Category: Trauma

Posted on

Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma

Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma

Neurosurg Focus 37 (1):E11, 2014

Thoracolumbar and lumbar trauma account for the majority of traumatic spinal injuries. The mainstay of current treatments is still nonoperative therapy with bracing. Classic treatment algorithms reserved absolute surgical intervention for spinal trauma patients with neurological compromise or instability. Relative indications included incapacitating pain and obesity/body habitus making brace therapy ineffective.

In the past decade, minimally invasive surgical (MIS) techniques for spine surgery have been increasingly used for degenerative conditions. These same minimally invasive techniques have seen increased use in trauma patients. The goal of minimally invasive surgery is to decrease surgical morbidity through decreased soft-tissue dissection while providing the same structural stability afforded by classic open techniques.

These minimally invasive techniques involve percutaneous posterior pedicle fixation, vertebral body augmentation, and utilization of endoscopic and thoracoscopic techniques.

While MIS techniques are somewhat in their infancy, an increasing number of studies are reporting good clinical and radiographic outcomes with these MIS techniques. However, the literature is still lacking high-quality evidence comparing these newer techniques to classic open treatments. This article reviews the relevant literature regarding minimally invasive spine surgery in the treatment of thoracolumbar and lumbar trauma.

Posted on

Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution

Patients with brain contusions_ predictors of outcome and

J Neurosurg 120:908–918, 2014

Traumatic parenchymal mass lesions are common sequelae of traumatic brain injuries (TBIs). They occur in up to 8.2% of all TBI cases and 13%–35% of severe TBI cases, and they account for up to 20% of surgical intracranial lesions. Controversy exists concerning the association between radiological and clinical evolution of brain contusions. The aim of this study was to identify predictors of unfavorable outcome, analyze the evolution of brain contusions, and evaluate specific indications for surgery.

Methods. In a retrospective, multicenter study, patients with brain contusions were identified in separate patient cohorts from 11 hospitals over a 4-year period (2008–2011). Data on clinical parameters and course of the contusion were collected. Radiological parameters were registered by using CT images taken at the time of hospital admission and at subsequent follow-up times. Patients who underwent surgical procedures were identified. Outcomes were evaluated 6 months after trauma by using the Glasgow Outcome Scale-Extended.

Results. Multivariate analysis revealed the following reliable predictors of unfavorable outcome: 1) increased patient age, 2) lower Glasgow Coma Scale score at first evaluation, 3) clinical deterioration in the first hours after trauma, and 4) onset or increase of midline shift on follow-up CT images. Further multivariate analysis identified the following as statistically significant predictors of clinical deterioration during the first hours after trauma: 1) onset of or increase in midline shift on follow-up CT images (p < 0.001) and 2) increased effacement of basal cisterns on follow-up CT images (p < 0.001).

Conclusions. In TBI patients with cerebral contusion, the onset of clinical deterioration is predictably associated with the onset or increase of midline shift and worsened status of basal cisterns but not with hematoma or edema volume increase. A combination of clinical deterioration and increased midline shift/basal cistern compression is the most reasonable indicator for surgery.

Posted on

Traumatic injuries to the craniovertebral junction: a review of rare events

Traumatic injuries CVJ

Neurosurg Rev (2014) 37:203–216

The craniovertebral junction is a specific region of the spine with unique anatomical and biomechanical properties that yields a wide variety of injury patterns.

Junctional traumatic fractures and/or dislocations are widely reported in clinical practice, but we could identify only a subgroup of upper cervical spine traumatic injuries with very few cases reported in the literature, and for this reason may be considered rare.

In some of these cases, the absence of spinal biomechanical instability, in association with moderate clinical symptoms (neck stiffness and pain) and the difficulty in fracture identification through standard cervical radiographs, leads to a high percentage of missed injuries.

In other cases, traumatic events have been commonly described only in autopsy series due to the high degree of spinal biomechanical instability.

Herein, we have summarized all the relevant literature concerning this issue and also included our cases, with the aim of emphasizing prompt diagnosis and correct management.

We provide a guide for correctly identifying “rare” craniovertebral junction traumatic injuries.

Posted on

Decompressive craniectomy for severe traumatic brain injury: is life worth living?

decompressive craniectomy

J Neurosurg 119:1566–1575, 2013

The object of this study was to assess the long-term outcome and quality of life of patients who have survived with severe disability following decompressive craniectomy for severe traumatic brain injury (TBI).

