Prediction of Serious Intracranial Hypertension from Low-Resolution Neuromonitoring in Traumatic Brain Injury: An Explainable Machine Learning Approach.

There is a strong association between intracranial hypertension (IH) that occurs following the acute phase of traumatic brain injury (TBI) and negative outcomes. This study proposes a pressure-time dose (PTD)-based parameter that may specify a possible serious IH (SIH) event and develops a model to predict SIH. The minute-by-minute signals of arterial blood pressure (ABP) and intracranial pressure (ICP) of 117 TBI patients were utilized as the internal validation dataset. The SIH event was explored through the prognostic power of the IH event variables for the outcome after 6 months, and an IH event with thresholds that included an ICP of 20 mmHg and PTD > 130 mmHg * minutes was considered an SIH event. The physiological characteristics of normal, IH and SIH events were investigated. LightGBM was employed to forecast an SIH event from various time intervals using physiological parameters derived from the ABP and ICP. Training and validation were conducted on 1,921 SIH events. External validation was performed on two multi-center datasets containing 26 and 382 SIH events. The SIH parameters could be used to predict mortality (AUROC = 0.893, p < 0.001) and favorability (AUROC = 0.858, p < 0.001). The trained model robustly forecasted SIH after 5 and 480 minutes with an accuracy of 86.95% and 72.18% in internal validation. External validation also revealed a similar performance. This study demonstrated that the proposed SIH prediction model has reasonable predictive capacities. A future intervention study is required to investigate whether the definition of SIH is maintained in multi-center data and to ensure the effects of the predictive system on TBI patient outcomes at the bedside.

Concurrent Surgery of Craniectomy and Splenectomy as Initial Treatment in Severe Traumatic Head Injury: A Case Report.

It is not a common case for neurosurgery department and the other departments to perform joint operation at the same time. Patients with severe head injury are a condition in which vital signs are unstable due to severe brain swelling and increased intracranial pressure, and emergency surgery is required. A 44-year-old man visited the trauma center with a motorcycle accident. The Glasgow Coma Scale score at the time of emergency department was 3 points, and the pupil was fixed at 6 mm on both sides. His medical history was unknown. His vital signs including blood pressure (BP), heart rate, respiratory rate and oxygen saturation were stable. Associated injuries included multiple fractures of whole body. Brain computed tomography revealed subarachnoid hemorrhage, intraventricular hemorrhage and severe cerebral edema. During the preparation of the craniectomy, abdominal ultrasonography performed because of decreased BP resulted in a large amount of hemoperitoneum. The bi-coronal craniectomy and splenectomy were performed simultaneously for about 4 hours. After fifty days of treatment, he was discharged with Glasgow Outcome Scale-extended 4 points and is undergoing rehabilitation. In severe polytrauma patients, active concurrent surgery is a good method to save their lives.

Continuous Renal Replacement Therapy for Acute Renal Failure in Patients with Traumatic Brain Injury.

OBJECTIVE: The purpose of this study was to investigate the impact of continuous renal replacement therapy (CRRT) on survival and relevant factors in patients who underwent CRRT after traumatic brain injury (TBI). METHODS: We retrospectively reviewed the laboratory, clinical, and radiological data of 29 patients who underwent CRRT among 1,190 TBI patients treated at our institution between April 2011 and June 2015. There were 20 men and 9 women, and the mean age was 60.2 years. The mean initial Glasgow Coma Scale score was 9.2, and the mean injury severity score was 24. Kaplan-Meier method and Cox regression were used for analysis of survival and relevant factors. RESULTS: The actuarial median survival time of the 29 patients was 163 days (range, 3-317). Among the above 29 patients, 22 died with a median survival time of 8 days (range, 3-55). The causes of death were TBI-related in 8, sepsis due to pneumonia or acute respiratory distress syndrome (ARDS) in 4, and multi-organ failure in 10. Among the various factors, urine quantity of more than 500 mL for 24-hours before receiving CRRT was a significant and favorable factor for survival in the multivariate analysis (p=0.026). CONCLUSION: According to our results, we suggest that early intervention with CRRT may be beneficial in the treatment of TBI patients with impending acute renal failure (ARF). To define the therapeutic advantages of early CRRT in the TBI patients with ARF, a well-designed and controlled study with more cases is required.

