Management of glioblastoma in elderly patients: A review of the literature.

High grade gliomas are the most common primary aggressive brain tumours with a very poor prognosis and a median survival of less than 2 years. The standard management protocol of newly diagnosed glioblastoma patients involves surgery followed by radiotherapy, chemotherapy in the form of temozolomide and further adjuvant temozolomide. The recent advances in molecular profiling of high-grade gliomas have further enhanced our understanding of the disease. Although the management of glioblastoma is standardised in newly diagnosed adult patients there is a lot of debate regarding the best treatment approach for the newly diagnosed elderly glioblastoma patients. In this review article we attempt to summarise the findings regarding surgery, radiotherapy, chemotherapy, and their combination in order to offer the best possible management modality for this group of patients. Elderly patients 65-70 with an excellent functional level could be considered as candidates for the standards treatment consisting of surgery, standard radiotherapy with concomitant and adjuvant temozolomide. Similarly, elderly patients above 70 with good functional status could receive the above with the exception of receiving a shorter course of radiotherapy instead of standard. In elderly GBM patients with poorer functional status and MGMT promoter methylation temozolomide chemotherapy can be considered. For elderly patients who cannot tolerate chemotherapy, hypofractionated radiotherapy is an option. In contrast to the younger adult patients, it seems that a careful individualised approach is a key element in deciding the best treatment options for this group of patients.

Concept and Evolution in 3-D Printing for Excellence in Healthcare.

Three-dimensional printing (3DP) has gained popularity among scientists and researchers in every field due to its potential to drastically reduce energy costs for the production of customised products by utilising less energy-intensive machines as well as minimising material waste. The 3D printing technology is an additive manufacturing approach that uses material layer-by-layer fabrication to produce the digitally specified 3D model. The use of 3D printing technology in the pharmaceutical sector has the potential to revolutionise research and development by providing a quick and easy means to manufacture personalised one-off batches, each with unique dosages, distinct substances, shapes, and sizes, as well as variable release rates. This overview addresses the concept of 3D printing, its evolution, and its operation, as well as the most popular types of 3D printing processes utilised in the health care industry. It also discusses the application of these cutting-edge technologies to the pharmaceutical industry, advancements in various medical fields and medical equipment, 3D bioprinting, the most recent initiatives to combat COVID-19, regulatory frameworks, and the major challenges that this technology currently faces. In addition, we attempt to provide some futuristic approaches to 3DP applications.

Magnetically Recyclable Nanoscale Zero-Valent Iron-Mediated PhotoRDRP in Ionic Liquid toward Smart, Functional Polymers.

A facile method based on recyclable nanoscale zero-valent iron (nZVI)-mediated photoinduced reversible deactivation radical polymerization in ionic liquid (IL) leads to the synthesis of narrow disperse poly(tert-butyl methacrylate) (PTBMA), amphiphilic PTBMA-block-poly(poly(ethylene glycol)methacrylate) diblock copolymer and double hydrophilic poly(methacrylic acid)-block-poly(poly(ethylene glycol)methacrylate) (PMAA-b-PPEGMA) diblock copolymers thereof. Stimuli response of the synthesized PMAA-b-PPEGMA diblock copolymer against variation in pH and temperature is assessed. Recyclability of the nZVI (catalyst) and IL (solvent) is established. Polymerization may be switched ON or OFF, simply by turning the UVA light irradiation ON or OFF, offering temporal control. The diblock copolymer self-aggregates into spherical nanoaggregates which are employed for encapsulation of coumarin 102 (C102, a typical hydrophobic dye), describing their potential application in drug delivery applications. The facile synthesis strategy may open up new avenues for the preparation of intelligent functional polymers for engineering and biomedical applications.

Consistency of Radiological Grading of Cervical Foraminal Stenosis.

