Posterior False Lumen and Paraplegia After FET Procedure in Acute Type A Aortic Dissection.

BACKGROUND: Postoperative paraplegia is the major concern with the frozen elephant trunk (FET) procedure in patients with acute type A aortic dissection (ATAAD). It is crucial to identify patients with a high risk of paraplegia before implementing the FET procedure. METHODS: From January 2013 to December 2018, 544 patients with ATAAD who underwent FET procedures were included in this study. The segment number of posterior false lumens (PFLs) between T9 and L2 levels was calculated. In-hospital outcomes and long-term survival were investigated on the basis of the number of PFLs. RESULTS: The average age was 46.5 ± 9.9 years, and the proportion of female patients was 19.5% in this cohort. The incidence of postoperative paraplegia was significantly increased when PFL was present in 3 or more segments. Patients were divided into a high-PFL group (3-6 segments; n = 124) and a low-PFL group (0-2 segments; n = 420). The demographic characteristics were similar between the 2 groups. Involvement of the celiac trunk and the superior mesenteric artery was significantly lower in the high-PFL group (all P < .05). The other baseline characteristics and procedural information were statistically balanced. The incidence of postoperative paraplegia was significantly higher in the high-PHL group (7.3% vs 1.9;P = .006). Multivariable logistic analysis revealed that high PFL was independently associated with postoperative paraplegia after an FET procedure (odds ratio, 3.812; 95% CI, 1.378-10.550; P = .010). Additionally, the moderate nasopharyngeal temperature of hypothermic circulatory arrest (≧23.0 °C) was clarified as a protective factor for paraplegia (odds ratio, 0.112; 95% CI, 0.023-0.535; P = .006). CONCLUSIONS: Patients with ATAAD who present with high PFL between T9 and L2 levels have a significantly high risk of postoperative paraplegia if they undergo an FET procedure.

The prognosis and recovery of major postoperative neurological deficits after corrective surgery for scoliosis : an analysis of 65 cases at a single institution.

AIMS: The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years. METHODS: A major neurological deficit was identified in 65 of 8,870 patients who underwent corrective surgery for scoliosis, including eight with complete paraplegia and 57 with incomplete paraplegia. There were 23 male and 42 female patients. Their mean age was 25.0 years (SD 16.3). The aetiology of the scoliosis was idiopathic (n = 6), congenital (n = 23), neuromuscular (n = 11), neurofibromatosis type 1 (n = 6), and others (n = 19). Neurological function was determined by the American Spinal Injury Association (ASIA) impairment scale at a mean follow-up of 45.4 months (SD 17.2). the patients were divided into those with recovery and those with no recovery according to the ASIA scale during follow-up. RESULTS: The incidence of major deficit was 0.73%. At six-month follow-up, 39 patients (60%) had complete recovery and ten (15.4%) had incomplete recovery; these percentages improved to 70.8% (46) and 16.9% (11) at follow-up of two years, respectively. Eight patients showed no recovery at the final follow-up. The cause of injury was mechanical in 39 patients and ischaemic in five. For 11 patients with misplaced implants and haematoma formation, nine had complete recovery. Fisher's exact test showed a significant difference in the aetiology of the scoliosis (p = 0.007) and preoperative deficit (p = 0.016) between the recovery and non-recovery groups. A preoperative deficit was found to be significantly associated with non-recovery (odds ratio 8.5 (95% confidence interval 1.676 to 43.109); p = 0.010) in a multivariate regression model. CONCLUSION: For patients with scoliosis who develop a major neurological deficit after corrective surgery, recovery (complete and incomplete) can be expected in 87.7%. The first three to six months is the time window for recovery. In patients with misplaced implants and haematoma formation, the prognosis is satisfactory with appropriate early intervention. Patients with a preoperative neurological deficit are at a significant risk of having a permanent deficit. Cite this article: Bone Joint J 2022;104-B(1):103-111.

Paraplegia After Open Surgical Repair Versus Thoracic Endovascular Aortic Repair for Thoracic Aortic Disease: A Retrospective Analysis of Japanese Administrative Data.

