofacial trauma.

Alcohol & timing Alcohol intoxication was common and associated with lower helmet use and higher TBI/craniofacial injury; injuries clustered in evening/overnight hours, indicating modifiable environmental/behavioral risks.

Highest-risk group Pedestrians had the most severe outcomes (higher TBI, admission and ICU rates), with greater injury severity when struck by electric devices; after propensity matching, electric vs mechanical riders had no significant outcome differences.

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Predicting chronic subdural hematoma risk in elderly patients with mild traumatic brain injury

Acta Neurochirurgica (2026) 168:40

This study develops and validates a concise bedside risk score to predict chronic subdural hematoma (CSDH) within 2–12 weeks after mild traumatic brain injury in patients aged 65+. Using a large retrospective cohort (7,246 events) and multivariable modeling, pathological CT at presentation, male sex, older age, and renal failure emerged as key predictors.

The score-based model (including anticoagulant use by expert choice) achieved AUROC 0.76 and 86% sensitivity at the chosen threshold, classifying ~61% as high-risk. Authors propose this tool to guide targeted surveillance and earlier intervention, while noting limitations from retrospective data and need for external validation.

Pathological CT Findings: Pathological findings on initial head CT after mild traumatic brain injury (TBI) are the strongest predictor for developing chronic subdural hematoma (CSDH) within 2–12 weeks in elderly patients.

Key Risk Factors: Older age, male sex, and renal failure are also significant independent predictors for CSDH following mild TBI.

Anticoagulant Use: Chronic use of anticoagulant medications showed a trend toward increased risk but was not statistically significant in this cohort; antiplatelet use was not associated with increased risk.

Prediction Model: A simple score-based risk model was developed, incorporating pathological CT (14 points), male sex (4), renal failure (4), anticoagulant use (4), and age (1 point per 5 years over 65), with a threshold of 5 points or higher identifying high-risk patients.

Model Performance: The risk model achieved an area under the ROC curve (AUROC) of 0.76 and a sensitivity of 86% for detecting CSDH, but the positive predictive value was low (1.6%) due to the rare occurrence of the outcome.

Clinical Implications: Early identification of high-risk patients may enable targeted surveillance, timely CT scanning, and consideration of non-surgical management options such as corticosteroids or middle meningeal artery embolization.

Population Impact: The incidence of CSDH is rising globally due to population aging and increased use of antithrombotic agents, with elderly adults being particularly at risk.

Study Scope: The findings support the use of bedside risk stratification in the emergency department for elderly patients with mild TBI, but further research is needed before widespread clinical implementation.

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Long-Term Mortality of Patients With Head Injuries—A 10-Year Follow-up Study With Population Controls Study Performed at Tampere University Hospital

Neurosurgery 98:105–114, 2026

This study reports a 10-year follow-up comparing survival and causes of death between 1,930 patients treated for head injuries at a Finnish university hospital and 9,605 matched population controls. After excluding deaths within the first year, patients had a hazard ratio of 1.84 for mortality, with excess deaths concentrated in the first five years and elevated unintentional/traumatic and alcohol-related causes.

Multivariable analysis found age, male sex, pre-existing conditions, chronic alcohol use, and substance abuse—rather than injury severity or CT-positivity—were independently associated with reduced survival, though greater TBI severity remained linked to additional mortality risk when comparing patient severity subgroups to their matched controls.

Long-term Mortality: Patients with head injuries have significantly reduced long-term survival compared to matched population controls, with a hazard ratio (HR) for death of 1.84 after excluding those who died in the first year post-injury.

Acute vs. Long-term Risk: Death rates are notably higher among patients with head injuries for up to 5 years after injury, then approach control levels thereafter.

Causes of Death: Unintentional and traumatic causes (9.6% vs 4.4%) and alcohol-related causes (8.4% vs 1.9%) are significantly more common among head injury patients than controls.

Patient Characteristics: Age, male sex, pre-existing conditions, chronic alcohol use, and regular substance abuse are independently associated with decreased survival, whereas injury severity and CT findings are not significant predictors in multivariate analysis.

