Functional Gains in Children Receiving Inpatient Rehabilitation After Brain Tumor Resection.

OBJECTIVE: To examine whether children with brain tumors treated with resection benefit from inpatient rehabilitation and to explore what factors present at admission may predict better functional outcomes. DESIGN: Retrospective cohort design. SETTING: Pediatric inpatient rehabilitation unit. PARTICIPANTS: Forty patients (N=40; ages 3-21y; 42.5% female) admitted to the rehabilitation unit between 2003 and 2015 after brain tumor resection. INTERVENTIONS: Patients received multidisciplinary rehabilitation therapies as part of their admission to inpatient rehabilitation, including occupational, physical, and speech-language therapy. MAIN OUTCOME MEASURES: Functional outcomes included the FIM for Children (WeeFIM) at discharge and 3-month follow-up as well as WeeFIM efficiency. RESULTS: A repeated-measures analysis of variance using patient WeeFIM Developmental Functional Quotients (DFQs) at admission, discharge, and 3-month follow-up showed significant gains in total WeeFIM DFQ scores across time. Admission WeeFIM DFQ, time from surgery to admission, and age at admission provided the strongest model for predicting discharge and 3-month follow-up WeeFIM DFQ scores. Admission WeeFIM DFQ and time from surgery to admission provided the strongest model for predicting WeeFIM efficiency. Total Neurological Predictor Scale (NPS) at admission did not add predictive power to any of the 3 models over and above patient characteristics (admission WeeFIM DFQ, age at admission, time from surgery to admission). CONCLUSIONS: Patients admitted to inpatient rehabilitation after brain tumor resection made significant functional gains (as measured by the WeeFIM) during inpatient rehabilitation and continued to make significant gains 3 months after discharge. Age and timing of admission provided the strongest models for predicting patient outcomes. The NPS did not predict functional outcomes after rehabilitation when controlling for other variables known to influence rehabilitation outcomes.

Efficacy of an Enhanced Recovery After Surgery (ERAS) Pathway in Elderly Patients Undergoing Spine and Peripheral Nerve Surgery.

OBJECTIVE: Elderly patients are a vulnerable patient population in elective spinal surgery. Older patients have more medical comorbidities and are also more sensitive to opiate medications. Despite this, spine and peripheral nerve surgery is still feasible in these patients, and an Enhanced Recovery After Surgery (ERAS) regimen can further enhance the safety profile. METHODS: This is a before and after cohort study at a single institution on elderly patients who underwent elective spine and peripheral nerve surgery. Patients were prospectively enrolled in a novel ERAS protocol from April 2017 to December 2018. The control group was a historical cohort of patients who underwent surgery from September 2016 to December 2016. The primary outcome was self-reported opioid use at 1- and 3-months postoperatively. The secondary outcome was compliance with the ERAS protocol across several measures including patient-controlled (PCA) use, patient-reported pain scores, mobilization and ambulation status, and Foley catheter use. RESULTS: Among 504 patients aged 65 and older compared to historic controls there was a significant reduction in the use of post-operative opioids at one month (36.2% vs. 71.7%, p < 0.001) and 3 months after surgery (33.0% vs. 80.0%, p < 0.001). 504 consecutive elderly patients were included in the ERAS protocol compared to a control group of 60. The two groups had similar surgical procedures and baseline demographics, with similar mean ages (ERAS 73.2 years vs. control 73.5 years, p = 0.67). The ERAS group showed improved mobilization and ambulation on POD 0 in compliance with our protocol compared to the control group (mobilization: 60.0% vs. 10.0%, p < 0.001; ambulation: 36.1% vs. 10.0%, p < 0.001), with no inpatient falls reported for either group. CONCLUSIONS: ERAS facilitates reduction in opiate use at 1- and 3-month intervals postoperatively in patients greater than 65 years old undergoing elective spine and peripheral nerve surgery. Early mobilization and ambulation are safe and feasible in this population.

How to Improve Outcomes of Spine Surgery in Geriatric Patients.

