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1.
Spinal Cord ; 62(2): 51-58, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38129661

RESUMO

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: Currently there is limited evidence and guidance on the management of mild degenerative cervical myelopathy (DCM) and asymptomatic spinal cord compression (ASCC). Anecdotal evidence suggest variance in clinical practice. The objectives of this study were to assess current practice and to quantify the variability in clinical practice. METHODS: Spinal surgeons and some additional health professionals completed a web-based survey distributed by email to members of AO Spine and the Cervical Spine Research Society (CSRS) North American Society. Questions captured experience with DCM, frequency of DCM patient encounters, and standard of practice in the assessment of DCM. Further questions assessed the definition and management of mild DCM, and the management of ASCC. RESULTS: A total of 699 respondents, mostly surgeons, completed the survey. Every world region was represented in the responses. Half (50.1%, n = 359) had greater than 10 years of professional experience with DCM. For mild DCM, standardised follow-up for non-operative patients was reported by 488 respondents (69.5%). Follow-up included a heterogeneous mix of investigations, most often at 6-month intervals (32.9%, n = 158). There was some inconsistency regarding which clinical features would cause a surgeon to counsel a patient towards surgery. Practice for ASCC aligned closely with mild DCM. Finally, there were some contradictory definitions of mild DCM provided in the form of free text. CONCLUSIONS: Professionals typically offer outpatient follow up for patients with mild DCM and/or asymptomatic ASCC. However, what this constitutes varies widely. Further research is needed to define best practice and support patient care.


Assuntos
Compressão da Medula Espinal , Doenças da Medula Espinal , Traumatismos da Medula Espinal , Humanos , Compressão da Medula Espinal/etiologia , Compressão da Medula Espinal/cirurgia , Estudos Transversais , Imageamento por Ressonância Magnética , Traumatismos da Medula Espinal/complicações , Doenças da Medula Espinal/diagnóstico , Doenças da Medula Espinal/etiologia , Doenças da Medula Espinal/cirurgia , Vértebras Cervicais/cirurgia
2.
Nature ; 530(7588): 71-6, 2016 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-26779949

RESUMO

Many procedures in modern clinical medicine rely on the use of electronic implants in treating conditions that range from acute coronary events to traumatic injury. However, standard permanent electronic hardware acts as a nidus for infection: bacteria form biofilms along percutaneous wires, or seed haematogenously, with the potential to migrate within the body and to provoke immune-mediated pathological tissue reactions. The associated surgical retrieval procedures, meanwhile, subject patients to the distress associated with re-operation and expose them to additional complications. Here, we report materials, device architectures, integration strategies, and in vivo demonstrations in rats of implantable, multifunctional silicon sensors for the brain, for which all of the constituent materials naturally resorb via hydrolysis and/or metabolic action, eliminating the need for extraction. Continuous monitoring of intracranial pressure and temperature illustrates functionality essential to the treatment of traumatic brain injury; the measurement performance of our resorbable devices compares favourably with that of non-resorbable clinical standards. In our experiments, insulated percutaneous wires connect to an externally mounted, miniaturized wireless potentiostat for data transmission. In a separate set-up, we connect a sensor to an implanted (but only partially resorbable) data-communication system, proving the principle that there is no need for any percutaneous wiring. The devices can be adapted to sense fluid flow, motion, pH or thermal characteristics, in formats that are compatible with the body's abdomen and extremities, as well as the deep brain, suggesting that the sensors might meet many needs in clinical medicine.


Assuntos
Implantes Absorvíveis , Encéfalo/metabolismo , Eletrônica/instrumentação , Monitorização Fisiológica/instrumentação , Próteses e Implantes , Silício , Implantes Absorvíveis/efeitos adversos , Administração Cutânea , Animais , Temperatura Corporal , Encéfalo/cirurgia , Desenho de Equipamento , Hidrólise , Masculino , Monitorização Fisiológica/efeitos adversos , Especificidade de Órgãos , Pressão , Próteses e Implantes/efeitos adversos , Ratos , Ratos Endogâmicos Lew , Telemetria/instrumentação , Tecnologia sem Fio/instrumentação
3.
Spinal Cord ; 60(6): 510-515, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35013548

