Systematic and integrative reviews: synthesising evidence for community nursing practice.

Ease of access to vast amounts of information presents significant opportunities and challenges for nurses in the community as they seek to base their practice on the best available evidence. Growing expectations around evidence-based practice have developed alongside developments in evidence synthesis, which adopts robust approaches to identifying, appraising and synthesising key evidence for clinical decision-making. The context in which evidence-based practice occurs is key, and this article discusses the skills and knowledge needed for community nurses to discern how evidence and information should influence their decisions to review and change approaches to clinical practice. Importantly, if nurses understand the status of evidence underpinning areas of practice, they can ensure that the preferences and needs of patients and families are met.

Awake Intradural Spinal Tumor Resection; Case Report and Literature Review.

BACKGROUND: Meningioma is a common slow-growing spinal tumor with a predilection for intradural occurrence. Patients usually present with pain followed by ataxia and sensory and sphincter problems. The gold standard treatment in these cases is gross total microsurgical resection under general anesthesia. However, there exist high-anesthetic-risk patients unsuitable for general anesthesia. Performing spinal surgeries under local anesthesia and sedation has been reported, albeit rarely for mostly minimally invasive procedures but not for open intradural pathologies. CASE DESCRIPTION: We report a 63-year-old woman with critical aortic stenosis, coronary artery disease, and severe chronic obstructive airways disease who presented with 10 months' history of worsening back pain and bilateral leg pain, ataxia, hyperreflexia in lower limbs, as well as altered lower limb sensation. Magnetic resonance imaging revealed a contrast-enhancing intradural lesion at T6/7 with severe spinal cord compression. However, the patient was American Society of Anesthesiologists class IV and her cardiac disease was not amenable to intervention. She underwent thoracic laminectomy and excision of the tumor under local anesthesia and sedation with no significant complications and clinical improvement. CONCLUSION: Our illustrative case and literature review suggest that using local anesthesia and sedation to perform spinal surgeries including intradural tumors is possible even in high-risk patients with good outcome. Our American Society of Anesthesiologists class IV patient tolerated the surgery well with gross total tumor resection and subsequent resolution of the symptoms.

Cervical ependymoma in a male adolescent with neck and back pain.

OBJECTIVE: This case study addresses the clinical presentation, imaging manifestations, and management of an intramedullary ependymoma in an adolescent who presented for chiropractic evaluation with severe neck and back pain. The atypical manifestations of this disorder are emphasized. CLINICAL FEATURES: A 16-year-old male adolescent presented with severe neck and back pain and diffuse paresthesia extending into the dorsum of the forearm and wrist bilaterally. Magnetic resonance imaging revealed an intramedullary mass extending from C1 to C7. Biopsy of this lesion indicated a grade III intramedullary ependymoma. INTERVENTION AND OUTCOME: The patient underwent a successful resection of the tumor with minimal neurological deficit. At 4 months after resection, the follow-up examination yielded minimal discomfort in the neck and upper back, however there was severe cervical kyphosis. Postoperative magnetic resonance imaging revealed no evidence of intramedullary lesion. CONCLUSION: Although it is a rare and slow growing neoplasm, early detection is critical for optimal postoperative functional outcome that is directly related to the preoperative functional status.

Ependymoma of the spinal cord presenting in a chiropractic practice: 2 case studies.

OBJECTIVE: The purpose of this study is to discuss the cases of 2 patients with previously undiagnosed primary spinal cord tumors presenting in a private chiropractic clinical setting. An overview of treatment and outcome for an ependymoma at T12-L1 and L1-L2 is discussed. CLINICAL FEATURES: One patient was a 46-year-old Hispanic woman with 3 to 4 years of intermittent backache that usually resolved with conservative care but failed to do so during an acute episode. Lower motor neuron signs, including bowel and bladder dysfunction, were revealed upon clinical assessment. The second patient, a 38-year-old white man under routine treatment, had no lower motor neuron signs or symptoms. INTERVENTION AND OUTCOME: Both patients were referred, one to a local hospital emergency department and the other directly to a neurosurgeon. Both underwent surgery. Upon returning home, the first patient received follow-up treatment primarily consisting of radiation therapy. Follow-up telephone interviews (3, 6, 12, 24, and 40 months) revealed the patient doing well. The second case did not require radiation therapy and was doing well at 4, 10, 12, and 18 months; the patient returned for unrelated treatment 1 year after the surgery. CONCLUSION: These cases show that with a careful history and patient examination, enough clinical data may be gathered to make an accurate health care determination under various conditions. It also illustrates the importance of interprofessional cooperation for various disciplines of health care providers regardless of training or specialty.