Methods. The authors assessed outcome beyond 3 years among a cohort of 39 patients who had been adjudged either severely disabled or in vegetative state 18 months after decompressive craniectomy for TBI. Assessments performed included the Extended Glasgow Outcome Scale, modified Barthel Index (mBI), Zarit Burden Interview, and 36-Item Short-Form Health Survey (SF-36). The issue of retrospective consent for surgery was also assessed.

Results. Of the 39 eligible patients, 7 died, 12 were lost to follow-up, and 20 patients or their next of kin consented to participate in the study. Among those 20 patients, 5 in a vegetative state at 18 months remained so beyond 3 years, and the other 15 patients remained severely disabled after a median follow-up of 5 years. The patients’ average daily activity per the mBI (Pearson correlation coefficient [r] = -0.661, p = 0.01) and SF-36 physical score (r = -0.543, p = 0.037) were inversely correlated with the severity of TBI. However, the SF-36 mental scores of the patients were reasonably high (median 46, interquartile range 37–52). The majority of patients and their next of kin believed that they would have provided consent for surgical decompression even if they had known the eventual outcome.

Conclusions. Substantial physical recovery beyond 18 months after decompressive craniectomy for severe TBI was not observed; however, many patients appeared to have recalibrated their expectations regarding what they believed to be an acceptable quality of life.

Posted on

Delayed Neurological Deterioration After Mild Head Injury: Cause, Temporal Course, and Outcomes

acutesdh

Neurosurgery 73:753–760, 2013

Mild head injury (MHI) complicated by an intracranial hemorrhage (ICH) is a common cause of hospital admission after head trauma. Most patients are treated nonoperatively, remain neurologically stable, and are discharged uneventfully. However, a small percentage of patients suffer delayed neurological deterioration (DND). Little is known about the characteristics of DND after an MHI complicated by ICH.

OBJECTIVE: To identify the cause, temporal course, and outcomes of patients who deteriorated neurologically after presenting with MHI and ICH. METHODS: A retrospective review was performed of all adult patients presenting over 54 consecutive months with MHI and ICH. Patients who were treated nonoperatively after initial head computed tomography and had a subsequent DND (Glasgow Coma Scale score decrease $2) were identified. Demographics, neurological status, clinical course, radiographic findings, and outcome data were collected.

RESULTS: Over 54 months, 757 patients with MHI plus ICH were admitted for observation; of these, 31 (4.1%) experienced DND. Eighty-seven percent of patients deteriorated within 24 hours after admission. Twenty-one patients (68%) deteriorated as a result of progressive intracranial hemorrhage, and 10 patients (32%) deteriorated as a result of medical causes. Seven patients (23%) died. Variables significantly associated with mortality included age . 60 years, coagulopathy, and change in Marshall computed tomography classification.

CONCLUSION: The incidence of delayed neurological deterioration after MHI with ICH is low and usually occurs within 24 hours after admission. It results in significant morbidity and mortality if it is the result of progressive intracranial hemorrhage. Further research is needed to identify risk factors that can allow early detection and improve outcomes in these patients.

KEY WORDS:

Posted on

The Value of Scheduled Repeat Cranial Computed Tomography After Mild Head Injury

concusion_TBI

Neurosurgery 72:56–64, 2013

After an initial computed tomography (CT) scan revealing intracranial hemorrhage resulting from traumatic brain injury, a standard of care in many trauma centers is to schedule a repeat CT scan to rule out possible progression of bleed.

OBJECTIVE: To evaluate the utility of routine follow-up CT in changing the management of mild head injury patients despite clinical stability, although repeat imaging is indicated to assess a deteriorating patient.

METHODS: The trauma database at our institution was retrospectively reviewed and the literature was searched to identify patients after mild head injury with positive initial CT finding and scheduled repeat scan. Patients were divided into 2 groups for comparison. Group A included patients who had intervention based on neurological examination changes. Group B comprised patients requiring a change in management according to CT results exclusively. The meta-analysis of the present cohort and included articles was performed with a random-effects model.

RESULTS: Overall, 15 studies and 445 patients met our eligibility criteria, totaling 2693 patients. Intervention rates of groups A and B were 2.7% (95% confidence interval, 1.7-3.9; P = .003) and 0.6% (95% confidence interval, 0.3-1; P = .21), respectively. The statistical difference between both intervention rates was clinically significant with P , .001.