OBJECTIVES: To comparatively examine the risk of postoperative paraplegia between open surgical descending aortic repair and thoracic endovascular aortic repair (TEVAR) among patients with thoracic aortic disease. DESIGN: Retrospective cohort study. SETTING: Acute-care hospitals in Japan. PARTICIPANTS: A total of 6,202 patients diagnosed with thoracic aortic disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcome of this study was the incidence of postoperative paraplegia. Multiple logistic regression models, using inverse probability of treatment weighting and an instrumental variable (ratio of TEVAR use to open surgical repair and TEVAR uses), showed that the odds ratios of paraplegia for TEVAR (relative to open surgical descending aortic repair) were 0.81 (95% confidence interval: 0.42-1.59; p = 0.55) in the inverse probability of treatment-weighted model and 0.88 (0.42-1.86; p = 0.75) in the instrumental-variable model. CONCLUSIONS: There were no statistical differences in the risk of paraplegia between open surgical repair and TEVAR in patients with thoracic aortic disease. Improved perioperative management for open surgical repair may have contributed to the similarly low incidence of paraplegia in these two surgery types.

Susceptibility and cytokine responses of human neuronal cells to multiple circulating EV-A71 genotypes in India.

Enterovirus-A71 (EV-A71) associated Hand, foot and mouth disease (HFMD) is a highly contagious viral infection affecting children in Asia-Pacific region and has become a major threat to public health. Although several EV-A71 genotypes (C, D, and G) were isolated in India in recent years, no recognizable outbreak of EV-A71 caused HFMD, Acute Flaccid paralysis (AFP) or encephalitis have been reported so far. It is essential to study the pathogenicity or cell tropism of these Indian isolates in order to understand their tendency to cause disease. We investigated the susceptibility and cytokine responses of indigenous EV-A71 genotypes (D and G) isolated from cases of AFP and genotype C viruses isolated from cases of HFMD and encephalitis, in human cells in-vitro. Although all three EV-A71 genotypes could infect and replicate in human muscle and neuronal cells, the genotype D virus showed a delayed response in human neuronal cells. Quantification of cytokine secretion in response to these isolates followed by confirmation with gene expression assays in human neuronal cells revealed significantly higher secretion of pro-inflammatory cytokines TNF-α IL-8, IL-6, IP-10 (p < 0.001) in G genotype infected cells as compared to pathogenic C genotypes whereas the genotype D virus could not induce any of the inflammatory cytokines. These findings will help to better understand the host response to indigenous EV-A71 genotypes for management of future EV-A71 outbreaks in India, if any.

The Potential Causes of Paraplegia after Coronary Artery Bypass Grafting: A Literature Review.

Paraplegia is an unpredictable neurologic complication after coronary artery bypass grafting (CABG) surgery. It is rare but fatal, and the mechanism still is unclear. We aimed to make a summary of the possible causes of paraplegia after CABG. Pubmed database was searched from January 1, 1978 to December 31, 2019, and 14 studies were finally included. Paraplegia after CABG is a multifactorial consequence, but spinal cord ischemia is the key pathological factor to postoperative paraplegia.

Paralysis Caused by Spinal Cord Injury After Posterior Fossa Surgery: A Systematic Review.