TBI Severity: Even patients with no documented traumatic brain injury (TBI) have reduced survival compared to controls; increasing TBI severity is associated with additional mortality risk.

Lifestyle and Pre-existing Factors: Much of the reduced survival is linked to patient characteristics and lifestyle factors (such as substance abuse), not solely to injury-related factors.

Immediate Causes of Death: Aspiration pneumonia and epileptic causes are significantly overrepresented as immediate causes of death in head injury patients who survive more than one year.

Control Group Limitations: Use of population controls and lack of detailed control data may overestimate associations between head injury and mortality due to unmeasured confounders.

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Dynamic Craniotomy With Khanna NuCrani Plates as an Alternative to Craniotomy With Fixed Plates in Traumatic Brain Injury

Neurosurgery 96:1353–1363, 2025

Dynamic craniotomy using Khanna NuCrani expandable plates allows reversible outward bone flap movement, accommodating postoperative brain swelling in traumatic brain injury. This technique reduced intracranial pressure, avoided repeat surgeries, and improved outcomes compared to fixed plate craniotomy or decompressive craniectomy.

• Dynamic craniotomy with Khanna NuCrani plates allows reversible outward movement of the bone flap, accommodating postoperative brain swelling and hemorrhage in traumatic brain injury patients.

• In a series of 25 patients, 84% experienced postoperative swelling, all compensated by outward bone flap migration, with no need for reoperation, cranioplasty, or wound healing complications.

• All patients had normal postoperative intracranial pressures, and 84% achieved good outcomes; mortality was 16%, related to injury severity and age, not surgical failure.

• Dynamic craniotomy reduced the need for repeat surgeries compared to fixed plate craniotomy and decompressive craniectomy, and avoided complications like bone flap failure and syndrome of the trephined.

• Bone flaps retracted to anatomic positions after swelling resolved, with no cosmetic complaints reported.

• Dynamic plates prevent the bone flap from sinking and tolerate significant increases in intracranial volume while maintaining normal ICP.

• The technique may offer substantial cost savings by reducing repeat surgeries and complications, with estimated savings of $68,000 to $85,000 per patient.

• Dynamic craniotomy is proposed as a hybrid alternative to fixed plate craniotomy and decompressive craniectomy, offering immediate intracranial volume expansion and fewer complications.

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Comparative Analysis of Duroplasty Techniques in Decompressive Craniectomy: The CANDID Study

Operative Neurosurgery 28:357–367, 2025

The CANDID study compares duroplasty techniques in decompressive craniectomy for TBI, showing better outcomes with vascularized pericranial grafts over synthetic dural substitutes. The study highlights improved Glasgow Outcome Scale scores at 6 months and 1 year, with fewer complications in the autologous graft group.

• Study Objective: Compare two duroplasty techniques in primary decompressive craniectomy for traumatic brain injury.

• Methods: Retrospective analysis of 97 patients, using VP and SR techniques.

• Primary Outcome: GOS-E scores at 6 months and 1 year post-injury.

• Results: VP group showed better GOS-E scores at 6 months (P = .011) and 1 year (P = .026).

• Complications: Brain abscesses found only in SR group, though not statistically significant.

• Conclusions: VP technique associated with better long-term outcomes compared to SR.

• Study Limitations: Retrospective nature, small sample size, and potential selection bias.

• Recommendation: Further research through prospective randomized controlled trials is needed.

• Authors: Mahesh Ramola et al. conducted the study at S.G.R.R. Institute of Medical & Health Sciences.

• Study Period: April 2015 to February 2022.

• Data Collection: From medical files and telephone questionnaires.

• Statistical Analysis: Propensity score matching used to minimize baseline differences.

• Funding: No financial support or conflicts of interest reported.