CONCLUSION: The available evidence indicates that it is unnecessary to schedule a repeat CT scan after mild head injury when patients are unchanged or improving neurologically. In the absence of supporting data, we question the value of routine follow-up imaging given the associated accumulative increase in cost and risks.

Posted on

The prognostic significance of traumatic brainstem injury detected on T2-weighted MRI

J Neurosurg 117:722–728, 2012

Magnetic resonance imaging is frequently used to evaluate patients with traumatic brain injury in the acute and subacute setting, and it can detect injuries to the brainstem, which are often associated with poor outcomes. This study was undertaken to determine which MRI and clinical factors provide prognostic information in patients with traumatic brainstem injuries.
Methods
The authors performed a retrospective analysis of cases involving patients admitted to a Level I trauma center who were identified in a prospective database as having suffered traumatic brainstem injury identified on MRI. Patient outcomes were dichotomized to dead/vegetative versus functional groups. Standard demographic data, admission Glasgow Coma Scale (GCS) scores, results of the motor component of the GCS examination at admission and 24 hours later, CT scan findings, and peak intracranial pressure were collected from medical records. Volumetric analysis of each patient’s injuries was performed with T2-weighted and gradient echo sequences. The T2-weighted MRI sequence for each patient was reviewed to determine the anatomical location of injury within the brainstem and whether the injury crossed the midline.
Results
Thirty-six patients who met the study inclusion criteria were identified. At 6-month follow-up, 53% of these patients had poor outcomes and 47% had recovered. Patients with injuries to the medulla or deep bilateral injuries to the pons did not recover. The T2 volumes were found superior to gradient echo sequences in regard to predicting survival (ROC/AUC 0.67, p = 0.07 vs 0.60, p = 0.29, respectively), but neither reached statistical significance. The timing of MR image acquisition did not influence the findings. The time from admission to MRI did not differ significantly between the recovered group and the poor-outcome group (p = 0.52, Mann-Whitney test), and lesion size as measured by T2 volume did not vary with time to scan (R2 = 0.03, p = 0.3, linear regression). Performing a stepwise logistic regression with all the variables yielded the following factors related to recovery: crossing midline, p = 0.0156, OR 0.075; and 24-hour GCS motor score, p = 0.0045, OR = 2.25, c-statistic 0.913. Further examination of these 2 factors disclosed the following: none of 15 patients with midline-crossing lesions and a 24-hour GCS motor score of 4 or less recovered; conversely, 12 of 13 patients with lesions that did not cross midline recovered, regardless of GCS motor score.
Conclusions
Bilateral injury to the pons and medulla as detected on T2-weighted MRI sequences was associated with poor outcome in patients with brainstem injuries; T2 volumes were found superior to gradient echo sequences in regard to predicting survival, but neither reached statistical significance. When MRI findings were coupled with clinical examination findings, a strong correlation existed between poor outcome and the combination of bilateral brainstem injury and a motor GCS score of 4 or less 24 hours after admission.

Posted on

Traumatic subdural effusion with concomitant hydrocephalus

J Neurosurg 116:558–565, 2012. DOI: 10.3171/2011.10.JNS11711

Traumatic subdural effusion (TSE) is a common sequela of traumatic brain injury. Surgical intervention is suggested only when TSE exerts mass effect. The authors have found that many patients with TSE exerting mass effect have concomitant hydrocephalus. Patient experiencing this occurrence were studied, and the pathogenesis of this phenomenon was discussed in the context of recent advances in the understanding of CSF circulation.

Methods. During a 2-year period, the authors’ institution treated 14 patients with TSE who developed hydrocephalus, after 1 of the patients suffered subdural drainage and other 13 received subdural peritoneal shunt (SPSs). Thirteen of those who had SPSs received programmable ventriculoperitoneal shunts (VPSs) for the hydrocephalus. The clinical characteristics as well as the imaging and operative findings of these patients were reviewed.

Results. All patients with symptomatic TSE exerting mass effect received SPSs. All of these patients had a modified Frontal Horn Index of more than 0.33 at presentation, and high opening pressure on durotomy. Following a brief period (4–7 days) of clinical improvement, the condition of all patients deteriorated due to hydrocephalus. Programmable VPSs were inserted with the initial pressure set at approximately 8–10 cm H2O according to opening pressure at ventriculostomy. Shunt valve pressure was gradually decreased to 5–7 cm H2O, according to clinical and radiological follow-up.

