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.

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.

Predictors for Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage Who Completed In-Hospital Rehabilitation in a Single Institution.

BACKGROUND: Although many studies evaluated independent prognosis factors of functional outcome in patients with subarachnoid hemorrhage (SAH) at a suitable time point, some patients take a long time to get functional improvement. The purpose of this study is to evaluate predictors for functional outcome in SAH patients who underwent surgical clipping and in-hospital rehabilitation in our single institution using Modified Rankin Scale (MRS) and Barthel Index (BI). METHODS: Two-hundred fifty-one SAH patients were admitted to our hospital from January 2008 to December 2017. Of them, 144 patients who diagnosed aneurysmal SAH, underwent surgical clipping within 72 hours, and completed subsequent in-hospital rehabilitation were included in this study. We explored their clinical variables and evaluated the relationships between those factors and functional outcome using MRS and BI. RESULTS: In multivariate analysis, independent prognostic factors of both MRS and BI were age, World Federation of Neurologic Surgeons grade, and symptomatic vasospasm. CONCLUSIONS: We suggest that age, SAH severity, and symptomatic vasospasm are associated with functional outcome in patients with aneurysmal SAH who completed surgical clipping and in-hospital rehabilitation.

Neuro-ICU patient disposition: optimal venue for acute needs.

PURPOSE OF REVIEW: This article revises the recent evidence on ICU admission criteria for acute neurological patients [traumatic brain injury (TBI) patients, postoperative neurosurgical procedures and stroke]. RECENT FINDINGS: The appropriate utilization of ICU beds is essential, but it is complex and a challenge to attain. To date there are no widely accepted international guidelines for managing these acute brain-injured patients (stroke, TBI, postneurosurgery) in the ICU. The criteria for ICU admission after neurological acute injury, high-dependency unit or a specialized neurosurgical ward vary from institution to institution depending on local structures and characteristics of the available resources. Better evidence to standardize the treatment and the degree of monitoring is needed during neurological acute injury. It is highly recommended to implement clinical vigilance in these patients regardless of their destination (ICU, stroke unit or ward). SUMMARY: Currently evidence do not allow to define standardized protocol to guide ICU admission for acute neurological patients (TBI patients, postoperative neurosurgical procedures and stroke).

Unmet need for specialised rehabilitation following neurosurgery: can we maximise the potential cost-benefits?

OBJECTIVE: To identify the needs for specialised rehabilitation provision in a cohort of neurosurgical patients; to determine if these were met, and to estimate the potential cost implications and cost-benefits of meeting any unmet rehabilitation needs. METHODS: A prospective study of in-patient admissions to a regional neurosurgical ward. Assessment of needs for specialised rehabilitation (Category A or B needs) was made with the Patient Categorisation Tool. The number of patients who were referred and admitted for specialised rehabilitation was calculated. Data from the unit's submission to the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database 2012-2015 were used to estimate the potential mean lifetime savings generated through reduction in the costs of on-going care in the community. RESULTS: Of 223 neurosurgical in-patients over 3 months, 156 (70%) had Category A or B needs. Out of the 105 patients who were eligible for admission to the local specialised rehabilitation service, only 20 (19%) were referred and just 11 (10%) were actually admitted. The mean transfer time was 70.2 (range 28-127) days, compared with the national standard of 42 days. In the 3-year sample, mean savings in the cost of on-going care were £568 per week. Assuming a 10-year reduction in life expectancy, the approximate net lifetime saving for post-neurosurgical patients was estimated as at least £600K per patient. We calculated that provision of additional bed capacity in the specialist rehabilitation unit could generate net savings of £3.6M/bed-year. CONCLUSION: This preliminary single-centre study identified a considerable gap in provision of specialised rehabilitation for neurosurgical patients, which must be addressed if patients are to fulfil their potential for recovery. A 5-fold increase in bed capacity would cost £9.3m/year, but could lead to potential net savings of £24m/year. Our findings now require confirmation on a wider scale through prospective multi-centre studies.

[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]. / Prolongiertes Weaning in der neurologisch-neurochirurgischen Frührehabilitation : S2k-Leitlinie herausgegeben von der Weaning-Kommission der Deutschen Gesellschaft für Neurorehabilitation e. V. (DGNR).

Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".