OBJECTIVE: Paralysis (paraplegia or quadriplegia) after posterior fossa surgery is a rare but devastating complication. We investigated previous reports of this complication to examine similarities among patients, risk factors, and methods by which it may be prevented. METHODS: A systematic review was completed according to PRISMA guidelines. Electronic databases were searched until November 2019 using keywords "paraplegia," "quadriplegia," or "spinal cord injury" added to "posterior fossa surgery." RESULTS: Thirteen case reports published between 1996 and 2019 were included. Five (38.5%) involved quadriplegia/quadriparesis and 8 (61.5%) involved paraplegia after surgery. Ten cases (76.9%) were tumor resections and 3 (23.1%) were posterior fossa decompressions (2 for Chiari malformations and 1 for Morquio syndrome). Seven surgeries (53.8%) were performed in the sitting position and 6 (46.2%) were prone. Proposed mechanisms of paralysis involved cervical hyperflexion yielding spinal cord ischemia in 8 patients (61.5%), arterial hypotension in 2 patients (15.4%), spinal cord compression from hematoma in 1 patient (7.7%), and decreased cardiac output in 1 patient (7.7%) (1 study did not propose a cause). Cervical hyperflexion was equally likely in the sitting and prone positions (4 patients each). Only 3 patients (23.1%) involved intraoperative complications (all cardiopulmonary in nature). CONCLUSIONS: Paralysis after posterior fossa surgery often involves spinal cord infarction apparently caused by cervical hyperflexion. Extreme care during patient positioning is needed in both the sitting or prone positions. Electrophysiologic monitoring might enable early identification of spinal cord dysfunction to minimize or avoid this complication.

Factors Associated With Ambulation in Myelomeningocele: A Longitudinal Study From the National Spina Bifida Patient Registry.

OBJECTIVE: Evidence is limited regarding clinical factors associated with ambulation status over the lifespan of individuals with myelomeningocele. We used longitudinal data from the National Spina Bifida Patient Registry to model population-level variation in ambulation over time and hypothesized that effects of clinical factors associated with ambulation would vary by age and motor level. DESIGN: A population-averaged generalized estimating equation was used to estimate the probability of independent ambulation. Model predictors included time (age), race, ethnicity, sex, insurance, and interactions between time, motor level, and the number of orthopedic, noncerebral shunt neurosurgeries, and cerebral shunt neurosurgeries. RESULTS: The study cohort included 5371 participants with myelomeningocele. A change from sacral to low-lumbar motor level initially reduced the odds of independent ambulation (OR = 0.24, 95% CI = 0.15-0.38) but became insignificant with increasing age. Surgery count was associated with decreased odds of independent ambulation (orthopedic: OR = 0.65, 95% CI = 0.50-0.85; noncerebral shunt neurosurgery: OR = 0.65, 95% CI = 0.51-0.84; cerebral shunt: OR = 0.90, 95% CI = 0.83-0.98), with increasing effects seen at lower motor levels. CONCLUSIONS: Our findings suggest that effects of several commonly accepted predictors of ambulation status vary with time. As the myelomeningocele population ages, it becomes increasingly important that study design account for this time-varying nature of clinical reality. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe general trends in ambulation status by age in the myelomeningocele population; (2) Recognize the nuances of cause and effect underlying the relationship between surgical intervention and ambulation status; (3) Explain why variation of clinical effect over time within myelomeningocele population matters. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Frozen elephant trunk does not increase incidence of paraplegia in patients with acute type A aortic dissection.

OBJECTIVE: We seek to assess the safety of total arch replacement with frozen elephant trunk for acute type A aortic dissection in respect to the risks of operative mortality, stroke, and paraplegia using an international multicenter registry (ARCH). METHODS: The ARCH Registry database from 37 participating centers was analyzed between 2000 and 2015. Patients who underwent emergency surgery for acute type A aortic dissection treated by total arch replacement with or without frozen elephant trunk were included. Operative mortality, permanent neurologic deficits, and spinal cord injury were primary end points. These end points were analyzed using univariate and hierarchical multivariate regression analyses, as well as conditional logistic regression analysis and post hoc propensity-score stratification. RESULTS: A total of 11,928 patients were enrolled in the ARCH database, of which 6180 were managed with total arch replacement. A comprehensive analysis was performed for 978 patients who underwent total aortic arch replacement for acute type A aortic dissection with or without frozen elephant trunk placement. In propensity-score matching, there were no significant differences between total arch replacement and frozen elephant trunk in terms of permanent neurologic deficits (11.9% vs 10.1%, P = .59) and spinal cord injury (4.0% vs 6.3%, P = .52) For patients included in the post hoc propensity-score stratification, frozen elephant trunk was associated with a statistically significantly lower mortality risk (odds ratio, 0.47; P = .03). CONCLUSIONS: The use of frozen elephant trunk for acute type A aortic dissection does not appear to increase the risk of paraplegia in appropriately selected patients at experienced centers. The exact risk factors for paraplegia remain to be determined.