Conclusions. Elevated modified Frontal Horn Index in patients with TSE is suggestive of concomitant hydrocephalus. The authors propose that tearing of the dura-arachnoid plane following trauma contributes to TSE and may also impede CSF circulation, causing hydrocephalus. Shunt pressure was adjusted to relative low pressure, indicating the old age of the patients and poor reexpansion of brain parenchyma after the mass effect. Subdural peritoneal shunts and VPSs are indicated in those patients with TSE exerting mass effect with concomitant hydrocephalus.

Posted on

Occipital condyle fractures. Prospective follow-up of 31 cases within 5 years at a level 1 trauma centre

Eur Spine J (2012) 21:289–294. DOI 10.1007/s00586-011-1963-7
Prospective investigation of incidence and outcome of occipital condyle fractures (OCF) in a level 1 trauma centre.
Methods  Over a period of 5 years, we prospectively recorded all cases of OCF, and performed a 1-year postinjury radiological and clinical follow-up using CT imaging, SF-36 and Neck Disability Index, respectively.
Results  A total of 31 patients with OCF were identified. Based on a total of 2,616 CT scans that had been performed during this period, the incidence was 1.19%. There were 27 unilateral and 4 bilateral OCFs. Furthermore, 3 out of 31 patients (9.7%) were additionally diagnosed with atlantooccipital dislocation (AOD), one of which was dorsally stabilised in a surgical procedure. All other patients were treated conservatively. 5 out of 31 patients (16.1%) died due to the severity of associated injuries. 22 out of 31 patients (70.9%) were prospectively followed-up for 1 year after trauma. During this period, CT imaging showed bony consolidation of fractures in all cases except for one, with no evidence of secondary dislocation or nonunion. Evaluation of the Neck Disability Index showed moderate disability. The SF-36 questionnaire showed an impaired quality of life in all areas; however, these were determined by associated injuries and independent of the type of fracture.
Conclusions  Both unilateral and bilateral OCFs represent a stable injury regardless of the type of fracture. If AOD has been diagnosed in addition, it requires surgical stabilisation—independent of the OCF—and it is a significant predictor for poor outcomes. The patients quality of life 1 year after trauma has not been affected by the OCF, but by the overall pattern of the injury and by comorbidities. Based on our results, we introduce a new, simple and practical classification for OCFs

Posted on

Traumatic brain injury in pediatric patients: evidence for the effectiveness of decompressive surgery

Neurosurg Focus 31 (5):E5, 2011. DOI: 10.3171/2011.8.FOCUS11177

Traumatic brain injury (TBI) is the current leading cause of death in children over 1 year of age. Adequate management and care of pediatric patients is critical to ensure the best functional outcome in this population.

In their controversial trial, Cooper et al. concluded that decompressive craniectomy following TBI did not improve clinical outcome of the analyzed adult population. While the study did not target pediatric populations, the results do raise important and timely clinical questions regarding the effectiveness of decompressive surgery in pediatric patients. There is still a paucity of evidence regarding the effectiveness of this therapy in a pediatric population, and there is an especially noticeable knowledge gap surrounding age-stratified interventions in pediatric trauma.

The purposes of this review are to first explore the anatomical variations between pediatric and adult populations in the setting of TBI. Second, the authors assess how these differences between adult and pediatric populations could translate into differences in the impact of decompressive surgery following TBI.

Posted on

Increased incidence of nonaccidental head trauma in infants associated with the economic recession

J Neurosurg Pediatrics 8:171-176, 2011.DOI: 10.3171/2011.5.PEDS1139

Nonaccidental head trauma (NAHT) is a major cause of death in infants. During the current economic recession, the authors noticed an anecdotal increase in infants with NAHT without an increase in the overall number of infants admitted with traumatic injuries. An analysis was performed to determine whether there was an association between economic recession and NAHT.

Methods. With Institutional Review Board approval, the trauma database was searched for NAHT in infants 0–2 years old during nonrecession (December 2001 to November 2007) and recession (December 2007 to June 2010) periods. Incidence is reported as infants with NAHT per month summarized over time periods. Continuous variables were compared using Mann-Whitney U-tests, and proportions were compared using the Fisher exact test.