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Wartime penetrating traumatic brain injury of the anterior skull base involving the paranasal sinuses: a single-center, first-year experience from Dnipro, Ukraine

J Neurosurg 142:829–838, 2025

• Study Focus: The study explores wartime penetrating traumatic brain injuries (pTBIs) involving the anterior skull base and paranasal sinuses during the first year of the Russian-Ukrainian war.

• Objective: To identify factors associated with favorable short-term outcomes and survival in patients with pTBIs.

• Methodology: A single-center retrospective review was conducted on patients treated at Mechnikov Dnipropetrovsk Regional Clinical Hospital in Ukraine.

• Key Findings: High Glasgow Coma Scale (GCS) scores, favorable injury lateralization, and low Injury Severity Scores (ISS) were linked to better short-term outcomes.

• Treatment Protocol: The study implemented early primary neurosurgical treatment, including debridement and skull base reconstruction, which showed promising early results.

• Patient Outcomes: 84% of patients achieved a favorable outcome, with low rates of postoperative complications like CSF leaks and infections.

• Comparison with Other Conflicts: The study highlights differences in management strategies compared to US military experiences in Iraq and Afghanistan.

• Limitations: The study lacks a direct comparison group and long-term outcomes are not available due to follow-up challenges.

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Percutaneous Screw Distraction for Anatomic Restoration: Case Series

Operative Neurosurgery 27:698–706, 2024

Percutaneous pedicle screw fixation with distraction reduces morbidity after traumatic thoracolumbar burst fractures; however, there are substantial limitations, particularly for correction of kyphosis. The use of fixed-angle screws may offer improved anatomic restoration, facilitating greater postdistraction vertebral height restoration and spinal canal fragment reduction. We examined the radiographic results of distraction across fixed-angle screws immediately after surgery and in long-term follow-up.

METHODS: Demographic and clinical characteristics were captured for patients with traumatic thoracolumbar fractures undergoing percutaneous pedicle screw fixation by a single surgeon. Radiographic measurements were collected at predistraction, postdistraction, and long-term follow-up time points. Paired t-tests, Student’s t-tests, Mann–Whitney U tests, and χ 2 tests were used to assess data where appropriate.

RESULTS: The case series included 22 patients (77.3% male; mean age 42.0 ± 18.4 years). Hounsfield density consistent with osteopenia was seen in 13.6% of patients at the time of injury. Sporting injuries and motor vehicle accidents were common (both 31.8%). Most injuries occurred at L1 (45.5%). Upon long-term follow-up, the mean injured-level predistraction cross-sectional area improved from 2.1 to 2.9 cm 2 (P < .01). Compared with the superadjacent level, the injured-level cross-sectional canal area improved by 28.6% (P < .01). Vertebral body index also improved significantly (18.8°mean change, P < .01). The mean bisegmental Cobb angle improved by 6.2°(P = .01), and injured vertebral body compression decreased by 22.4% (P < .01). Significant improvement in correction was achieved with experience, with final technique yielding superior cross-sectional area (P = .04) and compression ratios (P = .03).

CONCLUSION: Distraction across fixed-angle percutaneous screw instrumentation systems stabilizes traumatic thoracolumbar burst fractures, corrects deformity, and decompresses the spinal canal. Further comparative research is necessary to demonstrate whether outcomes are different between percutaneous instrumentation vs open fusion for thoracolumbar trauma.

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Is external hydrocephalus a possible differential diagnosis when child abuse is suspected?

Acta Neurochirurgica (2022) 164:1161–1172

Criteria for diagnosing abusive head trauma (AHT) or “shaken baby syndrome” are not well defined; consequently, these conditions might be diagnosed on failing premises.

Methods The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)—mean age 5.1 month, without age difference between genders.

Results Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH).

Conclusions BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors’ experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.

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The Richmond Acute Subdural Hematoma Score: A Validated Grading Scale to Predict Postoperative Mortality

Neurosurgery 90:278–286, 2022

Traumatic acute subdural hematomas (aSDHs) are common, life-threatening injuries often requiring emergency surgery.

OBJECTIVE: To develop and validate the Richmond acute subdural hematoma (RASH) score to stratify patients by risk of mortality after aSDH evacuation.