RESUMO

STUDY DESIGN: Prospective multi-center trial. OBJECTIVES: To characterize the complication profile associated with modest systemic hypothermia after acute cervical SCI in a prospective multi-center study. SETTING: Five trauma centers in the United States. METHODS: We analyzed data from a prospective, multi-center trial on the use of modest systemic hypothermia for acute cervical SCI. Patients with acute cervical SCI were assigned to receive modest systemic hypothermia (33 C) or standard of care medical treatment. Patients in the hypothermia group were cooled to 33 C and maintained at the target temperature for 48 h. Complication profile and the rate of complications within the first 6 weeks after injury were compared between the two groups. Multiple regression analysis was performed to determine risk factors for complications after injury. RESULTS: Fifty patients (hypothermia: 27, control: 23) were analyzed for this study. Median age was significantly lower in the hypothermia arm (39 vs 59 years, p = 0.02). Respiratory complications were the most common (hypothermia: 55.6% vs control: 52.2%, p = 0.81). The rate of deep vein thrombosis was not significantly different between the two groups (hypothermia: 14.8% vs control 17.4%, p = 0.71). The rate of complications was not statistically different between the two groups. CONCLUSION: In this prospective multi-center controlled trial, preliminary data show that modest systemic hypothermia was not associated with increased risk of complications within the first 6 weeks after acute cervical SCI. TRIAL INFORMATION: The study is registered on clinicaltrials.gov NCT02991690. University of Miami IRB (Central IRB) approval No.: 20160758. Emory University IRB #IRB00093786.


Assuntos
Medula Cervical , Hipotermia Induzida , Hipotermia , Traumatismos da Medula Espinal , Humanos , Hipotermia/etiologia , Hipotermia/terapia , Hipotermia Induzida/efeitos adversos , Pessoa de Meia-Idade , Estudos Prospectivos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/epidemiologia , Traumatismos da Medula Espinal/terapia
4.
Childs Nerv Syst ; 30(7): 1197-200, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24573961

RESUMO

PURPOSE: Diagnosing idiopathic intracranial hypertension (IIH), or pseudotumor cerebri, can be challenging in children. Diagnosis is based on lumbar puncture, opening pressures, and appearance of the optic disk. Misdiagnosis of papilledema, a typical finding, may lead to unnecessary treatments and procedures. We report 52 children over a 6-year period to better identify the true incidence of pseudopapilledema and other factors that may confound the diagnosis of IIH. METHODS: A retrospective chart review approved by the Institutional Review Board was performed. Fifty-two children under the age of 21 referred to us based on suspected IIH or papilledema from 2007 to 2013 are included in this study. Patients were assessed by a pediatric ophthalmologist and a neurosurgeon. RESULTS: Fifty-two children were initially diagnosed with IIH and/or papilledema; 26 diagnoses were revised to pseudopapilledema after pediatric ophthalmological review. Out of those 26 patients with pseudopapilledema, 14 had undergone lumbar punctures, 19 had MRIs, 9 had CTs, and 12 were taking medications-these medications were discontinued upon revision of the diagnoses. The difference in the CSF opening pressure between children diagnosed with true IIH (32.7 cm H2O) and children diagnosed with pseudopapilledema (24.7 cm H2O) was statistically significant. CONCLUSIONS: IIH diagnosis is heavily reliant on the appearance of the optic disk. Pediatric ophthalmological assessment is essential to carefully examine the optic disk and prevent further unnecessary investigation and treatments. Close communication between pediatricians, ophthalmologists, and neurosurgeons can avoid invasive procedures for children who do have pseudopapilledema, and not IIH or associated papilledema.


Assuntos
Oftalmopatias Hereditárias/diagnóstico , Disco Óptico/patologia , Doenças do Nervo Óptico/diagnóstico , Papiledema/diagnóstico , Pseudotumor Cerebral/diagnóstico , Adolescente , Criança , Pré-Escolar , Diagnóstico Diferencial , Oftalmopatias Hereditárias/epidemiologia , Feminino , Humanos , Incidência , Masculino , Doenças do Nervo Óptico/epidemiologia , Estudos Retrospectivos , Adulto Jovem
5.
Neurosurg Clin N Am ; 35(2): 229-234, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38423738

RESUMO

Smart spine implants promise to stimulate healing and provide objective information about healing progression. The ability of implants to accelerate healing and provide objective data could help guide postoperative care, foster better outcomes, and reduce complications. Real-time monitoring, remote control and programming, and data analytics are actively being developed and translated into clinical practice. This article discusses advances in smart spinal implant technology and how they may aid patients and surgeons.