BACKGROUND: The degree of cervical foraminal stenosis on MRI scans may be measured and categorised using the Kim or modified Kim methods. These grading scales have not previously been validated in a cohort of patients awaiting surgery. OBJECTIVES: To establish the normal foraminal and root diameters as well as the consistency of inter and intra-rater grading using the Kim and modified Kim grading systems in pre-operative surgical patients. METHODS: Asymptomatic cervical nerve roots and foramina demonstrated on the pre-operative MRI scans of adult surgical patients with cervical radiculopathy were measured and categorised by six raters using the Kim and modified Kim grading methods. Repeat "second pass" measurements were made by the same assessors on the same images a minimum of one month later. RESULTS: Foraminal diameters (mm) in asymptomatic foramina were C2/C3 (mean±SD): 4.18±1.44, C3/C4 2.96±1.23, C4/C5 3.02±1.19, C5/C6 3.15±1.33, C6/C7 3.53±1.36, C7/T1 3.93±1.34. Nerve root diameters were C3 3.11±0.87, C4 2.95±0.77, C5 2.56±0.73, C6 2.26±0.76, C7 2.56±0.82, C8 3.83±0.86. Inter-rater consistency was kappa [95% CI]: Kim 0.01 [0.00, 0.03], modified Kim 0.08 [0.05, 0.10]. Intra-rater consistency was kappa [95% CI]: Kim 0.81 [0.77, 0.86], modified Kim 0.69 [0.62, 0.76]. CONCLUSION: There was poor inter-rater consistency but good intra-rater consistency when assessing the severity of foraminal stenosis on axial T2 MRI scans. Foraminal diameter was narrowest at C3/C4 and C4/C5, whereas the smallest root diameter was C5/C6. Volumetric or oblique MR may improve consistency.

Strategies for ensuring required service level for COVID-19 herd immunity in Indian vaccine supply chain.

Post COVID-19 vaccine development, nations are now getting ready to face another challenge: how to effectively distribute vaccines amongst the masses to quickly achieve herd immunity against the infection. According to some experts, herd immunity for COVID-19 can be achieved by inoculating 67% of the population. India may find it difficult to achieve this service level target, owing to several infrastructural deficiencies in its vaccine supply chain. Effect of these deficiencies is to cause frequent lead time disruptions. In this context, we develop a novel modelling approach to identify few nodes, which require additional inventory allocations (strategic inventory reserves) to ensure minimum service level (67%) under the possibility of lead time disruptions. Later, through an illustrative case study on distribution of Japanese Encephalitis vaccine, we identify conditions under which strategic inventory reserve policy cannot be practically implemented to meet service level targets. Nodes fulfilling these conditions are termed as critical nodes and must be overhauled structurally to make the implementation of strategic inventory policy practically viable again. Structural overhauling may entail installation of better cold storage facilities, purchasing more quality transport vans, improving reliability of transport network, and skills of cold storage manager by training. Ideally, conditions for identifying critical nodes for COVID-19 vaccine distribution must be derived separately by substituting COVID-19 specific parametric values in our model. In the absence of the required data for COVID-19 scenario, JE specific criteria can be used heuristically to identify critical nodes and structurally overhaul them later for efficiently achieving service level targets.

Biosensors as Nano-Analytical Tools for COVID-19 Detection.

Selective, sensitive and affordable techniques to detect disease and underlying health issues have been developed recently. Biosensors as nanoanalytical tools have taken a front seat in this context. Nanotechnology-enabled progress in the health sector has aided in disease and pandemic management at a very early stage efficiently. This report reflects the state-of-the-art of nanobiosensor-based virus detection technology in terms of their detection methods, targets, limits of detection, range, sensitivity, assay time, etc. The article effectively summarizes the challenges with traditional technologies and newly emerging biosensors, including the nanotechnology-based detection kit for COVID-19; optically enhanced technology; and electrochemical, smart and wearable enabled nanobiosensors. The less explored but crucial piezoelectric nanobiosensor and the reverse transcription-loop mediated isothermal amplification (RT-LAMP)-based biosensor are also discussed here. The article could be of significance to researchers and doctors dedicated to developing potent, versatile biosensors for the rapid identification of COVID-19. This kind of report is needed for selecting suitable treatments and to avert epidemics.

Llif in the correction of degenerative scoliosis in elderly patients / Llif na correção da escoliose degenerativa em pacientes idosos / Llif en la corrección de la escoliosis degenerativa en pacientes de la tercera edad