Results. Six hundred thirty-nine infant traumas were observed during the study time period. From the nonrecession to the recession period, there was an 8.2% reduction in all traumas (458 in 72 months [6.4 /month] vs 181 in 31 months [5.8/month]) and a 3.5% reduction in accidental head traumas (142 in 72 months [2.0/month] vs 59 in 31 months [1.9/month]). Nonaccidental head trauma accounted for 14.6% of all traumas (93/639). The median patient age was 4.0 months and 52% were boys. There were no significant differences in the representative counties of referral or demographics between nonrecession and recession populations (all p > 0.05). The monthly incidence rates of NAHT doubled from nonrecession to recession periods (50 in 72 months [0.7/month] vs 43 in 31 months [1.4/month]; p = 0.01). During this recession, at least 1 NAHT was reported in 68% of the months compared with 44% of the months during the nonrecession period (p = 0.03). The severity of NAHTs also increased, with a greater proportion of deaths (11.6% vs 4%, respectively; p = 0.16) and severe brain injury (Glasgow Coma Scale score ≤ 8: 19.5% vs 4%, respectively; p = 0.06) during the recession.

Conclusions. In the context of an overall reduction in head trauma, the significant increase in the incidence of NAHT appears coincident with economic recession. Although the cause is likely multifactorial, a full analysis of the basis of this increase is beyond the scope of this study. This study highlights the need to protect vulnerable infants during challenging economic times.

Posted on

O-Arm–Guided Balloon Kyphoplasty: Prospective Single-Center Case Series of 54 Consecutive Patients

Neurosurgery 68[ONS Suppl 2]:ons250–ons256, 2011 DOI: 10.1227/NEU.0b013e31821421b9

Balloon kyphoplasty is widely used to treat vertebral compression fractures. Procedure outcome and safety are directly linked to precise radiological imaging requiring 1 or 2 C arms to allow correct visualization throughout the procedure. This minimally invasive spinal surgery is associated with radiation exposure for both patient and surgeon. In our center, we switched from using a C-arm to an O-arm image guidance system to perform balloon kyphoplasty. Our preliminary experience is reported in Acta Neurochirurgica, and the encouraging results led us to study this subject more extensively. This article presents our complete results. To the best of our knowledge, there is no comparable clinical series describing O-arm use in kyphoplasty procedures published in the literature. OBJECTIVE: To report our complete results of using the O-arm guidance system to perform balloon kyphoplasty.

METHODS: We prospectively evaluated O-arm–guided kyphoplasty procedure in 54 consecutive patients and measured x-ray exposure and fluoroscopy time.

RESULTS: The mean surgical time for the procedure was 38 minutes with a mean fluoroscopy procedure time of 3.1 minutes. The mean fluoroscopy time by level was 2.5 minutes. Mean irradiation dose by procedure was 220 mGy and by level was 166 mGy. There was a significant reduction in fluoroscopy time and x-ray exposure from 5.1 minutes with classic C-arm use to 3.1 minutes when with O-arm use without additional time required for positioning the system.

CONCLUSION: With this new intraoperative system, the overall surgical and fluoroscopy times can be further reduced in the near future.

Posted on

Risk Factors for Conversion to Permanent Ventricular Shunt in Patients Receiving Therapeutic Ventriculostomy for Traumatic Brain Injury

Neurosurgery 68:85–88, 2011 DOI: 10.1227/NEU.0b013e3181fd85f4

Intracranial pressure is routinely monitored in patients with severe traumatic brain injury (TBI). Patients with TBI sometimes develop hydrocephalus, requiring permanent cerebrospinal fluid (CSF) diversion. OBJECTIVE: To quantify the need for permanent CSF diversion in patients with TBI. METHODS: Patients who received a ventriculostomy after TBI between June 2007 and July 2008 were identified, and their medical records were abstracted to a database. RESULTS: Sixteen of 71 patients (22.5%) receiving a ventriculostomy required a ventriculoperitoneal or ventriculoatrial shunt before discharge from the hospital. The average number of days between ventriculostomy and shunt was 18.3. Characteristics that predispose these patients to require permanent CSF diversion include the need for craniotomy within 48 hours of admission (odds ratio, 5.20; 95% confidence interval, 1.48-18.35) and history of culture-positive CSF (odds ratio, 5.52; 95% confidence interval, 1.19-25.52). Length of stay was increased in patients receiving permanent CSF diversion (average length of stay, 61 vs 31 days; P = .04). Patient discharge disposition was similar between shunted and nonshunted patients. CONCLUSION: In this retrospective study, 22% of TBI patients who required a ventriculostomy eventually needed permanent CSF diversion. Patients with TBI should be assessed for the need for permanent CSF diversion before discharge from the hospital. Care must be taken to prevent ventriculitis. Future studies are needed to evaluate more thoroughly the risk factors for the need for permanent CSF diversion in this patient population.

