Comparison of Using Intraoperative Computed Tomography-Based 3-Dimensional Navigation and Fluoroscopy in Anterior Cervical Diskectomy and Fusion for Cervical Spondylosis.

OBJECTIVE: Anterior cervical diskectomy and fusion (ACDF) is a highly successful procedure to treat spinal cord or nerve root compression; however, complications can still occur. With advancements in imaging, 3-dimensional (3D) reconstruction allows real-time instrument tracking in a surgical field relative to the patient's anatomy. Here, we compare plate positioning and short-term outcomes when using 3D navigation to fluoroscopy in ACDF for degenerative spine disease. METHODS: All ACDFs for cervical spondylosis performed by 6 surgeons at a single center between 2010 and 2018 were included. ACDFs were divided into those performed using 3D navigation or fluoroscopy. Records were assessed for patient demographics, American Society of Anesthesiology score, number of operated interspaces, operative time, length of stay, perioperative complications, and 90-day readmissions. Postoperative images were reviewed for lateral and angular plate deviations. RESULTS: A total of 193 ACDFs performed with 3D navigation and 728 performed with fluoroscopy were included. After controlling for demographics and surgical characteristics, using 3D navigation was associated with less lateral plate deviation (P = 0.048) and longer operative times per interspace (P < 0.001) but was not associated with angular plate deviation (P = 0.724), length of stay (P = 0.393), perioperative complications (P = 0.844), and 90-day readmissions (P = 0.539). CONCLUSIONS: Using 3D navigation in ACDF for degenerative disease is associated with slightly more midline plate positioning and comparable short-term outcomes as using fluoroscopy and can be a suitable alternative. Advantages of using this technology, such as improved visualization of anatomy, should be weighed against disadvantages, such as increased operative time, on a per-patient basis.

Utility of Head Computed Tomography Scans Before Outpatient Follow-up for Low-Risk Mild Traumatic Brain Injury.

BACKGROUND: Neurosurgeons are frequently consulted for traumatic brain injuries (TBIs) resulting in intracranial hemorrhage (ICH). After inpatient confirmation of hemorrhage stability, outpatient head computed tomography (CT) is often performed to assess for hemorrhage resolution. Our objective was to assess the practice patterns and clinical utility of routine outpatient head CT scans for patients with mild TBI (mTBI). MATERIALS AND METHODS: A retrospective review was performed on all adult mTBI patients with ICH who presented to a level I trauma center over a 4-year period. A combination of the patient's initial clinical evaluation and CT findings was used to identify mTBI patients at low risk for neurologic deterioration and neurosurgical intervention. Findings from the outpatient follow-up clinical evaluation and head CT were assessed. Patients without outpatient follow-up within 3 months were excluded. RESULTS: Forty-nine patients met inclusion criteria for the study. Thirty-two had an outpatient head CT before their follow-up appointment. Twenty-one patients had at least 1 neurologic finding at the earliest follow-up appointment. All patients except those with a subdural hematoma (SDH) had smaller or resolving ICH on outpatient CT scans. Seven patients with an SDH had unchanged or expanded hemorrhage on outpatient imaging, 2 of whom had traumatic brain injury-related hospitalizations and 1 of whom underwent neurosurgical intervention due to an enlarging SDH. CONCLUSIONS: Routine outpatient head CT scans before follow-up for low-risk mTBI patients without an SDH appears to have limited clinical utility. In low-risk mTBI patients with an SDH, obtaining an outpatient head CT is reasonable to monitor for resolution.

Assessing the efficacy of mild traumatic brain injury management.

OBJECTIVE: Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. METHODS: Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. RESULTS: Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. CONCLUSION: Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

Resolution of Symptomatic Lumbar Synovial Cyst After Traumatic Event.