BACKGROUND: The incidence of spine surgery in elderly patients is increasing. Geriatric spine surgery has 3 main concerns: osteoporosis, continuing degeneration and more deformity, and comorbidities. Measures taken regarding these concerns would improve results, and elderly patients will experience much more benefit from surgery. This study reviewed the most recent literature to improve outcomes of geriatric spine surgery. METHODS: A literature search of the last 10 years was done. RESULTS: Outcomes of spine surgery using decompressive techniques only are similar to outcomes in younger patients. However, in patients with comorbidities, the outcomes are less favorable with more complications. Complication rates decrease when minimally invasive techniques are used. If a fusion surgery is necessary, especially in cases with deformity correction, complication rates significantly increase up to 60%. Osteoporosis comanagement is necessary to prevent nonunion and implant failure if a fusion surgery is planned. Enhanced recovery after surgery protocols can be an aid to preparation and rehabilitation of elderly patients. A frailty index can help to predict patients with the worst outcomes. Additional psychological support and some other measures will help to reduce the incidence of postoperative delirium. CONCLUSIONS: Geriatric patients pose more concerns for spine surgery. To achieve better outcomes with fewer complications, we must concentrate more on comorbidities in elderly patients. Measures to treat osteoporosis; application of enhanced recovery after surgery protocols for patient preparation; use of less invasive surgical techniques; and good postoperative rehabilitation, pain, and psychological management would help to improve the outcomes of spine surgery in geriatric patients.

Rehabilitation from meningioma.

This chapter discusses the complex process of acute rehabilitation of patients after meningioma. Acute inpatient rehabilitation after meningioma utilizes an interdisciplinary approach to provide comprehensive rehabilitation through a team of physical, occupational, and speech therapists, nurses, doctors, recreational therapists, neuropsychologists, case managers and social workers, all of whom specialize in providing rehabilitation care. The prognosis of rehabilitation outcomes in this population is similar to that of the stroke population, and patients benefit from rehabilitation to maximize function in the setting of ongoing treatment. Common functional deficits include speech, cognitive, motor, and visual deficits. Medical complications include heterotopic ossification, venous thromboembolism, bowel and bladder complications, and pain. Patients must also be managed for behavioral complications such as agitation and maintenance of the sleep-wake cycle. The wide variety of functional outcomes following meningioma diagnosis and treatment necessitates a flexible rehabilitation course including testing for deficits, monitoring of outcomes, and ongoing therapy support.

Recovery and Regrowth After Nerve Repair: A Systematic Analysis of Four Repair Techniques.

BACKGROUND: Outcome assessments that evaluate post-transection nerve repair do not often correlate with one another. The aims of this study were twofold: to compare four nerve repair techniques with each other and incorporate both negative and positive control groups and to identify possible correlations between outcome assessments. MATERIALS AND METHODS: Sciatic nerve transection and repair was performed in Lewis rats using one of the following techniques: interrupted epineural, running epineural, grouped fascicular, epineural with absorbable type I collagen wrap, and high tension for incorporation of a negative control. A sham surgery group was also included as a positive control group. Outcomes were compared using assessments of functional recovery (behavior and electrophysiology) and nerve regrowth (imaging and histomorphometry). Three-dimensional printed custom electrode stabilization and imaging devices were designed and fabricated to provide standardization in assessment between subjects. RESULTS: Nerve repair was performed in 48 male Lewis rats. In all animals, functional testing was performed at week 13. The sham group (n = 7) performed the best on both behavioral assays (P < 0.001) and electrophysiology assessments (P < 0.001). The negative control group (high tension) performed poorest on multiple assessments, and there were no significant differences observed for any of the four repair types. Positive correlations were observed between behavioral and histomorphometric tests. CONCLUSIONS: There was no difference in outcome between the four types of nerve repair. High-tension nerve repair represents an ideal negative control. Not all assessment methods correlate equally, and consistent use of complimentary outcome assessments could allow for improved comparison between studies.

Recovery of Severe Aphasia After Cranioplasty: Considerations on a Case Study.

Cranioplasty is the main surgical intervention for repairing cranial defects performed in about 80% of the patients following cancer surgery or decompressive craniectomy. Although some works have shown recovery of motor and cognitive function, including memory, attention, and executive functions, until today no studies have focused on language recovery after cranioplasty. A 68-year-old woman came to the Neurorehabilitation Unit of the IRCCS Neurolesi (Messina, Italy) because of a fluent aphasia due to a severe left nucleocapsular hemorrhage and greatly improved her motor and neuropsychological status after cranioplasty. Results confirmed that cranioplasty might significantly improve motor and neuropsychological function, besides aphasia. Healthcare professionals involved in rehabilitation should be aware of the potential role of cranioplasty in improving rehabilitative outcomes to better plan a more personalized rehabilitative program. Moreover, rehabilitation nurses can play a pivotal role within the rehabilitation process, as they are educated to interact and communicate with the patient suffering from aphasia.