Assuntos
Próteses e Implantes , Coluna Vertebral , Humanos , Coluna Vertebral/cirurgia
6.
Childs Nerv Syst ; 29(4): 531-3, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23423659

RESUMO

INTRODUCTION: In patients with programmable CSF shunt valves, the risk of unintentional valve adjustment associated with the environmental magnetic influence is ever present. We tested whether the iPad 3 with Smart Cover is capable of changing the setting of individual programmable valves ex vivo using direct fluoroscopic visualization. METHODS: The following valves were tested: Strata NSC Adjustable Pressure Valve, Strata NSC Burr Hole Valve, Strata II small valve, Sophysa Polaris model SPV, Aesculap valve proGAV, and Codman Certas Programmable Valve. The left front edge of the iPad 3 with Smart Cover was found to have the strongest magnetic flux, measuring approximately 1,200 G and was moved linearly directly over the tested valve and then parallel to the first path at approximately 30 cm/s. Also, this area was rotated once at varying distances above the valve at approximately 1 rad/s. RESULTS: Almost all shunt valves were immune to reprogramming by the iPad 3 at varying distances (including direct contact) except for the Strata II small valve, where rotating the peak flux location 4 mm above the valve changed the valve pressure settings every time. CONCLUSIONS: The iPad 3 can change pressure settings of the Strata II small valve at a distance comparable to the thickness of certain regions of the scalp. Although the specific rotational motion described here may be uncommon in real life, it is nevertheless recommended that children with hydrocephalus, caregivers, educators, and therapists are informed of the now-apparent risks of close contact with this increasingly popular technology.


Assuntos
Derivações do Líquido Cefalorraquidiano/instrumentação , Computadores de Mão , Desenho de Equipamento , Falha de Equipamento , Humanos , Hidrocefalia/cirurgia , Magnetismo/instrumentação
7.
JMIR Res Protoc ; 12: e46809, 2023 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-37812472

RESUMO

BACKGROUND: Health care decisions are a critical determinant in the evolution of chronic illness. In shared decision-making (SDM), patients and clinicians work collaboratively to reach evidence-based health decisions that align with individual circumstances, values, and preferences. This personalized approach to clinical care likely has substantial benefits in the oversight of degenerative cervical myelopathy (DCM), a type of nontraumatic spinal cord injury. Its chronicity, heterogeneous clinical presentation, complex management, and variable disease course engenders an imperative for a patient-centric approach that accounts for each patient's unique needs and priorities. Inadequate patient knowledge about the condition and an incomplete understanding of the critical decision points that arise during the course of care currently hinder the fruitful participation of health care providers and patients in SDM. This study protocol presents the rationale for deploying SDM for DCM and delineates the groundwork required to achieve this. OBJECTIVE: The study's primary outcome is the development of a comprehensive checklist to be implemented upon diagnosis that provides patients with essential information necessary to support their informed decision-making. This is known as a core information set (CIS). The secondary outcome is the creation of a detailed process map that provides a diagrammatic representation of the global care workflows and cognitive processes involved in DCM care. Characterizing the critical decision points along a patient's journey will allow for an effective exploration of SDM tools for routine clinical practice to enhance patient-centered care and improve clinical outcomes. METHODS: Both CISs and process maps are coproduced iteratively through a collaborative process involving the input and consensus of key stakeholders. This will be facilitated by Myelopathy.org, a global DCM charity, through its Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy community. To develop the CIS, a 3-round, web-based Delphi process will be used, starting with a baseline list of information items derived from a recent scoping review of educational materials in DCM, patient interviews, and a qualitative survey of professionals. A priori criteria for achieving consensus are specified. The process map will be developed iteratively using semistructured interviews with patients and professionals and validated by key stakeholders. RESULTS: Recruitment for the Delphi consensus study began in April 2023. The pilot-testing of process map interview participants started simultaneously, with the formulation of an initial baseline map underway. CONCLUSIONS: This protocol marks the first attempt to provide a starting point for investigating SDM in DCM. The primary work centers on developing an educational tool for use in diagnosis to enable enhanced onward decision-making. The wider objective is to aid stakeholders in developing SDM tools by identifying critical decision junctures in DCM care. Through these approaches, we aim to provide an exhaustive launchpad for formulating SDM tools in the wider DCM community. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46809.

