Thoracolumbar Spine Trauma.

Thoracolumbar spine trauma can result in potentially life-threatening consequences and requires careful management to ensure good outcomes. The purpose of this chapter is to discuss the anatomy, diagnostic tools, non-operative, and operative treatments important when addressing thoracolumbar trauma.

Current status of pediatric neurocritical care in Argentina. / Estado actual del soporte neurológico crítico en pediatría en la Argentina.

INTRODUCTION: Patients with neurocritical injuries account for 10-16 % of pediatric intensive care unit (PICU) admissions and frequently require neuromonitoring. OBJECTIVE: To describe the current status of neuromonitoring in Argentina. METHODS: Survey with 37 questions about neuromonitoring without including patients' data. Period: April-June 2017. RESULTS: Thirty-eight responses were received out of 71 requests (14 districts with 11 498 annual discharges). The PICU/hospital bed ratio was 21.9 (range: 4.2-66.7). Seventy-four percent of PICUs were public; 61 %, university-affiliated; and 71 %, level I. The availability of monitoring techniques was similar between public and private (percentages): intracranial pressure (95), electroencephalography (92), transcranial Doppler (53), evoked potentials (50), jugular saturation (47), and bispectral index (11). Trauma was the main reason for monitoring. CONCLUSION: Except for intracranial pressure and electroencephalography, neuromonitoring resources are scarce and active neurosurgery availability is minimal. A PICU national registry is required.

Introducción. Los pacientes con lesiones neurocríticas representan el 10-16 % de los ingresos a unidades de cuidados intensivos pediátricas (UCIP) y, frecuentemente, requieren neuromonitoreo. Objetivo. Describir el estado actual del neuromonitoreo en la Argentina. Métodos. Encuesta con 37 preguntas sobre neuromonitoreo sin incluir datos de pacientes. Período: abril-junio, 2017. Resultados. Se recibieron 38 respuestas a 71 solicitudes (14 distritos con 11 498 egresos anuales). La relación camas de UCIP/hospitalarias fue 21,9 (rango: 4,2-66,7). El 74 % fueron públicas; el 61 %, universitarias, y el 71 %, nivel 1. La disponibilidad fue similar entre públicas y privadas (porcentajes): presión intracraneana (95), electroencefalografía (92), doppler transcraneano (53), potenciales evocados (50), saturación yugular (47) e índice bispectral (11). El principal motivo de monitoreo fue trauma. Conclusión. Excepto la presión intracraneana y la electroencefalografía, los recursos de neuromonitoreo son escasos y la disponibilidad de neurocirugía activa es mínima. Se necesita un registro nacional de UCIP.

Validity Prediction of Amplitude-Integrated EEG in Early Neuromotor Development Outcomes in High-Risk Neonates.

With the continuous advancement of medical technology, the survival rate of high-risk children is increasing year by year, but the developmental problems that have gradually become apparent in the later stages have a serious impact on the quality of life of children. Amplitude-integrated EEG is an EEG monitoring technology developed for clinical use in newborns in recent years. Therefore, to better detect neuromata development in high-risk children, this study explores the validity prediction of amplitude-integrated EEG in early neuromata development in high-risk children. For 100 high-risk children, amplitude-integrated EEG was used for monitoring, and the exercise scale and validity predictors in the Bailey Infant Development Scale were used to assess whether high-risk children had neurobehavioral abnormalities. The experimental results show that the application of amplitude-integrated EEG can make accurate and effective predictions of early neuromata development outcomes in high-risk children. Compared with traditional neurological examination methods, it has higher sensitivity, specificity, positive predictive value, and consistency in predicting the early neuromata development outcomes of high-risk children. It is suitable for application and promotion in China and has a good application value.

[Conservative Treatment of Thoracic and Lumbar Vertebral Fractures - what's it all about?] / Konservative Behandlung von Wirbelfrakturen in BWS und LWS ­ was geht wie?

The basis for assessing thoracolumbar vertebral body fractures are two established classification systems. Important, especially in terms of further treatment, is the distinction between osteoporotic and healthy bones. The AO Spine classification offers a comprehensive tool for healthy bones to reliably specify the morphological criterias (alignment, integrity of the intervertebral disc, fragment separation, stenosis of the spinal canal). In addition to the fracture morphology, the OF classification for osteoporotic fractures includes patient-specific characteristics to initiate adequate therapy. In general an adequate pain therapy is required for early rehabilitation. While in the bone healthy population, physiotherapy reduces the risk of muscle deconditioning, in the osteoporotic population it additionally serves to prevent subsequent fractures. Unlike osteoporotic patients, bone healthy patients with vertebral fractures should not undergo a corset/orthosis treatment.

Neurophysiological monitoring during neurosurgery: anesthetic considerations based on outcome evidence.

