Topical hemostatic agents in neurosurgery, a comprehensive review: 15 years update.

Hemostasis in neurosurgery is of utmost importance. Bleeding management is one of the crucial steps of each neurosurgical procedure. Several strategies, namely thermal, mechanical, electric, and chemical, have been advocated to face blood loss within the surgical field. Over time, countless hemostatic agents and devices have been proposed. Furthermore, the ever-growing recent technological innovation has made available several novel and interesting tools. Pursuant to their impact on surgical practice, we perceived the imperative to update our previous disclosure paper. Therefore, we reviewed the literature and analyzed technical data sheets of each product in order to provide an updated and comprehensive overview in regard to chemical properties, mechanisms of action, use, complications, tricks, and pitfalls of topical hemostatic agents.

Clinical and radiological outcome after minimally invasive surgical approach for type II unstable odontoid fractures.

INTRODUCTION: Anterior odontoid screw fixation is a valid surgical option for unstable odontoid fractures, as type II Anderson D'Alonzo fractures. Grauer further divided type II fractures in subtypes according to the fracture line, providing recommendations for implementation of screw fixation techniques. OBJECTIVE: Primary endpoint of our study is to evaluate the postoperative results of minimally invasive odontoid screw insertion in terms of outcome, fusion rate and stability of cranio-cervical junction. Secondary endpoint was to investigate the influence of age or fractures' features on outcome and fusion rate. MATERIALS AND METHODS: We report the clinical and radiological features of 32 patients harbouring unstable type II fractures operated by a minimally invasive odontoid screw insertion technique. All patients underwent a high resolution multiplanar CT in order to assess fracture features according to Grauer's classification; the integrity of ligaments was investigated by MRI. In addition, a preoperative neurological performance (modified Rankin Scale, mRS) was evaluated for patients either directly or interviewing their families. Follow-up at one, three and six months and 1 year have been performed (averaging 13.5 months) by cervical CT (fusion rate and stability) and mRS update. In order to investigate the influence of age on postoperative neurological performance, two groups (≤50 yrs, 9 pts/>50 yrs, 23 pts) were separately considered and analysed. Overall, we observed no surgery related complications. We also analysed the fusion rate and its correlation with patient age and Grauer's subtype of fracture. RESULTS: At last available clinical follow-up, the preoperative performance was preserved (mRS 0/1: 24, 75%; mRS 2-4: 9, 15%) although with slight reduction of intact patients (mRS 0: 22 vs. 19; 71.8 vs. 59.3%). Younger patients (≤50 yrs) fared significantly better than older ones, achieving a good clinical outcome (mRS 0/1) in 100% vs. 69.5% (9/9 vs. 16/23 pts). Statistical analysis showed a fair correlation between age and outcome. Other factors such as sex and Grauer's type did not influence significantly the clinical outcome. Nine patients did not complete a full radiological follow-up and were therefore excluded from analysis of radiological outcome. Among the remaining 23 patients, only 25% of those who were followed three months or less showed fusion; conversely, all patients who have been examined from 6 to 48 months fused. Among the non-union patients, two underwent a second surgery by posterior approach. CONCLUSIONS: In our recent experience, the minimally invasive AOSF proved safe and effective in treating odontoid peg fractures. Selection based on Grauer's type is mandatory to achieve best results. While in the elderly, an anterior approach is well accepted as the first choice treatment, we recommend that this option should be offered as a suitable alternative to Halo or orthosis also in younger patients since it provides prompt, excellent clinical outcome and high fusion rate especially in this age group.

Whiplash-Associated Disorders : Clinical and medico-legal guidelines on the methods of ascertainment.

The manuscript presents the International Guidelines developed by the Working Group on Personal Injury and Damage under the patronage of the International Academy of Legal Medicine (IALM) regarding the Methods of Ascertainment of any suspected Whiplash-Associated Disorders (WAD).The document includes a detailed description of the logical and methodological steps of the ascertainment process as well as a synoptic diagram in the form of Flow Chart.

[Cervical disc herniation--diagnosis and treatment]. / Hernie discale cervicate--diagnostic et prise en charge.

A cervical disc herniation (CDH) is a frequently encountered pathology in primary care medicine. It may give rise to a compression of a nerve root (a radiculopathy, with or without sensory-motor deficit) or of the spinal cord (myelopathy). The majority of CDHs can be supported by means of a conservative treatment. When a radiculopathy is found and a clinico-radiological correlation is present, a moderate neurological deficit appears suddenly, or if it is progressive under conservative treatment or if pain is poorly controlled by well-conducted conservative treatment performed during 6 to 8 months, surgery is then recommended. A symptomatic cervical myelopathy is, by itself, an indication for a surgical treatment.