Clinical Characteristics and Surgical Outcome of Revision Surgery in Patients with Cervical Ossification of the Posterior Longitudinal Ligament.

OBJECTIVE: To investigate the clinical characteristics and surgical outcome of revision surgery after first surgical decompression of cervical ossification of posterior longitudinal ligament. METHODS: A retrospective analysis was performed of 913 patients who underwent surgical decompression of cervical ossification of posterior longitudinal ligament from 1998 to 2012. Of these patients, 35 underwent revision surgery. Neurologic and surgical outcomes, radiologic findings, surgical procedures, and complications were evaluated. Indications for revision surgery were compared between early (≤24 months after the first surgery) and delayed (>24 months after the first surgery) revision surgery. RESULTS: There was a higher prevalence of male patients with revision surgery (89%) compared with patients without revision surgery (71.2%, P = 0.033). Preoperative Japanese Orthopaedic Association score was significantly lower in patients with revision surgery (11.5 vs. 12.7, P < 0.01). Visual analog scale score for neck pain was improved both without revision surgery (from 3.0 to 2.1, P < 0.001) and with revision surgery (from 3.0 to 2.2, P < 0.001) patients. Symptomatic residual stenosis was a more frequent cause of revision surgery in early revision surgery than in delayed revision surgery (75% vs. 25%, P < 0.001). In delayed revision surgery, growth of ossification of posterior longitudinal ligament (50%) was the primary cause of revision surgery. CONCLUSIONS: Clinical outcomes (Japanese Orthopaedic Association and visual analog scale scores) of revision surgery are similar to the outcomes of patients who did not require revision surgery. Residual stenosis after the index surgery is the most common indication for early revision surgery. To avoid early revision surgery, surgeons should carefully consider achieving circumferential decompression of the spinal canal during initial surgery.

Outcomes of Ultra-Early Decompressive Craniectomy after Severe Traumatic Brain Injury-Treatment Outcomes after Severe TBI.

OBJECTIVE: The beneficial effect of decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial, but there is no debate that decompression should be performed before irreversible neurological deficit occurs. The aim of our study was to assess the value of ultra-early decompressive craniectomy in patients with severe TBI. METHODS: Total of 127 patients who underwent decompressive craniectomy from January 2007 to December 2013 was included in this study. Among them, 60 patients had underwent ultra-early (within 4 hours from injury) emergent operation for relief of increased intracranial pressure. Initial Glasgow coma scale, brain computed tomography (CT) scan features by Marshall CT classification, and time interval between injury and craniectomy were evaluated retrospectively. Clinical outcome was evaluated, using the modified Rankin score. RESULTS: The outcomes of ultra-early decompressive craniectomy group were not better than those in the comparison group (p=0.809). The overall mortality rate was 68.5% (87 patients). Six of all patients (4.7%) showed good outcomes, and 34 patients (26.8%) remained in a severely disabled or vegetative state. Forty of sixty patients (66.7%) had died, and two patients (3.3%) showed good outcomes at last follow-up. CONCLUSION: Ultra-early decompressive craniectomy for intracranial hypertension did not improve patient outcome when compared with "early or late" decompressive craniectomy for managing severe TBI.

Radiofrequency ablation of spine: an experimental study in an ex vivo bovine and in vivo swine model for feasibility in spine tumor.

