Prospective Assessment of a Protocol Using Neuromonitoring, Early Limb Reperfusion, and Selective Temporary Aneurysm Sac Perfusion to Prevent Spinal Cord Injury During Fenestrated-branched Endovascular Aortic Repair.

OBJECTIVE: The aim of this study was to analyze the outcomes of a standardized protocol using routine CSFD, neuromonitoring, LL reperfusion, and selective TASP to prevent SCI during F-BEVAR. BACKGROUND: SCI is to be the most devastating complication for the patient, family, and surgeon, with impact on patient's quality of life and long-term prognosis. An optimal standardized protocol may be used to improve outcomes. METHODS: Patients enrolled in a prospective, nonrandomized single-center study between 2013 and 2018. A SCI prevention protocol was used for TAAAS or complex abdominal aneurysms with ≥5-cm supraceliac coverage including CSFD, neuromonitoring, LL reperfusion, and selective TASP. Endpoints included mortality and rates of SCI. RESULTS: SCI prevention protocol was used in 170 of 232 patients (73%) treated by F-BEVAR. Ninety-one patients (55%) had changes in neuromonitoring, which improved with maneuvers in all except for 9 patients (10%) who had TASP. There was one 30-day or in-hospital mortality (0.4%). Ten patients (4%) developed SCIs including in 1% (1/79) of patients with normal neuromonitoring and 10% (9/91) of those who had decline in neuromonitoring ( P = 0.02). Permanent paraplegia occurred in 2 patients (1%). Factors associated with SCI included total operating time (odds ratio 1.5, 95% confidence interval 1.1-2.2, P = 0.02) and persistent changes in neuromonitoring requiring TASP (odds ratio 15.7, 95% confidence interval 2.9-86.2, P = 0.001). CONCLUSION: This prospective nonrandomized study using a standardized strategy to prevent SCI was associated with low incidence of the SCI during F-BEVAR. Permanent paraplegia occurred in 1%.

The role of diffusion tensor imaging as an objective tool for the assessment of motor function recovery after paraplegia in a naturally-occurring large animal model of spinal cord injury.

BACKGROUND: Traumatic spinal cord injury (SCI) results in sensory and motor function impairment and may cause a substantial social and economic burden. For the implementation of novel treatment strategies, parallel development of objective tools evaluating spinal cord (SC) integrity during motor function recovery (MFR) is needed. Diffusion tensor imaging (DTI) enables in vivo microstructural assessment of SCI. METHODS: In the current study, temporal evolvement of DTI metrics during MFR were examined; therefore, values of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were measured in a population of 17 paraplegic dogs with naturally-occurring acute SCI showing MFR within 4 weeks after surgical decompression and compared to 6 control dogs. MRI scans were performed preoperatively and 12 weeks after MFR was observed. DTI metrics were obtained at the lesion epicentre and one SC segment cranially and caudally. Variance analyses were performed to compare values between evaluated localizations in affected dogs and controls and between time points. Correlations between DTI metrics and clinical scores at follow-up examinations were assessed. RESULTS: Before surgery, FA values at epicentres were higher than caudally (p = 0.0014) and control values (p = 0.0097); ADC values were lower in the epicentre compared to control values (p = 0.0035) and perilesional (p = 0.0448 cranially and p = 0.0433 caudally). In follow-up examinations, no significant differences could be found between DTI values from dogs showing MFR and control dogs. Lower ADC values at epicentres correlated with neurological deficits at follow-up examinations (r = - 0.705; p = 0.0023). CONCLUSIONS: Findings suggest that a tendency to the return of DTI values to the physiological situation after surgical decompression accompanies MFR after SCI in paraplegic dogs. DTI may represent a useful and objective clinical tool for follow-up studies examining in vivo SC recovery in treatment studies.

Comparison of Preoperative Quantitative Magnetic Resonance Imaging and Clinical Assessment of Deep Pain Perception as Prognostic Tools for Early Recovery of Motor Function in Paraplegic Dogs with Intervertebral Disk Herniations.

BACKGROUND: Prognostic tools to predict early postoperative motor function recovery (MFR) after thoracolumbar intervertebral disk herniation (IVDH) in paraplegic dogs represent an opportunity to timely implement novel therapies that could shorten recovery times and diminish permanent neurological dysfunctions. HYPOTHESIS: Fractional anisotropy (FA) values obtained using diffusion tensor imaging have a higher prognostic value than a lesion extension ratio in T2-weighted images (T2W-LER) and clinical assessment of deep pain perception (DPP) for MFR. ANIMALS: Thirty-five paraplegic dogs with diagnosis of acute or subacute thoracolumbar IVDH. METHODS: Prospective, descriptive observational study. At admission, absence or presence of DPP, T2W-LER, and FA values was evaluated. MFR was assessed within 4 weeks after decompressive surgery. Values of T2W-LER and FA of dogs with and without MFR were compared using t-tests. All 3 methods were evaluated for their sensitivity and specificity as a prognostic factor. RESULTS: No differences were found between groups regarding T2W-LER. FA values differed statistically when measured caudally of lesion epicenter being higher in dogs without MFR compared to dogs with MFR (P = .023). Logistic regression analysis revealed significance in FA values measured caudally of the lesion epicenter (P = .033, area under the curve = 0.72). Using a cutoff value of FA = 0.660, the technique had a sensitivity of 80% and a specificity of 55%. Evaluation of DPP had a sensitivity of 73.3% and specificity of 75% (P = .007). CONCLUSIONS AND CLINICAL IMPORTANCE: Evaluation of DPP showed a similar sensitivity and a better specificity predicting early MFR than quantitative magnetic resonance imaging.