Ambulation on Postoperative Day #0 Is Associated With Decreased Morbidity and Adverse Events After Elective Lumbar Spine Surgery: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC).

BACKGROUND: While consistently recommended, the significance of early ambulation after surgery has not been definitively studied. OBJECTIVE: To identify the relationship between ambulation on the day of surgery (postoperative day (POD)#0) and 90-d adverse events after lumbar surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective multicenter registry of spine surgery patients. As part of routine postoperative care, patients either ambulated on POD#0 or did not. The 90-d adverse events of length of stay (LOS), urinary retention (UR), urinary tract infection (UTI), ileus, readmission, surgical site infection (SSI), pulmonary embolism/deep vein thrombosis (PE/DVT), and disposition to a rehab facility were measured. RESULTS: A total of 23 295 lumbar surgery patients were analyzed. POD#0 ambulation was associated with decreased LOS (relative LOS 0.83, P < .001), rehab discharge (odds ratio [OR] 0.52, P < .001), 30-d (OR 0.85, P = .044) and 90-d (OR 0.86, P = .014) readmission, UR (OR 0.73, P = 10), UTI (OR 73, P = .001), and ileus (OR 0.52, P < .001) for all patients. Significant improvements in LOS, rehab discharge, readmission, UR, UTI, and ileus were observed in subset analysis of single-level decompressions (4698 pts), multilevel decompressions (4079 pts), single-level fusions (4846 pts), and multilevel fusions (4413 pts). No change in rate of SSI or DVT/PE was observed for patients who ambulated POD#0. CONCLUSION: POD#0 ambulation is associated with a significantly decreased risk for several key adverse events after lumbar spine surgery. Decreasing the incidence of these outcomes would be associated with significant cost savings. As ambulation POD#0 is a modifiable factor in any patient's postoperative care following most spine surgery, it should be encouraged and incorporated into spine-related, enhanced-recovery-after-surgery programs.

Status dystonicus: Diagnosis and management of a rare and challenging entity.

We report the case of a six-year-old girl with Moyamoya disease who presented with bilateral internal carotid artery malignant infarct following encephaloduroarteriosynangiosis (EDAS). During her neurorehabilitation, she developed gradually worsening dystonic spasms with opisthotonic posturing, tachycardia, tachypnea and desaturation. This rare life threatening movement disorder was diagnosed as status dystonicus based on the history and clinical presentation. Status Dystonicus occurs commonly in children and the etiology is often diverse. It occurs in patients with preexisting dystonia or following an acute central nervous system insult of varied etiology. Status dystonicus is usually precipitated by one or more triggering factors. Rarity and lack of objective criteria for diagnosis often delays the management thereby increasing the risk of mortality and morbidity. Here, we discuss the challenges faced in the diagnosis and management of a child with denovo status dystonicus.

Development of an exercise intervention as part of rehabilitation in a glioblastoma multiforme survivor during irradiation treatment: a case report.

INTRODUCTION: This case report describes the rationale and development of an exercise intervention in a patient with glioblastoma multiforme (GBM ) and discusses potential relations of observed effects in functional performance and quality of life (QOL). METHODS: A 54-year-old GBM survivor completed a supervised six-week exercise intervention during irradiation treatment beginning 42 d after resection. Exercise modalities of cardiorespiratory, resistance, and balance training were designed on generic recommendations of various cancer populations and literature review. RESULTS: Our case attended all possible sessions without experiencing adverse effects, and improved in aerobe power (24%), muscle strength (0-38%), standing balance (71%), walking ability (9%), and QOL domains of "Global Health Status/QoL" and "Physical functioning." CONCLUSIONS: Based on this single case, exercise rehabilitation has the ability to maintain or improve functional performance and QOL domains even during heavy treatments. It also implies that patients with GBM are capable and may be willing to participate in exercise rehabilitation if supervised by physical therapists. Implications for rehabilitation The use of exercise as part of rehabilitation still needs attention in strong methodology studies of patients with gliomas. Exercise rehabilitation may maintain or even improve functional performance and QOL domains during medical treatment regimens. Functional independent patients with GBM are capable to comply with generic exercise recommendations and may be willing to participate in exercise rehabilitation if supervised by physical therapists.

