Second-look surgery in postoperative pediatric low-grade glioma.

OBJECTIVE: To review the literature on second-look surgery in pediatric low-grade gliomas (LGG) with a view to presenting both sides of the picture of re-exploration. METHODS: Collection of material from recent literature on pediatric LGG. This was a retrospective review of these publications. RESULTS: There are a number of publications recommending second-look surgery in selected cases, provided morbidity of the second surgery is minimum, and indeed some in which there is improvement in the neurodeficit after the second resection. CONCLUSION: There seems a fair balance of articles recommending and dissuading the practice of second-look surgery, but in our limited experience we have found it useful in selected patients.

Physiotherapeutic Rehabilitation for a Geriatric Patient With Discitis Associated With Pott's Spine: A Case Report.

Discitis linked to Pott's spine is an infrequent yet severe issue, especially difficult to manage among elderly individuals due to age-related bodily changes and concurrent health issues. This report details the successful physiotherapy-based recovery of a senior patient afflicted with discitis related to Pott's spine. The individual, a 61-year-old man, presented symptoms including intense back pain, restricted movement, and neurological issues. The diagnosis was confirmed via imaging scans, indicating spinal tuberculosis and vertebral disc involvement. Treatment embraced a comprehensive approach involving medication alongside physiotherapy. The physiotherapeutic regimen aimed at pain alleviation, enhancing spinal flexibility, strengthening weakened muscles, and promoting functional autonomy. Techniques such as manual therapy, targeted exercises, and patient education were employed. Despite the challenges posed by the patient's age and existing conditions, significant enhancements in pain management, mobility, and everyday functioning were noted during the rehabilitation journey. This case underscores the significance of prompt diagnosis, collaborative care, and personalized physiotherapeutic interventions in attaining positive outcomes for elderly patients grappling with discitis associated with Pott's spine. Further investigation is needed to delineate optimal rehabilitation approaches for this intricate condition among the elderly.

Acute Paraparesis in a Patient after High Velocity Manipulation of Cervical Spine and its Management.

Introduction: In this case report, we question the safety associated with high velocity manipulations of the cervical spine. These procedures do not frequently cause catastrophic adverse effects but few and rare case reports like this make us aware about the possible complications of the maneuvers. Case Report: This case report presents an uncommon presentation of acute neurodeficit to a 57-year-old male following a neck manipulation by a barber in the saloon which recovered partially with Intravenous steroid therapy but required active intervention surgically to treat his complete symptomatology. The magnetic resonance imaging (T2-weighted) showed a high signal intensity within the spinal cord at the C4C5 level (cord edema). Here, we discuss the possible mechanism of injury and the need to educate the lesser common risks of performing such sudden and forceful maneuvers. Conclusion: This case report is a reminder that people should be careful while trying alterative types of therapy which use forceful neck manipulations to relieve pain as this maneuver could cause injuries to the disc complex especially when the patient already has a disc prolapse which is asymptomatic, causing the disc to fail again making it symptomatic.

Analysis of risk factors and treatment outcome in patients presenting with neglected congenital spinal deformity and neurological deficit.

PURPOSE: Congenital spinal deformities (CSD) are uncommon; and usually present during early childhood. Rarely, patients have been reported to present with neglected CSD in association with myelopathy. The current study reports the largest series of patients with neglected CSD and major neuro-deficit; and discusses their long-term outcome. METHODS: We retrospectively analysed patients with CSD who presented with myelopathy and underwent surgical management between January 2008 and January 2018. Only patients who had complete clinico-radiological records and completed minimum 2-year follow-up were included. Neurology was graded according to American Spinal Injury Association Impairment, Nurick and modified Japanese Orthopaedic Association scores. Radiological details like deformity type, location, magnitude, and underlying anomaly were recorded. A comparative analysis of parameters between pre-operative and final follow-up periods was performed. RESULTS: Thirty three (age = 21.1 ± 11.9 years) patients with CSD and myelopathy were included. Mean duration since myelopathy was 5.2 ± 6.2 months. Thirty (91%) patients presented with kyphosis or kyphoscoliosis; and 18 had upper thoracic-level lesion (12 and 3 with mid- or low-thoracic and lumbar lesions). 16 (48.5%) and 12 (36.4%) presented with types 1 and 3 anomalies, respectively. Mean pre-operative mJOA and Nurick grades were 8.8 ± 2.4 and 3.4 ± 0.7. Based on ASIA score, 2, 5, 21 and five patients presented with grades A, C, D and E, respectively. All patients underwent surgeries from posterior-only approach. Mean follow-up was 4.7 ± 2.6 years. In kyphoscoliosis group, coronal and sagittal Cobb improved by 23.8° and 25.9°, respectively. Mean deformity improved by 19.6° and 15.6° in scoliosis and kyphosis groups, respectively. Neurological status improved in 5, remained stable in 23 and deteriorated in five patients. Mean mJOA and Nurick grades at final follow-up was 8.3 ± 3.1and 3.4 ± 0.9. CONCLUSION: Major neurological deficit is a rare complication of neglected CSD. In our series, such a presentation was observed in patients with kyphotic or kyphoscoliotic deformities, type 1 or 3 vertebral anomalies and proximal thoracic vertebral lesions. Surgery can be valuable in these patients, as it not only stabilises deformity, but also provides the best chance of preventing neuro-deterioration.

