Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS).

BACKGROUND: The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. METHODS: A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. RESULTS: A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). CONCLUSIONS: This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Safety-Net Hospitals Have Higher Complication and Mortality Rates in the Neurosurgical Management of Traumatic Brain Injuries.

BACKGROUND: Clinical outcomes in the surgical management of severe traumatic brain injury (TBI) have been shown to vary across different hospital institutions. The effect of the safety-net burden on postoperative mortality, complication rates, and failure to rescue rates is unclear. We evaluated the relationship of the safety-net burden with outcomes in the treatment of patients with severe TBI undergoing neurosurgery. METHODS: The hospitals were grouped according to their safety-net burden, defined as the proportion of Medicaid and uninsured patient charges for all hospitalizations during that time. Multivariate analyses were performed to examine significant associations with the degree of safety-net burden while controlling for potential confounders. RESULTS: Data from 20,989 encounters in 788 hospitals were included. Compared with low-burden hospitals (LBHs), high-burden hospitals (HBHs; odds ratio [OR], 1.48; 95% confidence interval [CI], 1.04-2.12; P = 0.03) had greater mortality rates. Major complications were more likely to occur at HBHs (OR, 1.44; 95% CI, 1.12-1.84; P < 0.01) compared with LBHs. The failure to rescue rates were similar among all safety-net burden hospital groups. Patients at HBHs also had an increased likelihood of an extended length of stay (OR, 1.92; 95% CI, 1.12-3.29; P = 0.02) and receiving a tracheostomy or gastrostomy (OR, 1.99; 95% CI, 1.36-2.89; P < 0.01) compared with patients at LBHs. CONCLUSIONS: The present study found that a greater hospital safety-net burden was independently associated with greater rates of mortality and major complications in the treatment of patients with severe TBI undergoing neurosurgery. Further research in evaluating the cause of disparities in mortality outcomes at high safety-burden hospitals is needed.

Clinical and radiological observation in a surgical series of 36 cases of fibrous dysplasia of the skull.

OBJECTIVES: To describe the clinical and radiological findings in a consecutive series of patients diagnosed with fibrous dysplasia of the skull. PATIENTS AND METHODS: A retrospective analysis of collected data for 36 patients with histopathologically confirmed fibrous dysplasia involving the skull is presented. The demographic data, clinical presentation, radiographic characteristics, and the management of these patients were reviewed. RESULTS: All 36 patients in this review were diagnosed with fibrous dysplasia involving at least part of the skull. In this study, the most commonly involved area of the skull was the frontal bone (52.78% of patients). The next most common area of skull was the temporal bone (30.56% of patients), followed by the sphenoid bone (25% of patients), the parietal bone (19.44% of patients), and orbital bone (13.89% of patients). The principal clinical presentation included headache, local lump, exophthalmos, visual disorder, cranial nerve paralysis, and facial malformation. These patients were treated by surgical treatment, and several of our patients underwent various degrees of reconstruction to optimize function. CONCLUSIONS: Effective surgical treatment may improve the short-term outcome in these patients, and a "tailored" surgical approach is necessary.

Clinical examination is highly sensitive for detecting clinically significant spinal injuries after gunshot wounds.

BACKGROUND: The optimal method for spinal evaluation after penetrating trauma is currently unknown. The goal of this study was to determine the sensitivity and specificity of a standardized clinical examination for the detection of spinal injuries after penetrating trauma. METHODS: After Institutional Review Board approval, all evaluable penetrating trauma patients aged 15 years or more admitted to the Los Angeles County + University of Southern California Medical Center were prospectively evaluated for spinal pain, tenderness to palpation, deformity, and neurologic deficit. RESULTS: During the 6-month study period, 282 patients were admitted after sustaining a penetrating injury; 143 (50.7%) as a result of gunshot wound (GSW) and 139 (49.3%) as a result of stab wound (SW). None of the patients sustaining a SW had a spinal injury. Of the 112 evaluable GSW patients, 9 sustained an injury: 6 with a true-positive and 3 with a false-negative clinical examination. The overall sensitivity, specificity, positive predictive value, and negative predictive value were 66.7%, 89.6%, 46.2% and 95.2%, respectively. For clinically significant injuries requiring surgical intervention, cervical or thoracolumbar spine orthosis, or cord transections, however, the sensitivity of clinical examination was 100.0%, specificity 87.5%, positive predictive value 30.8%, and negative predictive value 87.5%. CONCLUSION: Clinically significant spinal injury, although rare after SWs, is not uncommon after GSWs. A structured clinical examination of the spine in evaluable patients who have sustained a GSW is highly reliable for identifying those with clinically significant injuries.

Novel diffusion tensor imaging methodology to detect and quantify injured regions and affected brain pathways in traumatic brain injury.

PURPOSE: To develop and apply diffusion tensor imaging (DTI)-based normalization methodology for the detection and quantification of sites of traumatic brain injury (TBI) and the impact of injury along specific brain pathways in (a) individual TBI subjects and (b) a TBI group. MATERIALS AND METHODS: Normalized DTI tractography was conducted in the native space of 12 TBI and 10 age-matched control subjects using the same number of seeds in each subject, distributed at anatomically equivalent locations. Whole-brain tracts from the control group were mapped onto the head of each TBI subject. Differences in the fractional anisotropy (FA) maps between each TBI subject and the control group were computed in a common space using a t test, transformed back to the individual TBI subject's head space, and thresholded to form regions of interest (ROIs) that were used to sort tracts from the control group and the individual TBI subject. Tract counts for a given ROI in each TBI subject were compared to group mean for the same ROI to quantify the impact of injury along affected pathways. The same procedure was used to compare the TBI group to the control group in a common space. RESULTS: Sites of injury within individual TBI subjects and affected pathways included hippocampal/fornix, inferior fronto-occipital, inferior longitudinal fasciculus, corpus callosum (genu and splenium), cortico-spinal tracts and the uncinate fasciculus. Most of these regions were also detected in the group study. CONCLUSIONS: The DTI normalization methodology presented here enables automatic delineation of ROIs within the heads of individual subjects (or in a group). These ROIs not only localize and quantify the extent of injury, but also quantify the impact of injury on affected pathways in an individual or in a group of TBI subjects.