Association between false lumen segmental arteries and spinal cord ischemia in type A acute aortic dissection.

BACKGROUND: Spinal cord ischemia (SCI) and paraplegia are complications of surgery for type A acute aortic dissection (TAAAD). Since the segmental arteries play a key role in SCI, this study evaluated the association between SCI and false lumen segmental arteries (FLSAs: segmental arteries originating from the false lumen). METHODS: The study included 101 consecutive TAAAD patients (mean age, 66±13; range, 34-89 years) who underwent surgery from January 2011 to April 2017. The diagnosis of TAAAD and the number of FSLAs were determined by preoperative computed tomography (CT). Patients were divided into two groups according to the number of FLSAs at the Th9-L2 level: Group A (N.=13), ≥8 FLSAs; and group B (N.=88), ≤7 FLSAs. Preoperative, perioperative, and postoperative findings were compared between the groups, and risk factors for SCI were evaluated. RESULTS: The frequency of preoperative paralysis was significantly higher in Group A than Group B (P=.0070). The overall incidence of postoperative SCI was 8% (8/101) and significantly higher in Group A than Group B (5/13 [45%] vs. 3/88 (4%), P<0.0001). Hospital mortality was 8% (8/101) and significantly higher in Group A than Group B (3/13 [23%] vs. 5/88 [6%], P=.0302). Multivariate analysis showed that the independent risk factors for SCI were ≥8 FLSAs at Th9-L2 (odds ratio [OR], 20.4; 95% confidence interval [95% CI], 3.34-124.9, P=0.0011) and diabetes mellitus (OR, 22.3; 95% CI, 1.69-294.5; P=0.0184). CONCLUSIONS: In patients who underwent surgery for TAAAD, ≥8 FLSAs at the Th9-L2 levels on preoperative CT was a risk factor for SCI.

Strict Control of Blood Glucose With an Intravenous Insulin Infusion Decreases the Risk of Post-operative Lower Extremity Weakness After Complex Endovascular Aortic Aneurysm Repair.

OBJECTIVE/BACKGROUND: It has previously been shown that post-operative lower extremity weakness (LEW) is associated with elevated blood and cerebrospinal fluid (CSF) glucose levels after branched endovascular aneurysms repair (BEVAR) of extensive aortic aneurysms. The purpose of this study was to determine whether a post-operative insulin infusion protocol (IIP) to achieve tight blood glucose control decreases the rate of LEW. METHODS: From October 2013, blood and CSF samples were collected pre-operatively, immediately post-operatively, and on post-operative day one in asymptomatic patients undergoing BEVAR. In July 2016, an IIP was initiated to maintain post-operative blood glucose levels <120 mg/dL for 48 h. Data on demographics, operative repair, complications, and outcomes were collected prospectively. RESULTS: Between October 2013 and April 2018, 43 patients underwent BEVAR. Twenty-two (group A) underwent BEVAR before initiation of the IIP. Of these, seven (32%) developed LEW within 48 h of repair. This was temporary in five (23%) and permanent in two (9%) patients. Post-operative blood glucose levels were significantly higher in patients with LEW compared with those without LEW (140 ± 27 mg/dL vs. 117 ± 16 mg/dL; p = .02). Post-operative CSF glucose levels were significantly higher in patients with LEW compared with those without LEW (102 ± 15 mg/dL vs. 77 ± 15 mg/dL; p = .001). The subsequent 21 patients (group B) underwent BEVAR after initiation of the IIP. No patient in group B developed LEW while on the IIP, but one (5%) developed paraplegia on post-operative day four. The rate of early LEW (<48 h post-operatively) was significantly lower after initiation of the IIP (32% in group A vs. 0% in group B; p = .009). There was no difference in demographics, comorbidities, or operative time between the groups. CONCLUSION: An IIP to control blood glucose after BEVAR is associated with a decreased rate of post-operative LEW. Tight control of blood glucose should be considered after any extensive aortic reconstruction to minimise the risk of post-operative LEW.