Disseminated pilocytic astrocytoma involving brain stem and diencephalon: a history of atypical eating disorder and diagnostic delay.

The association of weight loss and pediatric brain tumors that affect the diencephalon or brain stem with weight loss is a recognized, but not fully understood phenomenon. Tumors located in the hypothalamic region may induce the diencephalic syndrome (DS), which is characterized by profound emaciation with almost complete loss of subcutaneous fatty tissue. Tumors that compress or infiltrate the brain stem rarely cause both psychological disturbance and emaciation. The clinical presentation may be different, depending on the location of the lesion and age of the patient. In this report we present an unusual case of severe emaciation in a 4(9)/(12)-year-old girl with a juvenile pilocytic astrocytoma of the hypothalamic region and brain stem with neuroaxis dissemination. This case illustrates the importance of considering intracranial mass-lesions in the differential diagnosis of weight loss, psychological disturbance and atypical eating disorder. We discuss the importance of tumor multifocality and the role of patient age in the clinical presentation with reference to the literature.

Schwannoma: challenging diagnosis.

OBJECTIVE: To discuss the presentation of a schwannoma in a 30-year-old man and to discuss the clincial features of this tumor. CLINICAL FEATURES: The patient had lower right back and abdominal pain that was made worse by any jarring motion. Magnetic resonance imaging showed an intradural extramedullary mass of the thoracic spine behind the T10 vertebral body, which was found to be a schwannoma. INTERVENTION AND OUTCOME: A full laminectomy of T10 and partial laminectomies of T9 and T11 allowed removal of the tumor. CONCLUSION: When undiagnosed abdominal pain is present, spinal tumor should be considered one possible diagnosis.

Consequences of neck manipulation performed by a non-professional.

Case report. Documentation of complication of neck manipulation by an untrained person. Tertiary care referral teaching hospital at Lucknow, India. Clinical evaluation, plain radiography of cervical spine, spinal MRI.A 30-year-old man who fainted after neck manipulation by a barber and developed spinal cord and brainstem dysfunction. His MRI revealed an extramedullary, intradural dumbbell shaped mass on the right side at C1 and C2 level compressing the spinal cord. Public awareness should be increased about the danger of neck manipulation by an untrained person especially in the communities where it is commonly practiced.

The surgical treatment of acute spinal paralysed patients.

Following the basic principles of Sir Ludwig Guttmann in respect of the comprehensive care and management of spinal cord injured patients, the German SCI centers try to admit those freshly injured preferably on the first day of onset, providing spinal surgery and intensive care. In our series of recent comprehensive spinal paralysed patients admitted from Jan 1st 1993 to Dec 31st 1995 178 patients requested operative decompression and stabilization out of a total of 255 patients. 51.4% of the patients had been operated within the first 24 h, but 10.5% later than 2 weeks. A high incidence of reoperations (45.2%) must be noted in cases operated prior to the admittance to the SCI center due to failures of instrumentation or lack of anterior reconstruction. Nineteen patients with various spinal tumors underwent surgical treatment, and seven patients with spondylitis and severe neurological deficit. Only 64.4% of the 1st day admissions came in time for administration of high dose methylprednisolone according to the NASCIS II study. The additional pelvic and long bone fractures were operated on following the principles of the Swiss AO, thus achieving immediate mobilization as was also possible after surgical spine stabilization. Neurological recovery could only be found in those with incomplete lesions in more than 50% but also two with neurological deterioration had to be accepted in the paraplegic cohort. Eight who were tetraplegic and 14 with paraplegia died within the first 3 months, but nine with paraplegia had a tumor or spondylitis.