METHODS: The 2016 National Trauma Data Bank (NTDB) was queried to identify adult patients with traumatic aSDHs who underwent craniectomy or craniotomy within 4 h of arrival to an emergency department. Multivariate logistic regression modeling identified risk factors independently associated with mortality. The RASH score was developed based on a factor’s strength and level of association with mortality. The model was validated using the 2017 NTDB and the area under the receiver operating characteristic curve (AUC).

RESULTS: A total of 2516 cases met study criteria. The patients were 69.3% male with a mean age of 55.7 yr and overall mortality rate of 36.4%. Factors associated with mortality included age between 61 and 79 yr (odds ratio [OR]=2.3, P<.001),age ≥80 yr (OR =6.3, P < .001), loss of consciousness (OR = 2.3, P < .001), Glasgow Coma Scale score of ≤8 (OR = 2.6, P < .001), unilateral (OR = 2.8, P < .001) or bilateral (OR = 3.9, P < .001) unresponsive pupils, and midline shift >5 mm (OR = 1.7, P < .001). Using these risk factors, the RASH score predicted progressively increasing mortality ranging from 0% to 94% for scores of 0 to 8, respectively (AUC = 0.72). Application of the RASH score to 3091 cases from 2017 resulted in similar accuracy (AUC = 0.74).

CONCLUSION: The RASH score is a simple and validated grading scale that uses easily accessible preoperative factors to predict estimated mortality rates in patients with traumatic aSDHs who undergo surgical evacuation.

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Blood Biomarkers and Structural Imaging Correlations Post-Traumatic Brain Injury: A Systematic Review

Neurosurgery 90:170–179, 2022

Blood biomarkers are of increasing importance in the diagnosis and assessment of traumatic brain injury (TBI). However, the relationship between them and lesions seen on imaging remains unclear.

OBJECTIVE: To perform a systematic review of the relationship between blood biomarkers and intracranial lesion types, intracranial lesion injury patterns, volume/number of intracranial lesions, and imaging classification systems.

METHODS: We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, and Cumulative Index to Nursing and Allied Health Literature from inception to May 2021, and the references of included studies were also screened. Heterogeneity in study design, biomarker types, imaging modalities, and analyses inhibited quantitative analysis, with a qualitative synthesis presented.

RESULTS: Fifty-nine papers were included assessing one or more biomarker to imaging comparisons per paper: 30 assessed imaging classifications or injury patterns, 28 assessed lesion type, and 11 assessed lesion volume or number. Biomarker concentrations were associated with the burden of brain injury, as assessed by increasing intracranial lesion volume, increasing numbers of traumatic intracranial lesions, and positive correlations with imaging classification scores. There were inconsistent findings associating different biomarkers with specific imaging phenotypes including diffuse axonal injury, cerebral edema, and intracranial hemorrhage.

CONCLUSION: Blood-based biomarker concentrations after TBI are consistently demonstrated to correlate burden of intracranial disease. The relation with specific injury types is unclear suggesting a lack of diagnostic specificity and/or is the result of the complex and heterogeneous nature of TBI.

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Evolution and Impact of the Brain Trauma Foundation Guidelines

Neurosurgery 89:1148–1156, 2021

The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Head Injury were the first clinical practice guidelines published by any surgical specialty. These guidelines have earned a reputation for rigor and have been widely adopted around the world. Implementation of these guidelines has been associated with a 50% reduction in mortality and reduced costs of patient care.

Over their 25-yr history the traumatic brain injury (TBI) guidelines have been expanded, refined, and made increasingly more rigorous in conjunction with new clinical evidence and evolving methodologic standards.

Here, we discuss the history and accomplishments of BTF guidelines for TBI as well as their limitations. We also discuss planned changes to future TBI guidelines intended to increase their utility and positive impact in an evolving medical landscape. Perhaps the greatest limitation of TBI guidelines now is the lack of high-quality clinical research as well as novel diagnostics and treatments with which to generate substantially new recommendations.