BACKGROUND: Synovial cysts are most commonly found in the lumbar spine and are associated with low back pain and radiculopathy. Frequent use of imaging modalities has led to an increase in intraspinal synovial cyst identification. Treatment typically ranges from conservative measures to surgical decompression, but spontaneous resolution has previously been reported. Here, we present the first report of symptomatic lumbar synovial cyst resolution after a traumatic fall. CASE DESCRIPTION: We present a case of a symptomatic synovial cyst between the fourth (L4) and fifth (L5) lumbar vertebrae identified on magnetic resonance imaging (MRI). The patient presented with right paramedian back pain and right-sided L5 radiculopathy. She underwent unsuccessful trials of antiinflammatory agents and physical therapy. Less than 1 year since initial diagnosis, the patient sustained a mechanic fall followed by resolution of prior symptoms. A subsequent lumbar MRI revealed complete resolution of the intraspinal synovial cyst. CONCLUSIONS: The diagnosis of synovial cysts are increasing in frequency due to their ease of identification with computed tomography and MRI. For cases of refractory pain and/or neurologic deficits, surgical decompression is usually necessary. In rare instances, synovial cysts may spontaneously regress or resolve secondary to other events. This is the first description of resolution after a traumatic fall. Due to limited data on this topic, this report may provide additional insight into the pathophysiology of synovial cyst formation and resolution.

Teaching childbirth with high-fidelity simulation. Is it better observing the scenario during the briefing session?

The design of optimal courses for obstetric undergraduate teaching is a relevant question. This study evaluates two different designs of simulator-based learning activity on childbirth with regard to respect to the patient, obstetric manoeuvres, interpretation of cardiotocography tracings (CTG) and infection prevention. This randomised experimental study which differs in the content of their briefing sessions consisted of two groups of undergraduate students, who performed two simulator-based learning activities on childbirth. The first briefing session included the observations of a properly performed scenario according to Spanish clinical practice guidelines on care in normal childbirth by the teachers whereas the second group did not include the observations of a properly performed scenario, and the students observed it only after the simulation process. The group that observed a properly performed scenario after the simulation obtained worse grades during the simulation, but better grades during the debriefing and evaluation. Simulator use in childbirth may be more fruitful when the medical students observe correct performance at the completion of the scenario compared to that at the start of the scenario. Impact statement What is already known on this subject? There is a scarcity of literature about the design of optimal high-fidelity simulation training in childbirth. It is known that preparing simulator-based learning activities is a complex process. Simulator-based learning includes the following steps: briefing, simulation, debriefing and evaluation. The most important part of high-fidelity simulations is the debriefing. A good briefing and simulation are of high relevance in order to have a fruitful debriefing session. What do the results of this study add? Our study describes a full simulator-based learning activity on childbirth that can be reproduced in similar facilities. The findings of this study add that high-fidelity simulation training in childbirth is favoured by a short briefing session and an abrupt start to the scenario, rather than a long briefing session that includes direct instruction in the scenario. What are the implications of these findings for clinical practice and/or further research? The findings of this study reveal what to include in the briefing of simulator-based learning activities on childbirth. These findings have implications in medical teaching and in medical practice.

Labor induction just after external cephalic version with epidural analgesia at term.

OBJECTIVE: To analyze the benefits of external cephalic version (ECV) with epidural analgesia at term and labor induction just after the procedure. MATERIALS AND METHODS: This is a retrospective observational study with patients who did not want trying a breech vaginal delivery and decided trying an ECV with epidural analgesia at term and wanted labor induction or cesarean section after the procedure. We present the results of 40 ECV with epidural analgesia at term and labor induction or cesarean section just after the ECV. RESULTS: ECV succeeded in 26 out of 40 (65%) patients. Among the 26 successful ECV, 6 delivered by cesarean (23.1%). 20 patients delivered vaginally (76.9%; 50% of all patients). CONCLUSION: Considering that a high number of cesarean deliveries can be avoided, induction of labor after ECV with epidural analgesia at term can be considered after being discussed in selected patient.

A Phase 1 Dose-Escalation Study of Oral 5-Aminolevulinic Acid in Adult Patients Undergoing Resection of a Newly Diagnosed or Recurrent High-Grade Glioma.