[Very long term follow-up after radiofrequency ablation for atrial fibrillation: the Geneva experience]. / Suivi à tres long terme après ablation par radiofréquence de la fibrillation auriculaire: expérience à Genève.

Catheter ablation (CA) has emerged as an increasingly popular treatment option for selected patients with atrial fibrillation (AF) because drugs are frequently limited by side effects and poor effectiveness. However, very little data is available regarding outcomes of CA of AF beyond 5 years. Guidelines' recommendations are not clear regarding long-term oral anticoagulation (OAC) after 2 years. We assessed thromboembolic events (TE) and AF ablation outcomes at very long-term follow-up (> 5 years) after CA. During a mean follow-up of 9 years after CA, 68% patients were in stable sinus rhythm without anti-arrhythmic drugs and the TE event rate was 0.41 per 100 patients/year. Our data suggests that patients post ablation with a high risk for stroke (CHA2DS2-VASc ≥ 2) should however continue OAC treatment.

Assessment of welfare of finishing beef cattle kept on different types of floor after short- or long-term housing.

This study aimed at evaluating short- and long-term effects of housing beef cattle on deep litter (DL) or concrete fully slatted floor (FS) on their welfare. Animal-based measures of the Welfare Quality® assessment protocol for cattle were used to assess health status and behaviour of bulls. The assessment was carried out in a large commercial farm on 15 batches of bulls (4 DL and 11 FS) 1 month after their receiving day (short-term) and on 12 batches (three DL and nine FS) the week before slaughter (long-term). Signs of better comfort on deep litter in terms of shorter lying down durations (5.1 ± 0.5 v. 6.5 ± 0.4 s; P<0.05) and lower risk of hairless patches (odds ratio=0.09; 95% confidence interval=0.01 to 0.68; P<0.05) were already observed after 1 month. Heavy bulls after a long-term housing on FS showed a higher prevalence of bursitis, hairless patches and lesions/swellings than animals on DL. Bulls on fully slatted floor were at higher risk of early culling (odds ratio=6.44; 95% confidence interval=1.57 to 26.37; P<0.01), mainly due to musculoskeletal system pathologies/lameness. Deep litter proved to be a valid alternative to slatted floor, making animals more confident to interact with powerful movements such as mounting at the end of the finishing period. A negative aspect of the deep litter was the poor cleanliness of the bulls. Compared with the fully slatted floor, there were higher odds ratios for dirty bulls at both, the short- (odds ratio=25.09; 95% confidence interval=8.96 to 70.22; P<0.001) and the long-term housing (odds ratio=276.13; 95% confidence interval=98.21 to 776.38; P<0.001). In order to improve health and welfare of beef cattle finished at a heavy weight, deep litter systems are a promising alternative to fully slatted floors. However, proper management of deep litter is necessary to maintain satisfactory cleanliness of the bulls.

[Minimally invasive spine surgery: past and present]. / Chirurgie du rachis lombaire minimalement invasive: passé et present d'une technique pleine d'avenir.

In the early twentieth century, the understanding of spine biomechanics and the advent of surgical techniques of the lumbar spine, led to the currently emerging concept of minimal invasive spine surgery, By reducing surgical access, blood loss, infection rate and general morbidity, functional prognosis of patients is improved. This is a real challenge for the spine surgeon, who has to maintain a good operative result by significantly reducing surgical collateral damages due to the relatively traumatic conventional access.

Clinically relevant complications related to posterior atlanto-axial fixation in atlanto-axial instability and their management.