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External Lumbar Drainage following Traumatic Intracranial Hypertension

Neurosurgery 89:395–405, 2021

Traumatic brain injury (TBI) often results in elevations in intracranial pressure (ICP) that are refractory to standard therapies. Several studies have investigated the utility of external lumbar drainage (ELD) in this setting.

OBJECTIVE: To evaluate the safety and efficacy of ELD or lumbar puncture with regard to immediate effect on ICP, durability of the effect on ICP, complications, and neurological outcomes in adults with refractory traumatic intracranial hypertension.

METHODS: A systematic review and meta-analysis were conducted beginning with a comprehensive search of PubMed/EMBASE. Two investigators reviewed studies for eligibility and extracted data. The strength of evidence was evaluated using GRADE methodology. Random-effects meta-analyses were performed to calculate pooled estimates.

RESULTS: Nine articles detailing 6 studies (N = 110) were included. There was moderate evidence that ELD has a significant immediate effect on ICP; the pooled effect size was –19.5 mmHg (95% CI –21.0 to –17.9 mmHg). There was low evidence to indicate a durable effect of ELD on ICP up to at least 24 h following ELD. There was low evidence to indicate that ELD was safe and associated with a low rate of clinical cerebral herniation or meningitis. There was very low evidence pertaining to neurological outcomes.

CONCLUSION: Given preliminary data indicating potential safety and feasibility in highly selected cases, the use of ELD in adults with severe TBI and refractory intracranial hypertension in the presence of open basal cisterns and absence of large focal hematoma merits further high-quality investigation; the ideal conditions for potential application remain to be determined.

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Minimally invasive posterior percutaneous transarticular C1–C2 screws: how I do it

Acta Neurochirurgica (2020) 162:2047–2050

Transarticular C1–C2 screw fixation, first described by Magerl, is a widely accepted used technique for C1–C2 instability with a good biomechanical stability and fusion rate.

Method We present a 69-year-old woman, who was diagnosed with a C2 Odontoid fracture type III and primarily treated with conservative treatment and collar. During first 2 weeks of follow-up, the patient developed cervical pain associated with C1–C2 instability. A minimally invasive posterior C1–C2 transarticular screw instrumentation with a percutaneus approach was performed.

Results and conclusion Minimally invasive approach with tubular transmuscular approach for C1–C2 transarticular screws instrumentation is safe and effective for C1–C2 instability.

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Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations

Neurosurgery 87:427–434, 2020

When the fourth edition of the Brain Trauma Foundation’s Guidelines for theManagement of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released.

The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of “living guidelines,” whereby topics are updated more frequently, and between new editions, when important new evidence is published.

The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice.

This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline canbe found at: https://braintrauma.org/guidelines/guidelines-for-themanagement- of-severe-tbi-4th-ed#/.

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Effect of decompressive craniectomy in the postoperative expansion of traumatic intracerebral hemorrhage: a propensity score–based analysis

J Neurosurg 132:1623–1635, 2020

Traumatic intracerebral hemorrhage (TICH) represents approximately 13%–48% of the lesions after a traumatic brain injury (TBI), and hemorrhagic progression (HP) occurs in 38%–63% of cases. In previous studies, decompressive craniectomy (DC) has been characterized as a risk factor in the HP of TICH; however, few studies have focused exclusively on this relationship. The object of the present study was to analyze the relationship between DC and the growth of TICH and to reveal any correlation with the size of the craniectomy, degree of cerebral parenchymal herniation (CPH), or volumetric expansion of the TICH.

METHODS The authors retrospectively analyzed the records of 497 adult patients who had been consecutively admitted after suffering a severe or moderate closed TBI. An inclusion criterion was presentation with one or more TICHs on the initial or control CT. Demographic, clinical, radiological, and treatment variables were assessed for associations.