BACKGROUND: The utility of oral 5-aminolevulinic acid (5-ALA)/protoporphyrin fluorescence for the resection of high-grade gliomas is well documented. This drug has received regulatory approval in Europe but awaits approval in the United States. OBJECTIVE: To identify the appropriate dose and toxicity or harms of 5-ALA used for enhanced intraoperative visualization of malignant brain tumors, reported from a single medical center in the United States. METHODS: Prior to craniotomy for resection of a presumed high-grade glioma, individuals were given oral 5-ALA as part of a rapid dose-escalation scheme. At least 3 patients were selected for each dose level from 10 to 50 mg/kg in 10 mg/kg increments. Adverse events, intensity of tumor fluorescence, and results of biopsies in areas of tumor and the tumor bed under white light and deep blue light were recorded. RESULTS: A total of 19 patients were studied in this phase 1 study. Serious adverse events were unrelated to the ingestion of 5-ALA. At the highest dose level studied (50 mg/kg), 2 out of 6 patients were observed to have transient dermatologic redness and peeling. These were grade 1 adverse events, which were not serious enough to be dose limiting. Patients at higher dose levels (>40 mg/kg) were more likely to have strong tumor fluorescence. There were no instances of false positive fluorescence. CONCLUSION: The use of 5-ALA for brain tumor fluorescence is safe and effective to a dose of 50 mg/kg. Dose-limiting toxicity was not reached in this study.

Insemination of bocachico fish (Prochilodus magdalenae) with fresh or cryopreserved semen: effect of spermatozoa/oocyte ratio / Inseminacion de bocachico (Prochilodus magdalenae) con semen fresco o crioconservado: efecto de la proporción espermatozoide/oocito / Inseminação do bocachico (Prochilodus magdalenae) usando sêmen fresco o criopreservado: efeito da razão espermatozoide/oócito

Background: cryopreservation is an important biotechnological tool in the conservation of biodiversity, particularly for endangered species. Objective: to evaluate six different spermatozoa/oocyte ratios using fresh and cryopreserved semen in bocachico fish (Prochilodus magdalenae). Methods: fresh semen was collected and its quality determined to verify cryopreservation feasibility. The semen was put in 5 mL straws and mixed with a solution (5.5% glucose, 12% egg yolk, and 10% dimethyl sulfoxide -DMSO-) in a 1:4 dilution (semen:solution). The semen was frozen in nitrogen vapor dry shipper for 30 min, rapidly transferred to storage thermos, and submerged directly into liquid nitrogen (LN; -196 °C). Straws were thawed at 60 ºC for 45 seconds. Motility, velocity, and sperm progressivity of fresh and cryopreserved semen were assessed using Sperm Class Analyzer (SCA®) software. Each proportion of spermatozoa/oocyte was assessed with 2 g of eggs (1,630 ± 87 eggs/g) to evaluate fertility (F), hatching (H), and larval survival (LS) rates. Results: the best reproductive performance for fresh semen was obtained inseminating with 160,000 spermatozoa/oocyte (F = 75.0%, H = 67.7%, LS = 32.7%). Similarly, the best reproductive performance for cryopreserved semen was achieved with 320,000 spermatozoa/oocyte (F = 70.0%, H = 48.6%, LS = 19.5%). Conclusion: it is possible to achieve adequate reproductive performance in bocachico fish using cryopreserved sperm (10% DMSO, 5.5% glucose, and 12% egg yolk) at twice the spermatozoa/oocyte ratio used with fresh semen.

Antecedentes: la crioconservación es una herramienta biotecnológica importante para la conservación de la biodiversidad, particularmente de especies en peligro. Objetivo: evaluar seis proporciones diferentes entre espermatozoides/ovocito en la fertilización de bocachico (Prochilodus magdalenae), usando semen fresco o crioconservado. Métodos: se colectó semen y se determinó su calidad para verificar su viabilidad de crioconservación. El semen fue colocado en pajillas de 5 mL y mezclado con una solución crioconservante (5,5% glucosa, 12% yema de huevo y 10% dimethyl sulfoxido -DMSO-) en una dilución 1:4 (semen:solución). El semen fue congelado en un termo de vapores de nitrógeno por 30 min y rápidamente se transfirió a termos de almacenamiento sumergiéndolo directamente en nitrógeno líquido (LN; -196 °C). Las pajillas fueron descongeladas a 60 ºC por 45 segundos. La motilidad, velocidad y progresividad de los espermatozoides, tanto de semen fresco como del congelado, fueron evaluadas usando el software Sperm Class Analyzer (SCA®). Cada proporción de espermatozoides/ovocito fue evaluada en 2 g de huevos (1.630 ± 87 huevos/g) para evaluar fertilidad (F), eclosión (H) y sobrevivencia larval (LS). Resultados: el mejor desempeño reproductivo con semen fresco fue obtenido inseminando con la proporción de 160.000 espermatozoides/ovocito (F = 75,0%, H = 67,7%, LS = 32,7%). De manera similar, el mejor desempeño reproductivo con semen crioconservado fue logrado con la proporción de 320.000 espermatozoide/ovocito (F = 70,0%, H = 48,6%, LS = 19,5%). Conclusión: es posible lograr un adecuado desempeño reproductivo en bocachico usando semen crioconservado (10% DMSO, 5,5% glucosa y 12% yema de huevo) cuando la relación espermatozoide/ovocito usada es del doble de la proporción aplicada para semen fresco.