8.
Br J Neurosurg ; 26(6): 864-7, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22768911

RESUMO

OBJECTIVE: To assess optimal angulation characteristics of lateral mass screws for subaxial (C3 to C6) fixation of the cervical spine in the neutral position. BACKGROUND: In the typical Magerl or Anderson placement technique, the screw trajectory is ideally parallel to the facet joint. For the rod and screw to align properly, the screw head must rotate enough to become perpendicular to the rod. If the optimal angle for the screw head is limited by the screw design, abnormal torsional forces will be generated at the rod/screw interface inducing kyphosis. In this paper, we examined the spinal anatomy in patients with normal CTs to determine the necessary range of motion between tulip head and screw to prevent forced persuasion and abnormal cervical spine alignment. METHODS: We examined subaxial radiographs of 292 vertebrae from C3 to C6 in 73 normal subjects. Computed tomography (CT) scans of the cervical spine with multiplanar reconstructions were evaluated in the axial and sagittal planes. A planned screw entry angle of 30° based upon the midpoint of the lateral mass was used in the axial plane, and parallel to the facet joint in the sagittal plane. The screw head angle (SHA) was then calculated from this 3D measured angle. RESULTS: The measured SHA ranged from 27 to 60°. The average SHA was 43.8°. The average SHA was not significantly different between the levels measured with consistent range and standard deviation. Seventy-six percent (223/292) of levels measured required a SHA >40°, and 12% (36/292) required a SHA >50°. CONCLUSION: The authors recommend using cervical instrumentation systems that allow for at least 55° of freedom of the polyaxial head to prevent abnormal segmental forces. In systems with lesser angulation, technique modifications must be applied to prevent translational forces.


Assuntos
Variação Anatômica , Parafusos Ósseos/normas , Vértebras Cervicais/fisiologia , Fixadores Internos/normas , Neurocirurgia , Ortopedia , Adulto , Idoso , Idoso de 80 Anos ou mais , Vértebras Cervicais/patologia , Vértebras Cervicais/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neurocirurgia/instrumentação , Neurocirurgia/métodos , Neurocirurgia/normas , Ortopedia/métodos , Ortopedia/normas , Adulto Jovem
9.
Global Spine J ; 12(1_suppl): 28S-38S, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35174734

RESUMO

STUDY DESIGN: Literature Review (Narrative). OBJECTIVE: To introduce the number one research priority for Degenerative Cervical Myelopathy (DCM): Raising Awareness. METHODS: Raising awareness has been recognized by AO Spine RECODE-DCM as the number one research priority. This article reviews the evidence that awareness is low, the potential drivers, and why this must be addressed. Case studies of success from other diseases are also reviewed, drawing potential parallels and opportunities for DCM. RESULTS: DCM may affect as many as 1 in 50 adults, yet few will receive a diagnosis and those that do will wait many years for it. This leads to poorer outcomes from surgery and greater disability. DCM is rarely featured in healthcare professional training programs and has received relatively little research funding (<2% of Amyotrophic Lateral Sclerosis or Multiple Sclerosis over the last 25 years). The transformation of stroke and acute coronary syndrome services, from a position of best supportive care with occasional surgery over 50 years ago, to avoidable disability today, represents transferable examples of success and potential opportunities for DCM. Central to this is raising awareness. CONCLUSION: Despite the devastating burden on the patient, recognition across research, clinical practice, and healthcare policy are limited. DCM represents a significant unmet need that must become an international public health priority.

10.
Surg Innov ; 18(4): 354-7, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21521699

RESUMO

INTRODUCTION: Currently, 175,000 people are on outpatient waiting lists in Irish hospitals. Many clinic slots are taken by patients returning for routine review postoperatively. METHODS: A Nokia mobile phone was used to send an outpatient text (OPT) to patients 2 weeks postdischarge. Patients replying that they were well were discharged. If no reply after 2 attempts was received, they were scheduled for the next outpatient clinic. RESULTS: Overall, 55 patients were offered the service over a 4-month period. Of these, 74.5% of patients were discharged from follow-up using text message surveillance. Patients were surveyed regarding their perception of the surveillance model, with all respondents ranking OPT surveillance as their preferred method of follow-up. There was a 13.6% decrease in outpatient visits over the study period. In addition, 6 emergency department visits were also avoided. CONCLUSION: Text message surveillance decreases outpatient waiting times and increases quality of care.


Assuntos
Assistência Ambulatorial/organização & administração , Agendamento de Consultas , Eficiência Organizacional , Vigilância da População , Envio de Mensagens de Texto , Análise Custo-Benefício , Feminino , Humanos , Irlanda , Masculino , Alta do Paciente , Preferência do Paciente , Cuidados Pós-Operatórios
11.
Bioelectron Med ; 7(1): 14, 2021 Sep 22.
Artigo em Inglês | MEDLINE | ID: mdl-34548098

RESUMO

Almost 100 years ago experiments involving electrically stimulating and recording from the brain and the body launched new discoveries and debates on how electricity, movement, and thoughts are related. Decades later the development of brain-computer interface technology began, which now targets a wide range of applications. Potential uses include augmentative communication for locked-in patients and restoring sensorimotor function in those who are battling disease or have suffered traumatic injury. Technical and surgical challenges still surround the development of brain-computer technology, however, before it can be widely deployed. In this review we explore these challenges, historical perspectives, and the remarkable achievements of clinical study participants who have bravely forged new paths for future beneficiaries.