RESULTS Two hundred three patients presenting with 401 individual TICHs met the selection criteria. TICH growth was observed in 281 cases (70.1%). Eighty-two cases (20.4%) underwent craniectomy without TICH evacuation. In the craniectomy group, HP was observed in 71 cases (86.6%); in the noncraniectomy group (319 cases), HP occurred in 210 cases (65.8%). The difference in the incidence of HP between the two groups was statistically significant (OR 3.41, p < 0.01). The mean area of the craniectomy was 104.94 ± 27.5 cm2, and the mean CPH distance through the craniectomy was 17.85 ± 11.1 mm. The mean increase in the TICH volume was greater in the groups with a craniectomy area > 115 cm2 and CPH > 25 mm (16.12 and 14.47 cm3, respectively, p = 0.01 and 0.02). After calculating the propensity score (PS), the authors followed three statistical methods—matching, stratification, and inverse probability treatment weighting (IPTW)—thereby obtaining an adequate balance of the covariates. A statistically significant relationship was found between HP and craniectomy (OR 2.77, p = 0.004). This correlation was confirmed with the three methodologies based on the PS with odds greater than 2.

CONCLUSIONS DC is a risk factor for the growth of TICH, and there is also an association between the size of the DC and the magnitude of the volume increase in the TICH.

 

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Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

Acta Neurochirurgica (2020) 162:469–479

Objective To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI).

Methods A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, “primary procedure” and “secondary procedure”, was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO2) values as well as the need for additional osmotherapy and CSF drainage.

Results Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average postsurgical ICP values, higher PbO2 values and required less osmotic treatments as compared with those treated with DC alone.

Conclusion Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.

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Ultra-Early (<12 Hours) Surgery Correlates With Higher Rate of American Spinal Injury Association Impairment Scale Conversion After Cervical Spinal Cord Injury

Neurosurgery, Volume 85, Issue 2, August 2019, Pages 199–203

Cervical spinal cord injury (SCI) is a devastating condition with very few treatment options. It remains unclear if early surgery correlated with conversion of American Spinal Injury Association Impairment Scale (AIS) grade A injuries to higher grades.

OBJECTIVE: To determine the optimal time to surgery after cervical SCI through retrospective analysis.

METHODS: We collected data from 48 patients with cervical SCI. Based on the time from Emergency Department (ED) presentation to surgical decompression, we grouped patients into ultra-early (decompression within 12 h of presentation), early (within 12- 24 h), and late groups (>24 h).We compared the improvement in AIS grade fromadmission to discharge, controlling for confounding factors such as AIS grade on admission, injury severity, and age. The mean time from injury to ED for this group of patients was 17 min.

RESULTS: Patients who received surgery within 12 h after presentation had a relative improvement in AIS grade from admission to discharge: the ultra-early group improved on average 1.3. AIS grades compared to 0.5 in the early group (P = .02). In addition, 88.8% of patients with an AIS grade A converted to a higher grade (AIS B or better) in the ultraearly group, compared to 38.4% in the early and late groups (P= .054).

CONCLUSION: These data suggest that surgical decompression after SCI that takes place within 12 hmay lead to a relative improved neurological recovery compared to surgery that takes place after 12 h.

 

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Correlation of magnetic resonance diffusion tensor imaging parameters with American Spinal Injury Association score for prognostication and long-term outcomes

Neurosurg Focus 46 (3):E2, 2019

Conventional MRI is routinely used to demonstrate the anatomical site of spinal cord injury (SCI). However, quantitative and qualitative imaging parameters have limited use in predicting neurological outcomes. Currently, there are no reliable neuroimaging biomarkers to predict short- and long-term outcome after SCI.

METHODS A prospective cohort of 23 patients with SCI (19 with cervical SCI [CSCI] and 4 with thoracic SCI [TSCI]) treated between 2007 and 2014 was included in the study. The American Spinal Injury Association (ASIA) score was determined at the time of arrival and at 1-year follow-up. Only 15 patients (12 with CSCI and 3 with TSCI) had 1-year follow-up. Whole-cord fractional anisotropy (FA) was determined at C1–2, following which C1–2 was divided into upper, middle, and lower segments and the corresponding FA value at each of these segments was calculated. Correlation analysis was performed between FA and ASIA score at time of arrival and 1-year follow-up.