ABSTRACT Objective The incidence of adult degenerative scoliosis (ADS) among individuals over 50 years old can be as high as 68%. Surgical interventions aimed at correcting the spinal deformity in elderly patients are accompanied by a high risk of complications. The use of lateral lumbar interbody fusion (LLIF) is associated with lower rates of complications when compared with open anterior or posterior fusions. Methods Ninety-three patients with ADS (23 men, 70 women) were operated at the Federal Neurosurgical Center. The average age was 63 (52 to 73 years). Results Back pain, measured according to the Visual Analogue Scale (VAS), decreased from 5.9/6 (4;8) (format - mean/median (1;3 quartile)) to 2.6/3 (1;3) points (p <0.0001). Leg pain according to the VAS decreased from 4.6/4 (3;7) to 1.4/1 (0;2) points (p < 0.0001). Functional adaptation according to the Oswestry Disability Index (ODI) improved from 47.8±17.4 to 38.5±14.5 (p < 0.0273). Pelvic tilt (PT) before the surgery was 23.9±12.2° whereas at 12 months follow-up it was 16.8±5.9° (p < 0.0001). PI-LL mismatch pre surgery was 12.1/13 (9;16)° whereas 12 months later it was 7.9/8 (6;10)° (p = 0.0002). Conclusions Restoration of local sagittal balance in ADS patients by short-segment fixation using LLIF technology leads to a statistically significant improvement in quality of life and increased functional adaptation. A lower incidence of early and late postoperative complications, less intraoperative blood loss and shorter hospital stay makes LLIF, in combination with minimally invasive transpedicular fixation, the method of choice to correct ADS in elderly patients. Level of evidence IV; Case series.

RESUMO Objetivo A incidência de escoliose degenerativa do adulto (EDA) entre indivíduos acima de 50 anos, pode chegar a 68%. As intervenções cirúrgicas destinadas a corrigir a deformidade da coluna vertebral em pacientes idosos são acompanhadas por um alto risco de complicações. A fusão intersomática lombar por via lateral (LLIF) está associado a uma taxa menor de complicações em comparação com as fusões anteriores ou posteriores abertas. Métodos Noventa e três pacientes com EDA (23 homens, 70 mulheres) foram operados no Centro Federal de Neurocirurgia. A média de idade foi de 63 anos (52 a 73 anos). Resultados A dor nas costas, de acordo com a escala visual analógica (EVA) diminuiu de 5,9/6 (4; 8 quartis) (formato média/mediana [1; 3 quartis]) para 2,6/3 (1; 3 quartis) (p < 0,0001). A dor nas pernas, também de acordo com a EVA, diminuiu de 4,6/4 (3; 7 quartis) para 1,4/1 (0; 2 quartis) (p < 0,0001). A adaptação funcional, de acordo com o Índice de Incapacidade de Oswestry (ODI) melhorou de 47,8 ± 17,4 para 38,5 ± 14,5 (p < 0,0273). A inclinação pélvica (PT) antes da cirurgia era de 23,9 ± 12,2°, enquanto nos 12 meses de acompanhamento era de 16,8 ± 5,9 (p < 0,0001). A incompatibilidade pré-cirúrgica de IP-LL foi de 12,1/13 (9; 16), enquanto 12 meses depois foi de -7,9/8 (6; 10) (p = 0,0002). Conclusões A restauração do equilíbrio sagital local em pacientes com EDA por fixação de segmento curto, usando a tecnologia LLIF, proporciona melhora estatisticamente significativa na qualidade de vida e aumenta a adaptação funcional. A menor incidência de complicações pós-operatórias precoces e tardias, a menor perda sanguínea intraoperatória e menor tempo de internação possibilitam que a LLIF, em combinação com a fixação transpedicular minimamente invasiva, seja o método de escolha para corrigir a EDA em pacientes idosos. Nível de evidência IV; Série de casos.

RESUMEN Objetivo La incidencia de escoliosis degenerativa del adulto (EDA) entre individuos con más de 50 años puede llegar a 68%. Las intervenciones quirúrgicas destinadas a corregir la deformidad de la columna vertebral en pacientes del grupo de la tercera edad son acompañadas por un alto riesgo de complicaciones. La fusión intersomática lumbar por vía lateral (LLIF) está asociada a una tasa menor de complicaciones en comparación con las fusiones anteriores o posteriores abiertas. Métodos Noventa y tres pacientes con EDA (23 hombres, 70 mujeres) fueron operados en el Centro Federal de Neurocirugía. El promedio de edad fue de 63 años (52 a 73 años). Resultados El dolor de espalda, de acuerdo con la escala visual analógica (EVA) disminuyó de 5,9/6 (4; 8 cuartiles) (formato promedio/mediana [1; 3 cuartiles) para 2,6/3 (1; 3 cuartiles) (p <0,0001). El dolor en las piernas, también de acuerdo con EVA, disminuyó de 4,6/4 (3; 7 cuartiles) para 1,4/1 (0; 2 cuartiles) (p <0,0001). La adaptación funcional, de acuerdo con el Índice de Incapacidad de Oswestry (ODI) mejoró de 47,8 ± 17,4 para 38,5 ± 14,5 (p <0,0273). La inclinación pélvica (PT) antes de la cirugía era de 23,9 ± 12,2°, mientras que en los 12 meses de acompañamiento fue de 16,8 ± 5,9 (p <0,0001). La incompatibilidad prequirúrgica de IP-LL fue de 12,1/13 (9; 16), mientras que 12 meses después fue de -7,9/8 (6; 10) (p = 0,0002). Conclusiones La restauración del equilibrio sagital local en pacientes con EDA por fijación de segmento corto, usando la tecnología LLIF, proporciona mejora estadísticamente significativa en la calidad de vida y aumenta la adaptación funcional. La menor incidencia de complicaciones postoperatorias precoces y tardías, la menor pérdida sanguínea intraoperatoria y un menor tiempo de internación posibilitan que la LLIF, en combinación con la fijación transpedicular mínimamente invasiva, sea el método de elección para corregir la EDA en pacientes de la tercera edad. Nivel de evidencia IV; Series de casos.