BACKGROUND: The Magerl transarticular technique and the Harms-Goel C1 lateral mass-C2 isthmic screw technique are the two most commonly used surgical procedures to achieve fusion at C1-C2 level for atlanto-axial instability. Despite recent technological advances with an increased safety, several complications may still occur, including vascular lesions, neurological injuries, pain at the harvested bone graft site, infections, and metallic device failure. METHODS: We retrospectively analyzed all patients (n=42 cases) undergoing a Harms-Goel C1-C2 fixation surgery with polyaxial C1 lateral mass screws and C2 isthmic screws at two different institutions between 2003 and 2012 and report clinical and radiological complications. One patient was lost to follow-up. The mean follow-up of the remaining 41 patients was 18.7 months (range 12-90). A clinically relevant complication was defined as a complication determining the onset of a new neurological deficit or requiring the need for a revision surgery. RESULTS: A total of 14 complications occurred in 10 patients (24.4% of 41 patients). Greater occipital nerve neuralgia was evident in 4 patients (9.8%). All but one completely resolved at the end of the follow-up. Persistent neck pain was reported by 3 patients (7.3%), hypoesthesia by 1 patient (2.4%), and anesthesia in the C2 area on both sides in 1 patient (2.4%). Furthermore, a superficial, a deep, and a combined superficial and deep wound infection occurred in 1 patient each (2.4%). One patient (2.4%) had pain at the iliac bone graft donor site for several weeks with spontaneous resolution. A posterior progressive intestinal herniation through the iliac scar was seen in 1 case (2.4%), which required surgical repair. No vascular damages occurred. Altogether, 5/41 patients (12.2%) had a clinically relevant complication including 4 patients necessitating a revision surgery at the C1-C2 level (9.8%). CONCLUSIONS: Atlanto-axial fixation surgery remains a challenging procedure because of the proximity of important neurovascular structures. Nevertheless, on the basis of our current experience, the C1 lateral mass-C2 isthmic screw technique appears to be safe with a low incidence of clinically relevant complications. Postoperative C2 neuralgia, as the most frequent problem, is due to surgical manipulation during preparation of the C1 screw entry point.

Application of the Welfare Quality® assessment system on European beef bull farms.

Welfare concerns for intensive beef production have often been raised, but on-farm welfare assessment studies are rare. The aim of this study was to apply the Welfare Quality® (WQ) welfare assessment system for fattening cattle on beef bull farms to evaluate the state of welfare at the level of WQ measures and of aggregated scores, as well as overall classification. In addition, the purpose was to evaluate two ways of providing feedback information to the farmers with regard to possible welfare improvements on the farms. The study was conducted in Austria, Germany and Italy on a total of 63 beef bull farms with deep litter or cubicle-housing systems. Assessments were carried out 3 times (1 month and 7 months apart from the initial visit). In every country, farmers were assigned to two treatment groups (feedback from initial visit as written report, F, written feedback plus oral advice, FA) and a control group (C), which did not receive any feedback. At the criterion level, the highest average welfare scores were obtained from 'Absence of prolonged hunger' (94/100 points) followed by 'Absence of pain induced by management procedures' (88/100) and 'Comfort around resting' (77/100). Most welfare concerns related to the criteria 'Absence of disease' (40/100), 'Expression of social behaviour' (44/100) and 'Positive emotional state' (48/100), thus indicating room for improvements. Two-thirds of the farms achieved the 'Enhanced' level, about one-third was judged 'Acceptable' and only one farm 'Excellent'. After 6 months of monitoring period, there was no significant welfare improvement in both the treatment groups as compared with the control group. Reasons for the lack of effect may mainly be seen in the short monitoring period and a lack of external incentives. In conclusion, the WQ assessment system revealed areas for improvement, but longer term studies and investigations on alternative ways of transferring outcomes from on-farm welfare assessments to farmers should be carried out in future.

Acute traumatic central cord syndrome: a comprehensive review.

Acute traumatic central cord syndrome (ATCCS) is the most common type of incomplete spinal cord injury, characterized by predominant upper extremity weakness, and less severe sensory and bladder dysfunction. ATCCS is thought to result from post-traumatic centro-medullary hemorrhage and edema, or, as more recently proposed, from a Wallerian degeneration, as a consequence of spinal cord pinching in a narrowed canal. Magnetic Resonance Imaging is the method of choice for diagnosis, showing a typical intramedullary hypersignal on T2 sequences. Non-surgical treatment relies on external cervical immobilization, maintenance of a sufficient systolic blood pressure, and early rehabilitation, and should be reserved for patients suffering from mild ATCCS. Surgical management of ATCCS consists of posterior, anterior or combined approaches, in order to achieve spinal cord decompression, with or without stabilization. The benefits of early surgical decompression in the setting of ATCCS remain controversial due to the lack of clinical randomized trials; recent studies suggest that early surgery (less than 72hours after trauma) appears to be safe and effective, especially for patients with evidence of focal anatomical cord compression.

On-farm animal welfare assessment in beef bulls: consistency over time of single measures and aggregated Welfare Quality(®) scores.