PURPOSE OF REVIEW: This article reviews the recent outcome studies that investigated intraoperative neurophysiological monitoring (IONM) during spine, neurovascular and brain tumor surgery. RECENT FINDINGS: Several recent studies have focused on identifying which types of neurosurgical procedures might benefit most from IONM use. Despite conflicting literature regarding its efficacy in improving neurological outcomes, many experts have advocated for the use of IONM in neurosurgery. Several themes have emerged from the recent literature: the entire perioperative team must always work together to ensure adequate communication and intervention; systems and checklists, in which each member of the perioperative team has a clearly defined role, can be useful in the event of a sudden intraoperative changes in electrophysiological signals; regardless of the IONM modality used, any sudden change in electrophysiological signal should prompt an immediate and appropriate intervention; a multimodal IONM approach is often, but not always, advantageous over a single IONM approach. SUMMARY: For neurosurgical procedures that can be complicated by neural injury, the use of IONM should be considered according to specific patient and surgical factors. Future studies should focus on improving IONM technology and optimizing sensitivity and specificity for detecting any impending neural damage.

Dynamic contrast-enhanced magnetic resonance imaging in denervated skeletal muscle: Experimental study in rabbits.

PURPOSE: To investigate the value of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) for evaluating denervated skeletal muscle in rabbits. MATERIALS AND METHODS: 24 male rabbits were randomly divided into an irreversible neurotmesis group and a control group. In the experimental group, the sciatic nerves of rabbits were transected for irreversible neurotmesis model. A sham operation was performed in the control group. MRI of rabbit lower legs was performed before nerve surgery and 1 day, 3 days, 5 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 6 weeks, 8 weeks, 10 weeks, and 12 weeks after surgery. RESULTS: Signal intensity changes were seen in the left gastrocnemius muscle on the T2-weighted images. DCE-MRI derived parameters (Ktrans, Kep, and Vp) were measured in vivo. In the irreversible neurotmesis group, T2-weighted images showed increased signal intensity in the left gastrocnemius muscle. Ktrans, Vp values changes occur as early as 1 day after denervation, and increased gradually until 4 weeks after surgery. There are significant increases in both Ktrans and Vp values compared with those in the control group after surgery (P < 0.05). Kep values show no significant difference between the irreversible neurotmesis group and the control group. CONCLUSION: DCE-MRI hold the promise of an early and sensitive diagnosis of denervated skeletal muscle.

Modulation of the Endocannabinoid System Following Central Nervous System Injury.

Central nervous system (CNS) injury, such as stroke or trauma, is known to increase susceptibility to various infections that adversely affect patient outcomes (CNS injury-induced immunodepression-CIDS). The endocannabinoid system (ECS) has been shown to have immunoregulatory properties. Therefore, the ECS might represent a druggable target to overcome CIDS. Evidence suggests that cannabinoid type 2 receptor (CB2R) activation can be protective during the early pro-inflammatory phase after CNS injury, as it limits neuro-inflammation and, therefore, attenuates CIDS severity. In the later phase post CNS injury, CB2R inhibition is suggested as a promising pharmacologic strategy to restore immune function in order to prevent infection.

An update on the management of adult traumatic nerve injuries-replacing old paradigms: A review.

Acute nerve injuries are routinely encountered in multisystem trauma patients. Advances in surgical treatment of nerve injuries now mean that good outcomes can be achieved. Despite this, old mantras associated with management of nerve injuries, including "wait a year to see if recovery occurs" and "there's nothing we can do", persist. Practicing by these mantras places these patients at a disadvantage. Changes begin to occur in the nerve, neuromuscular junction, and muscle from the moment a nerve injury occurs. These changes can become irreversible approximately 18 to 24 months following denervation. Thus, it is a race to reestablish a functional nerve-muscle connection before these irreversible changes. Good outcomes rely on appropriate acute management and avoiding delays in care. Primary nerve surgery options include direct primary repair, nerve graft repair, and nerve transfer. Acute management of nerve injuries proceeds according to the rule of 3's and requires early cooperation between trauma surgeons who recognize the nerve injury and consultant nerve surgeons. Care of patients with acute traumatic nerve injuries should not be delayed. Awareness of current management paradigms among trauma surgeons will help facilitate optimal upfront management. With the ever-expanding surgical options for management of these injuries and the associated improvement of outcomes, early multidisciplinary approaches to these injuries have never been more important. Old mantras must be replaced with new paradigms to continue to see improvements in outcomes for these patients. The importance of this review is to raise awareness among trauma surgeons of new paradigms for management of traumatic nerve injuries.

Protein Profiling in Serum and Cerebrospinal Fluid Following Complex Surgery on the Thoracic Aorta Identifies Biological Markers of Neurologic Injury.

Surgery on the arch or descending aorta is associated with significant risk of neurological complications. As a consequence of intubation and sedation, early neurologic injury may remain unnoticed. Biomarkers to aid in the initial diagnostics could prove of great value as immediate intervention is critical. Twenty-three patients operated in the thoracic aorta with significant risk of perioperative neurological injury were included. Cerebrospinal fluid (CSF) and serum were obtained preoperatively and in the first and second postoperative days and assessed with a panel of 92 neurological-related proteins. Three patients suffered spinal cord injury (SCI), eight delirium, and nine hallucinations. There were markers in both serum and CSF that differed between the affected and non-affected patients (SCI; IL6, GFAP, CSPG4, delirium; TR4, EZH2, hallucinations; NF1). The study identifies markers in serum and CSF that reflect the occurrence of neurologic insults following aortic surgery, which may aid in the care of these patients.