12.
Nephrol Dial Transplant ; 25(6): 2032-5, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20348150

RESUMO

We present a follow-up case report of possible transmission of lymphoma 12 years after deceased-donor renal transplantation from a male donor who was found at autopsy to have had an occult lymphoma. The female recipient underwent prompt transplant nephrectomy. However, 12 years later, she presented with cerebral B cell lymphoma. A donor origin for the cerebral lymphoma was supported by in situ hybridization demonstration of a Y chromosome in the lymphoma. There was a dramatic resolution of the cerebral lesions with tapering of immunosuppression and introduction of rituximab treatment. The finding of a Y chromosome in the cerebral lymphoma does not exclude a host contribution to lymphoma development.


Assuntos
Neoplasias Encefálicas/etiologia , Infecções por Vírus Epstein-Barr/etiologia , Transplante de Rim/efeitos adversos , Linfoma de Células B/etiologia , Transtornos Linfoproliferativos/etiologia , Doadores de Tecidos , Adulto , Neoplasias Encefálicas/genética , Neoplasias Encefálicas/virologia , Cromossomos Humanos Y/genética , Feminino , Herpesvirus Humano 4/genética , Herpesvirus Humano 4/isolamento & purificação , Humanos , Hibridização In Situ , Linfoma de Células B/genética , Linfoma de Células B/virologia , Transtornos Linfoproliferativos/genética , Transtornos Linfoproliferativos/virologia , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
13.
J Neurotrauma ; 35(6): 864-873, 2018 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-29179629

RESUMO

Despite 253,000 spinal cord injury (SCI) patients in the United States, little is known about how SCI affects brain networks. Spinal MRI provides only structural information with no insight into functional connectivity. Resting-state functional MRI (RS-fMRI) quantifies network connectivity through the identification of resting-state networks (RSNs) and allows detection of functionally relevant changes during disease. Given the robust network of spinal cord afferents to the brain, we hypothesized that SCI produces meaningful changes in brain RSNs. RS-fMRIs and functional assessments were performed on 10 SCI subjects. Blood oxygen-dependent RS-fMRI sequences were acquired. Seed-based correlation mapping was performed using five RSNs: default-mode (DMN), dorsal-attention (DAN), salience (SAL), control (CON), and somatomotor (SMN). RSNs were compared with normal control subjects using false-discovery rate-corrected two way t tests. SCI reduced brain network connectivity within the SAL, SMN, and DMN and disrupted anti-correlated connectivity between CON and SMN. When divided into separate cohorts, complete but not incomplete SCI disrupted connectivity within SAL, DAN, SMN and DMN and between CON and SMN. Finally, connectivity changed over time after SCI: the primary motor cortex decreased connectivity with the primary somatosensory cortex, the visual cortex decreased connectivity with the primary motor cortex, and the visual cortex decreased connectivity with the sensory parietal cortex. These unique findings demonstrate the functional network plasticity that occurs in the brain as a result of injury to the spinal cord. Connectivity changes after SCI may serve as biomarkers to predict functional recovery following an SCI and guide future therapy.


Assuntos
Encéfalo/fisiopatologia , Rede Nervosa/fisiopatologia , Vias Neurais/fisiopatologia , Traumatismos da Medula Espinal/fisiopatologia , Adulto , Idoso , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Descanso , Adulto Jovem
14.
J Neurosurg Sci ; 62(4): 406-412, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27149369