Antecedentes: a criopreservação é uma ferramenta biotecnológica importante na conservação da biodiversidade, particularmente de espécies ameaçadas. Objetivo: foram avaliadas seis proporções de espermatozoides/ovócito na fertilização usando sêmen fresco e crioconservado em fertilização de bocachico (Prochilodus magdalenae), Métodos: o sêmen fresco foi coletado e determinada sua qualidade para verificar a viabilidade de crioconservação. O sêmen foi colocado em palhetas de 5 mL e misturado com a solução crioconservante (5,5% glicose, 12% gema de ovo e 10% dimetilsulfóxido -DMSO-) em numa diluição 1:4 (sêmen:solução). O sêmen foi congelado em botijão de vapores de nitrogênio por 30 min e rapidamente transferido a botijão de armazenagem submergindo-os diretamente em nitrogênio líquido (LN; -196 °C). As palhetas foram descongeladas a 60 ºC por 45 segundos. A motilidade, velocidade e progressividade dos espermatozoides, tanto de sêmen fresco quanto de congelado, foram avaliadas usando o software Sperm Class Analyzer (SCA®). Para avaliar fertilidade (F), eclosão (H) e sobrevivência larval (LS), cada relação de espermatozóide/oócito foi avaliada em 2 g de oócitos (1.630 ± 87 ovos/g). Resultados: o melhor desempenho reprodutivo com sêmen fresco foi obtido inseminando com proporção 160.000 espermatozoides/oócito (F = 75,0%, H = 67,7%, LS = 32,7%). O melhor desempenho reprodutivo com sêmen crioconservado foi verificado na proporção de 320.000 espermatozoides/oócito (F = 70,0%, H = 48,6%, LS = 19,5%). Conclusão: é possível alcançar um adequado desempenho reprodutivo em bocachico usando sêmen crioconservado (10% DMSO, 5,5% glicose e 12% gema de ovo) quando a proporção espermatozoide/oócito usada é o dobro da utilizada para sêmen fresco.

Alternative model of birth to reduce the risk of assisted vaginal delivery and perineal trauma.

INTRODUCTION AND HYPOTHESIS: This study was conducted to evaluate the effects of an alternative model of birth (AMB) on the incidence of assisted vaginal delivery (AVD) and perineal trauma (PT). METHODS: One hundred ninety-nine women with epidural anesthesia were randomized to a traditional model of birth (TMB) (n = 96) or AMB (n = 103). Women in TMB pushed immediately after complete dilatation and delivered in lithotomy position. In AMB, women followed a postural changes protocol while they delayed pushing and used a specific lateral position for delivery. RESULTS: AMB was associated with a significant reduction in AVD compared with TMB (19.8% vs 42.1%, p<0.001). TMB was strongly associated with AVD (OR = 4.49; p< 0.05), which, in turn, was significantly associated with nulliparity (OR = 5.52; p<0.005) and fetal head unengaged at full dilatation (OR = 5.35; p<0.05). AMB significantly increased the intact perineum rate compared with TMB (40.3% vs 12.2%, p<0.001). Episiotomy rate was significantly reduced in AMB (21.0% vs 51.4%, p<0.001). CONCLUSION: A combination of postural changes during the passive expulsive phase of labor and lateral position during active pushing time is associated with reductions in AVD and PT.

Serum titanium levels after instrumented spinal arthrodesis.