Recurrent solitary bone plasmacytoma: A case report.

BACKGROUND: Plasmacytoma is an hematological malignancy that originates in bone. It may involve a single skeletal location. Notably, these lesions can progress to involve multiple segments in 50% of cases, at which point they are classified as having multiple myeloma (MM). CASE DESCRIPTION: One year ago, this patient had undergone a D6 laminectomy and biopsy for plasmacytoma. Now at age 73, she newly presented with the onset of a progressive paraparesis of 4 weeks' duration. On examination, she had 3/5 strength in both lower extremities accompanied by diffuse hyperreflexia, and bilateral Babinski signs. She underwent a D5-D7 decompression, D6 corpectomy with anterior mesh cage reconstruction, and a D3-D9 posterior fusion. CONCLUSION: Patients originally treated for plasmacytoma present 50% of the time with the new onset of neurological symptoms and signs due to the subsequent evolution of MM. As these lesions may be refractory to radiation and/or chemotherapy, surgery is often warranted.

Correlation between Intraoperative Serum Lactate and New-Onset Postoperative Neurodeficits in Patients Undergoing Elective Craniotomies.

Background: Elevated lactate levels in neurosurgical patients are seen in brain tumors, traumatic brain-injury, brain infarction, and subarachnoid hemorrhage. Hyperlactatemia during craniotomy may be caused by hypotension due to multiple factors. Recently, intraoperative hyperlactatemia has been associated with fresh-onset neurodeficits. Aims: We studied the prevalence of hyperlactatemia in patients undergoing craniotomy and relationship between intraoperative hyperlactatemia and development of new postoperative neurodeficit. Study Design: Eighty-six patients, American Society of Anesthesiologists Classes I,II and III, undergoing elective craniotomy for neurosurgical indications were included in this prospective, observational study in a tertiary care center. Materials and Methods: Baseline, intraoperative, and postoperative (upto 12 h) lactate levels were noted. Neurological examination to detect new-onset neurodeficits was done at intervals up to 72 h postoperatively. Lactate levels were compared between patients who developed neurodeficits and those who did not develop neurodeficits postoperatively. Statistical Analysis: Statistical analysis of the correlation between intraoperative hyperlactatemia and fresh postoperative neurodeficit was done using the Chi-square test. Results: The prevalence of intraoperative hyperlactatemia was found to be 52.3% and that of fresh-onset postoperative neurodeficits was 31.4%. The relationship between the two was statistically insignificant (P > 0.05). Conclusion: The intraoperative hyperlactatemia is not correlated with the development of fresh-onset postoperative neurodeficit. Implications: There may be no relationship between the intraoperative lactate levels and fresh-onset postoperative neurodeficits. Multifactorial reasons may be responsible for increased lactate levels which need to be identified by further research.

Clinical and radiological factors related to the presence of motor deficit in lumbar disc prolapse: a prospective analysis of 70 consecutive cases with neurological deficit.

PURPOSE: To analyse the clinic-radiological factors associated with neurological deficit following lumbar disc herniation. METHODS: A prospective, cross-sectional study was performed in 140 cases of micro-discectomy following lumbar disc herniation. Group 1 included 70 consecutive patients with motor deficit and group 2 (controls) included 70 patients with intact neurology. Motor deficit was defined as the occurrence of motor power ≤3/5 in L2-S1 myotomes. Multiple clinical and radiological parameters were studied between the two groups. RESULTS: Patients with diabetes (p 0.004), acute onset of symptoms (p 0.036), L3-4 discs (p 0.001), sequestrated discs (p 0.004), superiorly migrated discs (p 0.012) and central discs (p 0.004), greater antero-posterior disc dimension (p 0.023), primary canal stenosis (p 0.0001); and greater canal compromise (p 0.002) had a significant correlation with the development of neurological deficit. The presence of four or more of these risk factors showed a higher chance of the presence of motor deficit (sensitivity of 74%, specificity of 77%). Age, sex, previous precipitating events, severity of pain, smoking, and number of herniations levels did not affect the occurrence of deficit (p > 0.05 for all). Patients with or without bladder symptoms were similar with respect to all clinico-radiological parameters. However, the time delay since the occurrence of deficit was significantly shorter in patients with bladder involvement (p 0.001). CONCLUSION: Patients with diabetes, acute presentation, central, sequestrated and superiorly migrated discs, high lumbar disc prolapse, and greater spinal canal compromise are predisposed to the presence of motor deficit.