Brain lobectomy for severe head injuries is not a hopeless procedure.

INTRODUCTION: Posttraumatic transtentorial herniation or intractable intracranial hypertension are ominous signs, and are associated with very poor outcomes. Aggressive procedures, such as brain lobectomies, may benefit some of these patients. The published experience with brain lobectomies is very limited. PATIENTS: Retrospective study of head injury patients with focal brain lesions and intractable intracranial hypertension or herniation who underwent partial or anatomic brain lobectomies. The following parameters were included in the analysis: age, gender, mechanism of injury, hypotension at admission, initial Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale for head, chest, and abdomen, Injury Severity Score, time from admission to operation, type of brain lobectomy, intensive care unit and hospital stays, survival, and Glasgow Outcome Score. Stepwise logistic regression analysis was used to identify independent risk factors for mortality and functional outcomes. RESULTS: During the 13-year study period, there were 183 patients who underwent brain lobectomy for traumatic injuries. Eighty-eight patients (48.1%) underwent frontal lobectomy, 67 (36.6%) temporal lobectomy, and the remaining 28 (15.3%) other or combination lobectomies. The mean follow-up was 22 days. There were 50 deaths (mortality 27.3%). Excluding patients with major extracranial injuries, there were 47 deaths (26.9%). Patients with blunt trauma had a significantly higher mortality than those with penetrating trauma had (33.1% vs. 12.0%, p = 0.005). Among the risk factors studied, blunt injury mechanism was identified as the only risk factor for mortality. Overall, 48% of the 133 survivors had good functional outcomes, and 51.9% had poor functional outcomes (including 15.0% with persistent vegetative state). Multiple-response logistic regression identified blunt trauma, low initial GCS score, and frontal lobectomy as independent risk factors for poor outcomes. CONCLUSION: Selected severe head injury patients with focal brain lesions and intractable intracranial hypertension or herniation may benefit from brain lobectomies. The survival and functional outcomes after this procedure are acceptable. Blunt trauma, low initial GCS score, and frontal lobectomies are significant risk factors for poor outcomes.

Hypertrophic mononeuropathy.

Hypertrophic localized mononeuropathy is a condition that comes to clinical attention as a painless focal swelling of a peripheral nerve in an arm or leg and is associated with a slow but progressive loss of motor and sensory function. Whether the proliferation of perineurial cells is neoplastic or degenerative--an ongoing controversy among nerve pathologists--for some patients resection of the involved portion of a nerve with autologous interposition grafting results in better functional outcome than allowing disease to follow its natural course. Patients with a painless focal enlargement of a nerve associated with progressive weakness and/or sensory loss may benefit from surgery for resection and grafting.

A chronically implantable, hybrid cannula-electrode device for assessing the effects of molecules on electrophysiological signals in freely behaving animals.

We describe a device for assessing the effects of diffusible molecules on electrophysiological recordings from multiple neurons. This device allows for the infusion of reagents through a cannula located among an array of micro-electrodes. The device can easily be customized to target specific neural structures. It is designed to be chronically implanted so that isolated neural units and local field potentials are recorded over the course of several weeks or months. Multivariate statistical and spectral analysis of electrophysiological signals acquired using this system could quantitatively identify electrical "signatures" of therapeutically useful drugs.

Surgical management of head trauma.

In addition to its inability to predict pressure elevation accurately, head CTs done serially even at 12-hour intervals, cannot adequately portray the dynamic, sometimes rapid evolution (usually growth) of a traumatic hematoma. These limitations aside, CT scanning provides adequate imaging for rational surgical treatment of head injury. Whether for monitoring, diagnostic, or therapeutic purposes, cranial procedures for traumatic pathology are guided by CT.

Three-layer reconstruction for large defects of the anterior skull base.

OBJECTIVES: To evaluate and discuss a three-layer rigid reconstruction technique for large anterior skull base defects. STUDY DESIGN: Prospective, nonrandomized, non-blinded. SETTING: Tertiary teaching medical center. METHODS: Twenty consecutive patients underwent craniofacial resection for a variety of pathology. All patients had large anterior cranial base defects involving the cribriform plate, fovea ethmoidalis, and medial portion of the roof of the orbit at least on one side. A few patients had more extensive defects involving both roof of the orbits, planum sphenoidale, and bones of the upper third of the face. The defects were reconstructed with a three-layer technique. A watertight seal was obtained with a pericranial flap separating the neurocranium from the viscerocranium. Rigid support was provided by bone grafts fixed to a titanium mesh, anchored laterally to the orbital roofs. All patients had a computed tomography scan of the skull on the first or second postoperative day. Patients were observed for immediate and long-term postoperative complications after such reconstruction. RESULTS: Postoperative computed tomography scans showed small pneumocephalus in all patients. It resolved spontaneously and did not produce neurologic deficits in any patient. There was no cerebrospinal fluid leak, hematoma, or infection. On long-term follow-up, exposures of bone graft or mesh, brain herniation, or transmission of brain pulsation to the eyes were not observed in any patient. CONCLUSIONS: Three-layer reconstruction using bone grafts, titanium mesh, and pericranial flap provides an alternative technique for repair of large anterior cranial base defects. It is safe and effective, and provides rigid protection to the brain.