Outcomes in the Treatment of Femur Fractures in Patients with Pre-Existing Spinal Cord Injury.

INTRODUCTION: Spinal cord injured patients have an estimated 25% to 34% lifetime incidence of sustaining an extremity fracture. The objective of this study is to describe the outcomes of femur fractures treated in patients with pre-existing spinal cord injury (SCI) and lower extremity paraplegia. MATERIALS AND METHODS: An IRB approved retrospective review of patients 18 years of age and older who sustained a femur fracture a minimum of 2 years following spinal cord injury and received treatment at a regional academic level 1 trauma center over a 10-year period was performed. Patients were divided into two groups based on whether they received operative or nonoperative management of the femoral shaft fracture. The primary outcome assessed was re-operation. Additional outcomes including union, infection, implant failure, and mortality were recorded. RESULTS: Twenty-one patients sustaining a total of 25 femur fractures were identified. The most common mechanism of injury was fall during transfer. Sixteen fractures were treated non-operatively and nine were treated operatively. At a mean of 4.1 years of follow-up (range: 1.1 to 12.1 years) six out of nine (66.7%) patients in the operative group required an unplanned secondary surgery compared to two patients (12.5%) in the non-operative group (p = 0.006). Overall, the rate of fracture union was 48%, and there was no difference seen between treatment groups (56.3% in nonoperative group versus 33.3% in operative group, p = 0.28). Six operative patients (66.7%) developed an infection as compared to one patient (6.3%) in the non-operative group (p = 0.002). Three operative patients (33.3%) had failure of fixation with implant cutout. One patient died within 2 years of fracture in the non-operative group (6.3%) as did one patient in the operative group (11.1%), (p = 1.0). CONCLUSIONS: Surgical treatment of femur fractures in patients with a pre-existing SCI and lower extremity paraplegia had a higher rate of complications than nonoperative management in our series. Based on our experience, we recommend non-operative treatment of femur fractures in patients with pre-existing spinal cord injury and lower extremity paraplegia.

Incidence and Predictors of Neurological Complications Following Thoracic Endovascular Aneurysm Repair in the Global Registry for Endovascular Aortic Treatment.

OBJECTIVES: The aim of this study was to investigate the incidence and predictors of early and mid term neurological complications following thoracic endovascular repair (TEVAR) in the Global Registry for Endovascular Aortic Treatment (GREAT). METHODS: The GREAT is a prospective observational multicentre registry on Gore aortic endografts that was initiated in 2010. Only isolated thoracic aortic pathologies were included (aortic arch and descending thoracic aneurysms, type B dissections, penetrating ulcers, intramural haematomas, pseudoaneurysms, and transections). Thoraco-abdominal aneurysms and concomitant abdominal aneurysms were excluded. Neurological complications were classified as cerebrovascular accidents (CVA) and spinal cord injuries (SCI). Clinical, procedural, and technical data were evaluated for their association with early (30 day) and mid term CVAs and SCIs. RESULTS: In total, 833 patients were included: 28 with arch aneurysms (3.4%), 329 with descending thoracic aneurysms (39.5%), 273 with type B dissections (32.8%), and 203 (24.4%) with other thoracic pathologies. Altogether, 593 (71.2%) were elective procedures and 240 (28.8%) were urgent. Aortic coverage >20 cm was performed in 42.1% (n = 351); proximal landing zone 0-1-2 was adopted in 267 patients (32.1%) and of these 98 (36.7%) underwent left subclavian artery (LSA) revascularisation. There were 13 early CVAs (1.5%) and the four year freedom from CVA rate was 96.3%. On multivariable analysis, aortic arch aneurysm was the only independent predictor of early CVA (odds ratio 16.7, p = .001). LSA coverage (hazard ratio [HR] 3.31, p = .005) and hypercholesterolaemia (HR 2.96, p = .024) were independent predictors of mid term ischaemic CVAs. There were 15 (1.8%) early SCIs, and the four year freedom from SCI rate was 97.8%. No independent predictors of early SCI were identified, but length of coverage was an independent predictor of SCI at four years (HR 1.24; p = .044). CONCLUSIONS: In this real world registry, the overall rate of neurological complication after TEVAR for isolated thoracic aortic pathologies was low. Aortic arch aneurysms were associated with increased peri-operative CVA risk. Length of coverage was an independent predictor of mid term SCIs, as LSA coverage was associated with late CVAs.