Recent evidence for an expanded role of the kynurenine pathway of tryptophan metabolism in neurological diseases.

The kynurenine pathway (KP) of tryptophan metabolism has emerged in recent years as a key regulator of the production of both neuroprotective (e.g. kynurenic and picolinic acid, and the essential cofactor NAD+) and neurotoxic metabolites (e.g. quinolinic acid, 3-hydroxykynurenine). The balance between the production of the two types of metabolites is controlled by key rate-limiting enzymes such as indoleamine-2,3-dioxygenase (IDO-1), and in turn, molecular signals such as interferon-γ (IFN-γ), which activate the KP metabolism of tryptophan by this enzyme, as opposed to alternative pathways for serotonin and melatonin production. Dysregulated KP metabolism has been strongly associated with neurological diseases in recent years, and is the subject of increasing efforts to understand how the metabolites are causative of disease pathology. Concurrent with these endeavours are drug development initiatives to use inhibitors to block certain enzymes in the pathway, resulting in reduced levels of neurotoxic metabolites (e.g. quinolinic acid, an excitotoxin and N-Methyl-d-Aspartate (NMDA) receptor agonist), while in turn enhancing the bioavailability of the neuroprotective metabolites such as kynurenic acid. Neurodegenerative diseases often have a substantial autoimmune or inflammatory component; hence a greater understanding of how KP metabolites influence the inflammatory cascade is required. Additionally, challenges exist in diseases like multiple sclerosis (MS) and motor neurone disease (MND), which do not have reliable biomarkers. Clinical diagnosis can often be prolonged in order to exclude other diseases, and often diagnosis occurs at an advanced state of disease pathology, which does not allow a lengthy time for patient assessment and intervention therapies. This review considers the current evidence for involvement of the KP in several neurological diseases, in biomarkers of disease and also the parallels that exist in KP metabolism with what is known in other diseases such as HIV, Alzheimer's disease/dementia, infection, immune privilege and cardiovascular disease. This article is part of the Special Issue entitled 'The Kynurenine Pathway in Health and Disease'.

Successful Pregnancy Outcome in an Operated Case of Lipomeningomyocele: A Rare Case.

Lipomeningomyocele is one of the types of occult spinal dysraphism associated with tethered cord syndrome, which is characterised by neurodeficit symptomatology due to stretch- induced functional disorder of the spinal cord with its caudal part attached by an in elastic tissue. There is stretching of conus medullaris and nerve roots due to disproportionate growth between vertebral column and spinal cord, resulting in various neurological deficits. Its incidence is approximately 1 in 4000 births in the USA, with a slightly higher female preponderance, although its true incidence is not known. There are very few studies on pregnancy outcome in these patients and the management dilemma in this group has prompted us to report this case.

Studying the establishment of rat model of asphyxial cardiac arrest and the efficacy of CPR / 中华急诊医学杂志

Objective To study the establishment of rat model of asphyxia-cardiac arrest and efficacy of CPR in order to find the length of optimum time of asphyxia to cause injury.Methods One hundred and twenty-six male Sprague-Dawley rats were randomly (random number) divided into sham operation group and experimental groups.Cardiac arrest was induced by asphyxiation after intravenous injection of vecuronium bromide.The experimental groups were assigned into AP4 (four-minute asphyxia period),AP6 and AP8 subgroups in accordance with different lengths of time of asphyxia subjected to.In these groups,CPR,including pre-cordial compression and synchronized mechanical ventilation,was initiated 4,6 and 8 min after asphyxia-induced cardiac arrest,respectively.The successful ratio of resuscitation and hemodynamic variables were recorded.Brain water content,neural deficit scores (NDS),imaging changes on MR,pathological changes of brain tissue and neuronal apoptosis were evaluated at 1 d,3 d and 7 days after ROSC.All the data were analyzed by single-factor analysis of variance or Chi-square test.P ＜ 0.05 was considered statistically significant.Result The lowest NDS occurred at 1 d after ROSC,brain water content and imaging changes on MR were most obvious at 3 d after ROSC,while pathological changes of brain tissue and neuronal apoptosis increased and reached the peak at 7d after ROSC.The survival rates after 24 hours of AP4,AP6 and AP8 groups were 85％,75％ and 45％,respectively.The rate of ROSC and survival rate of AP8 group were significantly lower than those of other groups (P ＜0.01).The longer time of asphyxia the severer pathological changes of brain tissue,brain edema,neural deficit,and magnetic resonance imaging changes in all experimental groups.As compared to other groups,the brain damage index of AP8 group was most serious,while that of AP6 group was moderate.Conclusions The rat model following asphyxia-induced cardiac arrest and cardiopulmonary resuscitation was established successfully.From the evidence of survival rate and damage grade of brain tissue,asphyxia for 6 min may be the rational length of ischemic time in this model.