Posted on

“In-window” craniotomy and “bridgelike” duraplasty: an alternative to decompressive hemicraniectomy

J Neurosurg 113:982–989, 2010. DOI: 10.3171/2009.11.JNS09674

The object of this study was to propose an alternative procedure to the classic decompressive hemicraniectomy using an “in-window” craniotomy and a “bridgelike” duraplasty.

Methods. The authors performed a large, almost rectangular craniotomy involving the frontal, temporal, and parietal bones and part of the occipital squama in 5 patients. The dura mater is opened and its area is enlarged using a rectangular dural patch of the surgeon’s choice in the form of a bridge between the anterior and posterior dural edges. With a vertical cut, the bone flap is divided into 2 similarly sized pieces that function as “window lids.” The outer frontal and occipital sides of the bone are tied to the skull border at 2 points to function as a hinge joint. The angle of the bone cut must be beveled outward (inclination ~ 45° of the bone drill or saw) to allow the bone flap to rest on the adjacent skull and prevent its slippage toward the intracranial cavity.

Results. The above procedures were performed with effective control of intracranial hypertension due to cerebral venous sinus thrombosis, brain trauma, intracerebral hematoma, or malignant cerebral ischemia.

Conclusions. Decompressive surgery, which uses an in-window craniotomy that gradually opens according to the intracranial pressure, is an alternative solution for deploying autologous material. The procedure has the advantage of obviating the need for a second surgical procedure to close the bone defect, and thus preventing the metabolic cerebral impairment associated with the absence of an overlying skull.

Posted on

Dysfunction of hypothalamic-hypophysial axis after traumatic brain injury in adults

J Neurosurg 113:581–584, 2010. DOI: 10.3171/2009.10.JNS09930

Traumatic brain injury (TBI) is a major cause of serious morbidity and mortality. The incidence is 100–500/100,000 inhabitants/year. Chronic pituitary dysfunction is increasingly recognized after TBI. To define the incidence of endocrine dysfunction and risk factors, the authors describe a prospectively assessed group of patients in whom they documented hormonal functions, early diagnosis, and treatment of neuroendocrine dysfunction after TBI.

Methods. Patients aged 18–65 years were prospectively observed from the time of injury to 1 year postinjury; the Glasgow Coma Scale score ranged from 3 to 14. Patients underwent evaluation of hormonal function at the time of injury and at 3, 6, and 12 months postinjury. Magnetic resonance imaging was also conducted at 1 year postinjury.

Results. During the study period, 89 patients were observed. The mean age of the patients was 36 years, there were 23 women, and the median Glasgow Coma Scale score was 7. Nineteen patients (21%) had primary hormonal dysfunction. Major deficits included growth hormone dysfunction, hypogonadism, and diabetes insipidus. Patients in whom the deficiency was major had a worse Glasgow Outcome Scale score, and MR imaging demonstrated empty sella syndrome more often than in patients without a deficit.

Conclusions. To the authors’ knowledge, this is the third largest study of its kind worldwide. The incidence of chronic hypopituitarism after TBI was higher than the authors expected. After TBI, patients are usually observed on the neurological and rehabilitative wards, and endocrine dysfunction can be overlooked. This dysfunction can be life threatening and other clinical symptoms can worsen the neurological deficit, extend the duration of physiotherapy, and lead to mental illness. The authors recommend routine pituitary hormone testing after moderate or severe TBI within 6 months and 1 year of injury.

Posted on

Management of Type II Odontoid Fractures in the Geriatric Population

J Spinal Disord Tech 2010;23:317–320

Objective: To analyze geriatric patients with Type II odontoid fractures treated either with rigid cervical orthosis (CO) or surgery (Odontoid Screw or Transarticular screw).