Patient Co-Morbidity and Functional Status Influence the Occurrence of Hospital Acquired Conditions More Strongly than Hospital Factors.

BACKGROUND: Never events (NE) and hospital-acquired conditions (HAC) are used by Medicare/Medicaid Services to define hospital performance measures that dictate payments/penalties. Pre-op patient comorbidity may significantly influence HAC development. METHODS: We studied 8,118,615 patients from the NIS database (2002-2012) who underwent upper/lower gastrointestinal and/or hepatopancreatobiliary procedures. Multivariate analysis, using logistic regression, was used to identify HAC and NE risk factors. RESULTS: A total of 63,762 (0.8%) HAC events and 1645 (0.02%) NE were reported. A total of 99.9% of NE were retained foreign body. Most frequent HAC were: pressure ulcer stage III/IV (36.7%), poor glycemic control (26.9%), vascular catheter-associated infection (20.3%), and catheter-associated urinary tract infection (13.7%). Factors correlating with HAC included: open surgical approach (AOR: 1.25, P < 0.01), high-risk patients with significant comorbidity [severe loss function pre-op (AOR: 6.65, P < 0.01), diabetes with complications (AOR: 2.40, P < 0.01), paraplegia (AOR: 3.14, P < 0.01), metastatic cancer (AOR: 1.30, P < 0.01), age > 70 (AOR: 1.09, P < 0.01)], hospital factors [small vs. large (AOR: 1.07, P < 0.01), non-teaching vs teaching (AOR: 1.10, P < 0.01), private profit vs. non-profit/governmental (AOR: 1.20, P < 0.01)], severe preoperative mortality risk (AOR: 3.48, P < 0.01), and non-elective admission (AOR: 1.38, P < 0.01). HAC were associated with increased: hospitalization length (21 vs 7 days, P < 0.01), hospital charges ($164,803 vs $54,858, P < 0.01), and mortality (8 vs 3%, AOR: 1.14, P < 0.01). CONCLUSION: HAC incidence was highest among patients with severe comorbid conditions. While small, non-teaching, and for-profit hospitals had increased HAC, the strongest HAC risks were non-modifiable patient factors (preoperative loss function, diabetes, paraplegia, advanced age, etc.). This data questions the validity of using HAC as hospital performance measures, since hospitals caring for these complex patients would be unduly penalized. CMS should consider patient comorbidity as a crucial factor influencing HAC development.

Early outcomes of patients transferred with ruptured suprarenal aneurysm or dissection.

Objective Despite centralisation of the provision of vascular care, not all areas in England and Wales are able to offer emergency treatment for patients with acute conditions affecting the aorta proximal to the renal arteries. While cardiothoracic centres have made network arrangements to coordinate care for the repair of type A dissections, a similar plan for vascular care is lacking. This study investigates early outcomes in patients with ruptured suprarenal aortic aneurysm or dissection (rSRAD) transferred to a specialist centre. Methods Retrospective observational study over a five-year period (2009-2014) assessing outcomes of patients with ruptured sRAD diagnosed at their local hospital and then transferred to a tertiary centre capable of offering such treatment. Results Fifty-two patients (median age 73 years, 32 male) with rSRAD were transferred and a further four died during transit. The mean distance of patient transfer was 35 miles (range 4-211 miles). One patient did not undergo intervention due to frailty and two died before reaching the operating theatre. A total of 23 patients underwent endovascular repair, 9 hybrid repair and 17 open surgery. Median follow-up was 12 months (range 1-43 months). Complications included paraplegia (n = 3), stroke (n = 2), type IA endoleak (n = 4); 30-day and in-hospital mortality were 16% and 27%. For patients discharged alive from hospital, one-year survival was 67%. Conclusions Although the number of patients with rSRAD is low and those who are transferred alive are a self-selecting group, this study suggests that transfer of such patients to a specialist vascular centre is associated with acceptable mortality rates following emergency complex aortic repair.