Consistency over time of (on-farm) animal welfare assessment systems forms part of reliability, meaning that results of the assessment should be representative of the longer-term welfare state of the farm as long as the housing and management conditions have not changed considerably. This is especially important if assessments are to be used for certification purposes. It was the aim of the present study to investigate consistency over time of the Welfare Quality(®) (WQ(®)) assessment system for fattening cattle at single measure level, aggregated criterion and principle scores, and overall classification across short-term (1 month) and longer-term periods (6 months). We hypothesized that consistency over time of aggregated criterion and principle scores is higher than that of single measures. Consistency was also expected to be lower with longer intervals between assessments. Data were obtained using the WQ(®) protocol for fattening cattle during three visits (months 0, 1 and 7) on 63 beef farms in Austria, Germany and Italy. Only data from farms where no major changes in housing and management had taken place were considered for analysis. At the single measure level, Spearman rank correlations between visits were >0.7 and variance was lower within farms than between farms for six and two of 19 measures after 1 month and 6 months, respectively. After aggregation of single measures into criterion and principle scores, five and two of 10 criteria and three and one of four principles were found reliable after 1 and 6 months, respectively. At the WQ(®) principle level, this was the case for three and one of four principles. Seventy-nine per cent and 75% of the farms were allocated to the same overall welfare category after 1 month and 6 months. Possible reasons for a lack of consistency are seasonal effects or short-term fluctuations that occur under normal farm conditions, low prevalence of clinical measures and probably insufficient sample size, whereas poor inter-observer agreement leading to inflation of correlation can be ruled out. At the criterion and principle level, aggregation of information into scores appears to partly smoothen undirected variation at the single measure level without losing sensitivity in terms of welfare evaluation. Reliable on-farm animal welfare assessments should therefore be based on repeated assessments. Further long-term studies are recommended to better understand the factors influencing consistency over time.

[Lumbar disc herniation--diagnosis and treatment]. / Hernie discale lombaire--diagnostic et prise en charge.

A lumbar disc herniation (LDH) is a condition frequently encountered in primary care medicine. It may give rise to a compression of one or more nerve roots, which can lead to a nerve root irritation, a so-called radiculopathy, with or without a sensorimotor deficit. The majority of LDHs can be supported by means of a conservative treatment consisting of physical therapy, ergotherapy, analgetics, anti-inflammatory therapy or corticosteroids, which may be eventually administered by infiltrations. If a clinico-radiological correlation is present and moderate neurological deficit appears suddenly, if it is progressive under conservative treatment or if pain is poorly controlled by well-conducted conservative treatment performed during four to six months, surgery is then recommended.

Renal carcinoma relapse presenting as a peripheral nerve sheath tumor: A case report and brief review of the literature.

We report a rare case of renal carcinoma metastasis involving a lumbar nerve root. Metastases to nerve roots are rare occurrences, and to our knowledge, only six cases have been reported so far in the literature. The patient in this report presented with weakness in the right lower limb and intractable pain irradiating along the L5 dermatome. MRI findings revealed a right-sided L5 nerve root mass, suggestive of a schwannoma, involving the spinal ganglion and its extraforaminal region. Complete macroscopic resection of this mass was performed, and histopathologic analysis confirmed the lesion to be a metastasis of a renal clear cell carcinoma. Local radiotherapy was given and tyrosine kinase inhibitors administered. At 5 months, the patient was pain-free and his right limb weakness had completely resolved. A tumoral recurrence could be observed on the control MRI 5 months after surgery. This report presents the first case of a patient with a renal clear cell carcinoma metastasis to a L5 nerve root, as well as a brief review of previous cases of metastases to peripheral nerve roots.

Alternative solutions to the concrete fully-slatted floor for the housing of finishing beef cattle: effects on growth performance, health of the locomotor system and behaviour.