Consensus on Postoperative Recommendations After Transsphenoidal Surgery.

BACKGROUND: Guidelines for patient behavior following transsphenoidal surgery do not exist. To gain generally recommendations, the German pituitary working group conducted a study among pituitary surgeons to elucidate their opinions and customs of patients' counselling. METHODS: Questions concerning daily activities, exertion of sports and work life were addressed. It was asked to provide the postoperative time interval after which specific activities can be resumed both after a routine or an extended approach. RESULTS: Fourteen pituitary surgeons returned the completed questionnaire. Following routine operations, washing the hair was allowed within one week, blowing the nose after 3, flying on an airplane and driving a car after one, lifting heavy weights after 4, playing wind instruments after 6, use of CPAP (continuous positive airway pressure) device after 3, permit leisure sports after 2 to 4 weeks (except for scuba diving). Competitive sports can be resumed after 6 weeks. Occupation with mental demands was considered feasible after 2 weeks, with physical labor after 4 weeks. After extended transsphenoidal surgery, the recommended time interval was roughly twice as long compared to the routine approach. Driving a car was allowed within the first 4 weeks after surgery by some pituitary surgeons, while others allow driving only after 3 months analogous to the regulations after craniotomy. The risk of scuba diving was considered high. CONCLUSIONS: The data of our study and the literature, and expert opinions from related scientific fields resulted in a consensus on recommendations for patients' conduct to minimize risks after transsphenoidal surgery.

The Benefits of Implementing an Early Mobility Protocol in Postoperative Neurosurgical Spine Patients.

: Background: Despite the known benefits of early postsurgical mobility, there are no clear recommendations on early mobility among uncomplicated postoperative neurosurgical spine patients. PURPOSE: The purpose of this quality improvement initiative was to establish an NP-led early mobility protocol to reduce uncomplicated postsurgical spine patients' length of stay (LOS) in the hospital and eliminate the variability of postsurgical care. A secondary objective was to educate and empower nursing staff to initiate the early mobility protocol independently and incorporate it in their practice to improve patient care. METHODS: Two neurosurgery NPs led an interprofessional team to develop the early mobility protocol. Team members provided preadmission preoperative education to communicate the necessity for early mobility and provide information about the protocol. New nursing guidelines called for patient mobility on the day of surgery, within six hours of arrival on the medical-surgical unit. Nurses were empowered to get patients out of bed independently, without a physical therapy consultation; they also removed urinary catheters and discontinued IV opioids when patients' status permitted. RESULTS: Over a one-year period, implementation of the protocol resulted in a nine-hour reduction in LOS per hospitalization in neurosurgical spine patients who underwent lumbar laminectomies. The protocol also allowed nurses more autonomy in patient care and was a catalyst for patient involvement in their postoperative mobility. Given the success of the protocol, it is being replicated by other surgical services throughout the organization. CONCLUSIONS: This low-cost, high-reward initiative aligns with the strategic plan of the organization and ensures that high-quality, patient-centered care remains the priority. NPs in other institutions can modify this protocol to promote postoperative mobility in their organizations.

Postoperative rehabilitation after deep brain stimulation surgery for movement disorders.

Deep brain stimulation (DBS) is a highly efficient, evidence-based therapy for a set of neurological and psychiatric conditions and especially movement disorders such as Parkinson's disease, essential tremor and dystonia. Recent developments have improved the DBS technology. However, no unequivocal algorithms for an optimized postoperative care exist so far. The aim of this review is to provide a synopsis of the current clinical practice and to propose guidelines for postoperative and rehabilitative care of patients who undergo DBS. A standardized work-up in the DBS centers adapted to each patient's clinical state and needs is important, including a meticulous evaluation of clinical improvement and residual symptoms with a definition of goals for neurorehabilitation. Efficient and complete information transfer to subsequent caregivers is essential. A coordinated therapy within a multidisciplinary team (trained in movement disorders and DBS) is needed to achieve the long-range maximal efficiency. An optimized postoperative framework might ultimately lead to more effective results of DBS.

Structured postoperative physiotherapy in patients with cervical radiculopathy: 6-month outcomes of a randomized clinical trial.