[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.

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.

Does an intraoperative finding of an intact dural sac help to prognosticate neurological recovery in cauda equinal and epiconal injuries in thoracolumbar fractures? An analysis of 31 patients.

OBJECTIVE: To evaluate the effect of integrity of dural sac in determining motor neurological recovery in patients with cauda equinal and epiconal injuries in vertebral fractures at thoracolumbar junction. METHODS: Thirty-one patients with single-level vertebra fracture over T12-L2 with cauda equinal or epiconal injuries that underwent posterior spinal decompression and stabilization were evaluated in the period between 2006 and 2012. All patients included had motor incomplete ASIA C in neurology and were either Type B or C (AO/Magerl classification) of fracture morphology. Radiologist opinion to confirm the level of conus in MRI was done preoperatively. Intraoperative findings with respect to intactness of dura was noted. All MRI images were postoperatively evaluated by an independent, blinded radiologist for evidence of dural breach caused by the trauma. All participants provided basic demographic data, ambulatory status, and current neurology and received neurologic examination at intervals. The differences in neurologic injury sites and functional walkers in patients with different levels of vertebral injury were analyzed. Receiver operating characteristic curve analysis was used to define the cut-off value of lower extremities motor score (LEMS) in functional walkers and non-walkers. All patients were seen at a postoperative follow-up of minimum 18 months. RESULTS: Data of the 31 patients were analyzed. Seventeen patients (55%) had epiconus and lumbar roots lesions and 14 (45%) had cauda equina lesions. The injury was at the T12 vertebra in 9 patients (29%), L1 in 12 (39%) and in L2 in 10 patients (32%). Mean LEMS for patients with T12, L1, and L2 fractures were calculated. Fourteen patients had intraoperative findings of intact dura as against 17 patients with dural breach. MRI images when revisited by an independent radiologist by keeping him blind about the intraoperative surgeons findings showed statistically very good interobserver agreement (κ = 0.618) with regard to integrity of the dural sac. Postoperative neurological assessment at minimum 18 months follow-up showed that four out of the 14 patients with intact dura were walkers (28%) whereas of the 17 patients with dural breach, 13 were walkers (82%). CONCLUSION: Neurological recovery in cauda equinal and epiconal injuries in thoracolumbar fractures is significantly less likely in an intact dural sac, probably because the dural breach prevents the roots to take as much impact as compared to an intact dural sac.

[Course of rehabilitation in early neurological/neurosurgical rehabilitation. Results of a 2014 multi-center evaluation in Germany]. / Rehabilitationsverlauf von Patienten in der neurologisch-neurochirurgischen Frührehabilitation.

BACKGROUND: In Germany, neurological-neurosurgical early rehabilitation is well established in the treatment of severe neurological diseases. To develop quality standards, knowledge of the current rehabilitation course is required. PATIENTS AND METHODS: A retrospective analysis was performed on the course of rehabilitation from patients in an early neurological/neurosurgical rehabilitation program in 16 centers from 10 German states. The odds for a good or poor outcome were investigated using a multivariate logistic regression model. RESULTS: Seven hundred and fifty-four patients were included in the study. The average age of the patients was 68 ± 15 years. Of the patients studied, 26 % were on mechanical ventilation commencing their neurological rehabilitation. The average duration of stay was 56 ± 51 days. Weaning rate from mechanical ventilation was 65 % and the rate of weaning from tracheal cannula was 54 %. Mean improvement in the Barthel Index of 17 points, significant reduction of dysphagia (from 62 to 30 %) and depended walking (from 99 to 82 %), and the achievement of phase C (the next stage of rehabilitation) in 38 % can still be counted as signs of successful rehabilitation. During their course of stay, near 10 % of the patients died. Of these, 67 % received solely palliative care. In the multivariate logistic models, the absence of the factor "necessity for mechanical ventilation on admission" (odds ratio 0.61; 95 % confidence interval (CI): 0.42 … 0.89) increased the chance for good outcome and the presence of this factor the risk of dying with an odds ratio of 8.07 (95 % CI: 4.54-14.34). DISCUSSION: In spite of the severity of neurological deficits, significant functional progress has been made. These results could be interpret as positive proof of the efficacy of neurological/neurosurgical early rehabilitation programs.