Thirty-Day Mortality and Survival in Elderly Patients Undergoing Neurosurgery.

OBJECTIVES: With an aging population and advances in neuroanesthesia and critical care, an increasing subgroup of elderly patients have been undergoing neurosurgery. Of particular relevance is the cohort aged >80 years. The aim of the present study was to investigate the 30-day mortality and survival in this cohort after emergency and elective neurosurgery. METHODS: We performed a retrospective cohort study of all patients aged ≥70 years who had undergone a neurosurgical procedure from 2015 to 2017. The patient demographic data were identified, and independent predictors were found using logistic regression analysis. RESULTS: A total of 796 patients were included, of whom 622 were aged <80 years (group A) and 174 were aged >80 years (group B). Overall survival was 86.3% in group A and 79.9% in group B. The 30-day mortality between the elective (0.8%) and emergency (10.1%) patients was significantly different statistically (P < 0.001). Of the patients in groups A and B, 84.7% and 68.9% were discharged back to their usual residence, respectively. Logistic regression found emergency surgery to be an independent predictor of mortality. CONCLUSIONS: The current model for accepting elderly patients has been associated with good overall outcomes. The elderly should not be refused neurosurgery on the basis of their age alone. However, we applied fairly strict criteria, especially for those with subarachnoid hemorrhage, which should be factored into our results.

Giant spinal nerve sheath tumours - Surgical challenges: case series and literature review.

Background: Giant nerve sheath tumours (GNST) are rare and literature on their management is scant. Spinal GNST present as a surgical challenge due to the involvement of anatomical regions often outside the "comfort zone" of a spinal surgeon. This case series aims to identify challenges in the surgical management of GNSTs. Methods: Retrospective case note review of all spinal GNST cases from 2010 to 2016 managed in Sheffield Teaching Hospitals identified 8 patients, 3 of whom were incidental findings (kept under surveillance) and were excluded. 5 cases were treated surgically. Data collected included patient demographic, presenting symptom(s), radiological data, surgical approach to the tumour and challenges encountered, histopathology report and follow up. Results: Our cohort consisted entirely of females (N = 5) with a mean age of 56.4 years (range 45-70). Imaging studies and histopathological diagnoses confirmed 5 GNSTs (four benign schwannomas and one ganglioneuroma). A Single-stage anterior approach was adopted for three patients while a combined anterior-posterior approach was adopted for the remaining two. In one patient, a posterior approach was initially planned, but this was abandoned and converted to an anterior approach following onset of acute superior vena cava (SVC) syndrome secondary to SVC compression by the giant tumour on prone positioning of the patient. PET imaging of case 3 showed intense tracer uptake consistent with malignancy, however histology confirmed WHO grade 1 Schwannoma. The other three non-operated GNSTs are kept under yearly radiological and clinical surveillance. Conclusions: GNSTs are surgically challenging as they often invade territories that are beyond the comfort zone of one single specialty. A multidisciplinary approach with careful pre-operative surgical planning is recommended. Patients in whom a posterior approach is planned should have a trial of prone positioning pre-operatively. Careful interpretation of FDG-PET imaging is recommended due to the possibility of false positive result.

Spontaneous regression of retro-odontoid post traumatic cicatrix following occipitocervical fixation.