RESULTS Correlation analysis showed a positive but nonsignificant correlation (p = 0.095) between FA and ASIA score for all patients (CSCI and TCSI) at the time of arrival. Additional regression analysis consisting of only patients with CSCI showed a significant correlation (p = 0.008) between FA and ASIA score at time of arrival as well as at 1-year follow-up (p = 0.025). Furthermore, in case of patients with CSCI, a significant correlation between FA value at each of the segments (upper, middle, and lower) of C1–2 and ASIA score at time of arrival was found (p = 0.017, p = 0.015, and p = 0.002, respectively).

CONCLUSIONS In patients with CSCI, the measurement of diffusion anisotropy of the high cervical cord (C1–2) correlates significantly with injury severity and long-term follow-up. However, this correlation is not seen in patients with TSCI. Therefore, FA can be used as an imaging biomarker for evaluating neural injury and monitoring recovery in patients with CSCI.

 

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Anterior Reduction and Fusion of Cervical Facet Dislocations

Neurosurgery 84:388–395, 2019

Cervical facet dislocations are among the most common traumatic spinal injuries. Posterior, anterior, and combined surgical approaches have been described and are widely debated.

OBJECTIVE: To demonstrate efficacy in anterior-only surgical management for subaxial cervical facet dislocations.

METHODS: A consistent surgical algorithm for cervical facet dislocation was applied over a 19-yr period and analyzed retrospectively in adults with acute unilateral or bilateral facet dislocation of the subaxial cervical spine. The primary endpoint was maintenance of early cervical alignment. The need for additional posterior instrumented fusion was determined.

RESULTS: A database search identified 96 patients (mean age = 37.9, range = 14-74 yr, 68 (70%) male. The most common affected levels were C4-C5 (30), C5-C6 (29), and C6-C7 (30). Bilateral dislocation occurred in 51 patients (53%). Seventy-eight (81%) patients had neurological deficits, 31 (32%) being complete (Abbreviated Injury Score A) spinal cord injuries. Preoperative closed reductionwas attempted in 60 (63%) patients, with 33 (55%) achieving satisfactory alignment. After anterior cervical discectomy, reduction, allograft placement, and instrumentation, a total of 92 (96%) patients had achieved satisfactory realignment. Median time to surgery was 13.27 h. Eight (8%) patients required posterior fixation due to intraoperative determination of incomplete realignment (4; 4%) and development of early progressive deformity (4; 4%). Mean follow-up was 4.5 mo (range 0.5-24 mo) with 33 (34%) patients lost to follow-up.

CONCLUSION: Anterior approaches are viable for reduction and stabilization of cervical facet dislocations. Further prospective studies are required to evaluate clinical and longterm success.

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Novel Temporary Treatment for a Severe Case of Syndrome of Trephined

World Neurosurg. (2018) 120:200-204

Syndrome of the trephined is a unique neurosurgical condition that is seen in patients that have undergone craniectomy. While the symptoms of the condition range from mild to severe, the only definitive treatment for the condition is replacement of the bone flap. This article presents a novel, temporary treatment for syndrome of the trephined in a patient with severe symptoms who was unable to undergo immediate cranioplasty due to infection.

CASE DESCRIPTION: A 25-year-old gentleman with a history of trauma resulting in hydrocephalus, craniectomy, and eventually ventriculoperitoneal shunt placement presented with a cranial wound infection requiring removal of his bone flap. While being treated with antibiotics, with his bone flap removed, he developed severe syndrome of the trephined. An emergency bedside procedure was developed and executed to treat his condition.

CONCLUSIONS: Treating syndrome of the trephined with an external suction device proved useful and lifesaving fort the patient presented. Such a device can be made with common supplies found within any hospital. The technique used to treat the patient is novel and may be useful for others to consider if ever faced with a similar situation.

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