OBJECTIVE Structured physiotherapy has been suggested as treatment before as well as after surgery to improve clinical outcomes in patients with cervical radiculopathy (CR), but randomized clinical trials to inform evidence-based clinical guidelines for the treatment of patients with CR after surgery are lacking. The aim of this study was to compare the results of structured postoperative physiotherapy combining neck-specific exercises with a behavioral approach to a standard postoperative approach in patients who had undergone surgery for cervical disc disease with CR at 6 months after surgery. METHODS Patients with cervical disc disease and persistent CR who were scheduled for surgery were randomized preoperatively to structured postoperative physiotherapy (n = 101) or a standard postoperative approach (n = 100). The latter included pragmatic physiotherapy in accordance with the usual Swedish postoperative care. Outcome measures included patient-reported neck disability as measured with the Neck Disability Index (NDI), intensity and frequency of neck and arm pain, global outcome of treatment, and expectation fulfillment, as well as enablement. RESULTS Patients who received structured postoperative physiotherapy reported greater expectation fulfillment (p = 0.01), and those who attended at least 50% of the treatment sessions reported less neck pain frequency (p = 0.05), greater expectation fulfillment (p = 0.001), and greater enablement (p = 0.04) compared with patients who received the standard postoperative approach. No other difference between treatment groups was found (p > 0.15). The NDI and neck and arm pain intensity were improved in both groups at 6 months after surgery (p < 0.001). Additional use of postoperative physiotherapy was reported by 61% of the patients who received the standard postoperative approach. CONCLUSIONS The results from this first randomized clinical trial of postoperative physiotherapy showed only minor additional benefit of structured postoperative physiotherapy compared with standard postoperative approach 6 months postoperatively in patients who underwent surgery for cervical disc disease with CR. Patients who received structured postoperative physiotherapy reported higher expectation fulfillment, and many patients in the standard postoperative approach group perceived a need for additional treatments after surgery, suggesting that patients with CR are in need of further postoperative support. The results confirm that neck-specific exercises are tolerated postoperatively by patients with CR, but more studies of postoperative physiotherapy are needed to inform clinical guidelines for this patient group. Clinical trial registration no.: NCT01547611 (clinicaltrials.gov).

[Surgical indications and complications management in vestibular schwannoma]. / Chirurgische Indikation und Komplikationsmanagement beim Vestibularisschwannom.

BACKGROUND: Recent surgical treatment concepts for patients with vestibular schwannoma (VS) require an interdisciplinary approach as well as recognition and mastering of complications. OBJECTIVE: This paper provides an overview of indications, as well as possible options for function preservation and management of complications in the surgical resection of these tumors. METHODS: Up-to-date treatment concepts and surgical indications were differentiated according to size and extent of tumors. The frequency of important complications was extracted from the literature. Technical options to avoid and correct complications were compiled from personal experience and review of the literature. RESULTS: Complications unrelated to cranial nerves are not infrequent, particularly in older patients. Small and medium-sized tumors that do not reach the fundus and cochlear fossa can be completely removed with good chances of hearing preservation. As long as these tumors do not grow, patients benefit from observation. Large tumors are overrepresented in surgical series compared to their prevalence. Postoperative facial nerve function correlates to tumor volume. Hearing preservation in these tumors is rare. Intraoperative electrophysiological techniques are valuable for attempted preservation of cranial nerve function. Persistent facial palsies can be remedied by dynamic and static interventions for facial rehabilitation. CONCLUSION: Mortality and morbidity associated with surgical treatment of VS are very acceptable. Surgical concepts should be custom-tailored to the individual patient in order to ensure high quality of life.

Day of Surgery Impacts Outcome: Rehabilitation Utilization on Hospital Length of Stay in Patients Undergoing Elective Meningioma Resection.