This case report describes a patient who presented with myelopathy secondary to a large retro-odontoid post traumatic cicatrix. The objective of this study was to discuss the clinical presentation, pathogenesis, imaging, and surgical management of pseudoarthrosis tissue mass associated with odontoid nonunion. Atlantoaxial subluxation (AAS) has been widely reported in patients with rheumatoid arthritis. AAS leads to repeated cycles of partial tear and repair of ligaments around the altantoaxial complex, resulting in the formation of periodontoid mass (pseudotumor). It is thought that formation of retro-odontoid post traumatic mass (cicatrix), in certain cases of odontoid fracture, is because of similar pathology. This is a retrospective review of case note. Here, the patient underwent posterior decompression through a C1-C2 laminectomy and occipitocervical (C0-C4) fusion with instrumentation, which resulted in dramatic improvement in his symptoms and spontaneous regression of retro-odontoid post traumatic cicatrix. We have described an interesting and a rare case of a large pseudoarthrosis tissue mass associated with odontoid nonunion, which regressed following stand-alone posterior instrumentation. To the best of our knowledge, only a handful of such cases of spontaneous regression of retro-odontoid post traumatic cicatrix following occipitocervical fixation have been described in literature, and our case adds to the growing list of such cases and may help in understanding the natural history of the disease process one day. Although rare, post traumatic cicatrix should be considered as a differential diagnosis of enhancing retro-odontoid mass, especially if there is any history of cervical spine trauma.

Spontaneous resolution of symptomatic lumbar synovial cyst.

Lumbar synovial cyst arises from the facet joint and can lead to back pain, radiculopathy, neurogenic claudication or even cauda equina syndrome. Although most surgeons would consider surgery to be the treatment of choice, the natural history of the disease process remains unknown and uncertainty still exists regarding optimal management of this controversial entity. We illustrate a case of large L5/S1 synovial cyst for which surgery was initially planned. However, it resolved spontaneously without any treatment. We also provide a brief literature review regarding conservative, surgical and minimally invasive management of symptomatic lumbar synovial cyst with special reference to patient outcome.

Atypical teratoid rhabdoid tumour of the spine: report of a case and literature review.

Atypical teratoid rhabdoid tumour (ATRT) is a rare and highly aggressive malignant neoplasm of the central nervous system (CNS), which occurs predominantly in children less than 2 years of age. There are less than 50 cases described in adult. We report a case of primary spinal ATRT in a 65-year-old male who presented to us with cauda equina syndrome. To the best of our knowledge, our patient is the (1) second oldest patient to be diagnosed with ATRT and only the third case of adult spinal ATRT report in the literature; (2) first reported case of CNS ATRT occurring in a patient with non-rhabdoid renal cancer; (3) first adult patient of ATRT to present with cauda equina syndrome.

Fracture through fused cervical segments following trauma in a patient with Klippel-Feil syndrome.

Klippel-Feil syndrome (KPS) is a congenital spinal deformity characterised by the presence of at least one fused cervical segment. We report an unusual case of a fracture through fused cervical segment in a patient with KPS, who presented with quadriparesis and progressed on to develop respiratory failure and quadriplegia and who had a successful outcome following surgery. To the best of our knowledge, fracture through fused cervical segments in a Klippel-Feil patient has not been reported previously and this case report extends the spectrum of injuries seen in patients with KPS.

Ventriculoperitoneal shunt 30-day failure rate: a retrospective international cohort study.

BACKGROUND: With the need for transparency of surgical results, 30-day outcome measures have become increasingly important. Ventriculoperitoneal (VP) shunt failure is a substantial burden to patients and health care systems. OBJECTIVE: This study introduces the 30-day VP shunt failure rate as a possible barometer of surgical outcome and demonstrates its use in a national (United Kingdom [UK]) study and makes comparison with 2 published randomized, controlled trials (RCT). METHODS: A cohort study of all (except 1) pediatric neurosurgical centers in the UK and Ireland. All new and revision VP shunt operations were recorded for 2008 and 2009. Both newly placed and revised VP shunts were subject to Kaplan-Meier analysis, and 30-day failure rate was obtained. Data from 2 RCTs investigating new VP shunt technology were analyzed, and the 30-day failure rate was extracted for comparative purposes. RESULTS: The overall 30-day and 1-year failure rates for new shunts were 12.9% and 28.8%, respectively. The 30-day failure rate from 2 RCTs was comparable (14% and 16%, respectively). The failure rate of the subsequent revision of those new shunts was 20.7% at 30 days and 40.4% at 1 year. According to these data, shunt survival appears to be better if performed by a consultant pediatric neurosurgeon for revision surgery only. CONCLUSION: VP shunt survival in the UK is comparable to the published multicenter data investigating shunt survival. The 30-day failure rate may represent a better barometer of surgical outcome and should be used as a separate outcome measure in the design of future trials.