Effects of Hemin on neuroglobin expression after cardiopulmonary resuscitation in rats.

BACKGROUND: Despite a large amount of resuscitation research, the survival rate after cardiac arrest remains low, and brain injury is the key issue. Neuroglobin (NGB) is an oxygen-binding heme protein found in the brain with a protection role against ischemic-hypoxic brain injury. Hemin is an effective activator of neuroglobin. This study was undertaken to assess the effect of hemin on expression of neuroglobin (NGB) in the cerebral cortex, neuro-deficit score (NDS) and pathological changes after cardiopulmonary resuscitation (CPR) in rats. METHODS: A total of 120 male Sprague-Dawley (SD) rats were randomly divided into a control group (A), a CPR group (B) and a Hemin group (C). The animal model of cardiac arrest (CA) induced by asphyxia and CPR was established. NGB expression in the cerebral cortex with immunohistochemistry, NDS and pathological changes in the cerebral cortex were examined at 3, 6, 12, 24 hours after recovery of spontaneous circulation (ROSC) in each group. Experimental data were treated as one-factor analysis of variance and the Tukey test. RESULTS: In comparison with group A, NGB expression was increased significantly at 12 and 24 hours after ROSC (P<0.05 or P<0.01), NDS was decreased significantly at each time point after ROSC (P<0.01), and pathological changes were severe at each time point after ROSC in group B. In comparison with group A, NGB expression was increased significantly at 6, 12, 24 hours after ROSC (P<0.05 or P<0.01), NDS was decreased significantly at 3, 6, 12 hours after ROSC (P<0.01) in group C. In comparison with group B, NGB expression was increased significantly at 12 and 24 hours after ROSC, NDS was increased significantly at 12 and 24 hours after ROSC, and pathological changes were milder in group C. CONCLUSION: There were increased NGB expression in the cerebral cortex, decreased NDS, and severe pathological changes after CPR in rats. Hemin treatment up-regulated expression of NGB, improved NDS, mitigated pathological changes, and alleviated cerebral injury after CPR.

Effects of hemin on neuroglobin expression after cardiopulmonary resuscitation in rats / 中华急诊医学杂志

Objective To study the effect of Hemin on the level of neuroglobin (NGB) in cerebral cortex,neurodeficit score (NDS) and pathological changes in cerebral cortex after cardiopulmonary resuscitation (CPR) in rats. Method A total of 120 male Sprague Dawley(SD) rats were divided randomly into control group(A), CPR group(B) and Hemin group(C). The animal model of cardiac arrest (CA) induced by asphyxia was established and CPR was performed. The NGB level in cerebral cortex, NDS and pathological changes in cerebral cortex were examined 0.5 h,3 h,6 h, 12 h, 24 h after restoration of spontaneous circulation (ROSC) in each group. Experimental data were analyzed by using one-factor analysis of variance and Tukey test. Results In comparison with group A, the levels of NGB were significantly higher 12 h,and 24 h after ROSC (P ＜0.05 and P ＜0.01), the values of NDS were significantly lower at each interval after ROSC ( P ＜ 0.01 ) ,and the pathological changes were more severe at each interval after ROSC in group B. In comparison with group A, the levels of NGB were significantly higher 6 h, 12 h and 24 h after ROSC ( P ＜ 0.05 and P ＜ 0.01 ), and the values of NDS were significantly lower 3 h, 6 h, 12 h after ROSC ( P ＜ 0.01) in group C. In comparison with group B, the levels of NGB were significantly higher 12 h and 24 h after ROSC, the values of NDS were significantly higher 12 h and 24 h after ROSC, and the pathological changes were less in group C. Conclusions The NGB level increased in cerebral cortex, the NDS level decreased and severe pathological changes occurred in rats after CPR. The hemin treatment up-regulated the level of NGB, improved the NDS, mitigated pathological changes, alleviating the cerebral injury after CPR.