Magnetic resonance detection of myelodysplasia in children with Currarino triad.

PURPOSE: To evaluate the role of MRI in the detection of myelodysplasia in children with Currarino triad. MATERIALS AND METHODS: Six patients (two girls, four boys, aged 7 months-14 years, mean age 6 years) were studied with MRI, voiding cystourethrogram and barium enema or fistulography. CT and ultrasonography were also performed in two patients. RESULTS: All patients presented with partial agenesis of the sacrum. Three patients suffered from an intermediate form of anorectal malformation (ARM) and three had a high form of ARM. The presacral masses consistent with Currarino triad included anterior meningocoele in three patients, lipoma in two patients and anterior lipomeningocoele in one patient. MRI diagnosed tethering of the spinal cord in four of six patients. The tethering of the spinal cord was due to a lipomeningocoele in one patient, an intradural lipoma in one patient and a lipoma of the filum in two patients. CONCLUSION: The association of Currarino triad with tethered spinal cord seems more common than generally reported in the literature. Preoperative MRI of the lumbosacral spine is essential to detect significant myelodysplasia in all patients with Currarino triad.

Quadriplegia after chiropractic manipulation in an infant with congenital torticollis caused by a spinal cord astrocytoma.

An infant with congenital torticollis underwent chiropractic manipulation, and within a few hours had respiratory insufficiency, seizures, and quadriplegia. A holocord astrocytoma, with extensive acute necrosis believed to be a result of the neck manipulation, was found and resected. We believe that every child with torticollis, regardless of age, should undergo neurologic and radiologic evaluation before any form of physical treatment is instituted.

Electrocardiographic artifact with a transcutaneous electrical nerve stimulation unit.

We describe an unusual electrocardiographic artifact in a patient with a transcutaneous electrical nerve stimulation unit. The artifact, consisting of low amplitude high frequency deflections, can be misinterpreted as a runaway pacemaker.

Extradural implantation of sacral anterior root stimulators.

A technique for extradural deafferentation of the S2 to S5 segments and extradural implantation of stimulating electrodes is described, and its application to twelve patients with spinal cord lesions is reported. Nine patients use their implants for micturition, and seven are fully continent. The advantages and disadvantages of this technique compared with the more usual intrathecal procedure are discussed.

[The management of urinary and fecal incontinence due to a neurinoma of the cauda equina with an electrode implanted in the pelvic muscles (Caldwell) (author's transl)]. / Die Beckenbodenimplantatelektrode (Caldwell) zur Behandlung von Harn- und Stuhlinkontinenz nach Caudaneurinom (Fallbericht).

A woman, aged 49, had a complete sensory and motor deficit of the S2-5 segments with urinary and fecal incontinence due to a neurinoma of the cauda. A Caldwell electrode was implanted surgically into the muscles of the pelvic floor in April 1974. The patient was observed for 2 years thereafter and had an excellent result. The medical and technical problems of treating urinary and fecal incontinence due to a lower motor neuron lesion of S2-5 can be handled satisfactorily with an implanted electrode.

[Treatment of Spastic Gait Disorders Using an "Electro-Gait-Stimulator ("Schrittstimulator") (author's transl)]. / Zur Elektrobehandlung der spastischen Gangstörung mit einem "Schrittstimulator"

A short historical outline of electric treatment of spasticity is given. A specially developed management with a "gait-stimulator" is described. Four muscles of each lower extremity being mainly engaged in walk were electrically stimulated in the physiological sequences according to the normal gait. The used electric impulses were of a duration of 0,25 msec and an intensity up to 700 V. Using such a "gain-stimulator" in spastic-paraparetic patients a reduced spasticity has been achieved. Positive effect of this treatment has been mostly pronounced, when the programming of impulses was adjusted to the end of the expected physiological contraction of the corresponding muscles. Physiological and pathological data of the "Silent period" is proposed to be mostly involved. The application of impulses in physiological sequences seems to reactivate normal reflex - mechanisms which are disturbed by supraspinal laesion. The results indicate that the electric impulses activates muscle-sensory - organs and that impulses on these organs produce a pace-making function on the spinal cord, which lessens spasticity.