RESUMO

BACKGROUND: A number of clinical tools exist for measuring the severity of cervical spondylotic myelopathy (CSM). Several studies have recently described the use of non-invasive imaging biomarkers to assess severity of disease. These imaging markers may provide an additional tool to measure disease progression and represent a surrogate marker of response to therapy. Correlating these imaging biomarkers with clinical quantitative measures is critical for accurate therapeutic stratification and quantification of axonal injury. METHODS: Fourteen patients and seven healthy control subjects were enrolled. Patients were classified as mildly (7) or moderately (7) impaired based on Modified Japanese Orthopedic Association Scale. All patients underwent diffusion tensor imaging (DTI) and diffusion basis spectrum imaging (DBSI) analyses. In addition to standard neurological examination, all participants underwent 30-m Walking Test, 9-hole Peg Test (9HPT), grip strength, key pinch, and vibration sensation thresholds in the index finger and great toe. Differences in assessment scores between controls, mild and moderate CSM patients were correlated with DTI and DBSI derived fractional anisotropy (FA). RESULTS: Clinically, 30-meter walking times were significantly longer in the moderately impaired group than in the control group. Maximum 9HPT times were significantly longer in both the mildly and moderately impaired groups as compared to normal controls. Scores on great toe vibration sensation thresholds were lower in the mildly impaired and moderately impaired groups as compared to controls. We found no clear evidence for any differences in minimum grip strength, minimum key pinch, or index finger vibration sensation thresholds. There were moderately strong associations between DTI and DBSI FA values and 30-meter walking times and 9HPT. CONCLUSIONS: The 30-m Walking Test and 9HPT were both moderately to strongly associated with DTI/DBSI FA values. FA may represent an additional measure to help differentiate and stratify patients with mild or moderate CSM.


Assuntos
Anisotropia , Neuroimagem/métodos , Doenças da Medula Espinal/diagnóstico por imagem , Adulto , Vértebras Cervicais , Imagem de Tensor de Difusão/métodos , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Compressão da Medula Espinal/diagnóstico por imagem , Compressão da Medula Espinal/etiologia , Doenças da Medula Espinal/etiologia , Espondilose/complicações
15.
Brain Sci ; 7(2)2017 Feb 17.
Artigo em Inglês | MEDLINE | ID: mdl-28218643

RESUMO

Promising treatments are being developed to promote functional recovery after spinal cord injury (SCI). Magnetic resonance imaging, specifically Diffusion Tensor Imaging (DTI) has been shown to non-invasively measure both axonal and myelin integrity following traumatic brain and SCI. A novel data-driven model-selection algorithm known as Diffusion Basis Spectrum Imaging (DBSI) has been proposed to more accurately delineate white matter injury. The objective of this study was to investigate whether DTI/DBSI changes that extend to level of the cerebral peduncle and internal capsule following a SCI could be correlated with clinical function. A prospective non-randomized cohort of 23 patients with chronic spinal cord injuries and 17 control subjects underwent cranial diffusion weighted imaging, followed by whole brain DTI and DBSI computations. Region-based analyses were performed on cerebral peduncle and internal capsule. Three subgroups of patients were included in the region-based analysis. Tract-Based Spatial Statistics (TBSS) was also applied to allow whole-brain white matter analysis between controls and all patients. Functional assessments were made using International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) as modified by the American Spinal Injury Association (ASIA) Scale. Whole brain white matter analysis using TBSS finds no statistical difference between controls and all patients. Only cervical ASIA A/B patients in cerebral peduncle showed differences from controls in DTI and DBSI results with region-based analysis. Cervical ASIA A/B SCI patients had higher levels of axonal injury and edema/tissue loss as measured by DBSI at the level of the cerebral peduncle. DTI Fractional Anisotropy (FA), Axial Diffusivity (AD) and Radial Diffusivity (RD) was able to detect differences in cervical ASIA A/B patients, but were non-specific to pathologies. Increased water fraction indicated by DBSI non-restricted isotropic diffusion fraction in the cerebral peduncle, explains the simultaneously increased DTI AD and DTI RD values. Our results further demonstrate the utility of DTI to detect disruption in axonal integrity in white matter, yet a clear shortcoming in differentiating true axonal injury from inflammation/tissue loss. Our results suggest a preservation of axonal integrity at the cortical level and has implications for future regenerative clinical trials.

16.
J Neurosurg Sci ; 60(1): 1-10, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25968925

RESUMO

BACKGROUND: The objective of this study is to validate the safety of hyperacute stabilization. METHODS: Patient demographics, American Spinal Injury Association (ASIA) grade on initial evaluation and serial follow up grades, hospital length of stay, Intensive Care Unit length of stay, intraoperative blood loss, postoperative length of stay, comorbidities, Injury Severity Score and complications of recumbency were recorded. RESULTS: Corroborating previous studies, our study shows polytrauma patients undergoing a hyperacute stabilization of a spinal fracture displayed a trend towards better neurological outcome and decreased hospital stays while having a similar complication rate to those operated on in a delayed fashion. CONCLUSIONS: Hyperacute stabilization can be associated with improved ASIA grades even in complete injuries.