The aim of this study was to assess the effect of two potential alternative solutions to the concrete fully-slatted floor (FS), namely, a perforated floor (PF) and a perforated floor coated with a rubber mattress (RM), on growth, locomotor system health, and behaviour of intensively finished young bulls. Forty-eight male beef-crosses (Charolais × Aubrac) were allotted to six pens of eight animals (two pens/floor type) for a finishing period of 175 ± 7 days. Growth was recorded and two health checks and two 8-h behavioural observations were carried out by trained assessors 1 month after the beginning of the trial (Initial) and 2 weeks before slaughter (Final). Feed intake was not affected by floor type, but average daily gain of RM bulls was higher than that of FS (1.37 vs. 1.19 kg, P=0.01), with PF being intermediate (1.27 kg). Behavioural observations showed that FS bulls had a higher number of slipping events (6.5) than PF (2.1; P=0.01) and RM bulls (0.9; P<0.01). Bulls on FS showed more lying down attempts (2.2 vs. 0.1; P=0.001), a lower number of lying/standing transitions (4.5 vs. 7.3; P<0.001) and a longer lying duration (5.9 vs. 4.7s; P<0.01) than RM bulls. Signs of lameness were observed in five FS bulls at the final assessment. RM floor proved to be a good alternative to FS but it increased the likelihood of overgrown claws due to insufficient hoof wear.

Fibrillary structure is key for hemostasis: a similar effect of collagen fleece and oxidized cellulose on experimental hemorrhagic brain injury.

BACKGROUND: The choice of the ideal hemostatic agent for intraoperative cerebral bleeding is under continuous debate. Our aim was to assess the influence of such materials on bleeding time in hemorrhagic cerebral contusions. We compared oxidized regenerated cellulose in fibrillar form (ORC) to microfibrillar collagen fleece (CF) in an experimental study. METHODS: N=50 Sprague Dawley rats underwent a bilateral craniectomy. 3 separate standardized superficial cortical impacts were inflicted using a high-speed drill. Immediately after lesion placement, each of the 3 lesions was covered with (a) nothing (control), (b) ORC, or (c) CF. We observed the 3 lesions with a surgical microscope. The bleeding times were recorded for each cerebral lesion and compared using ANOVA test. RESULTS: All traumatic lesions produced significant bleeding. The statistical analysis showed a clear reduction in bleeding time for groups treated with either ORC or CF compared to the control group. Lesions covered with ORC and CF showed no significant difference with regard to bleeding time. CONCLUSIONS: ORC and CF significantly reduce blood loss from hemorrhagic contusions. Our data suggest that they effectively reduce bleeding time. We advocate the use of hemostatic material for limiting bleeding from superficial cortical lesions.

Posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws.

PURPOSE: C1-C2 instability or painful osteoarthritis are recognised indications for posterior atlanto-axial fixation. In the traditional trans-articular C1-C2 screw fixation, up to 20% of patients cannot have safe placement of bilateral screws in the event of a medially located vertebral artery and a straight screw trajectory in the sagittal plane. The more recently developed C1-C2 fixation technique with individual C1 lateral mass screws and converging C2 pars screws can be employed in case of a medially located vertebral artery and has comparable biomechanical strength. This is a prospective observational study to investigate the advantages, the safety, and the drawbacks of posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws. METHODS: Twelve consecutive patients with C1-2 instability (n = 11) and painful osteoarthritis (n = 1) underwent a posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws. The average follow-up was 16 months and all patients reached the 12-month follow-up. FINDINGS: No hardware failure occurred in any of the patients. Correct screw placement and construct stability was found in all 12 patients (100%) at 6 and 12 months after surgery. Mean neck pain on a visual analogue scale (VAS) was 2.1 at 6 months and 2.0 at 12 months. Only transient complications were observed: one patient presented with progressive intestinal herniation through the iliac crest scar; one suffered from severe pain at the posterior iliac crest for 3 months and three patients complained of annoying pain/dysaesthesia in the C2 dermatome for 3-6 months after surgery. CONCLUSION: This study confirms that posterior atlanto-axial fixation with polyaxial C1 lateral mass screws and C2 pars screws is a safe and effective surgical option in the treatment of atlanto-axial instability or painful osteoarthritis.

[Non fusion techniques in spinal surgery]. / Techniques de "non-fusion" en chirurgie rachidienne.

In order to prevent adjacent segment degeneration following spinal fusion new techniques are being used. Lumbar disc arthroplasty yields mid term results equivalent to those of spinal fusion. Cervical disc arthroplasty is indicated in the treatment of cervicobrachialgia with encouraging initial results. The ability of arthroplasty to prevent adjacent segment degeneration has yet to be proven. Although dynamic stabilization had not been proven effective in treating chronic low back pain, it might be useful following decompression of lumbar spinal stenosis in degenerative spondylolisthesis. Interspinal devices are useful in mild lumbar spinal stenosis but their efficacy in treating low back pain is yet to be proven. Confronted with a growing number of new technologies clinicians should remain critical while awaiting long term results.