Surgical assessment of the proximal thoracic curve in adolescent idiopathic scoliosis.

Existing predictive signs as available in current literature may miss potential proximal thoracic (PT) curve deterioration and shoulder imbalance, following selective main thoracic (MT) curve correction in adolescent idiopathic scoliosis (AIS). The present study is an attempt to evaluate and complement these signs, through a retrospective study of 56 AIS patients who underwent correction and fusion from 1986 till 2003 with follow-up 4-16 years. Forty-nine had fusion of MT curve, 7 of MT and PT. Cotrel-Dubousset instrumentation in 45, Luque in 12. Preoperative data: MT 50 degrees (40 degrees -80 degrees), PT 25 degrees (0 degrees -50 degrees), shoulder elevation from -4 cm (right) to 2 cm (left), clavicle angle from -14 degrees to 5 degrees , PT bending correction from 0 to 100% and T1 tilt from -15 degrees to 14 degrees . We introduced the first rib index (FRI), i.e., the difference between the diameter of right and left first rib arch as a percentage of the sum of both diameters, averaging from -22.7 to 14.3%. (Minus signs refer to or predict right, while positive left shoulder elevation.) Evaluation included all predictive parameters as related principally to postoperative left shoulder elevation > or =1 cm, patient satisfaction and surgeon fulfillment. Postoperative correction MT curve 53% (23-83%) and PT 35% (0-100%). One progressive paraplegic started 40 min following normal wake-up test. Immediate decompression, full recovery. Three cases with wound infection recovered after late removal of instrumentation. Loss of correction > or =10 degrees in five. Fifteen had postoperative persisting left shoulder elevation > or =1 cm. Seven of these expressed dissatisfaction. Statistically FRI proved valuable predictive factor always in combination with previously described signs. We concluded that a postoperative left shoulder elevation >/=2 cm is a potential cause of dissatisfaction and may be prevented with thorough validation of all predictive signs, principally the FRI.

Oxygen costs using a reciprocating gait orthosis in a paraplegic (T9) patient with a bilateral below-knee amputation: case report.

The Reciprocating Gait Orthosis (RGO) is a useful aid to ambulation for patients with paraplegia. Its use has been described previously though not in conjunction with limb prostheses. We report here the energy costs of ambulation of a patient, disabled by paraplegia at T9 and bilateral below-knee amputations, walking at her preferred rate using an RGO while gas exchange was measured by the Douglas bag method. Oxygen uptake (VO2) rose from 0.198 1 min-1 at rest to 0.582 1 min-1 in the last minute of exercise, representing a VO2 of 14.3 ml kg-1 min-1. During the fourth minute of ambulation, energy consumption was 30.44 J kg-1 s-1 with an energy cost of 4.17 J kg-1 m-1 at a velocity of 0.13 m s-1, Ambulation with this combination of disability is possible with the aid of limb prostheses and an RGO though it is slow and the energy expenditure as consumption per second and cost per metre are high.

[Costs and long-term results of plastic surgery treatment of decubitus ulcers in paraplegic patients]. / Aufwand und Langzeitergebnisse der plastisch-chirurgischen Behandlung von Dekubitalulzera bei Paraplegikern.

Costs and long-term results of plastic surgical procedures were evaluated in 17 paraplegics with a mean age of 39 years and Campbell-Grade 5 pressure sores. Seven sacral, nine ischial and one trochanteric ulcers were treated by myocutaneous or fasciocutaneous flaps. The mean hospitalization period was 82 days: up to 44 days in the plastic surgical department, 29 days in referring hospitals. During the follow-up period, averaging 18 (6 to 33) months, four patients suffered recurrences, all of them ischial sores. Evaluated regarding occupational resumption or duration of wheelchair mobility, eleven patients achieved full and two patients partial rehabilitation. The success rate justifies the operative procedures. Cost reduction by shortened hospitalization could be achieved through earlier transfer of patients to specialized units since preoperative preparation requires rarely more than one week and surgical relief can usually be achieved within a confined period of time. Orthopaedic deformities contributed to the majority of sores and to all recurrences.

Follow-up of paraplegic patients after comprehensive rehabilitation.

One hundred patients from a total of 239 paraplegic patients were surveyed after at least 6 months in community life in order to assess the value of the rehabilitation programme. The patients' average age was 24 years, and the highest neurological level being T1. All patients had received intensive care, the average time being 4.7 months. The results were similar to those described in the literature, but the lower socio-economic levels and the absence of comprehensive initial care in general hospitals soon after trauma were negative factors. It is concluded that (1) Brazil requires medical and paramedical staff with specific training for the acute phase in more Rehabilitation Centres; (2) that paraplegics are greatly benefited by a rehabilitation programme; (3) the Brazilian Social Security should sponsor the rehabilitation programme.

An update on the early management of traumatic paraplegia (nonoperative and operative management).

Both the spinal cord physician and the spinal surgeon must be fully cognizant of the alterations of functions in multiple systems of the body caused by a spinal cord injury. Complications can easily arise, particularly within the respiratory, urinary, and integumentary systems. Most are preventable if the medical and nursing staff are sufficiently knowledgeable to anticipate them and if the necessary equipment and facilities are available. Regionalization of care with early referral to a spinal cord injury center has become a cost-effective way to manage these patients. Only if their medical needs are met and complications are prevented will surgery, performed to allow early mobilization, really accomplish the desired result. This update reviews the current medical and surgical points of view concerning diagnosis, fracture classification, spinal stability, reduction and stabilization of the fracture deformity, and spinal canal decompression.