Assuntos
Fraturas da Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Descompressão Cirúrgica/métodos , Feminino , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo , Estudos Retrospectivos , Adulto Jovem
17.
J Neurosurg ; 124(6): 1752-65, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26587655

RESUMO

Nonhemorrhagic neurological deficits are underrecognized symptoms of intracranial dural arteriovenous fistulas (dAVFs) having cortical venous drainage. These symptoms are the consequence of cortical venous hypertension and portend a clinical course with increased risk of neurological morbidity and mortality. One rarely documented and easily misinterpreted type of nonhemorrhagic neurological deficit is progressive dementia, which can result from venous hypertension in the cortex or in bilateral thalami. The latter, which is due to dAVF drainage into the deep venous system, is the less common of these 2 dementia syndromes. Herein, the authors report 4 cases of dAVF with venous drainage into the vein of Galen causing bithalamic edema and rapidly progressive dementia. Two patients were treated successfully with endovascular embolization, and the other 2 patients were treated successfully with endovascular embolization followed by surgery. The radiographic abnormalities and presenting symptoms rapidly resolved after dAVF obliteration in all 4 cases. Detailed descriptions of these 4 cases are presented along with a critical review of 15 previously reported cases. In our analysis of these 19 published cases, the following were emphasized: 1) the clinical and radiographic differences between dAVF-induced thalamic versus cortical dementia syndromes; 2) the differential diagnosis and necessary radiographic workup for patients presenting with a rapidly progressive thalamic dementia syndrome; 3) the frequency at which delays in diagnosis occurred and potentially dangerous and avoidable diagnostic procedures were used; and 4) the rapidity and completeness of symptom resolution following dAVF treatment.


Assuntos
Malformações Vasculares do Sistema Nervoso Central/complicações , Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Demência/diagnóstico por imagem , Demência/etiologia , Tálamo/diagnóstico por imagem , Idoso , Malformações Vasculares do Sistema Nervoso Central/patologia , Malformações Vasculares do Sistema Nervoso Central/terapia , Angiografia Cerebral , Diagnóstico Tardio , Demência/patologia , Demência/terapia , Diagnóstico Diferencial , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tálamo/patologia , Tálamo/cirurgia , Tomografia Computadorizada por Raios X
18.
Neurosurgery ; 79(1): 23-32, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26645969

RESUMO

BACKGROUND: Optimal use of stereotactic radiosurgery (SRS) vs external beam radiation therapy (EBRT) for treatment of residual/recurrent atypical meningioma is unclear. OBJECTIVE: To analyze features associated with progression after radiation therapy. METHODS: Fifty radiation-naive patients who received SRS or EBRT for residual and/or recurrent atypical meningioma were examined for predictors of progression using Cox regression and Kaplan-Meier analyses. RESULTS: Thirty-two patients (64%) received adjuvant radiation after subtotal resection, 12 patients (24%) received salvage radiation after progression following subtotal resection, and 6 patients (12%) received salvage radiation after recurrence following gross total resection. Twenty-one patients (42%) received SRS (median 18 Gy), and 7 (33%) had tumor progression. Twenty-nine patients (58%) received EBRT (median 54 Gy), and 13 (45%) had tumor progression. Whereas tumor volume (P = .53), SRS vs EBRT (P = .45), and adjuvant vs salvage (P = .34) were not associated with progression after radiation therapy, spontaneous necrosis (hazard ratio [HR] = 82.3, P < .001), embolization necrosis (HR = 15.6, P = .03), and brain invasion (HR = 3.8, P = .008) predicted progression in univariate and multivariate analyses. Tumors treated with SRS/EBRT had 2- and 5-year actuarial locoregional control rates of 91%/88% and 71%/69%, respectively. Tumors with spontaneous necrosis, embolization necrosis, and no necrosis had 2- and 5-year locoregional control rates of 76%, 92%, and 100% and 36%, 73%, and 100%, respectively (P < .001). CONCLUSION: This study suggests that necrosis may be a negative predictor of radiation response regardless of radiation timing or modality. ABBREVIATIONS: AM, atypical meningiomaEBRT, external beam radiation therapyGTR, gross total resectionLC, locoregional controlOS, overall survivalPOE, preoperative embolizationRT, radiation therapySRS, stereotactic radiosurgerySTR, subtotal resection.