OBJECTIVE/BACKGROUND: Meningiomas account for approximately one third of all brain tumors in the United States. In high-volume medical centers, the average length of stay (LOS) for a patient is 6.8 days compared with 8.8 days in low-volume centers with median total admission charges equaling approximately $55,000. To our knowledge, few studies have evaluated day of surgery and its effect on hospital LOS. Our primary goal was to analyze patient outcome as a direct result of surgical date, as well as to characterize the individual variables that may impact their hospital course, early access to rehabilitation, and long-term functional status. METHODS: A retrospective database was generated for cranial meningioma patients who underwent elective surgical resection at our institution over a 3-year study period (2011-2014). Inclusion criteria included any patient who underwent elective meningioma resection and was discharged either home or to a rehabilitation facility with at least 6 months of follow-up. Exclusion criteria included any patient who was not discharged after resection (i.e., expired). Each patient's medical record was evaluated for a subset of demographics and clinical variables. Given that patients who undergo surgical resection of meningiomas have a national median LOS of 6 days, we subdivided the patients into 2 cohorts: early discharge (LOS < 3) and late discharge (LOS ≥ 3). Statistical analysis was performed using SPSS 21.0 to assess the significance of the results. RESULTS: We identified 139 (25 male, 114 female) meningioma patients who underwent surgical resection. Seventy of these patients had surgery during the early week (defined as Monday-Wednesday), and 69 had surgery in the later week (Thursday-Friday). The median age for both early and late groups was 58, and the median diameter of the tumor was 3.1 cm and 3.3 cm, respectively. Overall, 55% of the patients had public insurance and 43% had private insurance, with no significant variation between the early and late groups. The median LOS for the early and late populations was 3 and 4 days, respectively. Physical therapy recommendations for rehabilitation facility were made in 26% of early-week patients and in 42% of late-week patients. Additionally, we found a statistically significant decreased LOS (<3 days) in those patients who underwent surgery during the early week (Monday-Wednesday), as opposed to those who received surgery in the later week (Thursday, Friday) (P = 0.045, Mann-Whitney test). CONCLUSION: Day of surgery may play a significant role in LOS for meningioma patients. Clinicians should remain aware of those factors that may delay optimal patient discharge and early access to rehabilitation facilities. Further studies will need to be performed to assess the social variables that may affect LOS, as well as the financial implications for such extended hospital courses.

OUTCOME OF IMPLEMENTATION OF A MULTIDISCIPLINARY TEAM APPROACH TO THE CARE OF PATIENTS AFTER TRANSSPHENOIDAL SURGERY.

OBJECTIVE: Transsphenoidal surgery (TS) for sellar lesions is an established and safe procedure, but complications can occur, particularly involving the neuroendocrine system. We hypothesized that postoperative care of TS patients would be optimized when performed by a coordinated team including a pituitary neurosurgeon, endocrinologists, and a specialty nurse. METHODS: We implemented a formalized, multidisciplinary team approach and standardized postoperative protocols for the care of adult patients undergoing TS by a single surgeon (J.N.B.) at our institution beginning in July 2009. We retrospectively compared the outcomes of 214 consecutive TS-treated cases: 113 cases prior to and 101 following the initiation of the team approach and protocol implementation. Outcomes assessed included the incidence of neurosurgical and endocrine complications, length of stay (LOS), and rates of hospital readmission and unscheduled clinical visits. RESULTS: The median LOS decreased from 3 days preteam to 2 days postteam (P<.01). Discharge occurred on postoperative day 2 in 46% of the preteam group patients compared to 69% of the postteam group (P<.01). Rates of early postoperative diabetes insipidus (DI) and readmissions within 30 days for syndrome of inappropriate antidiuretic hormone (SIADH) or other complications did not differ between groups. CONCLUSION: Implementation of a multidisciplinary team approach was associated with a reduction of LOS. Despite earlier discharge, postoperative outcomes were not compromised. The endocrinologist is central to the success of this team approach, which could be successfully applied to care of patients undergoing TS, as well as other types of endocrine surgery at other centers.

Tissue Factor and Tissue Factor Pathway Inhibitor in the Wound-Healing Process After Neurosurgery.

OBJECTIVES: The aim of the study was to assess the concentrations of tissue factor (TF) and tissue factor pathway inhibitor (TFPI) in the blood of patients with a postoperative wound after neurosurgery. METHOD: Participants included 20 adult patients who underwent neurosurgery because of degenerative spine changes. The concentration of TF and TFPI in the patients' blood serum was measured 3 times: before surgery, during the first 24 hr after surgery, and between the 5th and 7th days after surgery. The control group comprised 20 healthy volunteers similar to the patient group with respect to gender and age. RESULTS: A statistically significant difference was observed between TF concentration at all three measurement time points in the research group and TF concentration in the control group (p = .018, p = .010, p = .001). A statistically significant difference was found between TFPI concentration at the second time point in the research group and TFPI concentration in the control group (p = .041). No statistically significant within-subject difference was found between TF concentrations before and after surgery. A statistically significant within-subject difference was found between TFPI concentrations within 24 hr after surgery and 5-7 days after surgery (p = .004). CONCLUSION: High perioperative concentrations of TF indicate not only the presence of thrombophilia but also the importance of TF in the wound-healing process. Perioperative changes in TFPI concentrations are related to its compensatory influence on hemostasis in thrombophilic conditions.