Risk factors for spinal cord ischaemia after thoracic endovascular aortic repair.

OBJECTIVES: Spinal cord ischaemia (SCI) is a serious complication of thoracic endovascular aortic repair (TEVAR). The purpose of this study was to assess the incidence, risk factors, clinical manifestations of SCI after TEVAR and which type of patients could benefit from cerebrospinal fluid drainage. METHODS: A retrospective review was conducted for 175 patients who underwent TEVAR from January 2008 to July 2014. All patients were divided into groups with and without SCI, and they were compared to identify significant risk factors for SCI. RESULTS: The incidence of SCI after TEVAR including paraplegia and paraparesis was 6.9%. SCI usually occurred within 24 h, but delayed SCI was observed after 5 days in 1 patient. In all patients with SCI, we tried to increase the blood pressure to improve spinal perfusion. Three patients recovered completely, and the 6 patients with some remaining neurological deficit included 3 with motion against gravity and bladder dysfunction and the 3 remaining patients with only bladder dysfunction. Three patients did not recover. In our study, significant risk factors for SCI were as follows: rupture, shaggy aorta, chronic obstructive pulmonary disease, 1-stage procedure, the coverage of more than 9 segments, the coverage from Th8 to Th12, minimum of postoperative haemoglobin and the number of postoperative patent segmental arteries. CONCLUSIONS: Sufficient perioperative care should be given to high-risk patients who have endografts that cover more than 9 segments and endografts that cover segments from Th8 to Th12. Adequate haemoglobin levels and mean arterial pressure are needed to provide sufficient spinal cord perfusion.

Paraplegic patients: how to measure balance and what is normal or functional?

PURPOSE: To review the current understanding and data of sagittal balance and alignment considerations in paraplegic patients. METHODS: A PubMed literature search was conducted to identify all relevant articles relating to sagittal alignment and sagittal balance considerations in paraplegic and spinal cord injury patients. RESULTS: While there are numerous studies and publications on sagittal balance in the ambulatory patient with spinal deformity or complex spine disorders, there is paucity of the literature on "normal" sagittal balance in the paraplegic patients. Studies have reported significantly alterations of the sagittal alignment parameters in the non-ambulatory paraplegic patients compared to ambulatory patients. The variability of the alignment changes is related to the differences in the level of the spinal cord injury and their differences in the activations of truncal muscles to allow functional movements in those patients, particularly in optimizing sitting and transferring. Surgical goal in treating paraplegic patients with complex pathologies should not be solely directed to achieve the "normal" radiographic parameters of sagittal alignment in the ambulatory patients. The goal should be to maintain good coronal balance to allow ideal sitting position and to preserve motion segment to optimize functions of paraplegia patients. CONCLUSION: Current available literature data have not defined normal sagittal parameters for paraplegic patients. There are significant differences in postural sagittal parameters and muscle activations in paraplegic and non-spinal cord injury patients that can lead to differences in sagittal alignment and balance. Treatment goal in spine surgery for paraplegic patients should address their global function, sitting balance, and ability to perform self-care rather than the accepted radiographic parameters for adult spinal deformity in ambulatory patients.