Summary of Background Data: Our literature search did not yield any studies on the outcome of Type II odontoid fractures in geriatric population treated with the rigid CO. We therefore designed a study to analyze geriatric patients with Type II odontoid fractures treated with either rigid cervical collar or surgery.

Materials and Methods: This is a retrospective chart review of patients with Type II odontoid fractures between July 1998 and June 2006. Inclusion criteria consists of males and females of 70 years of age or older with Type II odontoid fractures who were treated with rigid cervical collar or surgery. Exclusion criteria were displacement >4mm, posteriorly displaced fracture, neurologic compromise, multilevel cervical spine injury, and treatment in a halo vest. Medical comorbidities were assessed using the Modified Cumulative Illness Rating Scale for Geriatrics. Primary outcomes were mortality and fusion (union, stable nonunion, nonunion). Minimum of 3 months follow-up was acceptable.

Results: One hundred eighty four odontoid fractures were identified in 8 years. Twenty patients met our inclusion criteria (9 treated in rigid collar and 11 treated surgically). Median follow-up was 5.5 months. Out of 20 patients, 4 patients died (1 treated in CO, 3 treated surgically). Cumulative Illness Rating Scale for Geriatrics index was highest in patient treated in CO. In the rigid collar group, 6 patients had union (66.6%), and 2 developed stable nonunion (22.2%); whereas in the surgically treated group, 7 patients had union (87.5%), and 1 patient developed nonunion (12.5%).

Conclusions: Patients treated nonoperatively in rigid collar seem to have an overall favorable outcome. A well-designed prospective study, to compare the outcomes of surgical intervention with nonsurgical management of Type II odontoid in elderly is recommended

Posted on

Transcranial Doppler Pulsatility Index: Not an Accurate Method to Assess Intracranial Pressure

Neurosurgery 66 (6):1050–1057.
DOI 10.1227/01.NEU.0000369519.35932.F2

Transcranial Doppler sonography (TCD) assessment of intracranial blood flow velocity has been suggested to accurately determine intracranial pressure (ICP).

OBJECTIVE: We attempted to validate this method in patients with communicating cerebrospinal fluid systems using predetermined pressure levels.

METHODS: Ten patients underwent a lumbar infusion test, applying 4 to 5 preset ICP levels. On each level, the pulsatility index (PI) in the middle cerebral artery was determined by measuring the blood flow velocity using TCD. ICP was simultaneously measured with an intraparenchymal sensor. ICP and PI were compared using correlation analysis. For further understanding of the ICP-PI relationship, a mathematical model of the intracranial dynamics was simulated using a computer.

RESULTS: The ICP-PI regression equation was based on data from 8 patients. For 2 patients, no audible Doppler signal was obtained. The equation was ICP = 23*PI + 14 (R2 = 0.22, P < .01, N = 35). The 95% confidence interval for a mean ICP of 20 mm Hg was −3.8 to 43.8 mm Hg. Individually, the regression coefficients varied from 42 to 90 and the offsets from −32 to +3. The mathematical simulations suggest that variations in vessel compliance, autoregulation, and arterial pressure have a serious effect on the ICP-PI relationship.

CONCLUSIONS: The in vivo results show that PI is not a reliable predictor of ICP. Mathematical simulations indicate that this is caused by variations in physiological parameters.

Posted on

Interhemispheric hygroma after decompressive craniectomy: does it predict posttraumatic hydrocephalus?

Journal of Neurosurgery, June 2010. DOI: 10.3171/2010.4.JNS10132

The aim of this study was to determine the incidence of posttraumatic hydrocephalus in severely head-injured patients who required decompressive craniectomy (DC). Additional objectives were to determine the relationship between hydrocephalus and several clinical and radiological features, with special attention to subdural hygromas as a sign of distortion of the CSF circulation.

Methods The authors conducted a retrospective study of 73 patients with severe head injury who required DC. The patients were admitted to the authors’ department between January 2000 and January 2006. Posttraumatic hydrocephalus was defined as: 1) modified frontal horn index greater than 33%, and 2) the presence of Gudeman CT criteria. Hygromas were diagnosed based on subdural fluid collection and classified according to location of the craniectomy.