ABT-263 enhances sensitivity to metformin and 2-deoxyglucose in pediatric glioma by promoting apoptotic cell death.

Pediatric high grade glioma is refractory to conventional multimodal treatment, highlighting a need to develop novel efficacious therapies. We investigated tumor metabolism as a potential therapeutic target in a panel of diverse pediatric glioma cell lines (SF188, KNS42, UW479 and RES186) using metformin and 2-deoxyglucose. As a single agent, metformin had little effect on cell viability overall. SF188 cells were highly sensitive to 2-deoxyglucose however, combination of metformin with 2-deoxyglucose significantly reduced cell proliferation compared to either drug alone in all cell lines tested. In addition, the combination of the two agents was associated with a rapid decrease in cellular ATP and subsequent AMPK activation. However, increased cell death was only observed in select cell lines after prolonged exposure to the drug combination and was caspase independent. Anti-apoptotic BCL-2 family proteins have been indicated as mediators of resistance against metabolic stress. Therefore we sought to determine whether pharmacological inhibition of BCL-2/BCL-xL with ABT-263 could potentiate apoptosis in response to these agents. We found that ABT-263 increased sensitivity to 2-deoxyglucose and promoted rapid and extensive cell death in response to the combination of 2-deoxyglucose and metformin. Furthermore, cell death was inhibited by the pan-caspase inhibitor, z-VAD-FMK suggesting that ABT-263 potentiated caspase-dependent cell death in response to 2-deoxyglucose or its combination with metformin. Overall, these data provide support for the concept that targeting metabolic and anti-apoptotic pathways may be an effective therapeutic strategy in pediatric glioma.

Comparison of acrylic and titanium cranioplasty.

INTRODUCTION: There are many indications for cranioplasty with an increasing incidence partly attributable to an increase in decompressive craniectomy following trauma and stroke. The aim of this study was to compare the survival of acrylic and titanium cranioplasties used in our department. MATERIALS AND METHODS: Retrospective cohort study of 126 patients who underwent cranioplasty between 1997 and 2007. A comparison was made between those with acrylic (n = 61) and titanium (n = 65) cranioplasties. There was no significant difference in age and length of time between craniectomy and cranioplasty between the two groups. The indications for titanium cranioplasty tended to be classified as 'high risk' indications including trauma and stroke. A higher rate of pre-existing infection was noted in the acrylic group. Mean follow-up was 97.2 and 34 months for acrylic and titanium cranioplasties respectively. RESULTS: Mean survival (95% confidence intervals) was 135 months (134-153) and 92 months (82-102) for acrylic and cranioplasty respectively. Out of 13 failures, only two were associated with pre-existing infection. Overall cumulative survival was better for acrylic cranioplasty although this difference did not reach statistical significance. DISCUSSION: Although survival of acrylic cranioplasty appears to be better than titanium plates, there is no statistical significance. Acrylic has the advantage of being able to be applied at the time of surgery without any planning and does not cause artefact on future imaging. Titanium cranioplasty is strong, light-weight and inert and can be fashioned in the pre-operative setting.

Surgical outcome for foot drop in lumbar degenerative disease.

Controversy exists regarding the timing and outcome of surgery for lumbar degenerative disease (LDD) associated with foot drop. In this work, we report the results of a retrospective observational study from our center. We had a sample size of 26 patients with a minimum follow-up of 6 months. Of the 26 patients, 88% improved, with complete recovery observed in 61%. Thus, our data support the view that there is good recovery from operative management of foot drop secondary to LDD. Adjusting for preoperative strength, preoperative duration of weakness was a significant predictor of extent of recovery (odds ratio = 0.93; 95% confidence interval 0.88 to 0.98; p = 0.019). The model explained 50% of the variance in outcome in this study.

Case series of atypical high flow arterio-venous malformations in children.

Arteriovenous malformations (AVM) constitute a clinically significant form of vascular malformations in children. We present three cases of paediatric AVMs that demonstrated unusual features of high flow and significant shunting of blood without a clearly demonstrable nidus. Venous malformations were associated with the lesions. A discussion of the concepts underlying AVM physiology and how these case reports contradict these is included.