Prevalence of upper extremity pain in a population of people with paraplegia.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To determine the prevalence, patterns, and predictors of musculoskeletal pain in the upper extremity joints among wheelchair-dependent individuals with post-traumatic paraplegia. Secondarily, to document most common reported causes of upper extremity pain. SETTING: Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Germany. METHODS: The study was done by means of a structured questionnaire, which was mailed to the individuals who had been treated between 1990 and 2007 for newly sustained or pre-existing, accident-related paraplegia (n = 670). The questionnaire was designed mainly to obtain the information regarding shoulder, elbow, and wrist pain. Additional data included participant demographics, mechanism, level and completeness of injury as well as wheelchair dependence and time since injury. The Frankel classification system was used to define the completeness of injury. RESULTS: Four hundred and fifty-one (67%) questionnaires were included. Pain was reported by approximately 81% of the participants. Of this sample, 61% had shoulder pain, 33% had elbow pain, and 43% had wrist pain, 19% had shoulder, elbow, and wrist pain, 27% had shoulder and elbow pain, 34% had shoulder and wrist pain, 21% had elbow and wrist pain. The main diagnoses were rotator cuff tears for individuals with shoulder pain, epicondylitis for those with elbow pain, and carpal tunnel syndrome for those with wrist pain. The development of shoulder/elbow and wrist pain correlated with age and time since injury. CONCLUSIONS: Age and the length of time since injury correlated with a higher rate of shoulder, elbow, and wrist pain. The completeness of injury, neurological level, and gender were correlated with shoulder, elbow, and wrist pain, respectively.

MRI features in the non-traumatic spinal cord injury patients presenting at the Korle Bu Teaching Hospital, Accra.

BACKGROUND: Neurological limb deficit due to non-traumatic myelopathy is a disabling and distressing neurological condition. In recent time Magnetic Resonance Imaging (MRI) has proven to be the ultimate imaging modality for evaluating pathologies of the spinal cord. OBJECTIVE: To describe the Magnetic Resonance Imaging (MRI) features of patients with Non-Traumatic Spinal Cord Injury evaluated at the Korle Bu Teaching Hospital. METHODS: A descriptive cross-sectional study was carried out at the Korle Bu Teaching Hospital (KBTH), Accra, Ghana. RESULTS: Out of a total of 141 MRI's evaluated 60.3% were males and 39.7% female. The majority of the respondents 85.1% had paraparesis/paraplegia, 13.5% had quadriparesis/quadriplegia, 1.4% had weakness in one upper limb and both lower limbs. The commonest MRI features of NTSCI recorded was due to degenerative disease of the spine 75.9%, spinal metastases 5.7%, Pott's /pyogenic spondylitis 3.5%, demyelinating disease 2.8% and primary spinal tumours 2.8%. CONCLUSION: The commonest MRI findings in the study population were due to degenerative disease of the spine, followed by spinal metastases and infective spondylitis. FUNDING: Not declared.

Outcomes of Rotator Cuff Repair in Patients with Comorbid Disability in the Extremities.

BACKGROUND: Rehabilitation and overuse of the shoulder after rotator cuff repair are a concern in patients with comorbid disability in other extremities. Improvement of outcomes can be hampered in this situation. This study was to describe the clinical outcomes of rotator cuff repair in patients with comorbid disability in other extremities. METHODS: In two tertiary institutions, 16 patients with comorbid disability (9 men and 7 women; mean age of 57.1 years [range, 45 to 71 years]; 14 dominant arms; mean follow-up of 18 months [range, 12 to 38 months]) underwent rotator cuff repair. There were 5 massive tears, 1 large tear, 9 medium tears, and 1 small tear. Open repair was performed in 3 patients and arthroscopic repair in 13. The most common comorbid condition was paralysis (n = 7). Eight patients walked with crutches preoperatively. Anatomical outcome was investigated in 12 patients using either magnetic resonance imaging or ultrasonography at least 6 months postoperatively. RESULTS: Range of motion, visual analogue scale for pain and satisfaction, and all functional scores improved significantly. Healing failure occurred in 4 patients (2 large-to-massive and 2 medium size tears), but none required revision surgery. All 4 retears involved the dominant side, and 3 patients were crutch users. CONCLUSIONS: The current data suggested favorable outcome of rotator cuff repair in patients with comorbid disability. Careful surgical planning and rehabilitation is particularly important for crutch users and in the case of dominant arm involvement in disabled patients.