STUDY DESIGN: An experimental study of radiofrequency ablation (RFA) of spine in an ex vivo bovine and in vivo swine animal model. OBJECTIVE: To study the feasibility of RFA for spine tumors close to the spinal cord, to examine the safety and efficacy of RFA, and to suggest quantitative guidelines for clinical application. SUMMARY OF BACKGROUND DATA: RFA has received increased attention as an effective and minimally invasive method for treating soft tissue tumors. However, there is currently only anecdotal evidence to support RFA of spinal tumors and only a few experimental studies have been conducted. METHODS: We performed ex vivo experiments by producing 10 RFA zones in extracted bovine spines and an in vivo study by producing 8 RFA zones in a swine spine using internally cooled electrodes. The volume and diameter of ablation zones were evaluated and analyzed by the corresponding energy and ablation times. RESULTS: In the ex vivo study, the average diameters of the ablation zones were 3.05 cm, 1.85 cm, and 1.26 cm, for the D1, D2, and D3 zones, respectively, and the average ablation volume was 4.19 cm. In the in vivo study, the average diameters were 2.51 cm, 2.05 cm, and 1.28 cm, respectively, and the ablation volume was 6.80 cm. The ablation zones demonstrated a positive correlation with ablation time, but the coefficients were 0.942 ex vivo and 0.257 in vivo. The temperature in the ex vivo study was inversely proportional to distance, with a maximal temperature of 63.7°C at 10 mm; however, the maximum temperature was 38.2°C in the in vivo study. CONCLUSION: This study demonstrated that sufficient RFA zone volume could be induced, which suggests that RFA is feasible and safe for application to human spinal tumors with predictability. LEVEL OF EVIDENCE: N/A.

Primary spinal cord melanoma in thoracic spine with leptomeningeal dissemination and presenting hydrocephalus.

Primary spinal cord melanoma is a rare central nervous system malignant tumor. Usually it resembles an intradural extramedullary (IDEM) nerve sheath tumor or melanoma. We experienced a patient with upper thoracic primary IDEM spinal cord melanoma who was diagnosed to be with hydrocephalus and without intracranial lesions. Initial symptoms of the patient were related to the hydrocephalus and the primary spinal cord melanoma was diagnosed eight months later. At the first operation, complete resection was impossible and the patient refused additional radiotherapy or chemotherapy. At 22 months after surgery, the patient revisited our institution with recurrent both leg weakness. Leptomeningeal dissemination was present in the whole spinal cord and only partial resection of tumor was performed. The symptoms slightly improved after surgery. Primary spinal cord melanoma is extremely rare but complete resection and additional radiotherapy or chemotherapy can prolong the disease free interval. Hydrocephalus or signs of increased intracranial pressure may be the diagnostic clue of spinal cord malignancy and progression.

Radiologic changes of anterior cervical discectomy and fusion using allograft and plate augmentation: comparison of using fixed and variable type screw.

OBJECTIVE: To evaluate radiologic result of anterior cervical discectomy and fusion with allobone graft and plate augmentation, and the change of radiologic outcome between screw type and insertion angle. METHODS: Retrospective review of clinical and radiological data of 29 patients. Segmental angle, height and screw angles were measured and followed. The fusion rate was assessed by plain radiography and CT scans. We divided the patients into two groups according to screw type and angles. Group A: fixed screw, Group B: variable screw. Interscrew angle was measured between most upper and lower screws with Cobb's methods. RESULTS: Overall fusion rate was 86.2% on plain radiography. Fusion was also assessed by CT scan and Bridwell's grading system. There was no difference in fusion and subsidence rates between two groups. Subsidence was found in 5 patients (17.2%). Segmental lordotic angle was increased from preoperative status and maximized at the immediate postoperative period and then reduced at 1 year follow up. Segmental height showed similar increase and decrease values. CONCLUSION: ACDF with allograft and plate showed favorable fusion rates, and the screw type and angle did not affect results of surgery.

Posterior C2-C3 Fixation for Unstable Hangman's Fracture.

OBJECTIVE: This is a retrospective review of 13 unstable Hangman's fractures who underwent posterior C2-3 fixation to describe clinical outcomes with a literature review. METHODS: Thirteen patients for unstable Hangman's fracture were enrolled between July 2007 and June 2010 were included in this study. The medical records of all patients were reviewed. Concurrently, clinical outcomes were evaluated using Neck Disability Index (NDI) scores and Visual Analogue Scale (VAS) scores during preoperative and postoperative follow up period. Plain radiographs were obtained on postoperative 1day, 1week, and then at 1, 2, 6, and 12 months. CT was done at postoperative 12 months in all patients for evaluation of bone fusion. The mean period of clinical follow-up was 17 months. RESULTS: Mean age were 43 years old. Bone fusion was recognized in all cases at the final follow-up. The average preoperative VAS score for neck pain was 8.3±1.1, while the final follow-up VAS score was 2.07±0.8 (p<0.001). The average immediate postoperative NDI was 84% points and final NDI was 22% points (p<0.001). There were one case of infection and 1 case of screw loosening. CONCLUSION: In the treatment of the patients with unstable Hangman's fracture, posterior C2-C3 fusions is effective and curative treatments to achieve cervical spinal stability.