STUDY DESIGN: A retrospective study measuring postoperative serum titanium levels in patients with titanium alloy spinal instrumentation. OBJECTIVE: To determine serum titanium levels in patients after instrumented spinal arthrodesis with implants composed of titanium alloy and to identify potential factors responsible for any increase in ion levels. SUMMARY OF BACKGROUND DATA: Previous studies have documented localized metal debris in the tissues surrounding spinal instrumentation. Systemic distribution of metal debris has also been demonstrated by measuring elevated serum metal ion levels in patients with titanium spinal implants; however, no studies exist on the impact of instrumentation characteristics on serum ion levels. METHODS: Serum titanium concentrations were measured in 30 patients with titanium spinal instrumentation at a mean 26 months after surgery and compared with a control group without metallic implants. Comparisons were made regarding serum titanium levels with respect to specific instrumentation characteristics such as number of pedicle screws used, and the presence of cross connectors or titanium interbody devices. RESULTS.: Serum titanium levels were significantly higher in patients with titanium spinal implants (mean, 2.6 microg/L) when compared with controls (mean, 0.71 microg/L). Subjects who underwent an instrumented arthrodesis of only one spinal segment had decreased serum titanium levels when compared with those who were fused at 2 or more spinal segments (mean, 2.3 vs. 3.1 microg/L) and patients with 4 or less pedicle screws also had decreased serum titanium levels when compared with constructs of 6 to 8 pedicle screws (mean, 2.3 vs. 3.35 microg/L); however, both of these findings were not statistically significant. Patients without cross connectors had a slightly increased serum titanium level when compared with those with connectors (mean, 2.7 vs. 2.44 microg/L); however, this finding was also not statistically significant. Patients with titanium interbody devices had a statistically significant elevation in serum titanium levels when compared with those without (mean, 3.3 vs. 1.98 microg/L). CONCLUSION: Significantly higher serum titanium concentrations were observed in subjects with titanium spinal instrumentation when compared with controls. Continued research is necessary to examine the relationship between Ti interbody devices and cross connectors with regards to serum ion levels.

Effect of Neuregen nutrient medium on survival of cortical neurons after aspiration lesion in rats.

OBJECT: During brain surgery, it would be beneficial to irrigate the surgical cavity with a solution that promotes neuronal growth and survival. The authors find that incubation of cultured neurons with normal saline, also known as buffered salts, which are often used in brain surgery in humans, does not support neuron survival. Neuregen is an optimized serum-free culture medium that promotes regeneration of adult rat and human central nervous system neurons in vitro. It includes balanced salts, glucose, amino acids, vitamins, essential fatty acids, hormones, antioxidants, and other ingredients. The authors hypothesize that brain lesions irrigated and soaked in Neuregen nutrients will have better neuron survival rates in deafferented regions than lesions irrigated with saline. METHODS: Lesioning of the rat fimbria-fornix area was achieved by aspiration through the cortex; animals were killed 4 weeks later. Brain sections were stained with cresyl violet for neuron counts in the medial septum and cortex. Treatment of the lesion cavity with Neuregen resulted in a 55% increase in neuron density in the septum compared with saline treatment (p = 0.02). Cortical lesions treated with Neuregen showed a 27% increase in neuron density compared with saline-treated lesions (p = 0.015); the neuron density in Neuregen-treated rat brains was equivalent to that seen with sham treatment. Efficacy of Neuregen with basic fibroblast growth factor (bFGF) was significantly better than with Dulbecco modified Eagle medium bFGF, but not better than Neuregen alone. Neuregen produced a coincidental fourfold reduction in glial fibrillary acidic protein immunoreactivity at 4 weeks compared with saline (p = 0.002), to levels equivalent to those found in sham lesions. CONCLUSIONS: These results indicate that a highly optimized nutrient medium promotes neuron survival after brain surgery.

Self-inflicted vocal cord paralysis in patients with vagus nerve stimulators. Report of two cases.

Vagus nerve stimulation for treatment of epilepsy is considered safe; reports of severe complications are rare. The authors report on two developmentally disabled patients who experienced vocal cord paralysis weeks after placement of a vagus nerve stimulator. In both cases, traction injury to the vagus nerve resulting in vocal cord paralysis was caused by rotation of the pulse generator at the subclavicular pocket by the patient. Traumatic vagus nerve injury caused by patients tampering with their device has never been reported and may be analogous to a similar phenomenon reported for cardiac pacemakers in the literature. As the use of vagus nerve stimulation becomes widespread it is important to consider the potential for this adverse event.