Prognostic factors for outcome after median, ulnar, and combined median-ulnar nerve injuries: a prospective study.

BACKGROUND: A major problem in the surgical treatment of peripheral nerve injuries of the upper extremities is the unpredictable final outcome. More insight and understanding of the prognostic factors is necessary to improve functional outcome after repair of the peripheral nerves. The objective of this study was to identify prognostic factors for the functional recovery of peripheral nerve injury of the forearm and their independent contribution in the outcome in the first year after reconstruction. METHODS: A multicentered prospective study in the Netherlands resulted in the inclusion of 61 patients with a median, ulnar, or combined median-ulnar nerve injury. The age, level of injury, type of nerve injury, number of damaged structures, number of damaged arteries, education, smoking, and posttraumatic stress were analyzed as prognostic factors for functional outcome after repair of the peripheral nerves. The outcome parameters were sensory recovery (Semmes-Weinstein monofilament test) and motor recovery (Medical Research Council (MRC) score, power grip, and pinch grip) and the ability to perform daily activities. RESULTS: Gender, age, level of education, number of injured arteries and structures, damaged nerve, location of the injury, type of the nerve injury, and posttraumatic stress at 1 and 3 months after repair of the peripheral nerve injury were found to be predictors of functional recovery. CONCLUSIONS: Our prospective analysis of prognostic factors shows several factors to be predictive for the functional recovery after peripheral nerve injuries of the median and/or ulnar nerve of the forearm. Sensibility of the hand, power grip, and DASH score (DASH, Disabilities of Arm, Shoulder and Hand) have proven to be the three best prognostic factors in this study. Of these prognostic factors, only posttraumatic stress can be influenced to optimize functional outcome.

Physiotherapeutic interventions before and after surgery for degenerative lumbar conditions: a systematic review.

BACKGROUND: Physiotherapeutic management of patients immediately following lumbar spinal surgery is common. However, there is considerable variability in the interventions provided. OBJECTIVES: To assess the effect of peri-operative physiotherapeutic intervention in adults undergoing surgery for the management of degenerative lumbar conditions. DATA SOURCES: The Cochrane Library, Medline, Embase, CINAHL and PEDro were searched from inception to August 2012. STUDY SELECTION: Randomised controlled trials investigating physiotherapeutic interventions prior to and immediately following surgery for degenerative lumbar conditions were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers extracted data independently using a standardised form. Risk of bias was assessed using a modified version of the Cochrane Collaboration tool. The quality of evidence was assessed using the GRADE approach, and the treatment effect size was calculated where comparable outcome measures were used across multiple trials. RESULTS: Four studies were included. There is very-low-quality evidence that pre- and post-operative exercise in addition to standard physiotherapeutic care may reduce pain, time taken to achieve post-operative functional milestones, and post-operative time off work. Results from one study indicated that there is no clear benefit or risk of harm from performing either prone or side-lying transfers. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: Very-low-quality evidence suggests that physiotherapy may improve pain and function following lumbar surgery. Due to low numbers of included studies and variation in the interventions assessed, the current evidence provides limited guidance for physiotherapeutic practice. Further research is required to determine the effectiveness of physiotherapeutic interventions in this population.

Harnessing plasticity for the treatment of neurosurgical disorders: an overview.

Plasticity is fundamental to normal central nervous system function and its response to injury. Understanding this adaptive capacity is central to the development of novel surgical approaches to neurologic disease. These innovative interventions offer the promise of maximizing functional recovery for patients by harnessing targeted plasticity. Developing novel therapies will require the unprecedented integration of neuroscience, bioengineering, molecular biology, and physiology. Such synergistic approaches will create therapeutic options for patients previously outside of the scope of neurosurgery, such as those with permanent disability after traumatic brain injury or stroke. In this review, we synthesize the rapidly evolving field of plasticity and explore ways that neurosurgeons may enhance functional recovery in the future. We conclude that understanding plasticity is fundamental to modern neurosurgical education and practice.