Stand-alone cervical cages versus anterior cervical plate in 2-level cervical anterior interbody fusion patients: clinical outcomes and radiologic changes.

STUDY DESIGN: Retrospective study. OBJECTIVES: To compare the efficacy of 2-level anterior cervical discectomy and fusion with cage alone (ACDF-CA) and with cage and plate construct (ACDF-CPC) with regard to clinical outcome and radiologic changes. SUMMARY OF BACKGROUND DATA: The use of stand-alone cervical interbody cages in ACDF has become popular, but high subsidence rates have been reported in the literature. METHODS: A total of 54 consecutive patients who underwent 2-level ACDF-CA or ACDF-CPC after suffering from cervical radiculopathy were divided into 2 groups: group A (n = 28) underwent ACDF-CA, group B (n = 26) underwent ACDF-CPC. Fusion rate, global and segmental kyphosis, disk height, and subsidence rate were assessed by radiolographs. Clinical outcomes were assessed using Robinson's criteria. RESULTS: Solid fusion was achieved in 96.43% (27/28) in group A and in 96.15% (25/26) in group B. Fusion segmental kyphosis of >5 degrees occurred in 14.29% (4/28) of group A and in 7.69% (2/26) of group B; however, there was no statistical difference between the 2 groups (P>0.05). Subsidence occurred in 35.71% (10/28) of group A as compared with 11.54% (3/26) of group B (P<0.05). Clinical outcomes were similar in the 2 treatment groups. CONCLUSIONS: The use of cage and plate construct in 2-level ACDF results in a shorter fusion duration and a lower subsidence rate than that of cage alone; however, there is no significant difference in the postoperative global and segmental alignment and clinical outcomes between groups.

The clinical features and surgical outcomes of pediatric patients with primary spinal cord tumor.

BACKGROUND: Primary spinal cord tumors (PSCTs) in pediatric patients are rare, with a reported overall incidence rate of 1-2.6 per one million children. We reviewed our experience of surgically treated 27 pediatric patients with PSCT and discussed the clinical features, radiological findings, surgical outcomes, and prognostic factors. METHODS: Between March 1999 and March 2010, a total of 27 pediatric patients with PSCT were surgically treated in a single institution. We retrospectively analyzed their data. RESULTS: There were 13 females and 14 males, and their ages ranged from 6 months to 19 years (mean age, 12.1 years). The most common presenting symptom was motor weakness, and the histologic type of the tumors were mainly schwannoma, astrocytoma, and ependymoma. The tumor was completely resected in 17 patients, subtotally resected in 7 patients, and partial resection or biopsy was performed in 3 patients. Adjuvant chemotherapy was performed in 9 patients, and radiotherapy in 12 patients, respectively. The average follow-up period was 33.5 months (1.17-129). Five patients experienced the progression of disease, and three of them expired. The mean time for disease progression was 19.0 months (4.5-48.7). CONCLUSIONS: PSCT in pediatric patients can be surgically removed with an acceptable low surgical morbidity. Progression-free survival was found to be related to the grade of tumor and the extent of tumor resection. Early diagnosis and treatment anticipate good functional neurologic outcome.

Ectopic ventricular recurrence of an epidermoid cyst in the middle fossa.

We present the first case of ectopic ventricular recurrence of an epidermoid cyst in the middle fossa with confirming histological characteristics. A 51-year-old woman presented with an epidermoid cyst in the middle fossa and underwent complete resection. On the 6-month surgical follow-up MRI, a nodular lesion was detected in the frontal horn of the left lateral ventricle without evidence of recurrence at the primary site. The patient underwent transcortial tumor resection. Results of histological studies confirmed that the lesion was an epidermoid cyst similar to the primary lesion. This is a case report of the cerebrospinal fluid spread of an epidermoid cyst, which strengthens the case for special care at the time of surgery to prevent spread of the lesion.