Assuntos
Neoplasias Meníngeas/radioterapia , Meningioma/radioterapia , Radiocirurgia/métodos , Adulto , Idoso , Progressão da Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Neoplasias Meníngeas/patologia , Meningioma/patologia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Modelos de Riscos Proporcionais , Radiocirurgia/efeitos adversos , Radioterapia Adjuvante , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
19.
Spine (Phila Pa 1976) ; 41(9): 751-6, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26650876

RESUMO

STUDY DESIGN: A prospective cohort study. OBJECTIVE: In this study, we employed diffusion basis spectrum imaging (DBSI) to quantitatively assess axon/myelin injury, cellular inflammation, and axonal loss of cervical spondylotic myelopathy (CSM) spinal cords. SUMMARY OF BACKGROUND DATA: A major shortcoming in the management of CSM is the lack of an effective diagnostic approach to stratify treatments and to predict outcomes. No current clinical diagnostic imaging approach is capable of accurately reflecting underlying spinal cord pathologies. METHODS: Seven patients with mild (mJOA ≥15), five patients with moderate (14≥mJOA ≥11), and two patients with severe (mJOA <11) CSM were prospectively enrolled. Given the low number of severe patients, moderate and severe patients were combined for comparison with seven age-matched controls and statistical analysis. We employed the newly developed DBSI to quantitatively measure axon and myelin injury, cellular inflammation, and axonal loss. RESULTS: Median DBSI-inflammation volume is similar in control (266 µL) and mild CSM (171 µL) subjects, with a significant overlap of the middle 50% of observations (quartile 3 - quartile 1). This was in contrast to moderate CSM subjects that had higher DBSI-inflammation volumes (382 µL; P = 0.033). DBSI-axon volume shows a strong correlation with clinical measures (r = 0.79 and 0.87, P = 1.9 x 10-5 and 2 x 10-4 for mJOA and MDI, respectively). In addition to axon and myelin injury, our findings suggest that both inflammation and axon loss contribute to neurological impairment. Most strikingly, DBSI-derived axon volume declines as severity of impairment increases. CONCLUSION: DBSI-quantified axonal loss may be an imaging biomarker to predict functional recovery following decompression in CSM. Our results demonstrate an increase of about 60% in the odds of impairment relative to the control for each decrease of 100 µL in axon volume. LEVEL OF EVIDENCE: 3.


Assuntos
Axônios/patologia , Vértebras Cervicais/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética/métodos , Índice de Gravidade de Doença , Espondilose/diagnóstico por imagem , Adulto , Vértebras Cervicais/cirurgia , Estudos de Coortes , Imagem de Tensor de Difusão/métodos , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doenças da Medula Espinal/diagnóstico por imagem , Doenças da Medula Espinal/cirurgia , Espondilose/cirurgia
20.
J Neurosurg ; 122(5): 1120-6, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25794343

RESUMO

OBJECT External ventricular drains (EVDs) are commonly used for CSF diversion but pose a risk of ventriculitis, with rates varying in frequency from 2% to 45%. Results of studies examining the utility of prolonged systemic antibiotic therapy for the prevention of EVD-related infection have been contradictory, and no study to date has examined whether this approach confers additional benefit in preventing ventriculitis when used in conjunction with antibiotic-coated EVDs (ac-EVDs). METHODS A prospective performance analysis was conducted over 4 years to examine the impact of discontinuing systemic antibiotic prophylaxis after insertion of an ac-EVD on rates of catheter-related ventriculitis. Ventriculitis and other nosocomial infections were ascertained by a qualified infection disease nurse using definitions based on published standards from the Centers for Disease Control and Prevention, comparing the period when patients received systemic antibiotic therapy for the duration of EVD treatment (Period 1) compared with only for the peri-insertion period (Period 2). Costs were analyzed and compared across the 2 time periods. RESULTS Over the 4-year study period, 866 patients were treated with ac-EVDs for a total of 7016 catheter days. There were 8 cases of ventriculitis, for an overall incidence of 0.92%. Rates of ventriculitis did not differ significantly between Period 1 and Period 2 (1.1% vs 0.4%, p = 0.22). The rate of nosocomial infections, however, was significantly higher in Period 1 (2.0% vs 0.0% in Period 2, p = 0.026). Cost savings of $162,516 were realized in Period 2 due to decreased drug costs and savings associated with the reduction in nosocomial infections. CONCLUSIONS Prolonged systemic antibiotic therapy following placement of ac-EVDs does not seem to reduce the incidence of catheter-related ventriculitis and was associated with a higher rate of nosocomial infections and increased cost.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Ventriculite Cerebral/prevenção & controle , Drenagem/instrumentação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecção Hospitalar , Portadores de Fármacos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo , Adulto Jovem
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