Results Hydrocephalus was diagnosed in 20 patients (27.4%). After uni- and multivariate analysis, the presence of interhemispheric hygromas (IHHs) was the only independent prognostic factor for development of posttraumatic hydrocephalus (p < 0.0001). More than 80% of patients with IHHs developed hydrocephalus within the first 50 days of undergoing DC. In all cases the presence of hygromas preceded the diagnosis of hydrocephalus. The IHH predicts the development of hydrocephalus after DC with 94% sensitivity and 96% specificity. The presence of an IHH showed an area under the receiver-operator characteristic of 0.951 (95% CI 0.87–1.00; p < 0.0001).

Conclusions Hydrocephalus was observed in 27.4% of the patients with severe traumatic brain injury who required DC. The presence of IHHs was a predictive radiological sign of hydrocephalus development within the first 6 months of DC in patients with severe head injury.

Posted on

Exacerbation of Perihematomal Edema and Sterile Meningitis With Intraventricular Administration of Tissue Plasminogen Activator in Patients With Intracerebral Hemorrhage

Neurosurgery 66:631-638, 2010. DOI: 10.1227/01.NEU.0000367634.89384.4B

Intraventricular hemorrhage (IVH) is associated with a poor outcome. External ventricular drainage together with clot lysis through intrathecal tissue plasminogen activator (IT-tPA) has been proposed as a promising therapy. However, recent experimental work has implicated tissue plasminogen activator (tPA) in the pathogenesis of cerebral edema.

METHODS: We reviewed the records of all patients with IVH caused by primary supratentorial intracerebral hemorrhage who underwent external ventricular drainage without surgical evacuation between January 2001 and June 2008. Of these 30 patients, we identified 13 who received IT-tPA. The remaining 17 patients served as controls. Hemorrhage, edema volume, and IVH score were determined on admission and by follow-up computed tomographic scans for 96 hours after admission. Discharge outcome was evaluated using the modified Rankin Scale.

RESULTS: There were no significant differences between the treatment and controls in terms of age, Glasgow Coma Scale score, Graeb and LeRoux IVH scores, or intracerebral hemorrhage volume on admission. IT-tPA resulted in more rapid clearance of IVH as determined by the 96-hour decrease in both the Graeb IVH score (tPA, 3.00 ± .55; control, 1.00 ± 0.57; P = .05) and the LeRoux IVH score (tPA, 6.2 ± 0.80; control, 2.25 ± 1.32; P = .05). Patients treated with IT-tPA demonstrated significantly larger peak ratios of edema to intracerebral hemorrhage volume (1.24 ± 0.14 vs 0.70 ± 0.08 in controls; P = .002). Additionally, increased rates of sterile meningitis (46% vs 12%; P = .049) and a trend toward shunt dependence (38% vs 6%; P = .06) were observed in the tPA cohort. Nevertheless, no significant differences in outcome at discharge or length of hospital stay were observed between cohorts.

CONCLUSION: Although IT-tPA hastens the resolution of IVH, it may worsen perihematomal edema formation. Larger prospective studies are required to confirm these findings and to determine whether outcome is adversely affected by IT-tPA administration.

Posted on

Update on protein biomarkers in traumatic brain injury with emphasis on clinical use in adults and pediatrics

Purpose  This review summarizes protein biomarkers in mild and severe traumatic brain injury in adults and children and presents a strategy for conducting rationally designed clinical studies on biomarkers in head trauma.
Methods  We performed an electronic search of the National Library of Medicine’s MEDLINE and Biomedical Library of University of Pennsylvania database in March 2008 using a search heading of traumatic head injury and protein biomarkers. The search was focused especially on protein degradation products (spectrin breakdown product, c-tau, amyloid-β1–42) in the last 10 years, but recent data on “classical” markers (S-100B, neuron-specific enolase, etc.) were also examined.
Results  We identified 85 articles focusing on clinical use of biomarkers; 58 articles were prospective cohort studies with injury and/or outcome assessment.
Conclusions  We conclude that only S-100B in severe traumatic brain injury has consistently demonstrated the ability to predict injury and outcome in adults. The number of studies with protein degradation products is insufficient especially in the pediatric care. Cohort studies with well-defined end points and further neuroproteomic search for biomarkers in mild injury should be triggered. After critically reviewing the study designs, we found that large homogenous patient populations, consistent injury, and outcome measures prospectively determined cutoff values, and a combined use of different predictors should be considered in future studies.
Doi: 10.1007/s00701-009-0463-6
Proudly powered by WordPress